A spike in COVID-19 cases in Japan forced an abrupt ban on spectators at the Olympics this summer. Andrew Gordon and Michael R. Reich investigate the cause of the surprisingly slow vaccine rollout that left the Japanese population vulnerable.
By Michael R. Reich and Andrew Gordon
Empty stands may be the iconic image of the “2020” Tokyo summer Olympics. The world’s greatest athletes competed in 339 medal events, from gymnastics to horse dancing, with almost no public spectators from Japan or elsewhere.
The athletes, the great majority vaccinated before arriving in Japan, lived in a relatively safe bubble. They were tested and quarantined on arrival, tested daily while living in their separated quarters, carefully isolated when moving between the Olympic village and competition venues, and then quickly hustled out of the country as soon as their events ended. Like everyone else around the world, virtually everyone in Japan watched the games on television.
When the games began, no more than 20 percent of the Japanese population was vaccinated. As Japan watched the Olympics, the daily count of new COVID-19 infections soared to unprecedented levels. Approaching the closing ceremony on August 8, 2021, new infections per day (primarily of the Delta variant) were reported for over 5,000 residents of Tokyo and over 14,000 people nationwide—new records. By the time the games ended, Japan’s hospitals were stretched beyond capacity to treat seriously ill COVID-19 patients. And on September 3, Prime Minister Suga essentially took responsibility for the combination of a surging virus and a sad Olympics by announcing he intended to resign as prime minister.
This situation is puzzling. Through the fall of 2020, Japan and other Asian nations managed to contain the virus more effectively than other countries, and this probably contributed to complacency about the need to vaccinate quickly. But only in Japan were the Olympic games looming. Eight months prior to the games, the world learned about the highly effective vaccines from Pfizer and Moderna. Given this circumstance, why was Japan, with its affluence and technological sophistication, so sluggish in moving to vaccinate against COVID?
The situation is ironic as well. Japan created an Olympic bubble around the athletes and their trainers in order to protect the local population from infection by foreigners. In the end, however, the bubble arguably did more to protect the Olympic athletes from Japan’s soaring infections transmitted by the hardly vaccinated local population.
And this outcome was avoidable. The summer surge of the virus in Japan, the no-spectator format of the Olympics, the huge economic losses for businesses, individuals, and government, and the profound frustration of the Japanese people who could watch their Olympics only on television: all this could have been different. It resulted from decisions by Japan’s political leaders to move slowly on vaccines for COVID-19, starting in late 2020. By the summer of 2021, other countries had safely opened sports events to public visitors, because they had relatively high levels of vaccination. Japan could have been in a similar place, but the nation did not start vaccination soon enough or aggressively enough.
At the end of April 2021, for example, 43 percent of US residents and 26 percent of those in the EU had received at least one dose of the vaccine. This ratio stood at just under 3 percent in Japan. According to Kosaka et al., in the Lancet, the slow vaccine response in Japan resulted from regulatory procedures that required domestic clinical trials and review, delays in importing vaccine doses after regulatory approval, and slow implementation of vaccination efforts once the supplies arrived in Japan.
In short, Japan’s political leaders blinked. The pace of vaccination picked up in June and July, especially for older people, but the slow start could not be overcome by the time the Olympics began in late July. Japan fell behind in the global vaccine race, and the summer Olympics suffered as a result.
Some researchers have portrayed Japan as a country with “low confidence” in vaccines among the public, presented succinctly in an article published in 2020 in the Lancet. We were struck by this conclusion and the slow adoption of vaccines in late 2020, after Japan’s promising start in addressing the pandemic earlier that year. To understand Japan’s slow response to COVID-19 vaccines, we decided to examine the historical record of Japan’s social and policy responses to vaccines over the past 150 years.
The results of our historical study—now published in English in the Journal of Japanese Studies and in Japanese in the medical journal Igaku no Ayumi1—show that a simple conclusion of “low confidence” among the public does not explain the slow move to vaccinate the Japanese population from COVID-19. A more powerful explanation rests in vaccine hesitancy among political leaders and bureaucrats, in particular public health authorities.
We found that Japan’s history shows a complicated mixture of social responses to vaccines. Distinct and conflicting themes emerged of widespread vaccine acceptance and enthusiasm, vaccine hesitancy and mistrust, incidents of public harm from vaccines, and social mobilization both for and against vaccines. Let us briefly summarize our three main findings.
First, for well over a century, the Japanese government officially accepted and publicly promoted vaccines. This began with smallpox in the late nineteenth century, and continued with vaccines for cholera, typhoid, and influenza in the early decades of the twentieth century. Immediately after the Second World War, the Allied occupation authorities—principally Americans—imposed the strictest mandatory vaccine law in the world upon Japan in 1948 (the Preventive Vaccination Law, translated as “Immunization Act”). It met no open resistance.
In the early 1960s, Japan experienced a peak of public enthusiasm for vaccines, in line with global trends. Powerful demands from the mass media, social movements, and organized political interests led the government to import and rapidly administer polio vaccines. The Japanese government officially supported (and required) vaccination with little hesitation. And to this day, the public fully accepts routine childhood vaccinations—Japan’s Ministry of Health, Labour and Welfare reports over 90 percent coverage (and over 95 percent for most)—although they are not mandatory now.
Yet, we also found a second significant theme: a history of vaccine mistrust in Japan. In the mid-1800s, mistrust appeared in the early decades of smallpox vaccination. We found opposition to introducing “foreign” objects into bodies, in both senses: foreign substances from outside Japan and foreign substances from outside the body, although fear of the foreign was not strong enough to spark major antivaccine movements. Starting in the late 1960s, vaccine mistrust found fuel in cases of vaccine-related injuries, both real and alleged, especially for new vaccines introduced to control pertussis, mumps, influenza, and human papilloma virus (HPV).
Mistrust took the form of social mobilization by people claiming injury from vaccines. This activism resembles the political protests and legal remedies pursued in Japan by victims of pollution, food contamination, and pharmaceutical injury. The social movement of victims against vaccine-related injuries has contributed to major policy changes, including a national system of compensation for vaccine-related injuries, and a removal of mandatory requirements for vaccination. The legal cases of health injuries (related to vaccines against diphtheria, polio, and influenza) that occurred in the late twentieth century also led to growing public mistrust of the national health authorities.
Our third major finding—perhaps of greatest relevance to the COVID-19 story—was how these social movements and related litigation, socially amplified by Japan’s mass media, contributed to an increasingly risk-averse approach to new vaccines by Japan’s government and political leaders. This public mistrust has contributed to growing administrative and political vaccine hesitancy among Japan’s top health bureaucrats, who appear uncertain about how to manage the social dimensions of vaccines.
The legacy of movements for redress in cases of vaccine harm, whether real or alleged, provides an important historical context for Japan’s sluggish response to COVID-19 vaccines, and the sad sight of stadiums without spectators for the summer Olympics. In short, the Japanese government, as with other governments around the world, has not adequately solved the significant challenges of how to increase social trust in vaccines during a pandemic.
Yet, even with the slow official push to implement COVID vaccines in Japan, the public uptake of vaccines has been strikingly strong. As of September 9, 55 percent of people in Japan had received one shot, according to official government numbers (although some media sources—such as Nikkei and NHK—reported higher rates). By later this fall, Japanese vaccine rates could well be among the highest in the world. This does not show public vaccine hesitancy.
In sum, and to our surprise, we find that “vaccine hesitancy” appeared more strongly among Japan’s bureaucrats and political leaders than among the Japanese public. Japan’s health and political authorities, that is, did not move quickly to authorize the COVID-19 vaccines on an emergency basis, did not act early to contract and import the necessary vaccines from foreign firms, and did not organize effectively the supply chain and appointment system for vaccines to meet strong public demand. Had Japan’s leaders grappled more thoughtfully with the past and used national experiences with vaccines creatively and urgently, the world and the Japanese people would have been able to enjoy a more joyous summer Olympics, and the nation’s health would be stronger as well.
Weatherhead Center Faculty Associate (emeritus) Michael R. Reich is the Taro Takemi Professor of International Health Policy, Emeritus, in the Department of Global Health and Population at Harvard T.H. Chan School of Public Health. His research interests include political economy of public health policy (including health system reform), pharmaceutical policy, and global health policy.
Weatherhead Center Faculty Associate Andrew Gordon is the Lee and Juliet Folger Fund Professor of History in the Department of History at Harvard University. His research interests include public history and tourism in Japan and globally, with a focus on industrial heritage sites.
- The Olympic Flame is seen during the Opening Ceremony of the Tokyo 2020 Olympic Games at the Olympic Stadium in Tokyo. July 23, 2021. Credit: roibu, shutterstock
- Inside Tokyo's Olympic Village: Working to Prevent a Covid Superspreader Event. June 29, 2021. Credit: Wall Street Journal, YouTube
- Share of people vaccinated against COVID-19: US, EU, Japan, Apr 30, 2021. Credit: Mathieu, E., Ritchie, H., Ortiz-Ospina, E. et al. A global database of COVID-19 vaccinations. Nat Hum Behav (2021). Our World in Data
- Hōsō no kamitowa dare ka nazuken, akuma gedō no tatari nasu koto ka (Who named “god of smallpox”? Is that devil’s doing?). Advertisement for smallpox vaccination by Shuntei Katsukawa, 1770–1820, Artist, woodblock print. Credit: University of California San Francisco Japanese Woodblock Print Collection, Special Collections, ucsf_p253
1. Andrew Gordon and Michael R. Reich, “Nihon ni okeru wakuchin fushin wo meguru nazo (1, 2, 3, 4),” Igaku no Ayumi 277(11,12,13,14), 2021.