May 29, 2020

In Japan, Covid-19 caregivers and patients stigmatized

Japon Japan Covid Coronavirus

Fear of infection leads to ostracism of health workers and their children, while hospitals fear losing the rest of their clientele by accepting patients infected with the virus.

Lack of means, risk of contracting the disease, even a certain ostracism, the Japanese medical system is having a hard time coping with the Covid-19 pandemic. Here, there is no rally at 8 p.m. to applaud the work of health workers, no ministers visiting hospitals or expressing their support. On the contrary, “it’s as if people equate nurses with coronavirus,” a nurse’s aide who came to relax in a park and was firmly invited by mothers to leave. “We’d appreciate it if you’d stay away,” they told her.

“Shameful attitude,” reacted Tokyo Governor Yuriko Koike, while the Japanese Red Cross explained the ostracism as “fear and anxiety” caused by this “invisible virus, for which there is no vaccine or treatment”. It is said to trigger “survival instincts” that lead to “stigmatization of those who are potential carriers”. At the end of April, President magazine asked: “What can be done to protect children of caregivers from coronavirus-related harassment? ยป

Reactions that are not peculiar to the Japanese but from which they are not exempt: the atomized people of Hiroshima and Nagasaki were ostracized for a long time. Because of the blackout of the American occupants on the effects of irradiation, many thought that their symptoms were due to a contagious disease. The tsunami of 11 March 2011 had also revived the stigma, of a different nature and part of history, of the Korean community, accused of taking advantage of the disaster to steal or loot – facts that were never proven – and already targeted during the Tokyo earthquake of 1923.

The ostracism, which is hard on health workers, adds to the difficulties associated with the pandemic itself. Japan had “only” 15,477 cases of Covid-19 on 6 May, a long way from the countries of Europe. 577 people died and the number of new cases is officially declining. But the Japanese Medical Association believes that emergency care “has already collapsed”, falling victim to the shortcomings of a quality medical system but “not equipped to deal with a pandemic,” according to Makoto Aoki, a specialist in contagious diseases,
Insufficient means

Before the crisis, the number of beds in intensive care units was 4.5 per 100,000 inhabitants in Japan, compared to 7.5 in France. In February, there were more than 22,000 artificial respirators and nearly 1,400 extracorporeal membrane oxygenation devices (ECMO) in the country. Taking into account other pathologies, these means were insufficient. In Tokyo, the city most affected by Covid-19, 62 per cent of the available beds were occupied on 6 May. But the city had to multiply their number by five due to the influx of coronavirus patients.

The legislation surrounding contagious diseases seems ill-adapted. It obliges hospitalization of all people with the virus even in the case of mild symptoms. In order to alleviate the burden of services, municipalities, including Tokyo, have requisitioned hotel rooms for the less serious cases.

In addition, the management of the pandemic depends on the National Institute of Communicable Diseases (NIID), which is dominated by microbiologists. “In all countries, there is a balance between microbiologists, clinicians and epidemiologists, except in Japan,” says Professor Aoki.

This has an impact on the strategies followed, especially for tests, which are carried out sparingly and according to cumbersome procedures – it sometimes takes a week to get the results – although this policy could change. The commission in charge of monitoring the virus recommended, on Wednesday May 6, to intensify them by modifying the criteria for access to the test, in particular to wait four days at a temperature higher than 37.5 degrees. Japan would thus reconsider its choice to approach the virus epidemiologically by identifying and treating outbreaks of contamination. This strategy was aimed, among other things, at avoiding hospital overcrowding, but remains highly criticized. “The low number of tests is responsible for the multiplication of contaminations,” says Yasuharu Tokuda, a doctor in Okinawa.
Lack of protective equipment

And in the field, a lot of hospitals are turning patients away. Between April 1 and April 25, 1,919 people with high fever were turned away from five facilities before finding a place. One octogenarian had to be hospitalized 350 km from home, in this case in Tokyo, where he died. “Even if we decide at our level to accept a patient, the management may refuse,” explains an intensive care physician.

Private facilities are concerned that they may have to close. Tokyo’s Kosei Hospital had to shut down for a month for disinfection after a patient with Covid-19 was discovered. The usual patients may not return and the image may be degraded, as if the discovery of a Covid-19 case represented a failure. “Such behaviour is not surprising. In 1995, Shineaki Hinohara [1911-2017] was the only hospital director [St. Luke’s International Hospital] to accept victims of the sarin gas attack on the Tokyo subway. No other hospital wanted them, and the Ministry couldn’t force them,” said Ryoji Noritake, CEO of the Health and Global Policy Institute (HGPI). The doubling of grants to institutions accepting patients requiring ventilators or ECMOs did not change that.

Hospitals are also cautious because of the shortage of protective equipment and the lack of specialists in contagious diseases. “There are no quotas for specialties in Japan. There are no quotas for specialties in Japan,” says Kentaro Iwata, a specialist in contagious diseases in Kobe. There is also a shortage of nurses. The Namihaya hospital in Osaka (west), which has about 100 patients, has forced two of them, despite being contaminated, to come to work.

 

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