Did Japan Just Beat the Virus Without Lockdowns or Mass Testing?

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Japan’s state of emergency is nearing its end with new cases of the coronavirus dwindling to mere dozens. It got there despite largely ignoring the default playbook.

No restrictions were placed on residents’ movements, and businesses from restaurants to hairdressers stayed open. No high-tech apps that tracked people’s movements were deployed. The country doesn’t have a center for disease control. And even as nations were exhorted to “test, test, test,” Japan has tested just 0.2% of its population — one of the lowest rates among developed countries.

Yet the curve has been flattened, with deaths well below 1,000, by far the fewest among the Group of Seven developed nations. In Tokyo, its dense center, cases have dropped to single digits on most days. While the possibility of a more severe second wave of infection is ever-present, Japan has entered and is set to leave its emergency in just weeks, with the status already lifted for most of the country and likely to exit completely as early as Monday.

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Analyzing just how Japan defied the odds and contained the virus while disregarding the playbook used by other successful countries has become a national conversation. Only one thing is agreed upon: that there was no silver bullet, no one factor that made the difference.

“Just by looking at death numbers, you can say Japan was successful,” said Mikihito Tanaka, a professor at Waseda University specializing in science communication, and a member of a public advisory group of experts on the virus. “But even experts don’t know the reason.”

One widely shared list assembled 43 possible reasons cited in media reports, ranging from a culture of mask-wearing and a famously low obesity rate to the relatively early decision to close schools. Among the more fanciful suggestions include a claim Japanese speakers emit fewer potentially virus-laden droplets when talking compared to other languages.

Contact Tracing

Experts consulted by Bloomberg News also suggested a myriad of factors that contributed to the outcome, and none could point to a singular policy package that could be replicated in other countries.

Nonetheless, these measures still offer long-term lessons for countries in the middle of pandemic that may yet last for years.

An early grassroots response to rising infections was crucial. While the central government has been criticized for its slow policy steps, experts praise the role of Japan’s contact tracers, which swung into action after the first infections were found in January. The fast response was enabled by one of Japan’s inbuilt advantages -- its public health centers, which in 2018 employed more than half of 50,000 public health nurses who are experienced in infection tracing. In normal times, these nurses would be tracking down more common infections such as influenza and tuberculosis.

“It’s very analog -- it’s not an app-based system like Singapore,” said Kazuto Suzuki, a professor of public policy at Hokkaido University who has written about Japan’s response. “But nevertheless, it has been very useful.”

While countries such as the U.S. and the U.K. are just beginning to hire and train contact tracers as they attempt to reopen their economies, Japan has been tracking the movement of the disease since the first handful of cases were found. These local experts focused on tackling so-called clusters, or groups of infections from a single location such as clubs or hospitals, to contain cases before they got out of control.

“Many people say we don’t have a Centers for Disease Control in Japan,” said Yoko Tsukamoto, a professor of infection control at the Health Sciences University of Hokkaido, citing a frequently held complaint about Japan’s infection management. “But the public health center is a kind of local CDC.”

Burning Car

The early response was also boosted by an unlikely happening. Japan’s battle with the virus first came to mainstream international attention with its much-criticized response to the Diamond Princess cruise ship in February that led to hundreds of infections. Still, the experience of the ship is credited with providing Japanese experts with invaluable data early in the crisis on how the virus spread, as well as catapulting it into the public consciousness.

Other countries still saw the virus as someone else’s problem, said Tanaka. But in Japan, the international scrutiny over the infections onboard and the pace at which the virus raced throughout the ship raised awareness and recognition that the same can happen across the country, he said. “For Japan, it was like having a burning car right outside your house.”

For more on Japan’s response to the virus:
  • Japan Could Lift Emergency in Tokyo as Soon as Monday
  • Japan Welcomed Foreign Workers Then Left Them in Covid-19 Limbo
  • Tokyo Mortality Data Shows No Jump in Deaths During Pandemic
  • Tokyo Head Sees Olympics Canceled if Virus Isn’t Under Control
  • Who’s Succeeding Against the Coronavirus and Why: QuickTake

Although political leadership was criticized as lacking, that allowed doctors and medical experts to come to the fore -- typically seen as a best practice in managing public health emergencies. “You could say that Japan has had an expert-led approach, unlike other countries,” Tanaka said.

Experts are also credited with creating an easy-to-understand message of avoiding what are called the “Three C’s” -- closed spaces, crowded spaces and close-contact settings -- rather than keeping away from others entirely.

“Social distancing may work, but it doesn’t really help to continue normal social life,” said Hokkaido University’s Suzuki. “The ‘Three C’s’ are a much more pragmatic approach and very effective, while having a similar effect.”

Different Strain

Infectious disease experts also pointed to other determinants, with Shigeru Omi, the deputy head of the expert panel advising the Japanese government and a former chief of the WHO Western Pacific office, citing Japanese people’s health consciousness as possibly the most important factor.

The possibility that the virus strain spreading in Japan may have been different, and less dangerous, to that faced by other nations, has also been raised.

Researchers at the Los Alamos National Laboratory in the U.S. studied coronavirus variants in a database and found one strain of the virus spreading through Europe that had several mutations distinguishing it from the Asian version, according to a paper put in early May. Although the study has not been peer-reviewed and drawn some criticism, the findings point to a need to more thoroughly study how the virus changes.

Large questions still remain over the true extent of the pathogen’s spread. In April, a Tokyo hospital conducted tests on a handful of non-Covid patients and found that around 7% had the coronavirus, showing the danger of missing asymptomatic or mild carriers that can become the source of an outbreak. An antibody test on 500 people in the capital suggested the true outbreak could be nearly 20 times larger than figures have shown. Analog contact tracing breaks down when infection numbers are high, and reports of people unable to get tested or even medical treatment for Covid-like symptoms peppered social media during the height of the outbreak.

And the fact remains that Japan’s response was less than perfect. While the overall population is much smaller, Asian neighbors such as Taiwan had just seven confirmed deaths from the virus, while Vietnam had none.

“You can’t say the Japan response was amazing,” said Norio Sugaya, a visiting professor at Keio University’s School of Medicine in Tokyo and a member of a World Health Organization panel advising on pandemic influenza. “If you look at the other Asian countries, they all had a death rate that was about 1/100th of Western countries.”

Buying Time

While Japan may have avoided the worst of the health outcomes, the loose lockdown hasn’t protected the country from the economic impact. Its economy, already dealing with the impact of a sales tax hike in October, officially slid into recession in the first three months of the year. Economists have warned the second quarter will be the worst on record, and the specter of deflation, which haunted the economy for decades, once again looms. Tourist numbers plummeted 99.9% in April after the country shut its borders, putting the brakes on a booming industry that had promised to be a growth driver for years. As in other countries, bankruptcies have risen sharply.

Even with the end of the state of emergency in sight, authorities are warning that life will not return to normal. When case numbers slowed in early March, there was public optimism that the worst was over -- only for cases to spike again and trigger the emergency declaration.

If a deadlier second wave does follow, the risk factor in Japan, which has the world’s oldest population, remains high. The country has speedily approved Gilead Sciences Inc.’s remdesivir and is now scrambling to allow the use of still unproven Fujifilm Holdings Corp.’s antiviral Avigan. There are calls for the country to use the time it has bought itself to shore up its testing and learn in the way its neighbors did from SARS and MERS.

Officials have begun to speak of a phase in which people “live with the virus,” with a recognition that Japan’s approach has no possibility of wiping out the pathogen.

“We have to assume that the second wave could be much worse than the first wave and prepare for it,” said Yoshihito Niki, a professor of infectious diseases at Showa University’s School of Medicine. “If the next explosion of cases is worse, the medical system will break down.”

— With assistance by Gearoid Reidy, and Marika Katanuma

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Italy’s Next Opening Step May Not Include Northern Areas

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The next phase in Italy’s relaxation of emergency measures to combat the coronavirus may proceed at different speeds in various zones, with some northern areas temporarily excluded from a reopening of borders between regions, la Repubblica reported.

It may prove “difficult” for northern territories — particularly the hard-hit Lombardy region around Milan — to be allowed to open their borders on June 3 as planned, the newspaper reported, citing government views on the most recent figures from public health authorities.

A decree from Prime Minister Giuseppe Conte that allowed a wide range of businesses to reopen on May 18 stated that Italians will be allowed full freedom of movement within the country on June 3, though health experts warned from the outset that differences in regional infection levels could make that problematic. Some governors have lobbied Rome to avoid different opening dates by region.

The economic situation is particularly dire in the north, the epicenter of the Italian outbreak. About half of all small businesses in Lombardy are at risk of collapsing, business lobby Confcommercio has said.

Lombardy and some neighboring northern areas could be made to wait until June 10 to open borders with other regions, Repubblica said.

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Bolsonaro’s Fiery Rhetoric on Display in Controversial Video

A video of a controversial meeting between Brazil’s Jair Bolsonaro and members of his cabinet became public on Friday, fueling a political crisis that embroils the president just as the coronavirus pandemic grips the country.

The footage of the April 22 meeting had been under seal as part of evidence presented by former Justice Minister Sergio Moro, who resigned last month accusing the president of seeking to interfere with police investigations, some of which potentially involve members of Bolsonaro’s family. The Supreme Court allowed an investigation into the matter, which is ongoing.

“I already tried to change people in our security in Rio de Janeiro officially but I wasn’t able to,” the president says in the video, which is riddled with crude language uttered behind closed doors. “I’m not going to wait for them to screw over my whole family.”

His words fueled multiple interpretations, including that he may have been in fact requesting a change in Rio’s police chief for the protection of his family. Bolsonaro also offered incendiary remarks cursing the governors of Sao Paulo and Rio de Janeiro states and commenting that installing a dictatorship in Brazil would be “easy.”

The video could end up implicating other cabinet members as well. Minister of Education Abraham Weintraub made disparaging comments about the Supreme Court, saying he would throw the justices in jail.

The Brazilian real rose after the publication of the video. “There’s nothing that relevant in the video,” said David Cohen, a partner at Paineiras Investimentos. “The market was waiting for this for two weeks, concerned about what the video could contain, and now that risk seems to be out of the way.”

Roberto Padovani, economist at BV, said, “There’s nothing new in the content of the video, nor anything that can erode Bolsonaro’s 30% support. So markets relaxed.”

Video Unsealed

Bolsonaro, who denies Moro’s allegations, had requested that parts of the video that are not related to the probe remain private to protect national interests. Moro, on the other hand, wanted it to be released to the public in its entirety.

In his decision to unseal the video, Justice Celso de Mello said the Watergate case from the Unites States, which led to the resignation of President Richard Nixon in 1974, had informed his judgment. He said it was legitimate for the Court to review acts of the president especially when they have to do with “the Head of State’s supposed criminal practice.” He determined the video should be unsealed for the sake of transparency and rejected Bolsonaro’s request that only a portion of the video be made public, saying that no secret content required part of the video to be withheld.

As part of the investigation, Mello asked the federal prosecutors to decide whether three requests from opposition lawmakers to have Bolsonaro testify and turn in his personal phone — along with the phone of his son Carlos — should be undertaken as part of the investigation. There is no deadline for the prosecutor to respond. In a statement, Institutional Security Minister Augusto Heleno called the seizure order “unbelievable”, an insult to executive powers, and “a clear attempt to compromise the harmony among powers that could have unpredictable consequences for national stability.”

High Stakes

The stakes are high for Bolsonaro, who is facing political and economic crises on top of the catastrophic public health crisis. The country recorded 1,188 deaths from Covid-19 over the past 24 hours, a daily record, and the total case count has topped 310,000.

Bolsonaro’s popularity has declined during the outbreak, in part due to his refusal to adopt social distancing measures and promotion of the controversial anti-malarial drug chloroquine. Contrary to the president, 76% of Brazilians believe social distancing is the best way to prevent the spread of Covid-19, according to a recent poll by XP/Ipespe. And even though half of Brazilians think his administration is “bad” or “terrible”, polling suggests his support base is still quite robust: 25% evaluated the president’s performance positively.

Moro’s defense team issued a statement Tuesday saying the video “confirms entirely” the declarations of the former cabinet member, and that its release would be in the public interest.

Read more: Bolsonaro in the Crosshairs of Brazil’s Top Court: A Quick Guide

— With assistance by Marisa Castellani

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The Next Covid Crisis Could Be a Wave of Suicides

The isolation, grief and economic hardship related to Covid-19 are creating a mental health crisis in the U.S. that researchers warn could make the already-rising suicide rate worse.

A study released Friday tried to quantify the toll. The paper, which was not peer-reviewed, found that over the next decade as many as 75,000 additional people could die from  “deaths of despair” as a result of the coronavirus crisis, a term that refers to suicides and substance-abuse-related deaths. The research was done by the Well Being Trust and researchers affiliated with the American Academy of Family Physicians. 

“I hope in 10 years people look back and say, ‘Wow, they way overestimated it,’” said John Westfall, director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, who co-wrote the report.

Even as the American economy rebounded after the last recession, suicides and overdoses cut into Americans’ life expectancy. Mental health experts worry that the economic uncertainty and social isolation of the pandemic will make things worse at a time when the health care system is already overwhelmed. The suicide rate in the U.S. has been rising for two decades, and in 2018 hit its highest level since 1941, according to a viewpoint piece in JAMA Psychiatry in April called “Suicide Mortality and Coronavirus Disease 2019 – A Perfect Storm?” Author Mark Reger argued social distancing could hamper suicide prevention efforts and said ensuring that doesn’t happen is a “national public health priority.”

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“There’s a paradox,” said Jeffrey Reynolds, president of a Long Island-based nonprofit social services agency, the Family and Children’s Association. “Social isolation protects us from a contagious, life-threatening virus, but at the same time it puts people at risk for things that are the biggest killers in the United States: suicide, overdose and diseases related to alcohol abuse.” 

Since the middle of March, the number of people filing for unemployment benefits has reached around 33 million. Americans’ life satisfaction has eroded rapidly throughout that same period, according to a poll released Friday by Gallup. The percentage of U.S. adults who are very content with their current lives and optimistic about their future outlook has dropped to a low not seen since November 2008 during the Great Recession, showed the analysis of more than 4,000 surveys.

“One of the main things people should take away from this paper is that employment matters,” said Benjamin Miller, chief strategy officer at the Well Being Trust and a clinical psychologist who worked on the paper. “It matters for our economic livelihood, and for our mental and emotional health.” 

The financial uncertainty caused by the coronavirus pandemic, coupled with the pervasive sense of isolation exacerbated by stay-at-home orders, makes this moment unprecedented—different from any other economic downturn in recent history—and thus, potentially difficult to model based on past events.

“It’s useful to have a wake-up call,” said Ken Duckworth, chief medical officer at the National Alliance on Mental Illness. “Unemployment is going to have a very important impact on deaths of despair.”

Already data is showing lower-income Americans are more impacted by coronavirus-related stress than their wealthier counterparts: A Kaiser Family Foundation study that showed 26% of people making less than $40,000 a year said the virus had a “major negative impact” on their mental health; only 14% of people making $90,000 or more a year said the same held true for them.

Johns Hopkins Bloomberg School of Public Health started measuring “mental distress” starting in March drawing on studies from the SARS epidemic of 2003. Early in the month, hotspots like California, Washington, New York and Massachusetts reported mental distress “significantly increased” — even when adjusting for variables like age and income. Distress was higher among people who used alcohol or marijuana more frequently in the past week or who’d consumed more media or social media. It was also higher in younger people, perhaps surprising given that Covid-19 is more lethal for older people.

New York Governor Andrew Cuomo said his state is seeing a rise in drug use, alcohol consumption and domestic violence. “It has caused serious mental health issues,” he said in a public briefing last week. He encouraged New Yorkers to take advantage of a hotline set up for those in emotional distress. Meanwhile, on the national level, the Substance Abuse and Mental Health Services Administration reported an 891% increase in calls to its Disaster Distress Hotline in March compared with a year earlier.

“We've seen from past work that policies play a really important role in shaping people's experience and well-being,” Julia Raifman, assistant professor of health law at Boston University School of Public Health, said. New York, for example, asked psychologists and psychiatrists to volunteer to provide some free mental health care, which she said was a positive step. “I hope we'll see other states start to do that. I think there's a lot of room for innovation here.” States that had more generous unemployment benefits during the last recession saw fewer suicides, Raifman said. 

Miller’s paper this week proposes long-term solutions like helping unemployed people find meaningful work or training the armies of contact tracers who will be sent out into communities to identify people at risk of a mental health crisis. He sees building up community-based mental health care services as a way to serve more people in need. Congress granted $425 million for mental health and substance use disorder initiatives in the Coronavirus Aid, Relief and Economic Security Act, or CARES, but Miller called that “almost an embarrassment” considering airlines got $25 billion in aid. “We are not taking this seriously as a nation,” he said. 

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