With fans barred from the Olympics, the question looms: Why isn't Japan more vaxxed?

At a time when sports are returning to normalcy across much of the globe, the Olympics remain a dreary exception.

The Tokyo Games are caught between the mostly unvaccinated Japanese public’s COVID-19 concerns on one side and politicians who have invested too much in these Olympics to cancel them on the other.

Organizers announced last Thursday that Olympic events in Tokyo and most outlying cities will occur without fans. Seiko Hashimoto, president of the Tokyo organizing committee, called it a “sorry message,” but insisted “in order to prevent the spread, this was the only choice available for us to take.”

Athletes won’t receive a red-carpet welcome either. They must leave their loved ones at home, quarantine upon arrival, submit to frequent saliva tests and comply with a lengthy list of rules. Hugs, handshakes and high-fives are discouraged. So is venturing anywhere besides competition venues and a limited list of preapproved locations.

Japan is imposing these restrictions after other countries have relaxed their rules. In just the past few days, spectators have packed Coors Field for the MLB All-Star game, piled into Wembley Stadium for the Euro 2020 final and lined the slopes of Mont Ventoux to witness the Tour de France’s most iconic climb.

The contrast highlights the ramifications of Japan’s long-delayed vaccine rollout. Whereas mass vaccinations slowed the spread of the virus this spring in the U.S. and Europe, about only 3% of Japanese citizens had received even one dose by mid-May.

Efforts to ramp up vaccinations before the Olympics have since dramatically helped, but Japan still lags behind other developed nations. A little over 30% of Japan is now partially vaccinated, according to Our World in Data, compared to 70% of Canada, 68% of the United Kingdom, 58% of Germany and 55% of the U.S.

“If Japan had rolled out COVID vaccines a few months earlier, it would have been possible to suppress the transmission and hold the Olympics with spectators,” said Kenji Shibuya, a former World Health Organization member now in charge of overseeing vaccinations in Soma, Japan. “But it is now in a state of emergency with low vaccine coverage in the middle of delta resurgence.”

To understand why Japan took so long to get shots in arms even with the Olympics looming, Yahoo Sports contacted a half-dozen public health experts who are either based in the country or have extensive knowledge of it. Their answers portray a vaccination system hampered by politicization, public mistrust and inadequate infrastructure.

Fans will be banned from Tokyo-area stadiums and arenas when the Olympics begin. (AP)
Fans will be banned from Tokyo-area stadiums and arenas when the Olympics begin. (AP)

Japan’s uneasiness with vaccines

Japan’s uneasiness about potential side effects from vaccines predates COVID-19 by decades.

In the early 1990s, Japan received a flurry of complaints linking its version of the combined measles, mumps and rubella vaccine to unexpectedly high rates of aseptic meningitis and other adverse reactions. The Japanese government responded by halting use of the vaccine in 1993, leading to outbreaks. To this day, it doesn’t recommend a combined MMR shot.

The scandal shook public confidence in vaccines, increased media scrutiny on vaccine safety and sparked a barrage of lawsuits seeking damages. When a court ruling held Japan responsible for any adverse effects from vaccines, it discouraged the government from pushing immunizations and encouraged a more cautious, risk-averse approach.

In 1994, Japan reduced the scope of its national vaccination program and made inoculations an individual choice instead of a mandatory act. Kentaro Iwata, a physician and infectious disease expert at Kobe University, described subsequent Japanese policy as “very passive” toward the development and approval of new vaccines for children, causing the country to fall behind.

Public trust in vaccines eroded further in 2013 amid unsubstantiated Japanese media reports of neurological side effects from the human papillomavirus (HPV) vaccine. Japan withdrew its recommendation of the vaccine even though it had proven safe and effective elsewhere in preventing cervical cancer.

The country’s HPV vaccination rate dropped from 70% to less than 1%, according to a study published last year in The Lancet. The study estimated that if nothing changes, the vaccination crisis could result in nearly 11,000 preventable deaths from cervical cancer in Japan over the next 50 years.

“This is the eighth year now where the Japanese government has said, ‘If you ask for it, we’ll provide it, but we’re not going to proactively recommend it,’ ” said anthropologist Heidi Larson, director of the London-based Vaccine Confidence Project. “It’s kind of an ambiguous approach that leaves the public hesitant and questioning. If the government doesn’t promote it, people are going to think something isn’t right.”

In September 2020, Larson co-authored an analysis of global trends in vaccine confidence. Japan ranked among the countries with the lowest vaccine confidence in the world, surveys conducted across 149 countries showed.

That was the climate in Japan a year and a half ago when COVID-19 first infiltrated the island nation’s borders. The thirst for a vaccine wasn’t as strong as elsewhere in the world, nor was the country as prepared to develop one.

Japan’s success suppressing the pandemic’s first waves also lent itself to complacency. Neither the country’s death toll nor its infection rate in 2020 approached that of the U.S. or other hard-hit countries.

“The government initially did not understand the importance of vaccines and did not push forward on it,” Iwata said. “It wasn’t until later they became aware of it and now are pushing very hard.”

People line up to register for a dose of the Moderna vaccine on June 30 in Tokyo. The Japanese government has begun an after-hours vaccination campaign as it expands its coronavirus inoculation drive to include younger people. (Carl Court/Getty Images)
People line up to register for a dose of the Moderna vaccine on June 30 in Tokyo. The Japanese government has begun an after-hours vaccination campaign as it expands its coronavirus inoculation drive to include younger people. (Carl Court/Getty Images)

Debate over Japan’s extra step

In 2016, a team of Japanese Health Ministry advisers warned that Japan was unprepared if a pandemic broke out. Their report described Japan’s pharmaceutical industry as uncompetitive, questioned if it could efficiently develop a vaccine for Japanese citizens and noted the risk of trying to secure vaccines abroad in a time of crisis.

Shibuya, one of the authors of the report, likened Japan’s pharmaceutical industry to its financial industry before a 1991 crash. “So many companies, a lack of competitiveness, obviously heavily subsidized, a lack of global scale,” he said.

The assessment of Shibuya and his colleagues appears prescient five years later. Japanese pharmaceutical companies lacked the resources and funding to compete with their international rivals, forcing the country to obtain COVID-19 vaccines abroad rather than develop its own.

When Japan finally secured enough Pfizer and Moderna vaccine to cover its population, the government faced a crucial decision. Did it make more sense to rush the vaccine to the public with COVID-19 cases on the rise and the Olympics looming in July? Or was it more prudent to stick to typical protocol and do clinical trials in Japan in hopes of proving to a notoriously wary population that the foreign-made vaccines were safe?

Japan chose a rushed version of the latter option, differing with the dozens of other nations that accepted the results of Pfizer’s multinational tests and began vaccinations right away. Haruka Sakamoto, physician and researcher at Keio University in Tokyo, criticized the Japanese government’s decision, saying it was politically motivated and “not medically necessary.”

“The government decided to conduct an additional clinical trial to counter the anti-vaccine movement, media, and opposition parties,” Sakamoto said. “Therefore, the start of the vaccination was delayed by 2-3 months.”

Even after Japan belatedly began its vaccination rollout in mid-February, progress was initially slow. As Iwata put it in May, “Achieving a high rate of vaccination was never a mission in Japan for many vaccines and now the government is struggling to do what they have never even tried.”

New York-based Yuji Yumada was part of a group of 10 physicians who sought to speed up the process by combatting vaccine resistance. In February, they launched a promotional campaign to counter social media rumors and spread lessons learned from overseas — and they used an adorable cartoon dog to do it.

Corowa-kun is a chatbot clad in a white doctor’s coat and tasked with answering user questions about the vaccine. Yumada said 80,000 people actually engaged with the cheerful-looking dog since February.

“People in Japan tend to love cartoons,” he said with a laugh.

Yumada and his colleagues researched the efficacy of Corowa-kun during the spring. More than 10,000 users responded to his survey.

“Before using this app, the users’ vaccination confidence rate was 59 percent,” Yumada said. “But after using this app, 80 percent of people had great confidence in the vaccine.”

The spread of accurate information undoubtedly helped accelerate Japan’s vaccination process, as did the increasingly dire circumstances in the country this spring. A surge in cases hampered Japan’s economy and overburdened its healthcare system, forcing hospitals in the hardest-hit cities to use waiting rooms and hallways to create extra bed space, or even turn away severely ill patients.

Recognizing the need to get shots in arms, the Japanese government allowed paramedics, dentists and lab technicians to begin administering the vaccine. More than 1 million Japanese are now getting the vaccine every day, not enough for all citizens to be eligible to get a shot in time for the Olympics but maybe by November.

How does the medical community evaluate Japan’s decision to delay vaccinating its citizens this past winter to run extra clinical trials? Six months later, the response is mixed.

Yamada said the COVID-19 vaccine might have met the same fate as others in Japan had the government not taken that extra confidence-inspiring step.

“So I can’t really say it was truly a failure,” he said, “but from the standpoint of the Olympics it was a failure.”

Sakamoto took a harsher stance.

“If the vaccine had been administered sooner, of course, the death toll would have been even lower, and the economic loss would have been less,” she said. “Also, it might have been possible to hold the Olympics with an audience.”

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