Conspiracy theories about Japan’s approach to the coronavirus (COVID-19) are beginning to spread online, as people find it very difficult to believe that the country still has only 1000 cases of the virus even though it has not been testing a great deal. This has led to suggestions that Japan is covering up the true number of cases, and the epidemic is out of control in Tokyo.

This isn’t true: Japan has actually tested quite a lot of people, the epidemic is not out of control here as it is in so many other countries, there is no cover up, and what is happening in Japan is an example of what can be achieved with careful, early interventions. I will explain this here a little.

What is Japan’s epidemic situation?

According to the Ministry of Health, Labour and Welfare there were 1193 confirmed cases of COVID-19 on 25th March, of whom 272 had recovered,  43 had died and 57 required ventilator support. Japan’s first death from COVID-19 occurred on 13th February, about 41 days ago, a lot earlier than in other countries such as Germany (15 days ago), Italy (34 days ago) or the USA (25 days ago). For a disease as infectious as this one, these small differences in number of days should lead to huge differences in case numbers: Japan has had 16 days more than the USA to see this epidemic grow, but on day 9 the USA had only 645 cases – now it has 64,661 cases. It is obviously mystifying to many people that the US could see a 100-fold increase in the number of cases in the same time period that Japan saw only a two-fold increase. The obvious suspicion is that since Japan hasn’t tested that many cases, they must be hiding something. There are two reasons this theory doesn’t work: 1) Japan is actually testing more than people recognize and 2) you would definitely be able to tell if there was a 50-fold undercount of cases.

What is Japan’s testing situation?

Testing data can be obtained here. Japan has tested about 22,000 people, of whom 1193 have been confirmed positive. In contrast Germany has tested 167,000 and the UK has tested 65,000. This certainly seems like a lot of missed tests in Japan, but it is worth bearing in mind that the number of tests per positive person is actually about the same in these countries: 18.4 per positive in Japan, 19.7 per positive in the UK, and 25.5 per positive in Germany. In South Korea the number is unusual: 350,000 tests for about 9,000 cases, or 38.9 tests per positive case, but South Korea was dealing with a unique situation where a particular population group was known to be at risk (the weird religious group) and an aggressive testing policy could be targeted based on a social identity. In other countries the number of tests has approximately mapped the scale of the epidemic. This strangely stable ratio of tests to positive patients arises from the limitations on the test: it can only work on people who currently have the virus (it’s a PCR test) and it is expensive and still limited, so population-level testing cannot yet be conducted, and if done partially would miss cases. Basically every country is using passive case-finding to identify the disease, and only using the test where the symptoms suggest it, in order to conserve tests and avoid the social consequences (isolation and clinic shutdowns) associated with false positives. Japan is doing no differently here than Germany or the UK, it’s just that there are less people with symptoms, and less people to test as a result.

It’s worth noting that Japan set up a call centre for people with COVID-19 concerns on the 28th January, and since the middle of February it has been receiving about 3000 calls a day (also, somewhat cutely, 0-2 faxes per day: don’t ever change, Japan!), so there have been about 150,000 calls over the period of testing. In a country of 120 million this doesn’t seem to be a sign of a massively out of control epidemic. I can’t find statistics on the NHS 111 line but there are many stories out there about how it is congested with calls.

Why is Japan following this policy?

There are several levels of testing that can be conducted for any disease, ranging from population screening (seen in breast cancer programs) through voluntary testing (seen in HIV prevention programs), active case finding (where community health organizations target particular groups known to be at risk of a disease, usually used for TB) to passive case finding, which is used in almost all non-fatal sexually transmitted infections, influenza, and other infectious diseases. Screening is usually only conducted if the disease course can be changed by early detection. Passive case finding is useful when there is no identifiable group to target, or the disease prevalence is low so the chance of a positive test is low, or the test is rare/expensive/invasive. In this case the test is still restricted in availability, and the disease prevalence is low so you need to use a lot of tests to find one case. This is complicated in the case of COVID-19 by the possibility that the testing process itself will infect the tester, and so it’s better not to go charging out into the community exposing testers to large amounts of potentially infected people. South Korea conducted a kind of active case finding program, but that is because they knew where to look.

In this sense Japan’s policy is really no different to that in other countries. Japan has focused its efforts up until now on finding cases through cluster investigation: a lot of cases in Japan up until recently have arisen from cluster’s connected to specific events, and finding the people connected to these clusters and isolating them is super important. A single live music event in Osaka, for example, was responsible for 48 cases (about 5% of all the cases in Japan!), and had those cases not been tracked they would have turned into a huge outbreak. You can see the effect of this cluster approach in the statistics: often new cases (particularly in rural Japan) are asymptomatic, which indicates they were caught as part of a contact tracing effort; and even today with 40 new cases in Tokyo about half have a known contact already, which suggests they were tracked down (or their contacts will be). Quite a few cases are also imported: 5 of today’s 40, for example, have an overseas travel history. Focusing on clusters means targeting testing at people who need it, which avoids clogging up testing facilities and ensures that the test follow up is good quality.

Another reason for Japan’s low number of tests is its basic advice to people with suspected COVID-19. The advice from the government to citizens and medical institutions alike is: don’t come in for a consultation unless you have a fever >37.5C and coughing/chest tightness for at least 4 days (unless you’re pregnant or otherwise at risk). Until then you should self-isolate and avoid travel. This advice is super important in Tokyo, where most people travel by public transport, and ensures sick people aren’t infecting others on the train, and it avoids over-burdening health facilities with people who just have a cold. Two of my role-playing group have gone through this process; one went to the doctor after 4 days and was diagnosed with a cold based on x-ray and influenza tests, and the other self-isolated until her symptoms faded after 3 days. We’ll never know if she is immune to the virus now, but it doesn’t matter because she wasn’t at risk and she did not infect anyone else by getting on a train. Given that a lot of cases in Italy are now being  reported as hospital-acquired, this is good advice – but it also leads to the use of less tests.

So how do we know the size of Japan’s epidemic?

If we aren’t testing, how do we know what’s happening? First, we can assume given the ratio of positive results to tests is the same as in other countries that the process is working the same way here, and less tests are needed because less people have the virus. Second, though, we can look at the state of hospital emergency and intensive care wards, and make a judgment about the epidemic from the burden those wards are facing. In New York, for example, we now have horrifying accounts of emergency wards overflowing with cases and doctors working without breaks as their hospitals become basically COVID zones. In Italy new triage guidelines are being released for rationing ventilators. I am sure that is not happening (yet) in Japan, for two reasons: I work with doctors at a major hospital, and I am regularly visiting that hospital for medical care.

I have worked in and around hospitals for my whole career, doing data management and research, including in Japan, and I am familiar with how a hospital feels when it is working well and when it isn’t. You can tell from the way the doctors and nurses are working, the state of the physical environment, and what they complain about when they talk to you during your work day, whether they are struggling. Doctors are often wrong about epidemiology but they have an eye for when things are changing in their case load, and when they talk to you about it you can tell if things are going wrong. I don’t get that impression from my day job, or from any of my research colleagues from other hospitals here. There is not yet any pressure on emergency or intensive care services. I also receive the circulars for the medical staff in my work email, and so I can see how they are preparing for a surge that has not yet happened (today for example I received reassuring news about the stockpile of emergency equipment that my hospital has, the kind of news that would probably make an American very angry at how ill-prepared their system was). It’s not complacency or a lack of care: the wave just hasn’t hit yet.

The second reason I know this is that I have had to visit a lot of different parts of this hospital for medical care for my stupid knee, which I dislocated at kickboxing four weeks ago and have subsequently discovered has been missing some major components for the past 30 years. I only discovered this through multiple x-rays, MRIs, and CT scans (which I guess Aussie doctors didn’t feel I deserved over the first 30 years of my life!) As we all know, X-rays play a very important role in COVID-19 care since they enable doctors to see what kind of damage is going on. There is no way I would have sat just 10 minutes in the x-ray queue, watching orthopaedic patients hobble in and out calmly, if my hospital were overrun with COVID patients – I would probably be sent off to an external private provider or forced to wait all day. There’s also no way the CT scanner would be available for me to use 15 minutes before my appointment.

Unless Japanese people are uniquely able to resist this virus, the surge isn’t here yet, which means the epidemic is still in its infancy here – but that may all be about to change.

Japan’s prevention policy and what is coming soon

Japan has avoided major lockdowns yet, because it acted early and sensibly in light of warnings from China. The Japanese government listened to China, sent help early on, and paid careful attention to what was happening. The first advice from the Ministry of Health, Labour and Welfare was sent early – probably in early February – and the first restrictions on public behavior were instituted probably two weeks after the first death in mid February. My work events were being canceled by the end of February, and instructions were being disseminated throughout Japan to avoid large events. New advice about self isolation was issued early, and the National Institute of Infectious Diseases began its epidemiological investigations early. Japanese companies already have seasonal flu policies in place, and it is quite common for people to self-isolate if they have influenza, and those who don’t self-isolate will wear masks and behave responsibly with their disease. Japan is also not a touchy-feely huggy kind of country, and bowing is the standard greeting. In contrast, the UK was still considering what to do about large events in early March, and hand-shaking was still being discussed. It’s incredible that the day before the UK experienced its first coronavirus death, when Italy was starting to go pear-shaped, and in light of China’s experience, the British government still had no opinion on large events or shaking hands, one of the most disgustingly unhygienic ways you can greet someone.

This early action has served Japan well – even though it at no point closed its border to China! – but it may not be enough. Yesterday there were 40 new cases in Tokyo and 95 new cases in the whole country, and the Tokyo governor asked people to stay inside all weekend and not travel at all unless it was an emergency. There has been general uproar that a large kickboxing event (K1) was held on Sunday, and also consternation at the large numbers of people still going to parks and gardens for ohanami (it’s the season). If counter-measures aren’t stepped up it’s likely that Japan will lose a grip on this. It’s my expectation that by next weekend the Ministry of Health, Labour and Welfare will announce a lockdown, at least of the major cities, and an extended closure of restaurants and bars (to be clear, I have no inside knowledge of this – it’s just my judgment). The 40 cases we saw in Tokyo today were at least partly a result of last weekend’s ohanami madness, and we won’t know the effect of a weekend shutdown until next week, so my guess is the government will increase the restrictions next weekend. Given the small number of cases at present and the slow daily growth they probably only need to maintain a couple of weeks’ shutdown, not the extended horror we have seen in some cities, but my guess it is coming. If the Japanese government does what it’s very good at and dithers, expect Tokyo to become a zombie survival game show within a month. But so far the Japanese response has been measured and careful and effective, so I hope they will continue this and will get this right.

A note on conspiracy theories and racism

It’s worth recognizing that the European and Anglosphere countries (except perhaps for New Zealand) had two months’ warning of what was coming, they watched everything that was happening in China and they basically ignored it. Even Boris Johnson’s rapid turnabout on his irresponsible and inhumane “herd immunity” policy wasn’t driven by the clear knowledge available to the whole world from China; he waited until some white dudes at the University for Killing People and Stealing their Shit had had time to update their model with the Italian experience before he realized what a disaster he was unleashing. It seems that no one in the west at any point considered Chinese experience, Chinese struggle or Chinese lives worth anything, and ignored all the warnings they were being given until it was too late. Japan, on the other hand, listened to China and bought itself a month of slow growth as a result.

The conspiracy theories you see online about China and Japan are grown in the same fertile racist soil as the European policy mistakes. There is a long-standing image of Asians as shifty, untrustworthy, authoritarian and narcissistic, and that is exactly the racist image that drives these conspiracy theories. It’s not possible for white people to imagine that Asians could be doing something better than them, so they simply imagine that Asians are lying and covering up the truth. Inscrutable, untrustworthy and impenetrable societies are hiding the numbers and pretending everything’s okay for their own nefarious ends (or to “save face”).

Needless to say, it’s all bullshit. There is no conspiracy, and nobody is covering anything up. Asia is just doing it better, and the west needs to start listening to what’s happened over here, if they want to escape this with any of their grandparents alive.