Imagine having permanent residency in a country, owning a home there and paying a mortgage on it, having a job and paying taxes, your kids were born in the country and go to school there and you’ve been paying health insurance and pension contributions. Yet, once you leave you are not allowed back into the country where you live. That is what Japan has been like for the last five months for any resident holding a non-Japanese passport. Meanwhile Japanese citizens where free to travel to Europe and come back to Japan. Also, Japanese citizens living in the EU, the US, Canada, Australia and New Zealand were able to travel to Japan and then return to their homes in the respective countries as long as they observed applicable quarantine rules.

Japan was the only G7 country treating permanent resident different from its citizens with regards to returning after a trip abroad. This policy led to criticism by the international community but also by Japanese businesses who understand how this discrimination hurts Japanese prospects as a country to invest in and do business with. Because of this discrimination, Germany suspended non-resident Japanese from being able to visit Germany until Japan grants the same travel rights to resident EU citizens as the EU grants to resident Japanese citizen.

The criticism and sanctions worked and Japan has finally announced a change in their policy. From September 1, foreign residents of Japan will be able to travel abroad and later return to Japan again, provided they follow some regulations. Before they depart they will have to agree to comply with enhanced quarantine regulations on return. Before they return they will have to take a PCR test and provide a negative test result. Besides the test result, they will need to provide a form filled in and signed or stamped by the hospital or doctor conducting the test (link, Microsft Word .docx format). They will be tested again on arrival. If the test is negative, they can go home to quarantine themselves for 14 days, provided they don’t use public transport (i.e. they must use a hire car or be picked up in a private vehicle).

Here is a PDF with details of the new policy.

It’s been more than a year since I last visited my mother, who is 80 years old. I am a permanent resident of Japan, but if I go and see her in Germany, I will not be able to return to the country where I live with my wife and kids, own a home, run a business and have been paying taxes for the last 27 years.

Japan is currently the only G7 country that discriminates between citizens and permanent residents on their right to return to their place of residence. While EU countries, the United States, Britain, Canada and Australia exempt not only citizens but also legal permanent residents and other long-term visa holders from the current SARS-CoV-2 related travel restrictions, Japan does not. Once you leave, you can’t come back.

Japanese citizens may still enter Japan if they have spent time in any of 119 countries on the banned list during the last 14 days. They are expected to take a PCR test when they arrive back at the Narita or Haneda airport but if the test is negative, they can travel to their home as long as they avoid public transport (i.e. they can get picked up by family or hire a car and driver). They are then expected to self-quarantine for two weeks. Apparently it’s still OK for them to buy their own groceries while in quarantine. Unlike quarantines in Taiwan their movements are not monitored in any way (e.g. no GPS tracking, no random phone calls).

At this time, foreign Permanent Residents and spouses of Japanese Nationals may only enter Japan if they had already left before the ban on the country they visited was imposed (April 3 for EU countries). In this case they are expected to self-quarantine the same way as Japanese citizens.

If they leave after the ban was imposed, for example now, then they will only be readmitted if they have left for specific humanitarian reasons, such as visiting a dying close relative or attending their funeral or for urgent medical reasons. They will have to show evidence of this to an immigration officer when they leave and even then they will not be guaranteed that they will be re-admitted. They will actually have to sign a disclaimer telling them as much. The decision is always up to the immigration officer when they re-enter.

Holders of other Japanese visa, such as people on student visas, can not enter Japan, even if they had traveled abroad before the entry ban was imposed. They are stuck outside, though this may get addressed in coming weeks.

EU countries and all other G7 countries will admit both their citizens and legal long-term residents (with appropriate quarantine rules). If you are a Japanese citizen who is resident in Düsseldorf or London or Los Angeles, you will be able to travel freely between your home and Japan, for whatever reason, as long as you observe quarantine regulations. If however you are a non-Japanese Permanent Resident of Japan who lives there, owns a home there, pays taxes there and has lived there for decades, if you were to travel back to your native country for business or to visit your family, you would be indefinitely prevented from re-entering Japan, regardless of any Covid-19 tests or quarantine period you are willing to submit yourself to.

The Japanese government is talking about opening Japan to business travellers from selected countries in the region, followed by students on student visas and finally tourists. No mention is being made in this plan of the fate of residents based in Japan, as if they did not exist.

In July the European Union opened the EU for travel from a selected list of countries with relatively low prevalence of Covid-19, including Australia, New Zealand and Canada. However, the German government announced that China, South Korea and Japan will only be added to this list once they reciprocate and treat EU citizens the same as the EU treats their citizens. Let’s hope that Japan will soon amend its rules.

Every day Tokyoites are anxiously waiting for the latest daily count of new confirmed Covid cases: Is it less than 200 or more than 200? It was a big thing when it first exceeded 100. On April 11, it barely missed the next big number with 197 cases. But what does it really mean?

“Cases of Covid-19 confirmed with PCR tests” depends as much on the number of tests conducted as the actual number of people newly infected. Anyone not tested is by definition not included in the count. Until now, anyone testing positive has been sent to a hospital, which supposedly is legally required (only recently have light cases been moved out to specially rented hotel rooms). Therefore hospitals have been reserving tests to people with the most severe symptoms or with pre-existing conditions so that the most deserving patients will occupy the limited hospital beds they can take up.

It may seem counter-intuitive, but the primary purpose of testing has not been to track the growth of infections but to allocate hospital beds. The number does not reflect reality as it is artificially throttled. As long as this policy continues, new confirmed cases will basically only be allowed to grow at a rate at which hospital beds are found for them, which is becoming increasingly difficult, as more and more hospitals are turning away new patients to avoid healthcare associated infections (HAI). There have been a number of cases of infection hotspots in hospitals.

An article in the The Atlantic discusses positivity, the rate of confirmed infections found as a share of tests conducted in different states and countries (please don’t confuse this with prevalence, the rate of infected people as a percentage of the population).

Basically, the higher the percentage of tests that come out positive, the more likely a country or region is to be undercounting infections, for example because of limited lab capacities or limited access to hospitals that can do testing:

“[W]hile the U.S. has a 20 percent positivity rate, South Korea’s is only about 2 percent—a full order of magnitude smaller.

South Korea is not alone in bringing its positivity rate down: America’s figure dwarfs that of almost every other developed country. Canada, Germany and Denmark have positivity rates from 6 to 8 percent. Australia and New Zealand have 2 percent positivity rates. Even Italy—which faced one of the world’s most ravaging outbreaks—has a 15 percent rate. It has found nearly 160,000 cases and conducted more than a million tests. Virtually the only wealthy country with a larger positivity rate than the U.S. is the United Kingdom, where more than 30 percent of people tested for the virus have been positive.

Comparing American states to regions in other countries results in the same general pattern. In Lombardy, the hardest hit part of Italy, the positive rate today stands at about 28 percent. That’s comparable to the rate in Connecticut. But New York, so far the hardest hit state in the U.S., has an even higher rate of 41 percent. And in New Jersey, an astounding one in two people tested for the virus are found to have it.”

(The Atlantic, 2020-04-16)

So what this tells us is that a high positive rate in the tests conducted indicates a higher rate of uncounted cases that the system can’t keep up with.

What does that mean about the potential undercounting of explosive infection growth in Japan and specifically in Tokyo? According to statistics published by the Tokyo Metropolitan government on its website, by yesterday (April 16) Tokyo had 2,595 confirmed Covid-19 cases out of 7,244 cases tested. That’s a positivity of 36%, higher than the positivity for the UK (30%), Lombardy and Connecticut (28%), the US overall (20%), Italy (15%) and Canada, Germany or Denmark (6-8%). Only New York and New Jersey are worse.

Recently, Germany has been running 350,000 tests per week and is capable of running up to 500,000 tests per week. Tests are analyzed 7 days a week, 24 hours a day using shift work in the labs. Japan, with a population 52% larger, has averaged 22,000 tested individuals per week over the past two weeks (Apr 2-15).

Don’t take any comfort from numbers staying flat or growing moderately unless testing is also expanded exponentially to keep up with and exceed the growth rate of virus cases. Without greatly expanded testing, we’re like a pilot flying blind in a cloud without radar. Beware of the mountains ahead.

See also:

• A New Statistic Reveals Why America’s COVID-19 Numbers Are Flat (The Atlantic, 2020-04-16)
• Latest updates on COVID-19 in Tokyo
  
• 新型コロナ疑い患者 救急搬送で110か所から受け入れ不能 東京

America has Dr. Anthony Fauci and Dr. Deborah Birx, who provide scientific information at White House press conferences.

Germany has Prof. Dr. Lothar Wieler of the Robert Koch Institute, who speaks at biweekly press briefings. Dr Christian Drosten, chief virologist at the Charité hospital in Berlin, has provided frequent commentary to the public.

Where are these experts in Japan? The briefings I have watched in Japan primarily involved Prime Minister Abe Shinzo and Governer of Tokyo Koike Yuriko.

Yes, individuals scientists have been interviewed by the “wide shows” entertainment programs, but why are they not given a prominent official role in shaping public responses to the epidemic? Yes, the declaration of emergency is supposed to be based on the discussions of a circle of experts, but we don’t directly hear from them. It’s only the government that consults with them.

The impression this creates is that the decisions being made are ultimately driven by political and economic considerations, which take priority over any medical interpretation of the situation.

As Son Masayoshi of Softbank pointed out in a recent tweet, it is strange that in Japan Covid-19 policy is spearheaded by the Minister of Economic Revitalization instead of a health expert such as Dr. Fauci in the US. That tells you all you need to know about the priorities of the Abe government.

Following the “not a lockdown” in Tokyo and 6 other prefectures, the summer resort town of Karuizawa has reportedly experienced an influx of cars with Tokyo license plates as Tokyo residents with second homes (bessō) in the area are flocking to the town in Nagano that is not yet subject to the restrictions.

I would expect a similar pattern to unfold in resort areas around Yamanakako and Izu (in Yamanashi and Shizuoka, also not among the 7 prefectures).

Not only does this exodus from the city risk the spread of infections to prefectures that currently still have a lower incidence of Covid-19, it could also have infected bessō owners take up rural hospital beds then no longer available for the local population after they also get infected.

Other countries have clear policies that discourage people from dashing to second homes, which earned Prince Charles some criticism for self-quarantining in Scotland and cost Scotland’s chief medical officer her job. Don’t get me wrong, I understand why they’re doing it, but it’s selfish and against the spirit of sheltering in place. Why should others stay put in their tiny Tokyo apartments when some can drive across the country?

While it can be said that refugees from the city will spread the load on the health care system between urban and rural hospitals, that is something the national government should be thinking about, not something only those rich enough to own two or more homes to take advantage of.

There have been many comments on the relatively low mortality in Germany relative to the number of confirmed cases. The median age of infected persons in Germany is 47 compared to 64 years in Italy. Many Germans were infected while skiing in Austria or northern Italy (the same is true for Norway and Iceland, which also imported the problem this way) and these younger, healthier patients have a lower risk of severe outcomes.

Germany has relied heavily on PCR testing from an early stage. Because of this the total number of confirmed cases includes many light cases that might otherwise have remained undetected. Last week about 350,000 PCR tests were performed in Germany, an average of 50,000 a day. This compares to 28,000 people in total who have been tested in Japan so far. Japan’s population is about 50% larger than Germany’s.

By tracing these mostly mild cases with large scale PCR testing, the authorities have prevented the spread to other more at risk groups of the population.

The youngest person in Germany to die from Covid-19 so far was 28 years old and had a pre-existing condition.

There is a distinct gender bias in fatality. 84% of the 31 persons under 60 to die were male (26m, 5f). 73% of the 44 persons between 60-69 were male (32m, 12f). In the 70-79 bracket, 78% of the 130 who died were male (102m, 28f). For 80-89, the largest age group with 305 deaths, the ratio is 61% male (185m, 120f) even though far fewer men reach this age than women. Even in the 90 and above bracket (71 deaths), male deaths still outnumber female deaths (38m, 33f).

On March 30, the number of new infections in Germany dropped close to the number of fresh recoveries (4,450 vs. 4,289), which recently increased. Combined with 104 deaths this meant that the number of active cases (total confirmed infections – deaths – recoveries) only climbed by 57 or 0.1%. This is the lowest rate of increase since the start of the epidemic, which if it continues gives reason to be hopeful.

The number of confirmed COVID-19 cases has increased by this much daily (most recent three days average) in the following countries:

1) Korea: 1%
2) Japan: 5%
3) Italy: 14.2%
4) Spain: 22.8%
5) Germany: 26.8%
6) USA: 29.6%

Korea
Korea seems to be getting close to getting the epidemic under control. Patients who have officially recovered now outnumber new infections day by day. That is very encouraging.

Japan
Due to geographic proximity and economic relations with China, Japan was also one of the countries with early cases, many of them visitors to China. It crossed the 100 confirmed case threshold on February 22, one day before Italy, yet the outcome could not have been more different. Since then the case number doubled three times in Japan (about every 8 days on average) versus 8 times in Italy (about every 3 days). Confirmed case numbers can not always be taken at face value as they can be quite dependent on the amount of testing and most mild cases will most likely never be counted. There could easily be an order of magnitude more cases than listed in the official statistics. However, 28 deaths in Japan vs 2,503 in Italy (i.e. about 90 times more) suggests that there were actually hugely different outcomes in these two countries. Japanese infection case numbers have increased about 9 times since they were below 100 whereas in Italy they increased about 400-fold since that threshold. One would expect higher mortality in Italy once the medical system was stressed to limit and beyond. Quite plausibly Japan and Italy have been counting a similar percentage of actual cases, but case numbers have been growing much slower in Japan (9% daily average over 24 days) than in Italy (28% daily average over 23 days) and with less stress to the medical system, outcomes have been less lethal on top of numbers being smaller. With intensifying efforts at social distancing, Japan may be next at halting the spread for now. It will still be a difficult road.

Italy and Spain
In Italy the absolute number of daily new infections has been more or less flat for the last 4 days. As a percentage of existing cases it is now half of what it was about week ago, but as total numbers still tripled, the new cases are still at a peak, even if steady. In Spain too the daily increase as a percentage has slowed but like in Italy it has some way to go before it comes close to zero.

Germany and US
Neither in Germany nor in the US is there a clear drop in the daily case growth percentage yet. They are still in exponential growth. Hopefully self-isolation measures will bite soon.

Other numbers
Germany has 5 times as many respirators as France (25,000 vs 5,000).

Italy now has about half as many infections per million inhabitants (~500) than Hubei province, where Wuhan is located, had at the peak of the local outbreak (1,100 per million).

Sources:

• worldometers.info
• WHO Coronavirus disease (COVID-2019) situation reports