The effects of pandemic are global, and it tends to most significantly target the vulnerable in each society. Japan is not an exception. We need to ensure to protect those who are most at risk. In order to do so, we first need to identify the issues. These issues may be those that feel more comfortable ignoring and “burying your head in the sand”. Social determinants of health are not necessarily transparent in Japanese culture and infrequently reported.
In this article, unseen or untold gender inequality, an issue Japan has long faced, has been hypothesized as a factor in higher suicidal rates among women during the pandemic. Dr. Sakamoto and her colleague share deep insight from what they had originally published in the paper
The novel coronavirus (COVID-19) pandemic, which started at the end of 2019, has been responsible for 219 million infections worldwide and 4.55 million deaths as of October 5, 2021.1 In Japan, 1.71 million people have been infected and 17,700 lives have been lost.2 The various measures adopted to control this infection, such as social(physical) distancing, refraining from travel and going out with friends and family, and postponing or canceling school events, have also had a tremendous impact on socio-economic activities. This new version of daily life – one that forces people to avoid contact with others as much as possible, combined with a worsening economic situation and prolonged social unrest – is placing a significant burden on mental health.
Mental health and suicide have long been major societal problems in Japan, with 20,000 to 25,000 people dying by suicide every year in the 1980s.3 The economic crisis, epitomized by the Asian financial crisis in 1998 and the subsequent bursting of the bubble economy, spurred a sharp increase in the number of suicides through the early 2000s. At one point, the number of suicides exceeded 34,000 per year. The impact was particularly large among middle-aged and older males. However, in response to this situation, the national and local governments implemented various countermeasures, including the adoption of the Basic Law on Suicide Prevention in 2006. The number of suicides has been on a downward trend year by year ever since.
The annual number of suicides, which had been consistently decreasing in recent years, began to increase again in 2020. The impact was particularly significant in October and November among the younger generation of men and for all generations of women.4 Suicides have traditionally been more common among middle-aged and older men, but the uptick during the previous year revealed that suicides are increasing overwhelmingly among women and Japanese youth. It should also be noted that the number of suicides among children increased as well: in 2020. The number of suicides increased by eight among elementary school students, 40 among junior high school students, and 92 among high school students compared to the previous year, for a total of 479 suicides.5 This comprises highest number of child suicides since statistics were initially collected in 1978. Although it is difficult to verify a significant difference in the number of suicides among children due to the small number of incidents, the fact that the largest number of children have died since statistics have been collected should be taken seriously.
So why was the increase in suicide more pronounced among women? There are many hypothesis for the rise in female suicide, but one possible contributor is gender inequality in Japan. Japan has been lagging behind in gender equality, ranking 120th out of 156 countries in the Gender Gap Index 2021. COVID-19 has put women in even more vulnerable position for several reasons:
1) exacerbation of inequitable employment conditions,
2) impoverishment of single-parent households,
3) increase in domestic work, and
4) increase in domestic violence.
First, even before COVID-19, the unstable employment situation of women in Japan had been regarded as a major societal problem. For example, in Japan, about 80% of male employees are full-time workers while more than half of female employees are employed on a part-time basis.6 By industry, 58% of employees in the tourism, restaurant, and service industries and 38% of employees in the daily service and entertainment industries are female part-time workers.6,7 In April 2020, when the first state of emergency was declared in Japan, the workforce diminished significantly, but the extent of the decline varied greatly by gender. The number of male workers decreased by 390,000, while female workers decreased by nearly double that number — 700,000. Many of the people who lost their jobs during the crisis were women, especially those in non-regular employment. The inequitable working landscape between men and women became even more pronounced during the pandemic.
Next, we need to look at single-parent households. The total number of single-parent households has been increasing every year. While the number of father-child households has remained unchanged, the number of mother-child households has increased markedly. For example, in 1988, there were 1,022,000 single-parent households, of which 849,000 (83%) were mother-child households, and 173,000 were father-child households. In 2016, the total number of single-parent households had increased to 1,419,000, but the number of father-child households had not increased significantly (187,000), while the number of mother-child households considerably increased to 1,322,000 (93%).8 The employment inequalities for single mother is to be even more serious than non-single mothers, with 52.3% of single-mother households being employed as part-time workers.9 It is not hard to imagine that these households have been severely affected by COVID-19: 60.8% of single parents say they have financial difficulty in daily life, and more than half say they cannot afford to buy the food they need. The change in unemployment rates is also notable, with a 3 percentage-point increase in the unemployment rate for single mothers in 2020, compared to no change in the rate for married couples.
The impact of COVID-19 was not equal across the job market. Not all industries and sectors were hit uniformly; instead, the food and beverage sector as well as the tourism industry were hit the hardest. These industries have mainly been supported by part-time female employment; many women, especially single mothers, were in part-time employment, and that those part-time women were the first to lose their jobs during the pandemic. As a result, it can be said that women, especially single mothers, were forced into a more precarious financial situation.
Next, we will look at the increase in domestic work. Domestic work mainly includes the burden of housework and childcare as well as care for older adults. COVID-19 increased the burden of childcare and education at home due to the closure of nursery schools and kindergartens. It also caused an increase in the burden of nursing care in the home due to the closure of care facilities (especially day services and short stays). And most of those burdens are disproportionally placed on women. For example, there was an increase in women’s non-labor force participation rate in households with children (there was no change for men), suggesting that the increased burden of childcare at home is forcing women to give up their jobs. 7,10
Finally, domestic violence (DV) merits attention when considering new trends in suicidality. Domestic violence is on the rise worldwide due to the increased time spent in the home as a result of COVID-19, increased stress caused by economic insecurity, and increased alcohol consumption. The same trend can be seen in Japan, with the number of domestic violence consultations with public institutions increasing to 190,030 in 2020, about 1.6 times higher than the previous year.7 In addition, the number of consultations at the One-Stop Support Center for Victims of Sexual Offenses and Sexual Violence was 51,141 in 2020, also an increase of about 1.2 times over the previous year7. This increase in domestic violence certainly impacts mental health among women and may well be a factor in the increase in female suicides.
Infectious diseases have a tendency to target the most vulnerable members of society. While COVID-19 has also caused significant damage to society as a whole, the distribution of the damage is not necessarily homogenous. In Japan, COVID-19 has aggravated existing issues in gender inequality, especially the unstable employment situation among women and the unequal burden of housework, childcare, and nursing care imposed on women. As a result, the mental health of women has suffered and quite possibly led to a disproportionate increase in the number of suicides among women. Basic countermeasures against infectious diseases are important, but if we are to truly overcome the long-lasting effects of COVID-19, special consideration must also be given to the most vulnerable members of society. Furthermore, we hope that COVID-19 will serve as an opportunity to pinpoint and overcome the various problems that have existed in Japan since long before COVID-19, and that Japan will seize this chance to transform itself into a better society.
- Our world in data. https://ourworldindata.org/coronavirus-data
- 新型コロナウイルス感染症（国内の発生状況について）. 厚生労働省. https://www.mhlw.go.jp/stf/covid-19/kokunainohasseijoukyou.html
- 人口動態統計. 厚生労働省. https://www.mhlw.go.jp/stf/seisakunitsuite/bunya/hukushi_kaigo/seikatsuhogo/jisatsu/jinkoudoutai-jisatsusyasu.html
- Sakamoto, Haruka, et al. “Assessment of suicide in Japan during the COVID-19 pandemic vs previous years.” JAMA network open4.2 (2021): e2037378-e2037378.
- 児童生徒の自殺数に関する基礎資料集. 文部科学省. https://www.mext.go.jp/content/20210216-mxt_jidou01-000012837_009.pdf
- 労働力調査. 総務省. https://www.stat.go.jp/data/roudou/index.html
- 男女共同参画白書 令和３年版. https://www.gender.go.jp/about_danjo/whitepaper/r03/zentai/index.html
- 全国ひとり親世帯等調査. 厚生労働省. https://www.mhlw.go.jp/stf/seisakunitsuite/bunya/0000188147.html
- 労働政策研究・研修機構. 新型コロナウイルス感染症のひとり親家庭への影響に関する緊急調査
- 男女共同参画の視点からの新型コロナウイルス感染症拡大の影響等に関する調査報告書. 内閣府. https://www.gender.go.jp/research/kenkyu/covid19_r02.html
About the authors
Dr. Haruka SAKAMOTO, MD MPH, is a primary care physician and assistant professor at the Department of Health Policy and Management, Keio University. From 2011-2013 and 2016, she worked at the international cooperation department, Ministry of Health, Labour and Welfare of Japan, where she was deeply involved in health policy activities in Japan. She’s also currently working at the Department of Global Health Policy, the University of Tokyo as a project researcher, and World Health Organization Western as a consultant.
Mr. Cyrus Ghaznavi is an M.D. candidate at Washington University School of Medicine in St.Louis and visiting researcher at the Keio University School of Medicine Department of Health Policy and Management. His research interests include infectious diseases, sexual activity, and relationship formation, fertility, and social phenomena during pandemics.
Dr. Masahiro Ishikane is an Infectious disease specialist at the Disease Control and Prevention Center National Center for Global Health and Medicine Hospital, Tokyo, Japan. He works as focal points of WHO Collaborating Centre for Prevention, Preparedness and Response to Emerging Infectious Diseases since 2017 and WHO Collaborating Center for Prevention, Preparedness and Response to Antimicrobial Resistance since 2021.
Dr. Peter Ueda is an Assistant Professor at Karolinska Institutet, Sweden and a Visiting Researcher at the University of Tokyo, Japan. His research interests include a broad range of topics related to public health and clinical medicine.