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While Japan is lagging far behind other countries in developing COVID-19 vaccines, the United States is already supplying its shots to the rest of the world.

The gap reflects the differences between what the two nations have learned from past bioterrorism attacks and epidemics of emerging and re-emerging infectious diseases that occurred not only within the country but also elsewhere, and how they prepared for future risks and crises.

The following comment is not taken from a report, rather it is a remark made by a lecturer in 2000 during a class of disaster medicine at Harvard University School of Public Health.

“At 10:15 a.m., a professor at Shinshu University’s Faculty of Medicine, who treated patients in the sarin gas attacks in Matsumoto, Nagano Prefecture, faxed a report to hospitals in Tokyo which were receiving the subway sarin attack victims, describing the symptoms of sarin exposure and how to treat them. That was an incredibly good judgment.”

Indeed, the government has not compiled any report on the shocking sarin nerve gas attack on Tokyo’s subway system in 1995.

The attack was carried out by the Aum Shinrikyo doomsday cult during the morning rush hour on March 20.

Cult members, carrying sarin in plastic bags wrapped in newspaper, got into trains on four subway lines and punctured the bags with the tips of umbrellas immediately before getting off the trains.

Thirteen people died in the attacks and some 6,000 people received hospital treatment.

Since I was the only Japanese attending the class at Harvard, I was asked how things were at the time of the incident.

Jikei University Hospital in Tokyo’s Minato Ward, where I had studied and where I later worked, accepted many people caught up in the attack at Kamiyacho Station on the Hibiya Line.

The first victim was carried into the hospital’s emergency room on that day at around 8:30 a.m. Victims were rushed in one after another, saying they were having difficulty breathing and complaining of darkened vision.

The hospital did not have a department of emergency medicine at the time, and when emergency patients were brought in, nurses would call a doctor on duty at the department judged to be relevant to each case depending on the symptoms.

Since the attacks occurred in the morning when doctors were holding case conferences, it took some time for nurses to get hold of doctors. The emergency room soon started to overflow with patients.

At around 9 a.m., doctors took the initiative to begin treating patients without being called for, with a surgeon who had been on emergency duty serving as a leader to come up with a unified treatment policy.

Patients were placed not only in the emergency room but also on unoccupied beds in hospital wards and sofas in the waiting room for outpatients, without a doctor in charge.

As constriction of the pupils were confirmed on all of the patients, the doctor who was leading the team felt that something serious was happening that couldn’t be explained based on past experience. Without hesitation, the doctor asked a professor of forensic medicine for advice. That was about an hour after the first victim was carried into the hospital.

The professor immediately examined the patients in the emergency room and said the symptoms matched those of poisoning from organic phosphorus including agricultural chemicals and sarin, and pralidoxime iodide (PAM) should be used as an antidote.

At the time, there were only two ampoules of PAM in stock at the hospital pharmacy.

The hospital quickly administered those to patients with the severest symptoms, including disturbed consciousness and lowered blood pressure, and moved to order a large amount of PAM from wholesalers.

The antidote arrived soon and papers describing the treatment policy using PAM and atropine were handed out to departments.

Appropriate decisions

The number of patients continued to grow.

The hospital head who was leading the task force assigned a doctor to perform triage, and patients with less urgency — those only showing constriction of pupils — were taken to a clinical auditorium in the hospital courtyard.

However, no doctor had knowledge of decontamination at that time.

Meanwhile, other hospitals that received victims learned from a police announcement broadcast on TV at around 11 a.m. that they were suffering from sarin poisoning.

They had to get PAM from dealers as far away as Kansai, so were unable to administer it until the afternoon of that day.

Japan missed an opportunity to learn lessons from the March 1995 sarin attacks on Tokyo subway that could have been used in the fight against the coronavirus. | REUTERS
Japan missed an opportunity to learn lessons from the March 1995 sarin attacks on Tokyo subway that could have been used in the fight against the coronavirus. | REUTERS

Jikei University Hospital, although it accepted more than 2,000 victims of the sarin attack, did not report a single death because it was able to act swiftly based on appropriate decisions.

But such achievements were not made public, as the hospital refused media coverage so as to protect the patients’ privacy.

When studying at Harvard University, I also had the experience of being assigned to write a report on the potential worst-case and best-case scenarios in the event of an anthrax attack at a shopping mall in Boston.

As a graduate student, I thought, “That’s too much. Such a thing would never happen. I wouldn’t worry that much.” That was in the year 2000.

But in early fall the following year, the scenario became a reality. Following the series of terrorist attacks in the U.S. on Sept. 11, 2001, bioterrorism attacks involving letters containing anthrax occurred between September and October the same year.

Aum Shinrikyo had also attempted to carry out acts of bioterrorism using botulinum toxin and anthrax, although the group’s attempts failed.

The U.S. was able to predict the possibility of anthrax attacks taking place in the country because it had likely been thoroughly looking into cases in Japan by sending experts.

Anonymous letters laced with anthrax spores were first sent to media companies and then to two Democrat senators. Five people died from inhaling anthrax and 17 others became sick after exposure, many of them postal workers.

The U.S. government realized that conventional means and operations used in wars and past conflicts did not work against new threats.

That was why the Department of Homeland Security (DHS) was established in 2002, merging different federal departments and agencies related to the prevention of terrorist attacks.

Serious discussions began over such questions as what would happen to the U.S. if massive quantities of weaponized anthrax were sprayed into the air or whether all U.S. citizens should be vaccinated against smallpox.

Since then, the U.S. have taken various initiatives regarding its defense against bioterrorism.

Vaccine development

One of these was Project BioShield, launched in 2004 to accelerate the development of medical countermeasures, mainly vaccines and therapeutics.

Two years later, the Biomedical Advanced Research and Development Authority (BARDA) was established at the Department of Health and Human Services to invest in and procure medical countermeasures, including vaccines, drugs, therapies and diagnostic tools for public health medical emergencies.

Between 2013 and 2016, the most widespread outbreak of the Ebola virus took place in West Africa, which saw nearly 30,000 cases and some 10,000 deaths. A rapid spread of the Zika virus was reported in Brazil around the same time.

Such incidents represented the turning point for biological defense strategy in the U.S.

If a new or re-emerging infectious disease outbreak occurs somewhere in the world, the disease will likely enter the U.S. sooner or later.

In order to strengthen defense against all types of biological threats, the U.S. government announced the National Biodefense Strategy in 2018 to step up coordination among 15 federal departments and agencies including the DHS and the intelligence community.

Measures against bioterrorism, as well as against emerging and re-emerging infectious disease pandemics, became one of the key pillars of the country’s national security.

This foresight also proved to be true, when the world was hit by the COVID-19 pandemic.

In January 2020, mRNA vaccines had already been designed. An early stage trial of an mRNA vaccine was started in March and finished within April. In May 2020, the U.S. government announced Operation Warp Speed “to accelerate development, production and distribution of COVID-19 vaccines, therapeutics and diagnostics to produce and deliver 300 million doses of safe and effective vaccines with the initial doses available by January 2021.”

The U.S. had already been looking into attacks in Japan when American media organizations were sent packages containing anthrax in 2001. | REUTERS
The U.S. had already been looking into attacks in Japan when American media organizations were sent packages containing anthrax in 2001. | REUTERS

BARDA took the lead in efforts to develop vaccines in the U.S. by investing more than $12.8 billion in companies at home and abroad for development, production and distribution.

While it normally takes 10 years to develop a vaccine, the country met its target in the surprising speed of about a year.

Learning from failures

Japan failed to draw lessons from the sarin attacks while the U.S. learned a lot from its anthrax attacks. The difference became apparent more than two decades later in the gap between the two nations in their capabilities to develop vaccines against the coronavirus.

Japan took Aum Shinrikyo’s brutality as “an incident” rather than as terrorist attacks, its measures against the 2009 new influenza virus pandemic as “a success” rather than a failure, the Ebola virus and the Zika virus epidemics as “problems occurring far away,” and its measures against COVID-19 as “belated but turning out alright.”

The proverb “danger past, god forgotten” often seems to be appropriate in Japan.

On the other hand, the U.S. was aware of the fact that there are strong similarities between different risks and crises.

Under the assumption that terrorist attacks and pandemics would hit the nation some day, the U.S. made being prepared for such threats a pillar of national security and strategically established authorities like the DHS and BARDA.

At Harvard, I had the opportunity to study under the case method, which is still rather unfamiliar in Japan.

It is a type of problem-based learning aimed at thinking of better ways to cope with similar problems in the future, rather than blaming someone for past failures.

Most of the issues taken up were failed cases, but they were filled with lessons to draw on.

But when the case method is adopted in Japan, most of the cases used would be successful ones, and people would learn little from them.

The difference in the way of approaching cases led to a large gap between Japan and the U.S. in their fight against the coronavirus.

Mitsuyoshi Urashima MD, MPH, PhD is a professor at Jikei University Hospital. Provided by the Asia Pacific Initiative, an independent think tank based in Tokyo. API Geoeconomic Briefing is a series that looks into global political and economic trends, with a particular focus on technology and innovation, global supply chains, international rule-making, and climate change.

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