Covid-19 in Japan, Part 1

At a park near my apartment in Tokyo on Saturday. On a normal
weekend it'd be busier, but the city certainly isn't empty

If you take a look at the official statistics of cases by country, you may be surprised to see that Japan is nowhere near the top of the list. As of today, April 5th, Japan has reported 3,139 cases. Japan was one of the first countries to identify a case of the virus outside China, all the way back in mid January.

To top it off, the government has refrained from any significant quarantine or lock-down measures. I just started working remotely part of last week, but still went into the office on Tuesday and Wednesday. On both days, the metro was full--well, certainly not as packed as a typical morning rush hour in Tokyo, but all the seats were taken and many more passengers were standing. There was no way I could have kept a two meter / six foot gap recommended by social distancing. When I left the office for food, restaurants were still open and there were business people out and about on their lunch breaks.

This begs the question: how is it that Japan has managed to avoid a massive outbreak?

Japan's trajectory appears to show slower growth in cases and deaths than almost any other country;
slower even than South Korea, which has been much more proactive in containing the virus

Many of the online forums and news articles I'm reading cite a list of reasons along the following lines:
- Japan is a clean country with already high levels of hygiene. For example, most restaurants will give you a disinfectant towel to wipe your hands off before you eat
- wearing face masks is normal, and most people have adopted the practice during the outbreak
- a conformist culture assures that people follow recommended health guidelines
- Japanese people are on average healthier than their counterparts in the west
- close personal contact is uncommon; a bow at a distance is a normal greeting, versus a handshake in the US or a kiss on the cheek in many European countries

Most people on the metro are wearing masks, which were already
a common sight before the covid-19 outbreak

These are all valid points, which I think can explain some of the slower rate of infection in Japan. However, this fails to capture the whole story. I included the detail about the hand towel to note that to kill off the virus, you'd need an alcohol content of at least 60%, whereas most of the towels you get a restaurant have very little if any alcohol in them.

Also, many public restrooms in Japan don't have soap. I've noticed temporary bottles at some metro station bathrooms, but the one I tried to use was empty. I also witnessed multiple people only washing with water. So, although hygiene is generally good--and people in my office have been prudent with hand washing--adoption certainly isn't universal.

A lot of public restrooms, such as in parks and metros, don't have
soap or hot water. Some older ones, like this, also have squat toilets

When it comes to masks, I'll admit that I was initially skeptical. I read that it doesn't prevent you from breathing in small particles, and when I started to wear it (a requirement at work since early March) I felt that I actually touched my face more, not less, since I wasn't used to the sensation. I also thought that people who wore a mask might be less diligent in taking other necessary precautions under the false assumption that a mask would protect them.

Over the past month I've come around to masks--not as a cure all, but one of several things we can do to lower transmission. Even if your standard convenient store mask doesn't block fine particles, it still probably limits germs from spreading if you're sick, coughing, or sneezing. So it won't protect you from catching the virus 100% of the time, but if most people wear them, they should slow down transmission.

Over the past few weeks, a good 75% of people on the metro wore masks, and this week even more are doing so. That probably helps. Plus, I think the custom of bowing instead of some form of physical embrace makes a big difference.

Different degrees of bowing even signify different
levels of respect / importance.

But to me, those explanations don't tell the whole story. Japan continued to allow Chinese tourists to enter the country long after other countries imposed restrictions or full out bans. In February it let passengers from the Diamond Princess disembark without a proper quarantine, and some later tested positive after traveling home. Take South Korea, which has similar customs and nearly 10,000 confirmed cases. How is it that Japan has two and a half times the population but only one fourth the number of cases as Korea (I initially wrote this when Japan had about 2,500 cases)? Also keep in mind that Korea has been under much stricter social distancing for over a month. Some of the clusters have been in church groups, although I find it hard to believe that could be the full explanation for the difference.

This gets us to a major underlying issue--testing. While South Korea has been aggressively testing, Japan has done the opposite. Measured in terms of tests per million people, Japan has one of the lowest rates of any wealthy nation.

This one is an older chart, from early March. The US has since
ramped up testing, unlike Japan

Since early March many countries have started to test widely, but not Japan. As of today, the US has administered close to 5,000 tests per million. Some countries are over 10,000. Japan, on the other hand, is at 339 (see the table below for a comparison).

Why is Japan lagging behind, testing even fewer than the likes of Peru and Thailand? It's not because hospitals lack the capability; in fact, by mid March, the county had the capacity to administer 7,500 tests a day, but were only carrying out an average of less than 1,200. Even among those, many were testing the same patient multiple times. Although testing rates have slowly been increasing, it is still at such a low rate that the U.S. Embassy recently released a statement that "The Japanese government's decision not to test broadly makes it difficult to accurately assess the COVID-19 prevalence rate."
(https://www.japantimes.co.jp/news/2020/03/18/national/japan-testing-covid-19-sixth-of-capacity/#.Xol1heozapo; https://mainichi.jp/english/articles/20200404/p2a/00m/0in/014000c)

I believe part of the reason for the low testing rates was because of the Olympics. It wasn't until the 24th of March that the OIC officially announced the games would be postponed. Even though the writing was on the wall several weeks prior, the Japanese government was slow to acknowledge reality. Less than ten days before the postponement announcement Prime Minister Abe said in a press conference that the Olympics would go ahead "without problem, as planned."
(https://www.theguardian.com/world/2020/mar/14/shinzo-abe-insists-japan-olympics-will-go-ahead-as-planned-despite-covid-19).

So my theory is that the government was trying to show the world that everything was fine in Japan and they could handle the Games. That meant downplaying the severity of the outbreak here. I'm not suggesting they deliberately botched the numbers, but it could explain why so few people have been tested. There were also reports of the public health authorities refusing to allow doctors to test patients for the virus (from Wikipedia, so not corroborated). I'm open to other explanations, but haven't come up with any ideas yet.

Looking forward, I wonder if we'll see a spike in reported cases. The number has already doubled in the last nine days, with the largest cluster now in Tokyo. I imagine cases will continue to jump, but we won't see anything nearly has bad as the US or some Western European countries. The aforementioned factors--cleanliness mask-wearing, bowing, etc.--do help. I just hope there won't be more serious restrictions on going outside or business closures. I've started to work remotely several days a week, and might go full telework. I'll update you on that in another post. In the meantime, stay safe and try not to go crazy if you're stuck indoors!