The coronavirus situation in Japan is probably much worse than you think

I have been corresponding with a working group regarding the covid-19 situation in Japan.  They shared a draft of their white paper with me while attempting to circulate their revisionist conclusions in policy circles.

The speed premium is indeed increasing quickly.  The white paper has not materially changed since when I first saw it. Since then, the Olympics were postponed and experts in Japan have described the outbreak as “rampant.”  The working group feels that society needs to prepare, and that this outweighs the desire to wait for additional official confirmation.

The authors are an international team based in Tokyo. They cannot attach their identities to the white paper at present.  They are not medical researchers. They have reviewed their conclusions with a medical researcher and others.  You can weigh the evidence of their claims.

Here is the document (no, it is not malware), and here is the opening bit:

The governmental and media consensus is that Japan is weathering covid-19 well. This consensus is wrong. Japan’s true count of covid-19 cases is understated. It may be understated by a factor of 5X or more. Japan is likely seeing transmission rates similar to that experienced in peer nations, not the rates implied by the published infection counts. The cluster containment strategy has already failed. Japan is not presently materially intervening at a social level. Accordingly, Japan will face a national-scale public health crisis within a month, absent immediate and aggressive policy interventions.

There is a great deal of further detail, including the numbers, at the link.  Sobering.

Comments

“No, it’s not malware”

Sorry Tyler, but with both my wife and I working from home, as well as my children distance learning, my network cannot risk being exposed at the moment. I must continue to social distance myself from any in-post links.

Interesting because the COVID-19 situation in the US is MUCH better than everyone is saying. Just need to look at key numbers to see that.

What key numbers?

Only 3.6 roentgen, not great, not terrible.

Yeah, but what's the power on the flux capacitor?

Much more than the necessary 1.21 jigawatts.

;)

otoh the link sed
"Japan is undercounting asymptomatic individuals, who can spread the
virus."
if the numbers in the u.s. are "better" it may be for the same reason
that we are undercounting the asymptomatic peeps

No evidence of under-counting here.

The evidence is in the link.

No I mean no evidence of any undercounting in the US. Maybe they are undercounting in Japan but over here, despite the more limited testing, the numbers of infections and deaths attributable to corona have been scarily accurate.

your reasoning seems somewhat circular

any evidence is being buried by useless speculation and opinion...madness of the crowd in full flight right now..herd mentality run amok..cure is worse than disease

Actually, no it is not worse than I think, considering what a mess the Japanese made of a cruise ship quarantine. That it is worse than a number of blithering MR commenters believe, saying that Japan is open for business, and they have no problems, is no surprise, without even needing to have a link.

It could certainly change drastically in a few weeks with exponential growth. But so far the info we have is:

Date of first confirmed case: January 16th
Deaths, total: 45

Germany for comparison:

Date of first confirmed case: January 27th
Deaths: 229

Because it allows for even better comparisons -

Japan - confirmed cases 1,307
Germany - confirmed cases 40,585

So....what’s your conclusion? Deaths are deaths, and allow for a closer to apples to apples comparison.

Correct. Deaths are the best number we have to comparing the severity of the infection across nations.

Its not perfect due to differing standard of attributing the cause of death, but it is the best we have. The other metrics are near meaningless.

Yes, deaths are deaths, but countries that want to minimize for PR purposes (not saying Japan is one of those) could attribute Covid-19 deaths to flu, pneumonia or other diseases. How hard is it really to create incentives for medical staff and hospital officials to under-report? Just tie prestige and future funding to success in bringing down the numbers, and there you are.

Now we have thousands of people deceiving us . At any rate , there should be excess deaths regardless of labeling.
My guess is that the deaths are not fudged.
Japan is an island. They practice social distancing practices even in normal times. Considering many people traveled there from Wuhan in December and January, they should have a hospital crisis but they don’t.

If the death data are accurate, Japan has suffered 23 deaths in the past 12 days.

China has had 98 deaths in that time span.

Unless you are prepared to say Japan is flat out lying about deaths, the post is nonsense.

It doesn't require direct lying, it may just be a case of no testing of "flu" deaths among elderly patients.

To be clear, I'm doubtful of the premise also. I'd need more direct evidence to push me in that direction. But China has historically not reported deaths from the flu if there were multiple factors and thus reports very low yearly flu death rates.

Yeah, I also heard Germany isn't classifying deaths with comorbidities as corona, which complicates the country to country comparisons.

Still these would have to be massive differences to account for different experience. My impression is that Japan has controlled this thing very well, and Germany has done much better than other large European countries.

One clue was countries with high case loads but low deaths rates early (like Germany and Norway).

Saw a link today that suggests among th Swiss that Italians have been hit twice as hard as French, who have in turn been hit twice as hard as Germans. Presumably, they are using a uniform reporting standard for deaths.

Maybe a genetic/cultural difference? For whatever reason, no countries have come close to the Spanish and Italian experiences.

'Yeah, I also heard Germany isn't classifying deaths with comorbidities as corona'

Which not only means you heard wrong, the person saying it was wrong. "The RKI’s official mortality figures include both people who have died of the virus as well as those infected and with underlying health problems, where the precise cause of death could not be determined." RKI is the Robert Koch Institute.

Thanks for clarifying, this is helpful.

Only prior can offer a helpful clarification while being a complete dickhead.

Yeah, he really has poor social skills. I'm never sure if he's intentionally rude, or just oblivious to how rude he's being.

Prior_Approval? He's not rude. I thought he was just German. He's often pretty good with his cynical posts, in a bitter sort of way, the German way.

He claims to be an American living in Germany.

Some people have speculated that Italian cultural practices of close contact and kissing when greeting acquaintances causes them to have a higher R0.

OTOH, there's also been speculation that countries with warmer climates are getting fewer infections; the pattern for Europe overall doesn't match that.

...But it's still winter in Europe.

Of course, I hope the best for Japan. But it will be interesting if Japan takes a more low-key approach to COVID-19.

Oddly enough, the lockdown strategy was first implemented in China, the place not really known for human freedom and pretty much under the thumb of the Communist Party of Beijing.

The lockdown strategy is not working even in Hong Kong, a city-state of 7.4 million which is stuttering back and forth between various lockdowns and quarantines. They just banned all foreign visitors, and went into another lockdown. They are into their third month of this.

Can lockdowns really work in the United States? Or is the plan just to avoid peak load in hospitals, a reasonable plan and perhaps one that cannot be admitted to because it is admitting defeat. We cannot stop the virus without economic suffocation, let alone human freedom.

We have a million or more people cross into the United States every year , and perhaps many more border crossings, that are entirely off the books.

And will any sensible person advocate going back into lockdowns after we emerge from lockdowns?

Sometimes in policy-making there is the least-bad option. The least-bad option is to go back to work.

"Lockdowns" (inverted commas because I don't know exactly what you mean by the term) tend to be more effective in richer more educated countries because people have a better understanding of viral transmission and public health measures and they have higher levels of trust in their government. Although if I get more data on Italy I may change my mind.

"Much worse" than what? Japan typically sees very few flu deaths per year relative to other countries. During the H1N1 pandemic of 2009, Japan saw total number of flu deaths of 198, in a country of 120,000,000. A flu season in the US kills between 12,000 and 60,000 Americans per year.

Also, "true count" of covid-19 cases seems to be an unattainable goal. Is anyone counting those very mild cases that are just convalescing at home, which also appear to be much greater in number than the "confirmed cases"? Seems like death rate and serious cases are the only way to accurately track the rate of spread.

Which begs the question:

Are Japanese generically resistant to the flu, in a similar way that certain African countries are resistant to malaria? Is it their diet or public health system? What gives?

They wear masks and practice social distancing. They don't shake hands, they bow. They practice good hygiene. These are things that are observable and have been shown to be effective. Geneticist I am not.

I suspect it's partly cultural. They all wear masks on the subway, even in normal times, and they don't shake hands.

Really? I admit I've never been on a Japanese subway but in all the photos I've seen of Japanese cramming into their subways, there's not a mask in sight. Just did a Google image search, nope no masks.

This is from 2014:

https://japantoday.com/category/features/lifestyle/why-do-japanese-people-wear-surgical-masks-its-not-always-for-health-reasons

The slow growth rate in COVID-19 cases in Japan looks suspect, but if the Japanese data are correct, it might be because the Japanese bow instead of shaking hands. One thing I agree with President Trump on is that the handshake is a barbaric custom. (But he keeps doing it anyway!)

A "true" count of cases could be estimated reasonably well with widespread, repeated, randomized testing. That we still don't seem close to accomplishing this seems a major fail.

You can see they are coming to this realization by regions if you read Japan Times. https://www.japantimes.co.jp

Lead article in today's newspaper is how they are inching towards a lockdown.

You could also see that some prefectures were resisting and then got slammed.

Fascinating, and troubling. My attitude towards the white paper that Tyler cited on is a somewhat skeptical "wait and see" but that lead article is some pretty good evidence in favor of the paper's thesis.

Well, the number of deaths suggest much higher rates of infection (around 6,000-7,000 instead of the official 1,250 figure) but that applies to every country: Italy probably has well over 1,000,000 cases by this point and even Korea is undercounting infections as they probably have 15-20,000 infected out of 9,300 who tested positive.

Overall, it is easy to see that Japan is the G20 country that is the most effective in dealing with Covid-19. Not that they are doing very well but that they are not as terrible as in the west, where containment has absolutely failed.

The Japanese seriously bungled the Diamond Princess quarantine, it should be noted, to the extent that it is (reasonably) excluded from Japanese statistics, as it would distort them.

Number of cases is not a meaningful figure by itself as a newly infected person is not the same as someone who was infected 10 days ago.

As of yesterday, Korea ran over 340,000 negative tests on their population so, if they are undercounting, they must be undercounting people who were infected within the past few days.

As it happens, the number of deaths there has grown more or less proportionally with the number of cases and extensive testing has so far failed to provide evidence of significant undercounting. The Occam's Razor explanation is that Korea has, in fact, contained the virus. In Spain and Italy, on the other hand, the virus is growing at such a rapid rate and under-testing is a bit enough problem that estimating the number of cases is not a very meaningful exercise. We can try extrapolating from deaths there to calculate what the number of cases was a week ago but there will be a very wide confidence interval on the number of cases there now.

May get worse if they've re-opened as reported... doubt enough Japanese are immune to stop the spread.

https://asia.nikkei.com/Spotlight/Coronavirus/Japan-quietly-reopens-as-much-of-world-locks-down

Yes, this is the second wave fear. China opening up again too.

It's becoming clear that the first wave will likely be successfully controlled, though the toll in Spain and Italy will be pretty bad.

Japan and China are the new canaries in the coal mine.

Too bad our tardy economies haven't yet flooded the entire planet with N95 and N100 masks: respiratory spread continues unabated all across the globe.

As for Japan: not too early to begin offering predictions on how that country's demography will change courtesy of C-19--it could become "a young country" again in only short years.

Why can't the authors of the Japan White Paper reveal their identities yet? 🤔

I dunno...maybe they would have to be smuggled out of the country in a guitar case like Mr. Bean?

Good one!

Japan is far closer to China and was most likely infected earlier or at the same time as Italy/Iran and other problem states. I find it hard to build a consistent argument that allows for Japan's peak to be both delayed and more severe than its peers.

Of course testing understates the total infection rate. But I don't think they are lying about death counts.

Among other things, the "opening bit" is the clearest and most efficient use of a hundred words that I've seen in a while

Apparently Tyler has run out of things he can claim are world-endingly terrible, and has to post things he can claim are "worse than you think."

And apparently you have run out of non-idiotic things to say!

Ho ho ho heh heh ha ha ho ho

I bet it's actually not that bad in Japan. They have SARS1 under their belt (social distance culture), and the evidence for "overreact" is mounting.

Yet Brazil based its model on Japan and it worked.

The good news is that Japan's large number of hikikomori are already self-quarantining!

Those guys will finally come out of their bedrooms when their parents die.

I am really sick of people (as Tyler does) telling me what I think or thought, when what they really mean is that what they thought was wrong.

Masks do not filter out the virus. N95 or N100 filter out 95% or 100% of all particles over .3 microns. Measurements of the size of SARS-CoV-2019 ranges from a high of .14 micron to a low of .06 microns. The surgical masks are useless. If, however, a mask gets you to stop touching your face, use one. And Thanks Tyler, a great episode with Russ Roberts.

Viruses do not exist in total isolation - you are filtering what they are adhering to.

Wrong. If someone coughs or sneezes the virus is suspended in a particle which can range from 1-5 microns for dry particles to hundreds of microns for wet particles.

That a mask is certified as filtering 95 percent of particles over 0.3 microns doesn't mean it passes all particles smaller. Cheap furnace filters with air paths betwixt their fibers much larger than a dust particle catch a lot of dust. Every little bit helps. And as another mentioned above, the virii aren't necessarily floating free as isolated particles.

Which betting markets are tracking predictions like this? Are any of them robust enough to provide good consensus data? Are any of them financially reliable enough to make some money if I think I'm more informed than most, without counterparty risk overwhelming my +EV?

Maybe the fact that many Japanese live alone and wear masks in public explains this? I feel like if there numbers were that far off it’d be impossible to hide it this long.

They may live alone but highly densely.

For what it's worth, I know an American couple living in Tokyo, one of the has been very sick with Covid-19 symptoms for over a week (though he's now improving) and he was never tested despite multiple requests.

The virus has been present in Japan for months. The country - which contains 40 million people over the age of 60, has suffered about 50 deaths. (We have about 70 million over the age of 60 and have suffered 1,100 deaths). I'm reminded you fancy Nassim Taleb is a serious person.

The authors write "Japan has had a public policy of refusing to test asymptomatic individuals except for those having a deep degree of direct contact with an infected individual (濃厚接触者), and
initially only tested individuals with contact if they also had a fever or
difficulty breathing."

This is exactly the same policy that most countries have adopted, due to lack of testing capacity. It is exactly what's been happening in every European country I know of and in the US. Are there 3-6x as many cases as they know about? Of course. But if Japan's testing policy is consistent, and the virus is spreading in the same way it's been spreading elsewhere, their case rate should be doubling every 3-6 days. They should be seeing 15%, 22%, 30% daily case increases. The only way they can have maintained the pattern of 7-9% new cases per day, which it appears has been going on for the last month, is if the virus is not being spread as readily as it is in the US and Europe, or they're simply not testing people who have fever and coughing.

Basically, there needs to be a massive coverup, or staggering degrees of medical malpractice. Or the Japanese are just not as good at getting each other sick as the rest of us are.

It's basically a cover up. Japan creates a bureaucratic obstacle course to testing that is a bias confirming loop. Lots of cases are being discovered from people returning from overseas, from existing clusters, among celebrities. If you're sick as a dog, you'll likely not get tested.

Japan is also turning away patients, which is common in normal years. Recover at home.

They barely do autopsies in normal years. 3000 pneumonia deaths per month in a normal year. Yet, the government does not publish and refuses to release the latest death statistics.

Upwards of 1000+ COVID deaths could have occurred and no one could possibly know - a phenomenon seen and admitted to in other countries.

Maybe hospitals aren't filling up, but it requires doctors to intern patients. COVID starts mild then kills you pretty fast after escalating - if you're going to die from it. COVID positive patients have to be isolated in special rooms which are limited (by law). Infected hospitals have to be disinfected and staff quaranteened. No one wants to deal with it.

Japanese doctors are treated like Samurai, no one questions a damn thing they say. Japanese are known to just hospital shop until they get an answer they like.

Doctors have no reason to intern respiratory patients in this environment. They aren't. People are sent home to recover on their own. National hotlines for COVID always insist that people stay home, and there's a telephone run around on testing.

The requirements for testing are strict, and even when met tests are denied. Japan is testing at 10% of its capacity.

It's basically a cover up, largely because of Trump-like arrogance and government paralysis. Japan can be a shockingly incompetent society at times. They're mostly good at robotic tasks that can be improved to a level of mastery or perfection. They're a tropical republic otherwise, if not a Big Man gangster country.

It's going to be bad.

This requires believing that Japan is covering up thousands of deaths and doing so more quietly than even China could manage. Japan has twice the population of Italy so we should be seeing 1,000 or more deaths per day fairly soon if this is correct.

Why would a democratic country go to unheard-of lengths to cover up massive death and suffering given the almost 100% chance that the cover up will be discovered and exposed within the next few weeks?

Italy seems to have started their outbreak before everyone else, and Japan may have slowed theirs, but 1000 deaths in Japan would be missed. You aren't understanding how Japan works at all. How would anyone know that this many people died? 3,000 elderly die of pneumonia per month. If 3,000 more died, that would only be 4 deaths for a hospital instead of 2, 14 people in a crematorium instead of 7. You think they're all on hotline on twitter with each other to accumlate statistics?

Japan is almost certainly going to explode in April, and since they have done next to nothing, we may see 1,000 deaths a day by May.

Why would they cover up when there's a chance to be exposed? You don't understand Japan at all. These people are not rational, their commitment to face and cultural stockholm syndrome shames even China. It is not a Western democracy. It's barely a democracy (in form only). They don't have concepts of accountability or integrity or that kind of thing which you would see as the basic starting point of professional culture in the West.

Jeff, I live in Japan. I assume you live or lived in Japan too...? I agree with some of your criticisms of Japan, and the fact that some deaths could be hidden. However, one thing is that I haven't noticed any rumors spreading about people knowing of illnesses or deaths that are going officially unacknowledged. Are you aware of any such rumors?

I've read at least three dozen accounts on reddit and twitter of people complaining of corona symptoms. A couple of people whose elderly relatives died - though no connection is made. Without data, it all amounts to nothing, and Japan won't release the data.

Tyler, what are the criteria you're using to determine which conspiracy theories to publish? Why does this particular anonymous "working group" of non-medical researchers make the cut? Contrary to your suggestion, they don't have any evidence; they're just offering a set of assumptions that differs from the government's. Maybe they're right, but nothing about this presentation is persuasive.

"They have reviewed their conclusions with a medical researcher" - That was a neat idea.

We should expect case numbers to be massively under-reported pretty much everywhere. Personally, I would guess actual infections / confirmed cases to be in a range of 3 to 100 in most richer countries depending on the country and maturity of the outbreak there.

The high end of this would be poor countries in crisis, which do not have the capacity to do any significant testing, like Syria which has only 5 confirmed cases according to Johns Hopkins Uni... I would expect the actual number of infections to be several orders of magnitude higher there. Or Yemen, which has 0. In general, I would expect most of Africa and Latin America to be hit much harder than the current numbers would suggest.

Let's think about how false negatives (underreporting) and false positives (overreporting) might come about here:

False negatives could happen through

- lack of test availability
- asymptomatic patients or patients with very mild symptoms not visiting a doctor - e.g. they might think they just have a cold
- infection dynamics - i.e. incubation time
- actual false negative tests - e.g. by performing at-home test incorrectly

Of these, I would guess lack of testing to be the largest sources of cases, especially in areas with few confirmed cases. Depending on the area you're from, incubation time may rival or outstrip it, however (I would expect this especially in poor countries). To find out, we would have to ramp up testing significantly.

The asymptomatic case is trickier, requiring us to start randomly testing people in different areas and as representative sampling is always a bummer we'd probably need to test a significant fraction of the population (several ten percent) to avoid sampling bias. Actual false negatives are probably negligible right now.

False positives:
- false positive tests

We probably don't know enough to really gauge the false positive rate of our tests, but if we start screening more and more people, false positives may actually become a source of significant over-reporting. If it is, say, 1% then if you test 1M people, you would get 10k false positive cases. We could estimate this by testing people with multiple different tests and checking how well they corroborate each other (cross-validation if you will)

The question is how much do countries actually test? A nature article from three days ago https://www.nature.com/articles/d41586-020-00827-6 displays massive differences in the proportion of the population being tested with Saudi-Arabia testing 100 times as many people as Japan normalized for population.

So how do these stack up against each other? My guess (and it's only a guess) is that infection dynamics are currently the largest factor of underreporting in most countries, especially in the Americas and Africa and that it outstrips false positives by a large margin. If you fit a disease model to the data from China, you should expect more than 500k - 3M cases in the US alone already, and the accelerating number of confirmed cases seems to indicate that this isn't outlandish.

Differences in testing might also go some way to explain why countries like Germany, Austria and especially Saudi seem to have such a low death/case rate, as they test a lot more. 0.2% of people in Germany having been tested means 160k tests, of which 40k are supposedly confirmed cases (which feels to me like a very high percentage and means no significant screening going on at all).

It will be interesting to see how well these numbers stack up as time goes by. My feeling (and fear) is a lot of people already had Corona but never noticed and that in most countries it may be too late to stop it.

Norway is another high tester with low CFR (case fatality ratio) - https://sciencenorway.no/crisis-epidemic-mortality/very-low-mortality-rate-from-coronavirus-in-norway-compared-to-other-countries/1661751 . Finland and Iceland are also in the club (Iceland most so).

There's a nice OurWorldInData plot there linked in that article of country CFRs as they evolve through time.

There is a counterargument being made that low CFRs in those jurisdications are simply because they're earlier on the curve of infections, where case growth is high relative to deaths which lag infections.

But, while that may mean overall true IFR (infection fatality ratio) is higher* everywhere than initially, that's obviously does not explain lower CFR in the high testers, which just evolve along a completely different trajectory, and are not earlier in the same trajectory. As is even more obvious when you look at the confirmed case trajectory itself - https://ourworldindata.org/coronavirus#confirmed-covid-19-cases-by-country.

(The other argument against low CFR in Germany, which has had cases about as long as Italy, is that Germans are not counting coronavirus fatalities properly and dismissing deaths of Covid19 as due to some other underlying cause when a person had another condition. But that's was a bunk meme too. Not doing it.)

*Of course this balanced by the assumption that cases and fatalities are both equally under-reported to their true amount, which seems highly unlikely. Even in those small Italian villages with 4x their normal monthly death rate, many not explicitly attributed to Covid19, the total infection rate including infected and recovered is probably much more under-reported than deaths.

I'd like to understand better how false positives occur in testing. Is it that (1) some individuals will always test positive even though they don't have the disease? Or is it that (2) due to the sensitivity of the test, the test will randomly yield a false positive? The reason I'm asking is that it seems obvious that any positive result should be followed at once by a second test to eliminate case (2).

Don't have time to read the paper, but even if the technical details are correct, it is in practice likely to be nonsense. As others have noted, given the disparities in how each country is testing or not testing their population, the best metric to use is the number of deaths attributed to CV as a proportion of the country's population, controlled for its age distribution. Incidence of pneumonia (or possibly just hospitalization) attributed to CV would be even better, but that does not appear to be widely available. By that, it does not matter how many asymptomatic people they are missing. Since Japan was one of the first countries after China to have confirmed cases and furthermore has one of if not the oldest demographic in the world. It is simply remarkable how low their number of deaths is. I'm actually not sure how much of that is what the authorities are actually doing, outside of shutting down schools, versus their "culture". The Japanese, as a rule, are not a touchy feely people and in part because of their high population density, have norms that respect one another's personal space while in public. My conjecture is that this fact is largely responsible for how well things are going. Either that or they are doing something to keep old people from getting infected that no one seems to know about.

Italy's infection may have begun in December, and seems likely that that's the case given their head start.

As for Japan, they only perform autopsies on 2% of cases in normal years. Now, to avoid the spread of infection, the government has mandated immediate cremations with no medical examinations. Doctors, hospitals and hotlines are asking people to stay home if they're sick (and COVID usually begins with a lengthy period of relatively mild symptoms which escalate quickly).

There's no reason to think that Japan's death count is remotely accurate, given the large number of obstacles they've put in place to prevent case discovery.

Why aren’t their hospitals starting to get slammed? They’ve had it longer and have done hardly anything.

After following this discussion all day and looking at the statistics by country, I'm coming to the conclusion that cultural norms about "personal space" are an important determinant of the rate of spread of COVID-19, and probably the mortality rate as well, since those who inhale more of the virus are probably more likely to die. Cultures that show more respect for one's personal space are less likely to spread the virus quickly. People who bow are less likely to spread the virus than those who shake hands, who in turn are less likely to spread the virus than those who hug and kiss each other on both cheeks. That may largely explain the different rates of spread across countries and within the US. I grew up on a farm in a small family, and I want a lot more personal space than the average New Yorker.

Japan has a very poor sense of personal space, and people tend to bring their face very very close to yours to be polite and communicate clearly.

I agree with Jeff Maloney. I live in Japan. The "Japan's personal space" meme as an explanation of why the virus hasn't spread is baloney, usually spread by people who, apparently, don't have much first-hand experience of the country.

We at Safecast have been publishing critical articles about official response in Japan and elsewhere for weeks, and have made a crowdsourced online map people can use to share their experiences seeking testing. This article is rambling and poorly written, and the authors' insistence on anonymity is misplaced and makes me suspicious of their motivations. Nothing in it strikes me as incorrect per se, but they fail to "connect the dots" in any meaningful way. Yes, the Japanese gov't has been indicating for weeks that they're preparing for a large outbreak to occur by early April, while other official messaging has led to complacency. We'll know a lot more after a week. PS: Undercounting of asymptomatic cases as well as categorization of COVID-19 related deaths as due to pneumonia or other causes is happening in many countries. Very few seem to be getting it right.

I personally know a doctor in charge of corona at a designated hospital in Kansai. They are sitting around waiting for patients. Very few deaths there as of yet. A nurse friend at an Osaka hospital says she is not sure if they have any corona patients yet.

In France, COVID-19 deaths in medicalized retirement facilities (called EHPAD) are not included in the official tally. People are not tested, and even though they know that some of those deaths are attributable to COVID-19 (due to symptoms and sudden clusters or numerous deaths), they are registered as pneumonia, etc.

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