2021.3.23
I’m writing this column on March 23. After eight more days, I will be leaving my post as the chief administrator of Matsuzawa Hospital.
The government has now decided to lift the second Emergency Declaration, apparently based on the rather negative assumption that even if they were to extend it, citizens would merely ignore it. In Miyagi Prefecture, the infection rate spiked almost instantly after the GO TO ticket sales were restarted on February 23, forcing the prefectural government to halt sales of the restaurant vouchers and the governor into declaring an emergency for a second time. I hardly have any words to describe the utter idiocy of this charade. The profound economic impact on restaurants and other attendant economic fallout has broadened. People in this industry are earning less income, and small business owners are finding it difficult to carry on with their work. The profundity of the economic problems can hardly be denied. Yet the findings of a household survey released on February 5 by the Ministry of Internal Affairs indicated that the savings of households of two or more persons grew more in 2020 than in any year since the turn of the century. This shows, in my opinion, the foolhardiness of the government’s slipshod policy of disbursing 100 thousand yen to each person in a household by way of economic aid. This policy means only 100 to 200 thousand yen in aid reaches single individuals, single-parent households, elderly residents, and other low-income earners who are in the direst need of financial assistance. For a poor family living a year or longer under restrictions, 100 thousand yen is no more than an empty gesture. On the other hand, more prosperous households tend to have more members eligible to receive this aid, thus leading to increased savings. In other words, full-time employees of large corporations and civil servants who have the least need for the 100 thousand yen check have nonetheless received this amount times the number of eligible family members in what amounts to a special bonus.
Moreover, it would seem that the facile policy that gave birth to the GO TO Travel campaign, which aimed to help the ailing travel industry, and the GO TO Eat campaign, which aimed to do the same for the restaurant industry, succeeded only in destroying what measure of control we had over the spread of the pandemic and ended in making matters worse for those it was most intended to help. The economic problems faced by low-income households that have now blanketed our society might more rightly be called a political and administrative crisis rather than the ‘COVID crisis.’
In the past year, Matsuzawa Hospital has received more than 200 patients with COVID-19 and conducted more than 1000 PCR tests for emergency psychiatric patients with symptoms thought to be related to COVID-19, such as fever or symptoms of a cold.
In the course of this year, a number of issues related to our government’s medical care and psychiatric care policies have become clear to me. The first of these is the lack of consideration given to social factors that heightened the susceptibility of the elderly population to infection. According to the March 20 edition of the Nikkei Shimbun, 1131 of the 5491 clusters detected to date were at elderly care facilities. The data on infections between January and March 15 following the issuance of the second Emergency Declaration also demonstrated that the highest proportion of clusters (32.2%) occurred at elderly care facilities, followed by healthcare facilities at 20.5%. Of the patients who were admitted to Matsuzawa Hospital after receiving testing positive for COVID-19, the male patients ranged in age from 21 to 96 years, with an average age of 66 years and the median age of 67 years while the female patients ranged in age from 20 to 102 years, with an average age of 70 years and a median age of 73 years. If you leave out all the patients who became infected while visiting the clubs and bars in the red-light district, the remaining patients will all be found to be elderly patients who contracted the disease via cluster infection during hospitalization in a psychiatric hospital or at housing or care facilities provided for them. In addition, there were patients who were infected by other family members while receiving nursing care at home. Incidentally, many of the patients who contracted the disease via cluster infections during hospitalization in a psychiatric hospital were elderly individuals already in the chronic stages of their disease who did not engage in any high-risk behavior. The closed wards and elderly care facilities within the psychiatric department restrict the movement of the inmates regardless of their wishes, confining them within very small spaces. Likewise, in the Day Service for patients with dementia, elderly individuals are assembled willy-nilly into a designated area and forced to come into contact with other individuals not from their family. Many people may find words like “confinement” and “forced” to be repulsive, and that is indeed how the situation is bound to appear from the point-of-view of these elderly patients. In other words, the system which our society built in the belief that it would serve as an integral part of the social welfare system has had the effect of assembling individuals who were already highly vulnerable to infection due to advanced age, thus increasing their risk of infection even further. Aside from biological factors like advanced age and underlying illnesses, we were unprepared for risk factors created by society, in other words, societal factors, which have increased the risk of infection.
If people’s freedom is to be restricted on the pretext of medical or welfare concerns, it is only natural that due attention be paid to protecting those who must suffer this abridgement of their freedom from becoming infected. Since April of last year, we at Matsuzawa Hospital have worked assiduously to prevent infections under the mottos, “If infected, don’t infect” and “Nip super-spreaders in the bud!” Fortunately, as a result, we have had no cases of in-hospital infection to date, but as we approach the end of the old year and the beginning of the new, when the influx of patients and visitors is at its highest, we plan to continue exercising the utmost vigilance to keep our hospital virus-free.
The second issue has to do with the vulnerability of the psychiatric care system. I can’t really say how clusters of infections have been managed at senior citizens’ residence facilities because I have no data on this. But based solely on my experience at Matsuzawa Hospital, I can say that the clusters of infected individuals at these residences have been rather smaller than those seen at certain hospitals, and we have not experienced any serious issues with either admitting infected patients into our hospital for treatment or in discharging them after recovery. Nonetheless, this rosy picture might apply only to medical resource-rich areas like Tokyo. Furthermore, the infection clusters that do crop up in psychiatric hospitals appear broadly to polarize into two extremes. Hospitals with adequate medical staff, including physicians and nurses, that engage proactively in administering acute care medicine tend to deal with outbreaks relatively smoothly and bring them under control swiftly. On the other hand, facilities that chiefly provide long-term patient care appear to struggle with controlling outbreaks when they occur in their chronic disease ward and with stemming new infections. Since June of last year, Matsuzawa Hospital has been at the forefront of assisting other facilities struggling with outbreak control by dispatching to their aid internal medicine specialists, psychiatrists, nurse epidemiologists, and Matsuzawa Hospital’s own COVID-19 team consisting of psychiatric social workers, by scheduling patient admissions with the staff at the receiving hospital, and by establishing infection prevention measures, such as zoning, to the extent possible in each case. Following the first dispatch of our COVID-19 team, the coordinating committee of the public health centers and metropolitan government suggested that the situation might have been resolved more efficiently if we had not intervened. However, we take the opposite view; because we sent help when it was most needed with a clear understanding of the situation at each receiving institution, we made the most effective use possible of the response capabilities of Matsuzawa Hospitals and other centers in the Tokyo Metropolitan Hospital System. In fact, of late, the metropolitan government has begun asking us to send our COVID-19 team to other centers, and even some private facilities have asked us to advise on their infection prevention measures with a view to preventing mass outbreaks. We are delighted to answer these requests; indeed, serving in this way is a fulfillment of our mission as public servants.
The hospitals to which we sent our COVID-19 team after they experienced an explosive surge in infections had previously received the assistance of local health care centers, the city’s mental health and welfare services, and the Ministry’s own COVID-19 team, but the results of these interventions were not always good. One can imagine why; these government organizations either had no clue as to the situation in private psychiatric facilities or were aware of it but chose to ignore reality, focusing instead on offering advice on what these centers should do to achieve a preconceived, ideal state. As a result, they were unable to help with stopping the spread of infections. Psychiatric hospitals operate according to a special restriction under the Medical Care Act which allocates fewer physicians and nurses to their staff than ordinary wards. For example, in a psychiatric hospital where the majority of patients are long-term inmates with a chronic condition, the allocation of 1.25 physicians and 15 nurses to every 60 patients is considered satisfactory. But three of the nurses may be nursing assistants, and if 40% of the remaining 12 nurses are able to perform the entire range of medical care functions required of a registered nurse, according to the logic of this special exemption, only five such nurses need actually be employed. The figure I have given of 1.25 physicians includes on-duty staff, so the number of physicians during the day shift is probably a little less than one. Under these circumstances, if a physician falls ill or is found to have come into close contact with infected individuals, that ward suddenly finds itself without any physicians. If the physician from the next ward is asked to cover for the absentee, he or she is suddenly put in charge of 120 beds. The same applies to the nurses; if two nurses fall ill after having sat at lunch with the three others, the latter must be relieved of their duties as well for having come into close contact with their infected colleagues. All of a sudden, all nursing duties come to a screeching halt in a ward with 60 beds. In the midst of this mayhem, the government comes stepping in with by-the-book advice on how to better the situation, but their efforts are feckless because the hospital simply does not have the resources to respond. As a result, staff with inadequate medical knowledge and skills are brought in to perform the duties but succeed only in perpetuating this vicious cycle of infections. The special exemption which I spoke of earlier provides for the bare minimum number of physicians and nurses even in normal circumstances; thus, if there is an outbreak of infections among the staff, the entire medical care system falls apart in no time at all. This is not the fault of the individual psychiatric centers; rather, the blame for ignoring these vulnerabilities should be laid directly on the government’s doorstep.
The third issue is the dysfunctionality of the management arm of various government bodies, including the bureaucracy at the Ministry, the metropolitan government, local health care centers, and what touches us most closely, Matsuzawa Hospital. This state of affairs is intimately bound up with the decay of politics over the past ten years in Japan, but because embarking on this topic will set us on an endless digression, I would like to reserve it for another day.
The day-to-day administrators and private contractors at Matsuzawa Hospital are clearly doing their level best in the collective battle against this pandemic, but to this day, I have had no sense of the hospital administration center at the metropolitan government headquarters or the higher-ups in the administrative arm of our hospital offering any support to us in our efforts to combat this pandemic.
On March 17, The Nikkei Shimbun announced that vaccinations were to be rolled out at Tokyo Metropolitan Matsuzawa Hospital, which was designated a high-priority anti-COVID-19 center. Yet as of March 22, we have no idea when the vaccine itself will become available. The hospital administration center at the metropolitan government headquarters early announced that they would not be involved in allocating the vaccine and that they had no desire whatsoever to do so. The Nikkei Shimbun article ended with a statement from the metropolitan government: “The order in which the vaccine is allocated will be decided after taking into account a comprehensive range of factors, including whether the hospital is a primary care center, how many COVID-19 patients are currently hospitalized, and other figures. Metropolitan hospitals will not be prioritized.” This off-hand comment had the effect not only of lowering the morale of the employees of the metropolitan and other public health services, but also indirectly proves how out-of-touch bureaucrats are with the actual demands of managing a facility like a hospital.
One day last week, I thought I detected a slight, fuzzy outgrowth on the branches of the beeches jaggedly piercing the clear blue sky. The next day, the tips of the branches had already begun to take on a yellowish green hue. Spring had arrived. I can now see the beeches with their sprouting leaves like some landscape by Corot. In a few more days, the dark brown limbs will be clothed in fresh green raiment, and the thickening foliage will no longer permit glimpses of blue sky between the branches. I used to enjoy gazing on the beeches as they changed daily in springtime from my window in the director’s office. This spring, however, is the last time I will have this privilege, and the curtains will fall on the Director’s Column as well. I thank everyone for this opportunity to serve you. It has been a joyous nine years indeed.