Via Financial Times

For as long as anyone can remember, cleaners at Tokyo’s 179 metro stations have assiduously sanitised each escalator handrail twice daily. With the appearance of coronavirus in February, they have raised the frequency and used a stronger antiseptic solution.

Japan’s pristine handrails and the calm upping of standards are just two examples used to explain the country’s subdued coronavirus case numbers since the outbreak began in China in January.

But the country’s low infection rate is now being called into question, with a spike in Tokyo raising alarm that Japan has been overly complacent and is set for a “second wave” of illness. 

On Thursday, Tokyo reported 47 new infections, of which the source of infection was unknown for more than 20. This marked the fourth day of record one-day rises after 41 cases were reported on Wednesday, bringing the total number of cases in Tokyo to 257. The increase prompted Yuriko Koike, governor of Tokyo, to warn of potentially “explosive growth” in new cases and that people should stay home this weekend. 

“There is a need for everyone to share a sense of urgency,” said Satoshi Hori, one of Japan’s leading experts on infection control and a professor at Juntendo University. “But people are becoming tired of exercising restraint.” 

Japan had appeared to be an outlier. Despite its initial botched handling of the quarantine on the Diamond Princess cruise ship in Yokohama, it has reported just over 1,300 infections and 45 deaths in a population of 127m, excluding those linked to the ship.

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Experts have been divided on why. Japan was theoretically vulnerable to a dangerous and fast-moving epidemic, with a quarter of the population aged over 65, high smoking rates and notoriously congested cities and public transport systems.

Fewer than 20 per cent of companies have provisions for teleworking, according to government data, so while there has been a significant move away from offices and public transport, it has not been on a large enough scale to empty the commercial districts of major cities.

Experts say a variety of factors have favoured Japan. They include habits such as bowing rather than shaking hands, removal of shoes indoors, the routine provision of hand wipes in restaurants and the fact that wearing masks is standard in flu and hay fever seasons.

People gather by the Olympic flame in Fukushima. Once the Games were postponed Tokyo authorities warned of a potential lockdown in the city © Jae C. Hong/AP

The country also has one of the world’s most generous healthcare systems and many of the elderly live in rural areas far away from their city-dwelling offspring. Prime Minister Shinzo Abe’s surprise decision to shut down schools from the beginning of March may have helped too. 

But until recently, Japan tested for the virus very selectively, arguing it had to focus on the critically ill to avoid overwhelming hospitals. That helped to keep official cases low but also created a potential pitfall by allowing Mr Abe to hold back from declaring an emergency. 

 “It doesn’t make any sense that a country next to China is seeing an expansion in cases only at the same time as European countries,” said Masahiro Kami, a physician and head of the non-profit Medical Governance Research Institute. “It’s just a matter of testing.”

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The German Embassy in Tokyo on Tuesday warned the risk of infection in Japan “could not be assessed seriously” because of the lack of testing

The low numbers of official cases have given the public a potentially dangerous sense of security. After an initial phase of rigorous mask-wearing, hand sanitising, social distancing and avoidance of crowded places, Japan has spent the past couple of weeks in something close to normal life. Roads remain full of traffic, people are joining viewing parties for the springtime cherry blossom festival and the major shopping areas are bustling. Last Saturday, to the consternation of medical experts, 6,500 fans of K-1 kick-boxing crammed into the Saitama stadium, just north of Tokyo, despite efforts by the local government to call it off.

Mr Abe’s refusal to declare an emergency led to accusations his administration wanted to maintain a “business as usual” approach so long as the Tokyo 2020 summer Games had not been postponed — something denied by government officials.

But within 24 hours of the decision to delay the event, Tokyo governor Ms Koike issued her warning of a potential lockdown of the Japanese capital for the first time.

Prof Hori said Japan’s health system would be at risk if there was a “tsunami” of infections in Tokyo. Hospitals have managed so far by focusing on the critically ill. “But if there is an overshoot, even Tokyo would face a collapse in medical care,” he said, citing the shortage of doctors specialising in intensive care. 

Japan has 13.1 hospital beds per 1,000 people, the highest ratio among OECD countries. But it only has 2.4 practising physicians per 1,000 — well below the OECD average of 3.5.

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The Medical Governance Research Institute’s Mr Kami rejected suggestions the health system was in jeopardy. But he said any lockdown would create deeper turmoil and deal a blow to an economy already on the brink of a technical recession.

“Japan took a rational approach while keeping the number of deaths low,” he said. “Its economy is already weak so it has been difficult to do the kind of lockdown that was carried out in China and the US.”

However, changing the attitudes of the Japanese people after weeks of allowing them to operate in a relatively relaxed environment might not be straightforward. In a sign of just how hard this might be, ahead of a weekend during which residents of Japan’s biggest cities have been asked to stay indoors, none other than Akie Abe, the prime minister’s wife, was seen with a group of celebrities at a cherry blossom viewing party in central Tokyo.