Gearoid Reidy

There Is No ‘Back to Normal’ After Covid

Japanese virologist Hitoshi Oshitani has an impressive record fighting pandemics. As one of the leading experts advising the government during Covid, he helped formulate a strategy that has kept deaths in the country with the world’s oldest population lower than any other developed nation, without resorting to lockdowns. Now, as the world clamors for Japan to reopen its borders, he’s urging caution. Perhaps it’s time to listen.

“I don’t like the notion of ‘back to normal,’” Oshitani, a professor of virology at the Tohoku University Graduate School of Medicine, said in an interview in his Tokyo office. “That means going back to the pre-pandemic society. That pre-pandemic society is very, very fragile — for many risks, not just infectious disease.”
As one of the first major countries to try living with the virus, Japan offers lessons not just to Covid-zero China but to the rest of the world, as cases again rise from Singapore to the UK. Oshitani’s approach has helped keep Covid deaths in Japan lower than in Taiwan or New Zealand, where officials tried to eliminate the spread entirely.

Oshitani acknowledges tourism needs to resume in some form, but warns that the country isn’t out of the woods. He also cautions that the world will see more pandemics in the coming decades. That means it’s imperative societies rethink not just how tourism might look, but how all aspects of life should change in the future — before it’s too late.

The following transcript has been edited for length and clarity.

Gearoid Reidy: What is the status of Japan’s battle against the coronavirus?

Hitoshi Oshitani: We set our objective for a Covid-19 response on February 24, 2020. Many countries at that time were aiming at containment, but we knew that was extremely difficult. Living with Covid has been the main approach from the beginning.

At the same time, we said that we needed to suppress transmission so that deaths or severe cases could be minimized. We also knew that we needed to maintain social and economic activities. Although we did not implement a lockdown, people were very cautious from the beginning — every time we had a surge of cases, they changed their behavior. Most measures are on a voluntary basis. The Three C’s concept helped people understand what they should avoid.

Then omicron came, and things got a bit more complicated. Since the denominator became bigger than previous waves, we unfortunately had many deaths, particularly among the elderly. To suppress the transmission, we would need very aggressive measures, like what they are still doing in Shanghai.

Except for China, most countries and areas that had very low mortality impact in 2020 and 2021 had a big impact in 2022 — New Zealand, Australia, Vietnam, Hong Kong. Taiwan right now is having a significant outbreak. It’s like the game Othello 2 — the countries or areas with a better outcome can easily turn to the worst outcome. So Japanese people are still cautious, and I’m still considering the worst case scenario as a possible option in Japan.

The pandemic is not yet over. We should expect some surge of cases in Japan in the coming weeks, and our advantage can be a disadvantage in the next stage.

GR: So countries that initially contained the virus are not using the same sort of mitigation strategies?

HO: In the past two and a half years, we’ve had many, many problems. It’s not all a success story. Initially, we had many outbreaks in hospitals and nursing homes, and many elderly people died. But in the second wave, hospitals and nursing homes were much better prepared. They learned a lot of lessons and improved their systems.

But New Zealand, Taiwan and other places probably didn’t have a chance to build better systems — then suddenly they had a huge number of cases due to omicron. It was the same in South Korea. Our infection rate is still smaller than in the US, or many European countries or even South Korea. Although our vaccination rate is higher than some countries, still there are people who don’t have immunity. Something like South Korea can happen here anytime.

We are in a much better position than one or two years ago, because of vaccination, immunity by natural infection, better treatment and better systems in hospitals and nursing homes. But people are still cautious, most are still wearing masks.

GR: What would you say to those who want Japan to return fully to normal life and treat Covid like influenza?

HO: The situation now is completely different from 2020 and 2021. We are changing — but still there are many uncertainties. Many people compare seasonal influenza and Covid-19, which is kind of nonsense.

I’ve also been working on influenza for many years. Seasonal influenza is different; it's predictable. Usually you only have an outbreak in certain times of the year, from autumn to spring. While there is some difference in terms of mortality impact, we always see such impact within [a certain] range.

But Covid-19 is different — we cannot predict what is going to happen. We do know that there is the high possibility of a surge of cases [in Japan] in July and August. But that we do not know what mortality impact we are going to have. We still do not know what’s going to happen in winter this year.

The virus is still changing. A more problematic variant may emerge. It was a dramatic change from alpha to delta; then delta to omicron is a very significant change. For influenza, such a dramatic change only occurs when pandemic influenza emerges. But for Covid-19, every six months or so pandemic influenza-like incidents are occurring.

GR: The business community is calling for Japan to open its borders and go back to normal. What’s your position on tourism and border controls?

HO: Since June 1, the number of incoming passengers increased and there is no testing for many countries. New strains or infected people from [countries] with a higher incidence rate can come to Japan.

We need to think about this carefully. In 2019, we had 30 million people, mainly foreign tourists, coming to Japan. In 2020, the government was hoping we would have over 40 million foreign tourists because of the Olympics — of course, it turned out to be almost zero.

I don’t like the notion of “back to normal.” Back to normal means we are going back to the pre-pandemic society. The pre-pandemic society is very, very, fragile for many risks, not just infectious disease. When they are talking about increasing foreign tourists, I don’t think they consider the risks seriously.

GR: Japanese people can also go abroad and get infected.

HO: That direction is probably a higher risk. In the early days of the pandemic, we had many [Covid] cases among people who went to Egypt; Japanese tourists, mostly middle-aged. Many were infected and came back to Japan.

Even if we open the border — and we have to open the border, I understand that is definitely necessary — at the same time we should have some system to minimize the risk. What is the best way? I don’t think the border control measures of Japan, or many countries, are based on proper risk assessment.

I also don’t think this is the last pandemic in the next one or two decades. Pandemics will continue to occur. We were living in a completely different world in 2020 compared to 2003, when the SARS outbreak occurred. SARS spread to many countries just by one infected person, who traveled from Guangdong province to Hong Kong by bus, and stayed in one hotel.

In 2003, there was not as much traffic between Hong Kong and Guangdong. There weren’t many international connections. But 2020 was completely different — Wuhan was the industrial hub of China. By the time we realized [what was happening], the virus had already spread to Europe, Middle East, and the US. So the question is whether we should go back to this risky world or not?

GR: So you’re saying no one’s thinking about the possibility of the next pandemic — something that could be worse than Covid?

HO: That’s possible. Something like Ebola can be an airborne pathogen. Anything can happen. Right now, monkeypox is transmitted among a certain population, but the virus may change. So we have to be prepared and we have to think again what we should do in the next 20, 30 years. Is it a good idea just to go back to normal, to the pre-pandemic society?

GR: Is there enough discussion happening about that within the WHO or other international bodies?

HO: The problem is they are making the same mistakes again and again. They just try to learn lessons from the immediate past outbreak. In 2003, SARS was successfully contained. The system changed, influenza pandemic preparedness was improved — but then the 2009 [swine flu] pandemic was not that severe, And most people forgot, because they were just looking at the immediate past outbreak.

Then in 2014, there was a significant Ebola outbreak in west Africa. But what they did [in response] was just to build the capacity in rural Africa so that the early detection and early response can contain the outbreak — which was completely different for Covid-19. For Covid-19, the initial outbreaks occurred in New York, northern Italy and so on.

By the time we realized, it had already spread, mainly in major metropolitan cities. It was the opposite of the 2014 Ebola outbreak.

GR: It’s like they say, generals always fight the last war.

HO: Exactly. What they are trying to do in the WHO and the international community is just trying to learn the lesson from Covid-19, which may not be applicable for the next pandemic.

GR: What should we be doing instead?

HO: We have to build more resilient society. Of course, we need to have more tourists, more exchange. Before the pandemic, I often traveled on the Tohoku bullet train, which was packed with people, most of them businessmen. Now there are few — Zoom or other internet meetings can replace this. You don’t have to live in these inhuman cities like Tokyo. People can live in the rural areas; if you have a good internet connection, you can have a much better life with your kids. We have to think, is globalization really the right way to go?