The influence of superstitions in epidemics in Japan

Introduction
There are many superstitions in the world based on religion, old story, legend, fortune telling,
and personal experience. Such superstitions influence people’s behaviour in various social
situations. In medicine, studies have been reported on Friday the 13th, the eight month fetus,
and others. In Japan, Kaku reported that the superstition called Hinoe-Uma caused a
significant increase in the induced abortion rate and a sharp decrease in the birthrate in 1966.
Belief in Taian-Butsumetsu, a superstition relating to the six day lunar calendar, is common
among Japanese people and affects various social events in everyday life. For example,
people tend to have wedding ceremonies on Taian (a lucky day), avoiding Butsumetsu. The
figure shows the six day cycle of the lunar calendar (Sensho, Tomobiki, Senpu, Butsumetsu,
Taian, and Shakku) related to the solar (Gregorian) calendar system, which was adopted in
Japan in 1873. Despite this change Taian-Butsumetsu continued to gain popularity.
Patients often express the wish to leave hospital on a Taian day by extending, not shortening,
their stay. However, if doctors allow patients who do not need to be in hospital to extend their
stay they cause an unnecessary rise in the cost of medical care. To show the effects of this
behaviour we calculated the mean number of patients discharged on each day of the six day
cycle and estimated the costs of any extended hospital stays.
Background of the Study

The Japanese are unusually superstitious. To begin with, it is rare in which country you can
observe such a crowd of locals crowded in temples. However, this has a very indirect relation
to religion, rather, it’s just about all sorts of signs and plain rituals that can be quickly
performed by jumping into the nearest sanctuary on the way home or just walking. Pupils,
students, office workers, housewives, retirees - they all shake their predictive drums; amulets
of all kinds are buying; clap their hands, attracting the attention of the gods to their
person; bells are shaking; plunge headlong into aromatic incense ... but you never know the
means to communicate with higher powers!

Important events in life, such as: the birth of a child, a wedding, opening a business, building
a new house, promotion are noted in detail, ordering special services in Shinto shrines. The
departure to the other world occurs with the help of Buddhist rites. In the rest of the time, the
people communicate with the gods, as with good friends: drop by for a couple of minutes, ask
- how are you, tell about yours; give a small gift in the form of a few coins and ask for
protection for the next couple of days.

Discussion

Historically, numerous cultures globally have held certain superstitious beliefs about diseases. In
most of the cases, the superstitions have had some influence on the outcomes of the disease
outbreak. Even in the modern age, it is still possible to find that some cultures still have beliefs that
would affect how they manage disease outbreaks. However, the main focus for this case will be
premodern Japan and the superstitions and beliefs that the Japanese people held during the measles
and smallpox outbreaks. Premodern Japan found it considerably challenging to manage epidemics.
There were several epidemics that ravaged the nation and affected numerous people. At the time,
the Japanese people had certain beliefs about disease, which influenced how they viewed the ideas
outbreaks (Rotermund, 2001). It is probable that these superstitious beliefs had a positive and
negative influence on the management of the outbreaks. The proposal for the research is to
investigate how the cultural and superstitious beliefs influenced the management of measles and
smallpox outbreaks in premodern Japan.

Social and cultural factors such as religion and superstition influence change in a society and its
members. Superstition is one of the main factors that influences how members of society think
about and perceive certain issues in society. It refers to the beliefs about certain events, which
cannot be accounted for through scientific logic. It also refers to the beliefs or actions that a certain
group of people might hold that are usually described by unnatural elements (Hoseini et al., 2020).
Because of this, science does not agree with the issues raised by superstitious beliefs. Similarly,
people who have superstitious beliefs might not also believe in the principles presented by
scientists. Such a case was observed in premodern Japan during the measles and smallpox
outbreaks. The Japanese had strong superstitious beliefs that about diseases, which influenced how
they perceived modern medicine and science. They showed considerable resistance at first to
modern medicine owing to their beliefs, which affected their outcomes negatively. It is, therefore,
necessary to conduct research in order to determine how certain superstitious beliefs about
medicine can influence the outcomes of a society. At the same time, it is also necessary to
investigate the measures that can be taken in order to change these beliefs and to make the people
more receptive of modern medicine or scientific beliefs.

A considerable number of people still have superstitious beliefs about science and modern medicine.
Despite the advancement and the spread of modern science, a considerable number of people do
not accept the findings and the practices that are associated with it (Hoseini et al., 2020). This was a
common practice in the premodern world and it remains to be a considerable challenge in the
modern world, especially in developing countries. The case of Japan provides an ideal example of
how people can be affected by showing resistance to or by failing to accept modern medicinal
practices. Further, it shows how superstitious beliefs can affect people negatively, especially in the
event of a pandemic. From the case in Japan, one can also find the various approaches and methods
that the scientists at the time used in order to convince the people to adopt the practices presented
by then modern science. Although there was some resistance at first, the Japanese gradually
accepted the medical practices and they were able to see positive results from modern medicine.
This is especially important since it provides insight into the approaches that can be used to counter
superstitious beliefs in various communities in the modern age. The findings of this research can
contribute to the knowledge about the implications of superstitious diseases on the acceptance of
medicine as well as how to get people from superstitious communities to accept modern medicine.

Influence of Smallpox and Measles in Modern Japan

A few decades prior to the outbreak, Japanese court officials had adopted the Chinese policy of
reporting disease outbreaks among the general population. [1] This recording practice greatly
facilitated the identification of smallpox as the disease that afflicted Japan during the years 735–
737.
Increased contact between Japan and the Asian mainland had led to more frequent and serious
outbreaks of infectious diseases. The smallpox epidemic of 735-737 was recorded as having
taken hold around August 735[2] in the city of Dazaifu, Fukuoka in northern Kyushu, where the
infection had ostensibly been carried by a Japanese fisherman who had contracted the illness
after being stranded on the Korean peninsula.[3] The disease spread rapidly throughout northern
Kyushu that year, and persisted into the next. By 736, many land tenants in Kyushu were either
dying or forsaking their crops, leading to poor agricultural yields and ultimately famine. [4][5]
Also, in 736, a group of Japanese governmental officials passed through northern Kyushu while
the epidemic was intensifying. As members of the party sickened and died, the group gave up on
their intended mission to the Korean peninsula. Returning to the capital with smallpox, the
officials supposedly had spread the disease to eastern Japan and Nara.[6] The disease continued
to ravage Japan in 737. One manifestation of the pandemic's great impact was that by August of
737, a tax exemption had been extended to all of Japan. [7]
Based on fiscal reports, adult mortality for the smallpox epidemic of 735–737 has been estimated
at 25%-35% of Japan's entire population, with some areas experiencing much higher rates. [8] All
levels of society were affected. Many court nobles perished due to smallpox in 737, including all
four brothers of the politically powerful Fujiwara clan: Fujiwara no Muchimaro (680-737), Fujiwara
no Fusasaki (681-737), Fujiwara no Umakai (694-737), and Fujiwara no Maro (695-737). Their
sudden departure from the royal court allowed for the ascension of noted rival Tachibana no
Moroe to a high official position in the court of Emperor Shōmu.[7]
The epidemic not only killed a large segment of the population, it triggered significant dislocation,
migration, and imbalance of labor throughout Japan. Highly affected were construction and
farming, especially rice cultivation. [9]

While most Japanese believed that the smallpox deity controlled the disease, many
physicians trained in schools of Chinese medicine were aware that inoculation provided some
degree of resistance to smallpox. This method, which Chinese physicians had developed,
consisted of taking a small amount of material from a pustule on a person with an active case
and inserting it subcutaneously into an uninfected person (Leung 2011, 5–8). Although a full-
blown case of smallpox was possible, it frequently established life-long immunity. When
European physicians introduced the idea of inoculating individuals with cowpox, it found a
receptive audience in Japan. This technique consequently became established by the mid-
nineteenth century, eventually bringing the disease under control.
Measles, called hashika in modern Japanese, was more greatly feared than smallpox. An early
nineteenth century saying went, “Smallpox determines one’s appearance; measles determines
one’s life [Hōsō wa mime sadame; hashika wa inochi sadame].” This was especially true for
children under the age of five, among whom there was a case fatality rate of up to 25 percent.
Generally, physicians could do little for measles other than treat symptoms and make
recommendations regarding what foods to eat and avoid. Many people pasted images of
associated deities and talismans next to their doors as a mechanism of protection.
Traces of these narratives today are unusual, but a past “epidemic deity” (ekishin) (see Figure
1) has reappeared in the shadow of Covid-19. The deity, more accurately called a yōkai or
supernatural being, called amabie, was first recorded in 1846 as having appeared in the ocean
off the island of Kyushu. It reportedly told the official sent to investigate it that there would
be six years of bountiful harvests but there also would be epidemics, and that its picture
should be quickly drawn and shown to people, implying that doing so would prevent disease
from spreading. During the twentieth century, manga artists, including Mizuki Shigeru, drew
their own versions. The amabie has once again appeared, this time associated with preventing
the spread of Covid-19 (see Figure 2).
 Figure 1. Earliest amabie image, 1846, Kyoto University Library.

Effect of extended stay

For patients, an extended hospital stay does not necessarily constitute financial burden
because the public medical insurance system in Japan covers most of the costs. Even
extremely costly care is covered by public medical insurance system once the total cost
exceeds a certain level each month. This means that however much their care costs the
amount paid by patients is legally fixed at a low level and they do not see the true cost of
unnecessarily long hospital stays.
Doctors tend to be reluctant to refuse patients’ wishes to stay longer in hospital for fear of
ruining the doctor-patient relationship. Hospital management does not deter doctors from
meeting these patients’ wishes because of the financial incentives created by decreasing the
number of vacant beds. However, longer stays do increase the risk of patients contracting
nosocomial infections, which poses an ethical problem for doctors.
From the point of view of health policy unnecessary hospital stays have to be avoided to
reduce the national cost of medical care. If cost keeps rising the current insurance system will
have to be changed and rely more on private sector and out of pocket payments by patients.
Furthermore, unnecessarily long stays prevent other patients in real need from being admitted
to hospital promptly. The hospital stay in Japan is much longer than in Western countries
(mean hospital stay for somatic conditions in 1989: Japan 44.9 days, Austria 5.4 days, United
States 6.5 days, Canada 11.4 days13). Our data show that superstitious belief is likely to be
contributing, although in a minute portion, to this long hospital stay in Japan.
Modern medical care is based on a scientific tradition, but the health beliefs of patients may have a
very different basis. Belief in superstitions relating to the six day lunar calendar is common in Japan
and affects many social events. They found that most patients were discharged on Taian, said to be a
lucky day, and fewest were discharged on the unlucky day Butsumetsu. The authors conclude that
patients extend their stay in hospital so that they are discharged on Taian, and calculate that this
costs the hospital 7.4 million yen (£31 000) per year. However, they caution against outright
dismissal of such superstitions, warning that this may have a negative effect on some patients’
health.

Psychological effect of superstition

An action against superstitious belief could have a negative effect on the health of some
patients. In a study on the relation between superstition and health, Scanlon et al reported that
there were more hospital admissions as a result of traffic accidents on Friday the 13th (an
unlucky day in Western culture) than on other Fridays. Superstition may have a similar
influence on health as the placebo effect, in which patients’ health improves after a dummy
treatment because of their expectations or belief. Furthermore, if patients have a say in when
they are discharged from hospital, the “locus of control” is put in their hands to some extent,
which may add to the beneficial effect. Strong action against superstition, however, may
distress patients and lead to a deterioration in their health. In this context, doctors should pay
special attention to patients with somatisation (such as those with depression or anxiety
disorders). The relationship between Taian-Butsumetsu belief and health outcome is an
intriguing question for prospective study.
Influence of Covid-19 in Modern Japan
People in premodern times understood epidemics through everyday realities that are hard for
us to imagine. Before the rise of bacteriology in the nineteenth century, most people would
have found it hard to understand concepts such as bacteria, viruses, and other microbes. The
outbreak of Covid-19 in late 2019 is premised on the emergence of a novel virus—the
appearance of a pathogen with genetic material to which humans had never been exposed.
Understanding this fact assumes an understanding of microscopic pathogens that recreate
themselves inside the cells of the body, borrowing genetic material from the body to
reproduce. In the early nineteenth century, very few persons anywhere in the world
understood that the human body consists of cells; the concepts of microorganisms and genetic
material would have meant nothing at all (see McGrath and Arya and van der Valk, this
series, for examples of pre-modern Tibetan conceptions of epidemics and their agents).
 Figure 2. Japanese Government’s amabie poster Japanese Government’s amabie poster for
preventing Covid-19 in 2020, Japanese Ministry of Health, Labor, and Welfare.

Based on voices from the past and what science tells us today, it seems that the phenomena of
disease in the body—the symptoms and signs, the feelings of malaise and pain and overall
suffering—are not much different today than the past. Nevertheless, the ways people
historically understood what caused all that suffering could not be more different. While this
is true across the globe, the Japanese example is especially illustrative.

In premodern Japan, people understood the coming of epidemic disease in one or more
different ways. The “or more” is important in that people often used multiple epistemes
through which they understood what was happening. The following discusses these
understandings through smallpox (hōsō), measles (hashika), and cholera (korera), the three
most dangerous epidemic diseases of Edo-period (1600–1868) Japan (Jannetta 1987, 61–
172). By then, measles and smallpox had already existed on the Japanese archipelago for
centuries. Cholera, on the other hand, was a newcomer. It first appeared in Japan in 1821,
spread halfway across the country from Nagasaki to Osaka and Kyoto, only to disappear with
the oncoming of cold weather that year. Cholera returned again in 1858 and remained
epidemic until at least 1860. It became endemic in parts of the country by the 1870s, and
caused eight national epidemics before 1900.

From antiquity through the nineteenth century, measles and smallpox swept the country in
waves as the number of susceptible individuals grew in the intervening years, following the
previous wave. Once these diseases struck, a large enough percentage of the population
became immune, making further spread impossible until enough children who lacked
immunity were born to make a city or village susceptible again.
People did not think in terms of viruses and herd immunity when it came to epidemics, but
rather that such disease was governed by deities (kami) and buddhas, together called
shinbutsu. People believed that the smallpox deity, hōsōgami, could either prevent or cause
the disease. The hōsōgami was pleased by the color red, so people placed its image printed in
red on their houses along with images of Daruma dolls, owls, certain samurai warriors,
puppies, and other things associated with the prevention of smallpox. More generally, people
believed that a generic “epidemic deity,” or ekishin, had the power to control other
widespread afflictions.

Conclusion
This research clearly demonstrates that there are many things in contemporary popular belief in
Japan that can still and should be investigated further. By examining superstitions and popular
beliefs of a nation you get to know the people better and understand how and why they think and
act like they do. It can show us the differences as well as the similarities between people and
different cultures better than many other indicators. Therefore people should not keep prejudice
against superstitious beliefs but recognize them and embrace them.

The Japanese Ministry of Health, Labor, and Welfare has included its image on posters
urging people to stop the spread of the disease. Numerous variations also can be found for
sale in Japan on buttons and stickers, and it appears widely in newspapers, magazines, and
websites. While it might be considered a kind of “mascot” figure for the epidemic, amabie
also resonates historically as a uniquely Japanese image, reinforcing nativist narratives in a
time of national crisis. Probably few, if any, Japanese people believe that it actually will
prevent Covid-19, but it offers a source of succor and is a symbol of shared identity in much
the same ways that images of the hōsōgami and other epidemic deities also did in the past.