Two stories are circulating prominently in the media that attempt to draw a correlation between the level of COVID-19 testing and the number of unreported cases, one in Japan that some media are describing as a “bombshell” and one in the U.S. getting equal treatment.
Interpretation of the data depends on the eye of the beholder.
In Japan, a new study by the Tokyo Metropolitan Institute of Medical Science reported that between January 2020 and March 2021, Tokyo had an estimated 471,780 cases — nearly quadruple the 120,000 cases reported during that period. The study then drew the conclusion that some experts have been preaching since the start of the pandemic — that this is “because Japan did not test enough.”
In the United States, a November report by the Center for Disease Control (CDC) estimated that from February 2020 to September 2021, only one in every four COVID-19 cases was reported. The CDC goes on to estimate that 146.6 million Americans contracted the COVID-19 virus, as opposed to the originally reported figure of 36.6 million.
The United States received high marks for its mass testing program, while Japan has been criticized for its low level of testing.
For sure, the United States conducted 10 times the number of tests as Japan adjusted for population. According to updated data, the nation has conducted 215,247 PCR tests per 1 million people, while the United States has undertaken 2,159,192 per every 1 million, more than double its population.”
But what did mass testing achieve? What is the objective of mass testing? Did mass testing reduce the number of hospitalizations and deaths in the U.S. versus Japan?
To start, the stated objective of mass testing is to get an accurate understanding of the spread of the virus so authorities can contain it before it overwhelms the medical system.
But as the data suggests, mass testing cannot keep up with the spread of this virus. Test everyone or a more targeted list, and both the United States and Japan missed approximately three out of every four actual cases.
This should not have come as a surprise, as it is in the range estimated to exist in Europe and the United States by extensive antigen test studies conducted last year.
The new studies also show that mass testing does not directly lead to lower fatalities on a population-adjusted basis. While the number of tests in Japan were a tenth of the United States, Japan has had deaths on a population-adjusted basis of 6.2% of the United States.
To date, the U.S. has reported 794,864 deaths — 2,382 deaths per 1 million of its population. The CDC estimated that the United States had 921,000 deaths due to COVID-19. Japan has reported 18,347 fatalities, or 146 deaths per 1 million, with no significant change in the actual figure compared to the originally reported number.
The United States, the United Kingdom and other countries that have conducted mass testing dedicated enormous health care resources to contain the virus through mass testing.
There appears to have been an element of fear that drove this effort, as very little was known about the virus during the initial phases of the pandemic. Back then, no vaccines or treatments were available, and testing was the one thing that countries could do to show they were taking action.
Japan had a different view. With 29.3% of the total population 65 years or older — the highest in the world and about twice the percentage in the United States and most mass-testing countries — Japan already had extensive experience throughout its health care system in identifying and treating respiratory diseases among the elderly.
Since mass testing takes a tremendous amount of finite health care workers’ time and effort, a more focused approach allows many of those resources to be deployed instead on those cases that truly matter.
Japan’s health care experts immediately saw the threat of the coronavirus to the most vulnerable portion of its population. It designed a more concise response to the pandemic than to try and broadly contain it. Japan focused on keeping the virus out of senior homes, daycare centers and hospitals that cared for the elderly. The objective was very clear from the outset: Minimize the number of deaths among the elderly.
So why the commotion over mass testing? One plausible explanation is that the media has fallen into the pattern of reporting daily new cases like baseball scores. But treating all cases as if they are equal is seriously flawed thinking. Cases among the elderly and those with pre-existing medical conditions, clusters in hospitals and care facilities for older people, truly matter and need a laser-like focus of the health care system.
With no vaccines or known treatments for COVID-19 available back then, Japan turned to the three advantages it had.
First, it had already deployed more CT scanners per capita than any other country in the world, 111 per 1 million people compared to 42 in the United States, 35 in Germany and nine in the U.K.
CT scans provide rapid and very accurate early identification of interstitial pneumonia, the condition in COVID-19 cases that frequently leads to severe cases and deaths.
The results were available in 15 to 20 minutes. By comparison, PCR tests are notoriously inaccurate, with 20% of tests showing false positives or negatives according to a joint CDC-Johns Hopkins study. And in 2020, it still took two to three days to see results. That has since improved to just a few hours.
Second, Japan had a well-established public health center system with 470 locations staffed by doctors and over 35,000 nurses. First established in 1937, these centers dealt with identifying and tracking tuberculosis and other infectious diseases among localities. These field specialists became the first line of defense in rapid response to any suspected clusters and exposed individuals.
Third, in addition to its national health system, Japan had a separate lesser-known national framework for caring for older persons called kaigo hoken, a long-term care insurance program.
Once you turn 65 in Japan, you are automatically enrolled in the kaigo insurance program in addition to national health insurance. Kaigo staff provide a wide range of optional, low-cost in-home services and equipment. These include weekly or more frequent visits to the homes of the elderly, confirming they were taking prescribed medications, checking their condition for sudden changes, arranging doctor visits if required, even bathing for those bedridden. Japan’s kaigo system provided an early warning layer to its pandemic response.
With extensive experience in the identification and treatment of respiratory diseases and the above-noted tools in hand, Japan decided against mass testing of the general population, and instead deployed very targeted PCR testing combined with extensive tracing and follow-up of any clusters of five suspected cases or more, especially wherever the elderly congregated.
Here is the question that people should be asking. What would the impact on COVID-19 deaths have been if the nation had diverted the health care system to mass testing at the level seen in the United States, the United Kingdom and other countries highly praised for their mass testing versus the focused testing deployed in Japan? Would the Japan have seen far greater fatalities as they did or fewer as it did?
Edo Naito is a commentator on Japanese politics, law and history. He is a retired international business attorney and has held board of director and executive positions at several U.S. and Japanese multinational companies.
In a time of both misinformation and too much information, quality journalism is more crucial than ever.
By subscribing, you can help us get the story right.