Japan sidestepped COVID-19's worst, so what now?

By luck or by design, Japan has been spared the kind of devastating novel coronavirus outbreak taking place in other parts of the world.

That the nation sidestepped disaster without knowing how is cause for both celebration and concern. But as the debate continues over how much criticism or praise the government deserves for its strategy, what matters now is whether it will keep working and for how long.

The nation is approaching the end of an unnerving chapter as the last of its prefectures begin to reopen.

Where reactive countermeasures and delayed contingencies seem to have pacified the contagion until now, a more lasting strategy may be necessary to prevent a second wave in what is shaping up to be a long fight against the global pandemic.

“We need to build upon what we, as a society, have learned during this pandemic and use that knowledge to forge a new lifestyle,” said Koji Wada, a professor in public health at the International University of Health and Welfare.

That lifestyle, he noted, will need to be maintained for one or two years, maybe even three, at the least until a suitable treatment or vaccination for COVID-19 is developed and made available to the public.

With the world’s oldest population, Japan seemed ripe for a major outbreak when the contagion reached its shores in January. And Tokyo, one of the most densely populated mega-cities on the planet, resembled a petri dish.

From careless airport health examinations for Japanese nationals evacuated from Wuhan in late January to the questionable disembarkation process for a virus-infested cruise ship in Yokohama Bay a month later, there were several moments that seemed to offer the virus a foothold in Japan.

But every step of the way the world watched and waited for something that never came — at least, not yet.

Since the beginning, the government has focused its resources on seeking out and testing individuals thought to be at risk of infection. Where other countries, such as South Korea, sought to test as many people as possible, Japan conducted targeted testing in a ploy to buffer its health care system from a sudden surge in coronavirus patients.

Low testing masked the extent to which the contagion had spread within the country, which in turn made it difficult for experts to grasp what was going on, much less predict what would happen next.

This strategy, as well as the inability for Japanese municipal leaders to legally enforce citywide lockdowns with punitive measures, drew heavy criticism of the government’s response from foreign and domestic media as well as the public.

And yet, the coronavirus outbreak in Japan has been largely kept in check.

So far, the country has reported more than 17,000 cases and around 850 deaths.

In comparison, the United States, cast into the pandemic later than most countries, is facing the worst of it with nearly 1.6 million cases and nearly 100,000 deaths. The United Kingdom, Spain, Italy and France have also suffered heavy casualties.

Worldwide, the pandemic has infected more than 5.3 million people and taken the lives of more than 344,000 in at least 177 countries.

There are countless theories as to how, why and what conditions have allowed this nation to avoid calamity. Some point to factors that presumably had a positive impact but are impossible to quantify, while other notions range from pure conjecture to outright conspiracy. The truth remains elusive.

Shigeru Omi, former director of the Western Pacific Regional Office of the World Health Organization and a top member of the Japanese government’s expert coronavirus panel, said during a news conference earlier this month that Japan had avoided the high counts of severe cases and fatalities seen in Western countries due to three factors: its health care system, effective cluster tracing in the early stages of the epidemic and a propensity among its people for healthy living.

“Indeed, why is the number of infections so low in Japan?” Wada asked rhetorically, adding that cluster tracing and concern for personal hygiene may have helped contain the virus in the early stages of the outbreak in Japan.

If anything, Wada said, figuring out why the virus didn’t spread as quickly in Japan and other Asian countries might be less important than finding out why it did in the West.

“That the virus had a slow start over here may have led Western countries to let their guard down,” he said.

One study released in early May found that countries where tuberculosis vaccinations — specifically the bacillus Calmette-Guerin (BCG) vaccine — are mandated had reported fewer coronavirus fatalities than countries that don’t. In Japan, a BCG shot is mandatory for newborns.

But Omi cautioned that there was no scientific evidence to support the assertion. Furthermore, an Israeli research group found a negligible difference between the infection rate among those who had received the BCG vaccine and those who hadn’t.

Last week, a task force of eight colleges and research institutions teamed up to figure out if the low number of severe cases in Japan was a matter of genetics. Researchers in the task force intend to create a genetic sequence of 600 patients across 40 hospitals in the country.

Others have postulated that the strain of coronavirus spreading in Japan, South Korea and other east Asian countries is less aggressive than the one wreaking havoc in Europe and the Americas.

Japan has been heavily criticized for conducting fewer COVID-19 tests than most other countries. The central government has touted its efforts to test only those already suspected of infection as an attempt to prevent a spike in patients and protect its health care system.

Rumors emerged that the government wanted to minimize the number of reported infections to prevent a postponement or cancellation of the Tokyo 2020 Olympic and Paralympic Games. Even if that were the case — though it seems unlikely — the plan clearly didn’t work given that the games were postponed in March until next summer.

In any case, experts say the death count is probably the most reliable indicator since the figure, while it may be subject to error, would be difficult to hide or manipulate.

Low testing has, however, concealed an even greater secret: the true extent of the spread of the novel coronavirus in Japan.

A high frequency of asymptomatic transmission implies that a large number of cases has gone undetected. Omi said during a meeting of the government’s expert coronavirus panel that the number of cases in the nation “could be 10 times, 15 times or even 20 times higher than what’s reported.”

Experts have said time and again that comprehensive, proactive testing is the only way to accurately measure how fast the virus is spreading and where.

This is why the threat of a second wave looms large over every municipality looking to peel back restrictive measures and reopen society.

Prime Minister Shinzo Abe declared a state of emergency across seven prefectures on April 7, extending it nine days later to the rest of the country. The declaration was set to expire on May 7, but Abe extended it to May 31 after results from the first month were unconvincing.

On May 14, the government decided to lift the state of emergency in 39 prefectures deemed safe to reopen. Last week, the order was lifted in Osaka, Kyoto and Hyogo prefectures. And on Monday, the state of emergency for the five remaining prefectures — Tokyo, Saitama, Chiba, Kanagawa and Hokkaido — was lifted as well.

Where some countries have imposed citywide lockdowns that include curfews, heavy fines or armed police officers, coronavirus countermeasures in Japan have been completely voluntary because the law doesn’t give the central government or municipal leaders the authority to punish those who disobey requests for residents to stay indoors or businesses to temporarily close.

And yet, pedestrian traffic took a steep dive in Tokyo after the state of emergency was declared. While a rapid increase in new cases leading up to the initial declaration in early April pushed its health care system to its limits, if not beyond, the capital seems to have weathered the storm.

According to data published on May 16 by Google LLC, nearly all sectors of Japanese society saw a drop in mobility since around the time the state of emergency was declared. On average, between April 4 and May 16, restaurants, cafes, museums and other retail or recreational locations saw a 40 percent drop in movement compared to the average between Jan. 3 and Feb. 6, the report said. Parks, beaches and other public outdoor areas saw a 52 percent drop, while workplaces saw a 23 percent drop and public transportation hubs saw a 55 percent drop. According to the report, residential spaces saw an unsurprising 14 percent rise in mobility during the same period.

Tokyo is one of the last places in the nation to be released from the state of emergency. Experts say reopening society abruptly or prematurely could trigger another surge in infections. In Japan, where a voluntary moratorium was first imposed on public activity and local businesses early last month, residents are likely itching to get back to how things used to be.

Kenji Shibuya, director of the Institute of Public Health at King’s College London and a senior advisor to the director general of the WHO, said a second wave of the novel coronavirus in Japan was “inevitable.”

In principle, the possible resurgence of the novel coronavirus will haunt society until herd immunity is achieved or a vaccine is developed and becomes commercially available.

Vaccination won’t be an option for months, if not years, and herd immunity might not be feasible.

According to the Johns Hopkins Bloomberg School of Public Health, herd immunity is achieved when 70 to 90 percent of a population becomes immune to an infectious disease one of two ways: they receive a protective vaccine or a large portion of the population gains natural immunity by becoming infected.

Given Japan’s population of about 126 million, somewhere between 88 to 113 million residents would need to become immune for the country to achieve herd immunity.

Health minister Kastunobu Kato said earlier this month that the country planned to start testing 10,000 people to gauge how far the virus has spread and to see if the population is approaching herd immunity.

Sometimes people intentionally expose themselves to infectious diseases to gain immunity, like with chickenpox before there was a vaccine. Doing so with COVID-19, however, would be dangerous given its much higher risk of severe infection and death.

In the U.S., which is currently dealing with the world’s biggest outbreak, hundreds of millions of Americans would need to become infected for the country to establish herd immunity.

In Japan, the number of reported cases so far accounts for barely more than 0.01 percent of the population.

Hints of new clusters began to emerge quickly after lockdowns were lifted earlier this month in Hong Kong, Singapore, South Korea and Wuhan, China.

While Japan seems to have emerged from the first stage of this global pandemic with only minor bruises and cuts, the possible advent of a devastating outbreak will, for the time being, remain ever present.

“It’s better to assume that there will be a second wave,” said Yasutoshi Nishimura, cabinet minister in charge of handling the novel coronavirus, earlier this month. “Small waves are inevitable, and those will turn into a big wave if we let our guard down.”