Tuesday 23 February 2021

Scepticism and Distrust towards Vaccines in Japan: Uncertainty Avoidance and Cultural Uniqueness


Vaccine info sent to over 64's

While COVID-19 jabs in the UK have been progressing at a brisk pace - the goal to vaccinate 15 million people by mid-February has already been met - Japan is very much behind the curve. The first batch of Pfizer vaccines arrived at Narita on February 12th and were formally approved two days later under an emergency process with simplified screening. Health-care workers started to get shots from February 17th with full-scale jabs for over-64s to begin April 26th. Under-65s with underlying health conditions should be eligible by July or August - which means, even as an educator, I probably won't be getting mine until the autumn! But while I'm keen to get it done soon most Japanese are very cautious as the survey data below shows.

(Average data from three surveys: Yomiuri, Dec, Mynavi, Dec, and akippa, Feb)

The degree of scepticism hit home in a recent conversation with my dentist, a well-educated English-speaker who trained in the US. She bemoaned the fact that as a health professional she would probably have no choice but to be vaccinated despite her worries over safety and potential side-effects. The akippa survey echoed these sentiments, finding 82% of Japanese were worried about side-effects while 71% were worried about safety. Thus, while there are few true ideological anti-vaxxers in Japan, like those libertarians in the US or France, there are real doubts about the vaccine and a strong "wait-and-see" (yōsu o miru =様子を見る) attitude, making Japanese some of the biggest COVID-19 vaccine sceptics in the world.

IPSOS Global Attutudes survey, January (available here)

The global data shows that Japan is ranked low in terms of willingness to be inoculated and even lower (2nd from bottom) in terms of enthusiasm and trust in the effectivity and safety of the vaccine. "The Japanese," IPSOS summarises, "seem to be the most hesitant to be vaccinated." These attitudes pre-date COVID-19; an article in the medical journal The Lancet last year based on 2015 research found Japan to have the second lowest vaccine confidence in the world - just above Mongolia. So why the scepticism? There are a number of reasons. One is what the Washington Post calls a "history of vaccine mistrust" caused by a series of vaccine scares in the post-war period. The second is a national character that leans towards risk avoidance. And the third is a belief in Japanese uniqueness. A final overarching factor may be a growing distrust of government: while in the past Japanese have typically put a lot of trust in their government recent years have shown a growing intolerance for mistakes and obfuscation (think Fukushima).

First, many older Japanese remember the Preventive Vaccine Law (PVL) of 1947 which made vaccinations mandatory (until 1994); refusers were actually fined until 1977! However, in the post-war period a number of incidents chipped away at people's trust in the public health system, including the 1980s HIV-tainted blood scandal (which saw some officials, executives, and doctors charged with manslaughter). Then, in 1993, the measles, mumps, and rubella (MMR) vaccine was withdrawn after only 4 years after reports of a few adverse reactions were highlighted in the media (recent years have seen a rubella resurgence here). A more recent example of the sensitivity of the Japanese vaccine side-effects came when the government stopped recommending the human papillomavirus (HPV) vaccine in 2013 after stories of severe headaches and seizures. These cases illustrate the hyper-sensitivity of the government to public opinion on the matter of vaccines regardless of the scientific data (MMR and HPV are seen as safe and effective by WHO and almost all other countries, including the UK).

Source: Hofstede Insights (available here)

The second reason explaining why Japanese might distrust vaccines relates to a tendency to minimise risk whenever possible. Geert Hofstede, the Dutch social psychologist who devised a framework for classifying national cultures, found Japan to be "one of the most uncertainty avoiding countries on earth." He pointed to the fact that Japan is constantly threatened by natural disasters, like earthquakes, as one explanation for its emphasis on planning and preparation for the future. In terms of vaccine anxiety, Yongue highlights risk avoidance as a key factor in vaccine regulation. "This can be illustrated by two policy choices," she argues, "approval of fewer vaccines than in other developed nations and extreme caution vis-a-vis the introduction of combination vaccines." Of course, citing "national character" can also be a convenient excuse to protect local companies from foreign competition. In fact, the idea of Japanese as particularly risk adverse seems odd given that Japan is the 3rd largest gambling market in the world and also suffers the third biggest losses - this despite gambling, aside from a few exceptions, being illegal since 1907!

The third and final factor contributing to the low level of confidence towards vaccines in Japan relates to an ideology that sees the Japanese as unique, a homogeneous people (tan'itsu minzoku) who constitute a racially unified nation (tan'itsu minzoku kokka). This has led to various claims that Japanese are physically different from others: a case in point came in 1987 when agriculture minister Tsutomu Hata  claimed that Japanese are more suited to eating grains than meat because their intestines are longer than those of Westerners! In the field of vaccines, this belief manifests itself in a strong reluctance by Japanese regulators to accept foreign data, meaning that companies are required to conduct new trials in Japan, a barrier which can be prohibitively expensive for foreign drug companies (Yongue 2017:228). The concerns are not entirely unjustified. In 2003, a rheumatoid arthritis drug, leflunomide, was approved without conducting late-stage trials in Japan; later a number of patients died from pneumonia, something which had not been seen in the West. In the case of the COVID-19 vaccines, even though drug trials contained some 5% Asian participants, the perception that Japanese in Japan are somehow "different" from "foreigners" undoubtedly contributes to the feelings of mistrust among the general public (only 160 participated in the Japanese trial for the Pfizer vaccine which is the only one to date which has been approved).

So what is the government doing to recover trust in the safety of the covid-19 vaccine? One thing it is doing is conducting a detailed survey of 20,000 health-care workers who were the first to receive the vaccine: data from the survey will apparently be made public weekly. The government's secret weapon, though, is an anime-like dog character called Corowa-kun (mixing "corona" and "vaccine" the latter which is pronounced wakuchin in Japanese, reflecting the German influence of many medical terms in Japan). The chatbot is available on the Line app where a panel of doctors answer users' questions and dispel any doubts they may have. Will this be enough to convince a nation of sceptics - and perhaps save the Olympics? I have my doubts.

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