It's been a year
On watching a global pandemic from Japan
It’s been a year since this pandemic got “real” (people starting working from home en-masse) and it’s taken me a while to get to the point of being able to articulate something that I feel is an under-rated (and surprising) strength of what has been the Japanese response to COVID: aspects of its public health messaging.
Thinking back to the start of all this, I recall getting into arguments with my wife about whether Japan was “doing enough to control COVID” – she would compare (unfavourably) the Japanese response with the more strident measures the UK was taking.
I would counter that the “novel” nature of the virus meant that even experts do not yet have a good handle on how to improve medical outcomes, and that it’s the job of politicians and leaders to do with that information what's in the nation's best interest. In other words, to make a call on which courses of action to pursue – actions with as-yet unforeseen, yet assuredly profound and complex, implications on society – based on (then) low-confidence scientific data on how to blunt negative public health outcomes. I argued that it was too early to say whether Japan was doing a good job.
She was never convinced by my dithering – “we know this is serious, we shouldn’t be satisfied with half measures, we should be doing what we can.” Then again, we’re both stubborn, because I was never convinced by her absolutism either. I guess I’m becoming something of a classical consultant, because I would call it trade-off thinking, or (better still) economic decision-making.
“You never open your mouth until you know what the shot is” – Al Pacino in Glengarry Glen Ross (1992)
Put it this way: if you don’t know
what is at stake (“how bad can this get if we don’t do anything?”) OR
what is the best way to proceed to achieve a desirable outcome ("what are the preventative measures we could take?”) OR
how much difference our actions can make (“how effective are those measures?”)
then how can you say for certainty that not enough is being done?
To use a Texas Hold ‘Em poker analogy: Without knowing what’s in the pot or what cards you’re holding, how can you possibly know whether (and how much) to bet, and in which direction to bluff?
(Incidentally, at the time I recall Sweden was the outlier in Europe for its measured response, with a Japan-like emphasis on asking people to act responsibly for the greater good, rather than overly relying on rules. I wouldn’t be drawn into the fool’s game of commenting on whether the Swedes were getting their response right, but I did appreciate that they were at least trying to grapple with the trade-offs at play)
As residents of Japan, the last 12 months have been a mixed blessing. While case numbers have not risen as much as feared, there have been missteps and scandals that have kept us on edge. Local municipalities diverged in their record-keeping practises, calling into question whether or not we had a handle on the full extent of the problem. The Olympics muddied the waters, making it unclear whether the government really would do what it took to keep us safe. The Go-To Travel campaign was also confusing and appeared to put the business interest of Travel & Hospitality industry ahead of the public health interest (... whether or not it led to a significant increase in case numbers is still an open question).
However, despite these arguable missteps, the crisis in Japan has been mild by almost all measures. Case numbers are trending around 1,000 new cases a day (430k total now). We are seeing around 60 deaths a day. Excess deaths for the year 2020 have actually been negative.
A quick calculation of per-million COVID statistics. Data extracted from Google’s COVID dashboard on 1st March 2021.
What’s that in comparison? UK, with around half the population, has 9,000 new cases a day (4 million to-date) and 300+ deaths a day. USA, with 2.5x the population, is uncovering 68k new cases a day (29 million total), and around 2,000 deaths per day. So compared to USA and UK, the problem in Japan has been in the region of 1/10 or 1/20 the scale, in per capita terms. On the other side, the COVID problem in Japan is in the order of roughly 2~4x the magnitude of the problem in South Korea, which has been widely praised for effective measures.
So we can see that the medical outcomes have been far from worst-case scenario – pretty good but not class-leading (that accolade belongs to South Korea, New Zealand, Taiwan). How was this managed? An extant culture of mask-wearing and a high baseline of cleanliness and awareness of transmissible diseases? Sure – that’s something that Japan has in common with much of East Asia.
But unlike many other East Asian “model responders,” freedom of movement was not infringed in Japan. There hasn't been a “lockdown" in the way that Brits or Italians would recognise. There has been no centralised quarantine. And it never once became a punishable offence to go to someone’s house or even to hold a party of fifty or a hundred people.
There would have been social pressure to avoid such activities – which is, of course, precisely the point.
Compared to the middling-to-good health outcomes, what stands out in Japan is the soft stuff. This is difficult to quantify, but life in Japan “feels normal,” and has done for a while now. This isn’t just a result of whatever cocktail of physical interventions (masks, hand-washing) that have worked – there’s definitely a psychological component.
We're at the point in March 2021 when vaccines are rolling out in many countries (not just the UK and USA) and the history books are starting to get written, and the lessons summarised.
The pandemic has changed us. We have all learned new vocabulary or gained a new perspective on them: new normal, next normal, contract tracing, social distancing, the shift to commerce, distanced learning, lockdown, telemedicine, BOPIS, zoom-bombing, digital transformation, MOOCs, ABW, zero-trust security, synchronous / asynchronous communication, credibility bookshelves.
Some of these have been exposed as fads – for instance, did we really believe that curbside pickup for groceries would become a sustained business trend that warranted specialised infrastructure and investment, rather than something that required just a chat group and plastic bags in a freezer box? It seems strange, but that was a moment in early summer 2020 – I recall discussing the notion with a digital transformation lead at one of the big three convenience store chains.
On the other hand, certain other concepts have only increased in salience as the pandemic months have rolled on into years. I think that the key "Three Cs" public messaging in Japan is one such thing. It’s not a physical measure like masks or hand-washing, but nonetheless it’s been perhaps transformative in terms of the overall outcome. The psychological effect – of empowering people to take more agency in how they assess risk and live their own lives – has been profound.
It was in April 2020 that the Japanese authorities rolled out the “Three Cs” messaging – avoiding closed spaces, crowded places, and close-contact settings. In visual media such as posters, these Three Cs are always represented in Venn diagram form, with a callout that the risk of clusters is particularly high among situation where the Cs overlap.
In English, the key communication (the text in large font) is just 10 words – (1) Avoid (2) the (3) Three (4) Cs (5) Closed (6) spaces (7) Crowded (8) places (9) Close-contact (10) settings – accompanied by a simple overlapping Venn diagram that does some visual work to convey the relationship between the criteria: avoid each of the Cs, but especially combinations of them. Worst of all are conditions where all three overlap, denoted by the bright red triangle in the centre.
I think it’s absolutely, unreservedly brilliant. Not only for improving the COVID infection outcomes, but also for keeping people sane during this trying time. And it's surprising, because Japanese authorities are not known for being great at PR.
To see why this is so effective, shall we compare it to an equivalent piece of public communication in the UK?
"Stay home > protect the NHS > save lives” is a roughly similar number of words – 7 words, compared to 10 for the previous “Three Cs” example.
1. Usefulness ratio
So we know that the number of words is similar, but how much useful, active content is there?
The three lines are presented as causal, i.e. the first line causes the second, and the second the third. The implication, then, is that all that any individual can do is to meet the first condition, for the others to follow. The active (i.e. actionable) content is actually just 2 words – “stay home.” A nation of 66 million people are being told two words to guide them in their lives, and that lives will be lost if they fail.
If it wasn’t so sad, it would be funny (… almost as absurd as asking 66 million people a simple two-option referendum, the – apparently – binding result of which would set the country on a path that will have far-reaching and unforeseeable consequences on society and the economy for decades to come!)
On the other hand, coming back to the “Three Cs,” all 10 words of the key content are descriptive – there’s an economical denseness and usefulness to the communication. It doesn’t lay out a binary “home vs not home” distinction – instead it admits 2 basic truths: 1. the world is complicated, and 2. assessing risk is difficult. What it does, by simplifying and dimensionalising risk along the axes that most matter, is empower non-experts to make better decisions.
Grappling with the complexity of the world, while also working to simplify the dimensions that matter, is a very difficult balancing act, and the “Three Cs” makes the grade.
2. Stakes
To its credit, what the "stay home" example does convey succinctly is the stakes at play for behavioural modification – the implication is that the NHS will collapse if not enough people stay at home, and this will lead to deaths. If the NHS is protected, then, lives will be saved. So stay home. This appeal to altruism is well-intentioned, but is it effective?
What gives me pause is that starkness of the stay-home order dooms people to fail even every time they leave their front door. The implication is that going for a shop or a walk is killing people, and this layers guilt onto even innocuous activities.
Of course I'm exaggerating a bit – people are not being urged not to buy food and daily necessities. But the psychological effect of “breaking the rules,” even in a virtually meaningless way (to go buy bread and milk for one’s family, or to go out for a socially-distanced walk to get some fresh air) has not been studied. Perhaps it should. Does it register as failure in some part of the brain? Has the conscientious lockdowner who abstains of exercise and outdoor socialisation and only leaves their house for a weekly shop "failed" 52 times in the last year? And the kicker: Why bother trying, if the mission was doomed to failure in the first place?
The “Three Cs" messaging, on the other hand, doesn’t really convey any stakes. The negative consequence for not following are a secondary communication priority (= there is mention of clusters, but not of illness or death). Failing to avoid the Three Cs isn’t something fatal or final – it’s just something that you can try to do again and again.
3. Threat vs Recommendation
The "save lives" communication is an implicit threat – if you don't heed this directive, then you're to be labelled anti-NHS and anti-life.
The “Three Cs” communication is not a threat, but a guide to behaviour:
It’s not saying “don’t meet people,” it’s saying “if you do, meet outside somewhere quiet and don’t stand too close to them.”
It’s not saying “don’t go out to the restaurant,” it’s saying “if you do, make sure you’re not sitting too close to people, and in a restaurant that is well-ventilated – and if it's an option, probably best to do take out.”
It’s not saying “don’t take the train,” it’s saying “if you got to get where you need to go, take the train – but when you do, best you ensure the train windows are open, and don’t speak to the other passengers.”
In short, it becomes a manual on how to live a life in a society with an airborne virus. The "stay home" example is not about living with the virus – it's about putting life on hold to wait it out. This helps explain how life in Japan “feels normal” (more or less) now.
4. Visibility
Here’s a logical riddle –
Question: You see people breaking the “stay home” order. What does that say about you?
Answer: it means that you have been breaking the rule as well – because the likelihood is that you’re outside to see them breaking the rules.
I think a lot about the subconscious psychological implications of this logical fallacy – can you judge anyone for their reckless behaviour as you walk past them in the street? Is it any better that one of you is wearing a mask and the other is not? That one of you avoids walking too close to people while the other does not?
On some level, the answer to all of these questions is “no” – because you’re both offenders, having violated the first commandment when you left your front doors.
You had one job.
On the other hand, the Three Cs are always there for us continually to reassess our actions in light of changing circumstances and risk profiles in the different environments we come across. "Does that supermarket look a little crowded? Maybe let’s walk a bit further to the convenience store for those carrots we needed, even if it’s a bit more expensive than the grocers.” Seeing someone out on the street is not a red alert, it is a completely neutral event.
Japanese politics are criticised (often fairly so!) for being sclerotic and ineffective, and remaining out-of-touch in its communication with its constituents. So it's both ironic and telling that both COVID-era prime ministers have seen their approval ratings crater – evidently, doing the right thing and getting credit for the right thing are different skillsets. It is the very weakness of politics in Japan that makes the success of the "Three Cs” communication (since adopted by the WHO) quite so surprising – because it is a triumph of politics, just as much as of the sound science that underpins it.
For me, the COVID era has been a year of realising the profound importance of politics (writ large) as a crucial determinant of outcomes for a society. Because it doesn’t matter whether you know how to beat a virus. The only thing that matters is that you beat it. And that requires changing people's minds and affecting behaviours, not having debates about whether things are correct.
Put it a harsher, starker way: the intent doesn’t matter, what matters is results.
I will leave you with the final paragraph of Yuval Noah Harari’s recent one-year COVID retrospective from the FT:
If COVID-19 nevertheless continues to spread in 2021 and kill millions, or if an even more deadly pandemic hits humankind in 2030, this will be neither an uncontrollable natural calamity nor a punishment from God. It will be a human failure and – more precisely – a political failure.