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Japan’s worst COVID-19 outbreak yet has thrown a spotlight on the inability of the country’s otherwise highly regarded medical system to adapt quickly to emergencies and its lack of reform to meet such needs.

As new cases surged to more than 25,000 a day this month driven by the delta variant, the number of medical emergencies nationwide that required an ambulance dispatch, but had difficulty finding a hospital to accept the patient, rose for six straight weeks to a historic high, according to data from Japan’s Fire and Disaster Management Agency.

Defined as cases where emergency medics were turned down by more than 3 hospitals and at the scene for more than 30 minutes, the figure jumped to 3,361 in the week of August 9-15, said the agency that oversees the ambulance system nationally. The case number ticked down slightly last week, but was still the third-highest ever recorded in Japan. About half the patients were suspected of having COVID-19.

The ambulance quandary has resulted in a handful of high-profile COVID deaths, sparking a debate over the efficacy of what is widely recognized to be one of the world’s most successful health-care programs. While the Japanese system has nurtured the world’s longest-living citizens with preventative care, the pandemic has laid bare the long-standing dysfunction in emergency care, where private hospitals aren’t required to take in COVID patients and don’t coordinate with local governments and ambulance services.

The crisis has underscored how the best health-care systems in the world, especially in developed economies, are flailing under the pressure of the pandemic.

Many of Japan’s private hospitals are small and aren’t designed to deal with infectious diseases. Although the number of COVID beds has increased amid government funding support, the delta surge has pushed added capacity to the limit, while medical worker staffing is also an issue.

“The strain on the medical system is caused by a problem with its design and policy. Most of the hospitals and clinics in Japan are privately operated, and it’s difficult for the whole system to work together strategically,” said Hiroyuki Morita, a medical journalist and practicing doctor in Kagoshima in southern Japan.

The Japanese health-care system has an abundance of medical equipment, hospital beds and near universal health care coverage. But it is built on the strength of preventative and primary care at private hospitals, and cracks in its emergency care provision—resulting in a notorious “death by delay” problem that’s existed for decades—have not been addressed.

Although COVID deaths have remained low in Japan, reflecting its sucess in vaccinating nearly 90% of the elderly, the number of patients in a serious condition has continued to rise each day for the past two weeks with little medical capacity to treat them. A controversial hospitalization policy change announced by Prime Minister Yoshihide Suga in early August has meant more COVID patients are asked to recuperate at home, raising the likelihood that they’ll need ambulances and emergency care should their conditions deteriorate quickly.

Last week, a pregnant woman with COVID in Kashiwa city, northeast of Tokyo, couldn’t find a hospital to take her in when she experienced labor pains. The baby died after she gave birth at home.

An influential nightly news show this week broadcast a segment on a doctor treating a diabetic COVID patient in Tokyo who had developed severe complications at home. After the patient was carried onto the ambulance, the hospital called to say it could no longer take him. He died few days after the video recording was made, reports said.

“We have 10 ICU beds for serious COVID patients and they have constantly been occupied. The minute one frees up, it’s immediately taken,” said Takaaki Nakata, head of emergency and critical care at Chiba University Hospital. Nakata’s hospital is publicly operated and required to take in emergency patients. Despite the lack of beds, he says it will provide emergency outpatient care while waiting to find a hospital for those who need it.

Lack of Reform

The current system relies on public health centers—a web of over 450 institutions embedded in local communities that do everything from contact-tracing to investigating child abuse—to coordinate and find hospitals for patients during an infectious disease outbreak.

But the centers, which have seen their numbers shrink due to lack of public funding, become easily overwhelmed during virus surges as the nurses that staff them are also tasked with other epidemic work, like tracing and tracking close contacts of the infected.

The lack of medical reform has been blamed on Japan’s slow-moving bureaucracy and the vested interest of physicians’ lobbies. Streamlining emergency care would likely require a rethink of the entire system, which many in Japan are defensive of, given the overall health of its citizens. “No one is looking at the issues with a bird’s eye view,” Morita said.

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The government has attempted to address the current COVID crunch with strongly worded requests to hospitals to take in patients at the risk of being publicly shamed. The country’s top virus adviser said Thursday that temporary hospitals may need to be built.

“The COVID beds in my hospitals are almost constantly full. When we get a patient sent in from the public health center, they’re already in serious condition,” Norifumi Ninomiya, a doctor and consultant to the emergency care department at Flowers & Forest Tokyo Hospital, said in an email. “We’re seeing an increase in patients that get worse and pass away despite treatment. These are lives that can be saved if they’re treated earlier.”