Fear and anxiety over the potentially life-threatening COVID-19 outbreak are ongoing, although the intensity of these waves of anxiety varies.

In April, when the number of infected people increased sharply as a result of factors such as the first cluster outbreak in Shiga Prefecture, anxious residents of the prefecture flooded the authorities with inquiries and requests. Some were so afraid of being infected themselves or that the people around them would be infected that there were even calls for the identification and isolation of patients. I was very frightened by this, because I felt that people would lose their compassion for others, causing strain in the social fabric, and that if this situation was not addressed, the foundations of our society would collapse. And I discussed these feelings honestly with the citizens of the prefecture.

Amid this crisis, what would a better type of regional and local government look like? The thing that I kept in mind above all was "responsive dialogue." The first thing I considered was grasping and analyzing the feelings, doubts, and requests of the citizens of the prefecture in order to enable us to respond to them. We read through each of the opinions we received in our program of “Letters to the Governor,” and exchanged opinions with the members of the prefectural assembly on a regular basis. We made use of the opinions of the citizens of the prefecture that we understood through this process in countermeasures. In addition, many parents were worried about how to balance the safety of children with opportunities for education. We therefore conducted a questionnaire survey of the children concerned, analyzed all of the approximately 32,000 responses received, and formulated new indicators for children’s activities and behavior, which we call "Smile/Action."

Against the background of the COVID-19 crisis, division of functions and cooperation between local governments is essential. The prefecture has been able to build a system of collaboration and cooperation between local governments to implement essential services for residents, while the prefecture is in charge of public health services that cannot be handled by smaller municipalities. The proposal of a variety of suggestions to the national government from the regions at the forefront of countermeasures against the virus through the National Governors' Association and the subsequent exchange of opinions led to the reform of national systems and the formulation of a supplementary budget. The making of proposals by the regions, which understand the actual conditions of their own area, and cooperation between regional administrations and the national government to formulate countermeasures, may be one effective method of transforming Japan’s social systems in the future.

Rather than seeing the COVID-19 crisis as a transient phenomenon, I would like to treat it as a lesson for the future and a turning point for social change. Through this experience, we are proposing to the citizens of our prefecture “the spirit we seek to cherish,” “the perspective we seek to cherish,” and “the attitude we seek to cherish.” The spirit that we seek to cherish is an altruistic spirit that is accompanied by self-reflection. The perspective that we seek to cherish refers to freedom and equality for all, diversity and sustainability. And the attitude that we seek to cherish is the guarantee of rights, responsive dialogue, and change through collaboration. Based on these, we are taking up the challenge of pursuing better local government and true democracy, aiming to realize a “healthy Shiga” in the true sense of the word.

Japan's Infectious Disease Control Act and health center system are very effective measures in responding to COVID-19. Even when the first hospital-borne infection in Japan was confirmed at Saiseikai Arida Hospital in Wakayama Prefecture in mid-February this year, it was early detection and early isolation, the bases of the Infectious Disease Control Act, that were considered most important in responding. In addition, the behavioral histories of infected patients were thoroughly investigated, and triage was conducted to prioritize tests from persons closely related to those patients, while the hospital also suspended acceptance of outpatients. This response was due to the importance of thinking rationally and implementing the fundamentals. However, Saiseikai Arida Hospital also went to extra lengths. At that time, we did not know what kind of illness it was, and the citizens of the prefecture were afraid. We therefore rejected the government’s stance of restricting the subjects of PCR tests, and conducted tests on 474 individuals who were suspected of having contact. In three weeks, the hospital was successfully cleared of COVID-19, and resumed all normal operations on March 4.

Thorough investigation of the behavior history of infected people is still important. It has been possible to adequately implement these checks because of the existence of the Japanese health center system. What is particularly essential in conducting investigations of behavior histories has been the “integrated networking” of health centers in the prefecture. As we have gradually learned, if health centers operate independently of each other, we cannot make our responses work. Health center in Wakayama City, a core city in the prefecture, was previously under the jurisdiction of the mayor, but with the mayor’s understanding, the prefecture now manages the health centers in an integrated fashion, enabling smooth implementation of early detection and isolation.

This series of responses was praised as the “Wakayama model,” but involved the exercise of the authority granted to the prefecture under the Infectious Disease Control Act. The prefecture is in a position to also take the initiative in implementing the measures stipulated by the amendment to the Act on Special Measures for Pandemic Influenza and New Infectious Diseases Preparedness and Response. Within the scope of the authority granted by the law, we have tested and improved a variety of measures, and we have attempted to incorporate good practices from other prefectures. Sometimes our position differs from the instructions of the national government, but if it is possible to explain the situation to the citizens of the prefecture after making a logical judgment, I think that one should then take responsible action within the scope of one’s authority as the governor. For example, Wakayama Prefecture did not follow the instruction from the national government for citizens not to visit a hospital for four days even if they showed symptoms that made them suspect a COVID-19 infection. The government has now withdrawn this instruction. The government has also, ultimately, displayed readiness to correct its responses in the right direction. The national and regional governments should not be in conflict, but should adopt roles that enable them to respond effectively in each area that we are dealing with. It is important for each to take responsibility independently.

Japanese people tend to think that Europe and the United States always provide the model, but Europe and the United States do not have the Infectious Disease Control Act and the functions of Japan’s health centers (early detection, early isolation, and thorough investigation of behavior history based on the Infectious Disease Control Act). Japan should make the most of these assets.

Amagasaki City is one of Hyogo Prefecture’s core cities, with a population of 450,000. The city is provided with health center under the jurisdiction of the city administration, and a research facility where PCR tests can be performed. Adjacent to Osaka City at the eastern end of Hyogo Prefecture, it is a city with a strong sense of unity with Osaka as an economic zone and living area. Because the city is in the closest contact with residents and is the entity at the forefront of administration, the way in which we should share information with residents represented an issue. The first problem we faced was the question of the degree to which privacy should be protected when dealing with information regarding infected patients. Residents had a need to obtain as much detailed information as possible, but if too much information was provided, the patient in question could be identified. In Amagasaki, we knew from the experience of other cities the harmful effects of providing too much information, and so we sought to disclose information in a comparatively controlled fashion while consulting with the health center. For example, we make announcements regarding the family members of infected patients by describing them as “living in the same household,” without identifying the precise family relationship.

While performing our duties, we frequently communicated with leaders of municipal administrations in the Hanshin area via SNS, sharing information and reviewing it with a sense of considerable urgency. It was useful to us to see the different aspects of the situation taking shape between different local governments as multiple leading figures in different administrations communicated together at the same time. After getting an idea of each other's thinking and the direction of our initiatives, we organized measures that would not be effective if implemented by only some local governments (such as requesting pachinko parlors to close) to be implemented across a wider area, while individual local governments made their own decisions on the implementation of unique measures tailored to their specific needs.

On the other hand, it was difficult for health centers to implement “horizontal” information sharing. Health centers are decentralized and strongly locally-focused organizations. For example, in the case of a person who was a resident of Amagasaki but worked in Osaka, while the individual’s family would be under the jurisdiction of a health center in Amagasaki, the individual’s workplace would be under the jurisdiction of a health center within Osaka. If we do not combine the two sets of information, it can be difficult to see the big picture, but this has been difficult at times due to the huge amount of work involved. In the future, following the construction of an integrated database on a national scale, which will involve the utilization of HER-SYS (a support system for the acquisition and management of information concerning patients infected with COVID-19, etc.), which represents the information platform for COVID-19 responses, the preparation of manuals for the operation of this database that balance the acquisition of information with the protection of privacy will enable us to prepare for the next epidemic and new infections.

Not restricted to the current COVID-19 situation, horizontal cooperation between leading officials, local governments and health centers that transcends prefectural borders will become increasingly important in the future. It is extremely difficult to establish, in advance, wide-area administrative mechanisms that are able to respond to all situations. It will therefore be important to determine how to acquire the ability to flexibly respond to unexpected situations.

The largest city in Fukui Prefecture by area, Ono City is a small municipality with a population of 32,000. It is located about an hour away from Fukui Station on a local line. The spread of COVID-19 necessitated completely different responses to conventional disaster and infectious disease countermeasures. Following our normal disaster responses, we have clear guidelines as to how to rescue, reconstruct and restore, but COVID-19 is a new virus, and we did not have information regarding the disease that would guide the formulation of measures. The only way for the city to respond was to implement measures one-by-one while confirming precisely which information was accurate based on the announcements of the national and prefectural governments and television and newspaper reports.

Because Ono City is remote from Tokyo, both the government and citizens initially felt that the spread of the infection was like a story from a distant world. However, the request from the national government at the end of February to close all elementary, junior high, and high schools nationwide triggered a change in our awareness. Realizing that the national government, which possessed the greatest amount of information about our viral enemy, had decided that uniform action must be taken nationwide, I also resolved to decide on our own measures. I told city employees that what we faced was an emergency situation, and that if they approached it using their normal ideas of work, we would be unable to respond. It was necessary to think of it as a disaster response, and to take action.

The first infection in Fukui Prefecture occurred in the middle of March, and several people were infected in Ono City in April. During this period, tensions increased day by day. As the idea that we might have to close certain facilities, or that Ono City staff might become infected or be involved in close-contact activities became increasingly realistic, we held meetings of our Novel Coronavirus Response Headquarters almost every day. Based on the reports coming from relevant departments and personnel and information from prefectural press conferences, every weekend I organized things to my own satisfaction and considered countermeasures for the next week, and shared these at the Countermeasures Headquarters meeting on Monday. In formulating measures, it was difficult for Ono City alone to provide all the necessary financial resources, and maximum use was therefore made of national and prefectural government measures and budgets. Ono City’s first supplementary budget was established in early May, and a budget incorporating measures unique to the city was established in mid-May. After this, we were able to prepare to make use of extraordinary grants from the national government.

Without knowing the true nature of the infectious disease that we were facing, we were compelled to make fumbling responses, questioning what was the correct information and what measures we should take on its basis, but we continued to seek the best measures, knowing that we had to make the correct responses in order to protect the citizens of Ono City. It was unavoidable that our responses would involve trial and error. I asked the administration’s staff to understand that our course of action was not set, and they worked their hardest. I believe that we will be able to put all of the worries and experiences that we have accumulated throughout this period to good use in the future.

Tottori Prefecture has the lowest population of any of Japan’s prefectures, and is home to a high proportion of elderly people. Due to insufficient medical resources, we feared that once the infection spread, it would become a catastrophic situation, and we therefore discussed how we should engage with COVID-19 from an early stage. Japan’s first positive case was discovered on January 16th. On that day, we set up a consultation desk for residents, and we held a liaison meeting five days later. Our basic strategies were “early detection by testing,” “prevention of hospital-borne infections”, and “thorough prevention of the spread of infection.” As a result of our urgent implementation of measures to respond to a desperate situation, as of March, Tottori Prefecture was the leader in Japan in terms of the number of beds secured per population.

Despite being a prefecture with limited medical resources, we were able to put a variety of measures in place in advance of the national government because we responded with a sense of urgency based on lessons learned from the speed with which new influenza infections we had experienced in the past had spread. The infectivity of these new strains of influenza had been extremely strong, and the pace with which the number of patients had increased had risen rapidly.

Initially, the prefecture's hospitals had only 12 beds available for countermeasures against COVID-19. Judging that it would not be possible to fight the disease with only these resources, I hurriedly decided to obtain the cooperation of the regional medical associations. Due to the small size of Tottori Prefecture’s community, face-to-face networks had been developed between prefectural administrators and medical personnel. However, the doctors and medical staff who were putting their lives on the line on the scene were very anxious due to a serious shortage of masks at medical institutions. We therefore provided as much support as possible, including providing all of the 220,000 masks stockpiled by the local government to the medical associations. The medical associations responded to this with gratitude, and in a short period of time, we were able to increase the number of beds to 300. It is a result of this relationship of trust that more than 80% of clinics in Tottori Prefecture cooperate with the Medical Care and Testing Facilities, of which there is a shortage nationwide.

Given that we have 47 prefectures, we will have 47 strategies. The conditions for measures to respond to COVID-19, such as the status of spread of the infection, the medical resources that have been secured, and the degree of understanding and cooperation of the residents, vary widely from region to region, and each region has its respective solutions. Simply following guidelines from the national government will not get the job done; we should emphasize approaches that are guided by the situation on the ground. Initially, despite the fact that the responsible prefectural personnel thought that certain measures should be implemented, things did not always proceed as planned due to the restrictions of government laws, but the government’s response gradually became more flexible, and overall, communication between national and regional governments functioned effectively; in most regions, responses were adopted that were suited to the specific circumstances of that region. If the relationship of trust that has been created between regional and national governments in this crisis can be further developed, it has the potential to significantly change the nature of administration in this country.

The wide variety of attempts being made to halt the spread of COVID-19 may also represent the trigger for significant changes in the relationship between Japan’s central and regional governments, and between regional and local governments themselves.

Needless to say, in order to determine the actual nature of an unknown virus and prevent its spread, it is necessary to mobilize all the knowledge of relevant experts and put measures in place on a national scale. In addition, the establishment of laws and the organization of financial programs are essential to the implementation of the measures, and these are also primarily the role of the national government. Provision of the necessary support to individuals infected with the disease, in addition to people and companies that have suffered financial hardship, must also be national government-led initiatives.

At the same time, it is not always necessary to adopt uniform measures in a country as large as Japan. It is the role of regional and local governments to implement targeted measures that take into consideration the specific situation in their specific region. Depending on the situation, they may have no choice but to make different decisions to the national government. And given that regional and local governments are closer to the residents of their areas, it is also their role to respond to the diverse opinions of those residents and put the necessary measures in place.

These issues were apparent even before the spread of COVID-19, but they have surely come to be felt as increasingly urgent since the appearance of concrete COVID-related problems and the need to respond to them. It would be of great significance at this time to collate information regarding the unique countermeasures implemented by each of Japan’s regional and local governments, and mutually share the knowledge that they have acquired in doing so. For this issue of My Vision, we therefore interviewed the leaders of five local and regional administrations, and discussed the difficulties faced by these administrations during the COVID-19 pandemic and the ideal relationship that should exist between the national and regional/local governments and between regional and local governments themselves in responding to such a situation.

It is symbolic of our theme that the Governor of Shiga Prefecture, Taizo Mikazuki, has been concerned above all else with what he terms “responsive dialogue.” In every part of Japan, there are cases in which fear of this new and unknown virus has increased calls for the identification and isolation of patients. If this situation were to escalate, not only would it invite human rights violations, but it could potentially lead to the collapse of the foundations of society. The individual analysis of the opinions expressed in the deluge of “Letters to the Governor” received in Shiga Prefecture, and their reflection in policy decisions, is perhaps a contribution to the response to our situation which could only be offered by using the characteristics of regional and local governments. It is important that we take note of Governor Mikazuki’s assertion that Shiga Prefecture has emphasized the freedom and equality of its citizens and the values of diversity and sustainability, and in these respects has also not forgotten its foreign residents.

The case of Wakayama Prefecture is also important. When the first hospital-borne infection in Japan occurred in the prefecture, prefectural authorities developed their own model, rather than following the national government’s recommendation of restricting the subjects of PCR tests. Prefectural Governor Yoshinobu Nisaka tells us that the decision to conduct tests on everyone suspected of possibly being infected, complete isolation through hospitalization, and the thorough analysis of the behavior history of infected patients allowed the spread of the infection to be prevented at an early stage. At that time, the “integrated network” of health centers within the prefecture proved to be highly effective, and this provides valuable information for future pandemic responses. Governor Nisaka’s words “[…] having made a logical judgment, I think that one should take responsible action […]” have a powerful impact.

What about Japan’s cities, towns and villages? Kazumi Inamura, Mayor of Amagasaki City, which is located at the eastern end of Hyogo Prefecture and has strong ties with Osaka as an economic zone and a living area, points out that information exchange with the leaders of neighboring local governments in the Hanshin region has been important. While measures that will have limited impact if implemented only by some local governments have been rolled out over a wide area, it is also noteworthy that various local governments have decided to put in place measures that are specific to their own situations. Mayor Inamura’s indication that if people’s residences and workplaces are located across prefectures, the difficulty of sharing information between health centers in different jurisdictions necessitates the creation of a nationwide integrated database, provides us with much food for thought.

The case of Ono City, located about one hour from Fukui Station on a local line, which is the largest city in Fukui Prefecture by area, but a small city with a population of only 32,000, is also important. Shiho Ishiyama, Mayor of the city, tells us of the unique difficulties generated by the fact that they did not have information regarding the disease that would guide the formulation of measures. For the residents and the administration of Ono City, the national government’s request for the nationwide closure of elementary, junior high and high schools triggered a change in awareness regarding COVID-19. As indicated by Ms. Ishiyamas statement that the city “[made] maximum use […] of national and prefectural government measures and budgets,” it is important for small municipalities like Ono City to seek out measures that are unique to their own region while also effectively utilizing the support of the national and prefectural governments.

Shinji Hirai, the Governor of Tottori Prefecture, tells us that “Given that we have 47 prefectures, we will have 47 strategies.” If we add municipalities to the list, the number will become even higher. Tottori Prefecture has the lowest population of any of the nation’s prefectures, and also has a high proportion of elderly residents. If the virus had spread against a background of inadequate medical resources, the situation could have become catastrophic. This sense of crisis saw the prefecture work to introduce measures that would halt the spread of the virus in advance of the national government. Because the number of beds for COVID-19 patients was low, the administration enlisted the aid of the prefecture’s medical associations, and donated them the supply of masks that it had collected. Governor Hirai points out that national laws initially constrained approaches based on the situation on the ground, but that a relationship of trust eventually developed between the regional and national administrations, a fact which we find to be of considerable interest.

How can we maximize the ability of each of the nation’s regions to search for solutions and flexibly formulate responses, having secured the support of the national government? And will we create a nationwide database to share the knowledge that is obtained from these processes? It is my hope that the formulation of measures to respond to COVID-19 will allow us to develop the relationship between national and regional administrations and between regional and local administrations themselves.