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Japan seemed to have escaped a massive coronavirus outbreak. Now cases are rising.
On Sunday afternoon in the Dai Nagoya Building in Nagoya, Japan’s industrial capital and one of the centers of the novel coronavirus outbreak in the country, Tully’s Coffee is shuttered. A small sign outside the entrance says that, due to Covid-19, the rooftop cafe will be temporarily closed.
Every single other store in the mall is open — and bustling.
The mall is a microcosm of the nation’s response to the virus. Some public schools are set to reopen over the next few weeks, just over a month after Prime Minister Abe Shinzo shut them down on February 27.
The spring university semester begins in early April throughout the country and colleges are proceeding with many classes and orientations, despite canceled graduation and induction ceremonies. Some popular tourist attractions, including Universal Studios Japan, are scheduled to reopen before the end of the month.
Yukino Ichikawa, a college student, said that the main impact of the coronavirus on her life so far has been having a tour she’d reserved getting canceled and improved hand-washing diligence. Others I spoke to had similar experiences. “I may lose my company bonus and I can’t travel,” said Erika Imaeda, a company employee. “I’ve also started to wear a mask to work.”
The country’s reserved approach to tackling the coronavirus has faced scrutiny and speculation about under-testing. Despite taking only moderate social-distancing measures (the government recently asked people to “refrain” from getting together in big groups for cherry-blossom viewing parties), Japan has faced a surprisingly linear growth in cases — that is, until cases suddenly started accelerating in Tokyo earlier this week.
There are nearly 1,400 confirmed cases and over 44 deaths as of March 27. On March 5, 55 new cases were reported. Almost three weeks later, on March 25, just 98 new cases were reported.
Compare that to the US, where 66 newly confirmed cases on March 5 turned into nearly 14,000 new cases on March 25. While much of the world’s new case graphs look like terrifying exponential growth, Japan’s appears to be mainly linear.
But experts say the true number of cases in the country almost certainly exceeds 1,400. The government has been criticized for its strict testing criteria, which requires patients to have had a fever of greater than 37.5 Celsius (99.5 F) for more than four days, unless the patients are elderly, have other underlying health conditions, or are connected to a previously confirmed case. Some people who meet the criteria have been denied tests.
Even the United States’ badly flawed and belated testing effort eclipses Japan’s minuscule effort — as of March 20, the US had conducted 313 tests per million people compared to Japan’s 118 tests per million people. Japan is using just 15 percent of its supposed testing capacity of 7,500 tests per day. South Korea, widely praised for its drive-through testing measures, is conducting more than 6,000 tests per million people.
The Japanese National Institute of Infectious Diseases has argued that the strict testing criteria are in place to preserve limited medical resources for those in need of urgent care. “Just because you have capacity, it doesn’t mean that we need to use that capacity fully,” health ministry official Yasuyuki Sahara told the press in a briefing last week. “It isn’t necessary to carry out tests on people who are simply worried.”
Abe’s government is going directly against the WHO’s firm recommendation to “test, test, test,” leading many to conclude that the coronavirus may be far more widespread in Japan than the numbers indicate.
Now, a growing coronavirus outbreak in Tokyo is threatening Japan’s status quo as 40 new cases in Tokyo alone were confirmed on March 25. While the government has been able to identify the infection route of most of the cases, it’s a worrying sign that life was relatively normal in Tokyo, with muted but still considerable cherry-blossom viewing parties, just a few days before this sudden jump.
Thus far, Japan has managed to escape exponential growth, but the worst may be yet to come. “This may be the tip of the iceberg,” said John Ioannidis, professor of disease prevention at the Stanford School of Medicine. “If you don’t test, you find no cases and even no deaths.”
Timeline of the coronavirus in Japan and the government’s response
Japan’s first case of Covid-19 was a Chinese national who’d traveled to Wuhan — the city in Hubei province, China, where the virus first emerged — and returned to Japan on January 6; the person tested positive for the virus sometime between January 10 and 15.
Two weeks later, Japan confirmed its first case of an individual who had not traveled to Wuhan, a taxi driver in Tokyo who had recently driven a Wuhan tour group.
One arm of Japan’s coronavirus policy has been to build a firewall against the influx of cases from overseas. On February 3, the government moved to bar the entry of people who had a history of traveling to Hubei province, or Chinese nationals with a Hubei province-issued passport.
A month later, those entry restrictions were expanded to include people from certain regions devastated by the coronavirus in South Korea, Italy, and Iran as well as two-week quarantines for all visitors coming from China and South Korea.
Throughout the month of February, most of Japan’s cases were individuals connected to Wuhan, and the majority of cases were isolated and traced. A government-appointed panel reported on March 9 that 80 percent of the cases identified had not passed on the infection to anyone.
But when case numbers failed to abate through February (232 confirmed cases as of February 28), Abe moved to close all schools and request that community gatherings be suspended. Japan was hit by a wave of closures to tourist attractions, sporting events, concerts, and festivals.
The governor of Hokkaido proclaimed a state of emergency beginning on February 28 and asked the population to stay indoors. For comparison, lockdowns began in Northern Italy on March 8, when more than 7,000 coronavirus cases had already been confirmed.
Based on the recommendation of a panel of bureaucrats and infectious disease experts, the central policy has been to focus on providing medical attention to those who are severely ill in order to prevent the nation’s health care infrastructure from becoming overwhelmed, and to do extensive contact tracing to identify infection clusters. The health ministry and doctors are asking individuals with mild symptoms to stay at home so that they do not pass on the disease.
But as cases have steadily increased, not much has changed in terms of the government’s policy response since late February. The prime minister’s office announced on March 20 that according to the expert panel’s latest recommendation, they would continue to focus on infection cluster countermeasures and preparing the health care infrastructure to be able to treat the seriously ill in the event of a leap in infections.
While Japan has a strong national health care system and more than four times the number of hospital beds per 1,000 people than the US, a shortage of medical supplies is an ongoing concern. More than 90 percent of medical institutions in Nagasaki prefecture have said they are facing shortages of masks and disinfectant, and hospitals in Hokkaido are providing just one mask per hospital visitor per day to protect their supply.
Rather than enacting widespread private or public closures, as has been prevalent throughout Europe and the US, the government’s panel of experts simply asked people to “continue to avoid environments that simultaneously meet the following three conditions: poor ventilation, dense crowds, and dense conversation.”
Many in Japan did not comply with this request. Just this past Sunday, more than 6,500 people gathered for a martial arts event in Saitama, a city just north of Tokyo, despite the Saitama governor’s pleas that the event be shut down. One attendee later came down with a fever and is currently awaiting the results of a coronavirus test.
Better hand-washing, a government conspiracy, or both?
There has been plenty of speculation about the reasons behind Japan’s lack of exponential case growth. Suggestions, both optimistic and pessimistic, have covered everything from the fact that people in Japan don’t typically shake each others’ hands in greeting to the possibility that the government is failing to test tens of thousands of pneumonia patients for the coronavirus.
Here’s an overview of the major factors at play — and what the numbers and experts say about their impact on “flattening the curve” in Japan.
Moderate social distancing was effective because it happened early
Social distancing in Japan is currently a mixed bag. Rush-hour traffic on Tokyo subways is down just 10 percent compared to mid-January. Street traffic in Tokyo has barely budged from its historical average.
A survey conducted by the Osaka Chamber of Commerce and Industry on March 12 showed that 55 percent of large corporations have implemented remote working procedures, but a strict working culture has kept even white-collar workers in the office. Movie theater revenue for March is down around 50 percent across the country.
But even this modest social distancing seems to have had an impact. Sato Akihiro, a data analysis expert and professor of neuroscience at Yokohama City University, calculated that Japan’s nationwide event cancellations and social distancing measures beginning at the end of February have cut the infection rate to 50 percent of what it would’ve been otherwise.
He said that in order to stop the virus completely, the country needs to increase its testing capacity by sixfold to adequately identify and track cases. “We saw event cancellations in Japan from a very early stage,” Sato told me. “I think that cases in Japan are not growing at an exponential rate as a result of these early interventions to reduce human contact.”
Cluster identification and contact tracing
As Sato points out, the key to Japan’s linear rate of infections may stem not from acting more aggressively, but simply earlier, before sustained community spread took root.
Japan began testing individuals with coronavirus symptoms — and not only those with a history of travel to Hubei province — at the discretion of local governments around February 12. The government then created a specialized team of public health and medical experts to identify and isolate infection clusters.
Whenever a hospital confirms a new case, the government dispatches teams of medical and data experts to cooperate with local governments to locate and test anyone who has been in contact with the infected individual. Oftentimes as a result, the corresponding local facilities are closed down, such as a senior care facility in Aichi prefecture that was associated with an infection cluster.
A lack of large case explosions, such as what happened with South Korea’s “Patient 31,” who singlehandedly spread the disease to thousands, suggests that these cluster countermeasures have been mostly effective thus far.
Sanitation and mask-wearing are real factors
While it’s more likely that Japan’s early cluster tracking and social distancing measures are the main factors in limiting an explosive spread of the virus, famously clean Japan does have difficult conditions for a virus to thrive in.
While good hygiene is far from universal in Japan, many people practice frequent hand-washing, gargling, and disinfection. Japanese people rarely shake hands, hug, or kiss when greeting — a key chance for the virus to spread.
For reference, a 2015 survey found that 15 percent of Japanese did not wash their hands after using the toilet, compared to 40 percent of Americans. Hand-washing reduces the risk of respiratory infection by 16 percent, according to the CDC.
In terms of surgical and N95 masks, a Weather News survey from January 2018 revealed that 53 percent of Japanese people wore masks regularly — a number that has almost certainly increased this year with the alarm bells about coronavirus. A 2017 scientific study found that mask-wearing reduced risk of influenza among Japanese schoolchildren by 8 percent.
“Personal hygiene and social responsibilities are main pillars for disease prevention practice,” HyunJung Kim, a PhD student in biodefense at George Mason University, told me. “However, it is [irresponsible] to assume that 100 percent of the population of a country will have the highest level of hygiene and social responsibility. Outliers always exist.”
Japan may have other factors on its side, as well. Mitsuyoshi Urashima, a practicing pediatrician and professor of medicine at Jikei University, suggested that the coronavirus was spreading in Japan in mid-January, at the height of the flu season, whereas the virus did not spread in the US and Europe until after the flu season’s peak.
“[My view is that] the outbreaks were ‘batting’ against each other in Japan, reducing the prevalence of both diseases,” Urashima said.
Japan also has an accessible, inexpensive, and widespread national health system that is excellent at treating pneumonia, the main way that coronavirus kills. Edo Saito, owner of a Japanese/multinational executive consulting agency, points out that from the age of 65, all citizens are enrolled in senior care services programs, which include home pickup to senior day care centers and having doctors and nurses call in on homes.
These expansive and accessible health care options may be providing an additional safety net for Japan’s large elderly population. Japan’s elderly population is also uniquely (and tragically) isolated, which may reduce contact with asymptomatic virus-carriers.
Some speculation around Japan’s low coronavirus numbers suggested that the government was repressing the extent of the infection to ensure that the 2020 Tokyo Olympic Games would be held on schedule. With the recent announcement that the games will in fact be postponed, that should be off the table.
When asked about the possibility that large numbers of coronavirus-related deaths are being ignored or written off as pneumonia, Matsumoto Tetsuya, a professor of public health at the International University of Health and Welfare Graduate School in Otawara, said that it was possible but not likely. “While we can’t rule out the possibility, deaths by pneumonia of unclear origins are rigorously investigated,” Matsumoto said.
Concern moving into spring
It nevertheless remains clear that under-testing is masking the extent of the infection in Japan.
A leap of cases in Tokyo may prove that the virus has been spreading throughout Japan via mild and asymptomatic spreaders, and just as people begin to let their guard down, a newfound explosion of cases will emerge.
“This is why I feel it is so important to test random, representative samples of the population, to see where we stand,” said Ioannidis. “Otherwise, it may be like trying to pick molecules of air with our fingers, given that so many cases are asymptomatic or very mildly symptomatic and go undetected. If the virus is shown to be already widely spread, [the] focus should be on preparing the health system as well as one can, plus fiercely protecting high-risk individuals.”
“From last week, we’ve also started to see a lot of cases in people returning from overseas,” Sato said. “I’m concerned that when the number of cases reaches 3,000 to 5,000, the health care infrastructure will start to become overwhelmed.”
There is also concern about the government’s border-control approach. Kim points out that a pillar of the Japanese response has been to limit the entry of foreigners from affected regions into the country.
“However, there are many loopholes,” Kim said. “Foreigners are not a sole risk factor of incoming diseases. South Korea cases reveal that the majority of cases are introduced by Korean citizens returning from travel and business trips abroad.”
Based on the latest round of recommendations from the expert panel, the Japanese government is seeking “thorough behavioral changes” to improve citizens’ response to the coronavirus and ensure that people avoid places that meet the three conditions of poor ventilation, dense crowds, and dense conversation.
Faced with skyrocketing infections, much of Europe and the US have moved toward lockdowns. Japan hasn’t. The government insists that it doesn’t need to, citing that in some areas, almost all of the local coronavirus patients have been identified via contact tracing.
But Sato warns that as long as cases continue to rise, no one can afford to take their foot off the gas: “Even if we continue with the measures already in place, the spread will not end.”
It’s a worrying sign for a country that’s clearly ready to take off the masks and enjoy the cherry blossoms.
Some doctors say Mexico could become the new Italy — or worse.
As Mexico fast approaches what’s highly likely to be a large coronavirus outbreak, the country’s leadership — mainly its president — mostly insists that everything is fine.
In speech after speech, President Andrés Manuel López Obrador, known by his nickname AMLO, tells Mexicans they shouldn’t fear Covid-19, even as hundreds of thousands of people have confirmed infections worldwide. Despite warnings from global health officials, he continues to hold political rallies, kiss supporters, and request that Mexicans go out shopping to prop up the country’s sputtering economy during a global slowdown.
“Live life as usual,” he said in a video posted to Facebook on March 22, showing him outside at a restaurant. “If you’re able and have the means to do so, continue taking your family out to eat … because that strengthens the economy.”
AMLO’s advice, experts say, is deadly. What makes matters worse is that his policies over the past few years have set the stage for a profound health crisis. In a major effort to cut government spending, AMLO has reduced funds for the country’s hospitals and medical centers by millions. It’s left the nation short of physicians, medical equipment, beds, and coronavirus tests.
That last part is especially frustrating, because Mexico has been hit hard by outbreaks before. In 2009, the H1N1 influenza was identified, originating in Mexico before it spread around the world, killing about 17,000 people in an initial count. (A 2012 Lancet study estimated there were hundreds of thousands of deaths associated with the disease.) Then, Mexico aggressively tested hundreds of thousands of its citizens to identify clusters of infection and stem the tide against transmission, said Alejandro Macías, the “czar” for the government’s emergency response at the time. “We acted then like South Korea has today,” he told me.
That’s not happening this time. The country has barely tested people, likely accounting for the low official number of 475 cases as of March 26. That comes as millions continued to move freely outside, including tens of thousands who attended a large outdoor festival in Mexico City last week.
And while AMLO’s administration has just started taking some more serious measures, including instituting a social distancing program and suspending all nonessential activities, for many it’s far too little, far too late. The consequences of the inaction, experts say, could prove disastrous.
Mexico once handled a medical crisis much better than this
To understand the extent of AMLO’s failure to address the coronavirus crisis, it’s worth revisiting how Mexico handled the H1N1 influenza outbreak.
Macías, the H1N1 czar, told me then-President Felipe Calderón and his team sprang into action in two main ways to curb the spread. They had no other choice, he said: “We were the China of that outbreak.”
First, they instituted strict social distancing measures. Calderón shut down government agencies and nonessential businesses, and told everyone to stay inside. “There is no safer place than your own home to avoid being infected with the flu virus,” the president said during an April 29, 2009, national address.
Second, the administration tested as many Mexicans as possible to track the spread of the virus and quarantine the sick and those that may have come in contact with them.
Macías said it also helped that the government had access to a lot of flu medication. It wasn’t always effective for patients with H1N1, but it helped a lot of them. The biggest positive of having those drugs, he claimed, was the calming effect it had on the population. “It was more important than the actual therapeutic benefits of the medicine,” he told me. In the end, more than 70,000 Mexicans contracted the virus.
Mexico’s experience in handling the H1N1 crisis left it in a good position to combat the next health scare. “There is still some capacity from an institutional perspective,” Carlos Petersen, a former Mexican government official now at the Eurasia Group consulting firm, told me. The country’s deputy health minister today, he noted, played a big role in curbing the influenza outbreak 11 years ago.
But from the moment he came to power, AMLO started making reforms that have left Mexico less prepared for the coronavirus than it otherwise would’ve been.
How AMLO left Mexico vulnerable to the coronavirus
A major part of AMLO’s presidential campaign was his anti-corruption initiative, in which he vowed to end high-level grift for the benefit of the average Mexican. Now in power, he’s kept to his word, but in ways that made his administration less able to confront the coronavirus crisis.
First, he started cutting salaries of public sector workers — a major campaign promise — so there would be more money in the federal budget for private citizens. He even fought the country’s Supreme Court last year, forcing the justices to accept a 25 percent pay cut; AMLO himself makes less money than his predecessors.
“We can’t have a rich government in a poor country,” he’s said many times.
But the unfortunate result is that hundreds of competent officials have left the government because they don’t like AMLO’s meddling and the lower salaries. What’s more, he’s fired others whom he believed to be political enemies or singularly corrupt. That, according to former US Ambassador to Mexico Roberta Jacobson, left the country with fewer seasoned professionals to deal with the crisis.
“He really gutted the technocratic capabilities of the public sector when he came to office,” she told me. As a US official during the 2009 H1N1 outbreak, she remembers working with her Mexican and Canadian counterparts on efforts to find a cure. “You don’t see any of that kind of cooperation now.”
Second, he’s severely cut the health care sector as part of his austerity measures to control government spending. In 2019, for example, around 10,000 health professionals were laid off due to a 44 percent cut to a public health and welfare agency. That’s led to delays in surgeries for children, reductions in staff, and cancellations of many forms of treatments for patients.
The Eurasia Group’s Petersen, however, told me that previous Mexican administrations had made cuts to the country’s health care system over the years. AMLO isn’t unique in that regard, then, but he is among the most aggressive in cost-cutting measures for that sector.
Mexico’s health care system is in poor shape. It has about 1.4 hospital beds per 1,000 people, according to the Organization for Economic Cooperation and Development, just over 2,000 ventilators in the entire country, and few coronavirus tests.
“If Mexico has undetected cases circulating, the spread of the disease is going to be brutal,” Moreno, the doctor at the ABC Medical Center, told Bloomberg on March 11.
What’s more, physicians note they don’t have enough personal protective equipment like masks and gloves to treat patients.
“I’m working in the hospital trying to figure out how the hospital is going to be getting through the next weeks because we know the explosion of cases is going to be in the next weeks,” Moreno told the New York Times on March 24.
Some medical staff are protesting in the streets to demand the government spend more to provide materials and personnel. “We can’t work without equipment,” a nurse in the state of Tabasco said in a Twitter video this week. “We also have families — children and parents.”
“We’re only asking for basic things, nothing else,” she continued, adding that four of her colleagues now have symptoms that resemble those of Covid-19.
Personal del IMSS en Tabasco protestan por falta de insumos para enfrentar la pandemia de #COVIDー19 #Coronavirus.— Elisa AlanísZurutuza (@elisaalanis) March 22, 2020
Tienen temor por cuatro compañeras enfermeras que tienen síntomas de problemas respiratorios.
@Milenio @mileniotv pic.twitter.com/Af0AxXOZFe
AMLO also made two reforms that have clearly backfired.
One change was to the Seguro Popular (Popular Insurance), a program in which the central government gave states money to cover some medical expenses for the uninsured. The president worried, rightly, that some officials took the money for their own use or misallocated the funds.
AMLO therefore completely centralized the program and gave it a new name. But that move made some procedures more expensive while also eliminating coverage for others. Lower-income people, then, were made worse off by the change, experts say.
The other reform was in how the Mexican government purchased medicines. In the past, government officials would buy the drugs from distributors, not the companies that made them. To cut out the middleman, AMLO decided his administration would buy directly from the firms.
The problem is that the deals were made poorly, Petersen said. For example, the cost of transporting the medication wasn’t included in some of the tenders. As a result, the price of certain medications went up, making it harder for non-wealthy Mexicans to buy them.
All these reforms put extra stresses on the already struggling Mexican health care system. “If numbers of coronavirus cases run high, they will be completely unprepared as a health system to deal with it,” Jacobson, the former ambassador, told me.
But it’s not just medicines that are lacking; it’s leadership.
AMLO is prioritizing the economy over public health
Last week, AMLO defied the advice of medical experts and spoke at a large gathering to celebrate the nationalization of Mexico’s oil sector. During the event, he made sure to shake hands and kiss friends, just like he’d done all over the country despite the coronavirus outbreak.
For experts, such an event was emblematic of AMLO’s response to the crisis. Instead of setting an example for people to stay home, he’s prioritizing the economy above all else.
That’s not to say the economy isn’t in urgent need. Petróleos Mexicanos, the state-owned oil company, is deeply in debt and in crisis, especially as global oil prices plummet. The country’s economy contracted by 0.5 percent in the fourth quarter of last year, and many indicators point to a years-long slump. As the world confronts the possibility of a pandemic-induced recession, it’s not unreasonable for AMLO to want to boost the economy.
Experts, though, say he needs to accept reality and start implementing aggressive measures to curb the spread. “You need to prioritize people’s health and worry about how many might die before the economy’s health,” said Macías, the H1N1 czar.
He has the power to do that. AMLO notoriously micromanages every aspect of his administration, which makes his own inaction the greatest impediment to a speedy and effective response. If he took the crisis seriously, Mexico would have a better chance of keeping the crisis from getting completely out of hand.
Other than personally acting in a way medical professionals prescribe, experts want AMLO to offer economic support for hurt by the crisis, help health care workers, and impose stricter social distancing measures.
There are some signs that the Mexican government is moving on those fronts.
In response to the protests by medical staff, AMLO’s team says it will provide $150 million in additional medical supplies and fill the more than 40,000 job openings for medical personnel. In coordination with the US government, crossings between their shared border have been severely limited.
On March 24, the government unveiled its most significant social distancing requirements yet, including a ramp-up in suspensions of large events. And the next day, AMLO’s team banned all nonessential activities from happening in Mexico.
The government even created a superhero — Susana Distancia (A Healthy Distance) — to remind people to stay six feet apart.
It’s a start, but large challenges remain.
The biggest challenge outside of the urgent need for medical treatment of coronavirus cases, experts say, will be helping the nearly 60 percent of Mexicans who work in the “informal economy” — the street chefs, musicians, artists.
Without a tax ID number or connection to organized labor, they may not get the economic support from the government they will eventually and desperately need. They also wouldn’t be affected by a government-mandated shutdown of business, which might require federal authorities to force these workers off the streets and to house them humanely.
None of this gets done without AMLO’s buy-in. He may decide it’s time to act now that his poll numbers — once high — have begun to drop sharply. But if he doesn’t, the Eurasia Group’s Petersen says, “the situation could take a turn for the worse.”
Clarification March 28: This article has been updated to explain differing counts included of deaths from H1N1.