Understanding & Coping in a State of Emergency
On Tuesday, April 7, the ACCJ hosted a discussion regarding the imminent state of emergency declaration and what it means for the ACCJ community. The following panelists participated in this discussion:
Christopher LaFleur, ACCJ Chairman, event moderator
Karin Lang, Minister-Counselor for Consular Affairs and Consul General, U.S. Embassy
Anton Kort, Senior Regional Security Officer, Police Liaison & Security Affairs, U.S. Embassy / Overseas Security Advisory Council Co-Chair
Dr. Thomas Lomax, Medical Doctor at Tokyo Medical and Surgical Clinic
Scott Warren, Partner, Squire Patton Boggs
This panel provided an opportunity to hear expert insights and an opportunity for members and guests to ask questions. We thank each panelist for participation and appreciate the U.S. Embassy’s efforts to assist the American community during these challenging times. Continue reading for insights regarding what to expect as a result of a declaration of a state of emergency.
Please click here to review the State of Emergency declaration.
Please click here for more information on COVID-19 from the Cabinet Secretariat.
NOTE: At the time of this webinar, the GoJ still had not declared the state of emergency. These notes reflect discussion in anticipation of that declaration.
The imminent state of emergency will cover Tokyo, Osaka, and five additional prefectures. Governors in these prefectures will request that:
Residents stay home except to carry out essential tasks
Businesses work remotely if possible and thoroughly implement infection control measures
Schools, childcare facilities, entertainment, and public facilities close
Businesses exempt from closures are those deemed essential, which will likely include:
Transportation
Telecommunication
Utilities
Hospitals
Medical services
Supermarkets
Convenience stores
Drugstores
The state of emergency will also authorize governors to requisition land for healthcare-related facilities, medical and healthcare supplies, and food.
Summary of Remarks from Karin Lang, Minister-Counselor for Consular Affairs and Consul General, U.S. Embassy
Since March 19, the United States has advised citizens against international travel. We recommend making arrangements to travel or return to the U.S. if you are not prepared to stay in Japan for an indefinite period. Japan has barred travelers who arrive from level 3 countries, which includes the U.S., but there are very limited exceptions. This restriction does affect permanent residents of Japan should they decide to travel to the U.S.
The U.S. Embassy is operating on a limited basis, providing only emergency or urgent visa services. We recommend enrolling in the Smart Traveler Enrollment Program (STEP) and following our website and other social media platforms to stay apprised of the latest developments.
Summary of Remarks from Anton Kort, Senior Regional Security Officer, Police Liaison & Security Affairs, U.S. Embassy / Overseas Security Advisory Council Co-Chair
The security services in Japan are not posturing themselves toward the kind of lockdown measures we have seen elsewhere in the world. The state of emergency grants governors additional authority to adopt measures curbing the spread of infection, but does not grant authority over law enforcement.
There are no indications that there are major security operations on the horizon. Some police agencies have cases of COVID-19 and as a result, many are now teleworking.
We are assessing risk in Japan based on a number of data points, such as closures, suspended operations, repatriations, travel options, and healthcare infrastructure. We also account for law and order, freedom of movement, and access to basic needs – all of which remain relatively intact. Overall, we are in a steady state, but we do stress that those highly concerned should consider repatriating to the U.S. while travel opportunities are still available. We do not expect a complete cessation of air travel services, but we do expect continued reductions as Japan imposes more restrictions. In addition, we are monitoring American commercial aviation networks, given that those closures will impact one’s ability to return.
Summary of Remarks from Dr. Thomas Lomax, Medical Doctor at Tokyo Medical and Surgical Clinic
Please note that the following should not be construed as medical advice. Consult a medical professional if you need further assistance.
Many have speculated about the slow spread of COVID-19 in Japan relative to other countries. Although there is nothing conclusive, there are several factors cited as reasons for the gradual increase of coronavirus cases. One reason lies with health policies. Japan has not tested significant numbers of people and has attempted contract tracing, but not as thoroughly or effectively as other Asian countries. Health policy alone likely does not account for all the differences in the rate of cases. Another proposal is the potential biological differences. Medical experts have offered that the Bacillus Calmette–Guérin (BCG) vaccine against tuberculosis may provide indirect protection given that everyone in Asia is required to have it. Lastly, social behavior such as non-contact greetings and the practice of wearing face masks may have decreased the rate of infections.
However, with the number of cases increasing in March, gradually then substantially by the end of the month, the Japanese Medical Association stated that action is required now, or it will be too late. Policy debates are ongoing, but the decision to instate a state of emergency was likely influenced by the medical association’s position.
The state of emergency will include additional measures designed to curb the spread. We will be able to gauge their effectiveness once the measures are announced, but we do know that social distancing is very effective when implemented correctly and executed thoroughly. The coming weeks are critical, and we should see Japanese citizens and companies complying with the order and restricting their movements in spite of the absence of punitive measures for noncompliance.
Summary of Remarks from Scott Warren, Partner, Squire Patton Boggs
Please note that the following should not be construed as legal advice. Consult a legal professional if you need further assistance.
Two main conditions need to be satisfied in order for a state of emergency to occur:
● A situation causing a grave threat to the lives and health of individuals
● The situation causes serious economic damage harming the livelihood of the public
In this instance, the state of emergency confers certain authorities to the governors of affected prefectures. In turn, the governors will empower their local governments to determine the specifics of a lockdown. Businesses will not be able to formulate a detailed response plan until they learn the specific limitations or restrictions imposed in their areas.
For businesses in Tokyo, Governor Koike has intimated they will fall into one of three categories:
Businesses that close (assumedly of their own volition)
Businesses that are asked to close
Businesses deemed essential and should be able to continue operations. (There is still ambiguity as to the definition of “essential,” and will continue to be refined.)
COVID-19 is having a profound impact on businesses and the state of emergency will further compound the challenges businesses are already facing. There are two matters under labor law that businesses of particular note.
First, under Japanese labor obligations, employers have a duty to ensure the health and safety of its employees. It is under this obligation that employers may ask employees to work from home, wear masks while at work, or take other preventative measures. The new working situations brought on by the virus raises related labor law questions, such as the issue of wages. The state of emergency complicates this as companies attempt to continue business operations efficiently and safely. In addition, it may cause great financial strain on the company, which may involve the need for lay-offs or bankruptcy. In general, before any lay-offs would be allowed under the labor laws, the company has to demonstrate it has taken all reasonable action in order to avoid it. In the event terminations are absolutely essential, it must then show they have been fairly determined and imposed.
Second, there is the question of what employers can do to meet their obligations in the work environment. It is largely accepted to mandate certain behavior to stem the infection rate, like the wearing of face masks and washing hands. However, uncertainty remains on the extent of enforcement, such as the employers right to temperature scan its employees before entering the workplace. In such cases, especially as this involves health data, it is strongly recommended you work to obtain the consent of the employee, optimally overtly or, at the least implicitly, if taking any action that may infringe on their privacy.
Questions & Answers
[The following Q&A were addressed during the webinar]
What do I do if I have flu-like symptoms but do not have a medical provider in Japan? Do I have to get tested [for coronavirus]?
Because individual providers are implementing different policies, call a local clinic to learn if they can admit you and have other special guidance.
No, testing is not mandatory. However, you will be advised to isolate at home if you have a respiratory infection and coronavirus has not been ruled out.
Can you clarify the GOJ’s exit and entry conditions for permanent and special permanent residents before and after April 3 and their impact on business travelers?
Please refer to the Japanese Immigration Bureau’s website for the latest information. Contact information is also available for specific inquiries. http://www.immi-moj.go.jp/english/
What is the risk of letting my children socialize with a few friends?
Unfortunately, there is no straightforward answer. Everyone has to assess their individual risk and the impact on those in the household, such as elderly inhabitants. The risk of infection exists on a spectrum and the level of risk decreases with decreased social contact.
If we are returning to the U.S., where can we fly to and what are the challenges of returning if we do not live near a major city or airport hub? What does quarantine look like in the U.S.?
Please refer to the Centers for Disease Control website for more guidance. Public transportation is not recommended. https://www.cdc.gov/
When arriving in the U.S., you will be directed to self-quarantine for 14 days.
What is the capacity of the healthcare system in Tokyo and are there enough respirators?
Japan has among the highest hospital bed ratios in the world, but hospital policies regarding the treatment of COVID-19 patients have had an impact on its capacity. At the moment, it is possible to receive care if needed and there is capacity for respiratory ventilation. If the outbreak becomes more serious, it is likely that the government will swiftly reallocate resources to areas in need to ensure proper care can still be provided.
When will the U.S. Embassy reopen for F1 visas? Are Embassy services for American citizens still available?
We are committed to promoting U.S. education and look forward to welcoming student visa applications back to the embassy as soon as we can.
Routine services for American citizens are somewhat limited. However, we are always available to issue emergency passports and assist in emergencies.
How long will the reduction in flight operations last?
The airlines are really dependent on the traffic and in turn, the traffic is dependent on how quickly the virus is contained. It is difficult to forecast how long airlines will operate at reduced capacity, so if you are planning to leave Japan, it is best to do so sooner rather than later.
Will the national or local governments postpone or reduce tax payments for businesses and individuals whose incomes are dramatically reduced?
The government has delayed submissions and payment dates for taxes in Japan, though there were no specific provisions for those affected by the virus. More information may be available with the release of the stimulus package.
ADDITIONAL Q&A
Due to time constraints, not all questions asked could be answered. The ACCJ reached out to the panelists following the event to have the remaining questions answered in writing:
Will the declaration of the state of emergency in Japan give the government the authority to ban exports that are on critical supply lists?
The order is not clear on whether Japan intends to exclude the export of critical items.
Are US citizens in Japan eligible for the stimulus payments? Do we need to do anything besides what citizens in the US do?
There is no information yet confirming whether the stimulus payments will apply differently based on nationality. It seems to suggest it will be distributed to ‘households’ and small and medium-sized businesses meeting certain criteria. It would seem that a household or entity paying taxes in Japan would be eligible to apply, but they are still working out the details of how and to whom this will be distributed.
What is the availability of COVID-19 tests in Japan? Can your clinic or other clinics administer tests as you determine appropriate?
Testing for Covid-19 is still determined by health units (hokenjo) and is not available on request. This is very likely to remain the case for the foreseeable future - even in countries with massive (over 100,000 per day) test capacity, the number of people with respiratory symptoms or fever on any given day is likely to exceed the number of available tests so some form of triage is necessary to determine who gets tested. This applies even more in Japan which still has a relatively limited testing capacity for its population - test capacity is currently being expanded to 20,000 per day.
Presently there are two routes to approach testing in Japan. Individuals can call their local health unit Covid-19 information line and discuss their symptoms. If the health unit feels that testing may be appropriate, they will usually ask the caller to attend a local hospital or clinic for an initial assessment which will typically consist of a chest x-ray and a rapid blood test. With the information from these tests, the patient may then be directed to attend a testing facility for a Covid-19 test. Alternatively, people with concerns can simply go directly to their local provider who will evaluate, if appropriate, perform initial investigations (chest x-ray and a blood count) and then discuss with the health unit with a view to arranging a Covid-19 test.
A few points to note about the system:
Although I believe that the health units have the authority to send people directly to testing facilities, in practice, it seems that they are unlikely to do so and will typically want an initial assessment with a local provider first.
If the initial assessment is normal - the chest x-ray is unremarkable and the blood test shows no sign of infection - then it's much less likely that the health unit will agree to arrange a Covid-19 test.
Patients can't simply go to a designated Covid-19 testing facility and request a test - they will be sent away and told to call the health unit. The health units are not releasing lists of designated testing facilities in their areas, presumably to reduce opportunistic attendance.
Is there an estimate for when an antibody test would be widely available in Japan and would this kind of test be significant in deciding when full economic activity could be resumed?
As of now, it's not possible to say if or when these tests will be available here. Though they are in use in other countries they are not yet well validated - unlike PCR tests, antibody tests are likely to have a significant false positive rate and until this is determined accurately, this creates some danger. Specifically, a healthy person might ask for an antibody test as they might feel that a respiratory infection which they had in February but weren't treated for was in fact Covid-19. As there are other (non-Covid) coronavirus infections which circulate freely, this individual might have had such an infection - but might have produced antibodies which generate a positive result on a Covid-19 antibody test. This person might then feel that they had no risk of infection with Covid and take fewer precautions - but could actually not have functioning immunity to Covid and so would be placed at risk. Due to limited data on how well antibody tests work, at present, the Japanese health ministry has decided not to grant them regulatory approval.
Is there any data on Japan's pneumonia deaths (versus those classified as COVID-19)?
I haven't been able to find any stats showing country wide mortality from pneumonia (all causes) for early 2020 as compared to other years. I think that the underlying question here is whether a significant number of people in Japan died of Covid early in the outbreak without being identified as Covid-19 patients. I believe that this did happen in China but I doubt that it happened here or at least, not on a large scale. While I can't back this up with data, I would say that these types of infection typically spread mostly through more mobile and socially interactive individuals initially and them later in the course of an outbreak, onto older people who may be less socially engaged (eg less likely to commute on crowded trains or work in busy offices). When these older people get infected they then present to the healthcare system in larger numbers at which point the problem becomes apparent. While we can't prove this pattern for Covid-19, we know this is typically how influenza behaves. From talking to doctors who work in hospitals across Japan I know that early in the outbreak a certain number of younger, healthier patients were seen with suspicious findings on chest CT (patchy ground glass pneumonia shadowing in both lungs), but that often these individuals were not deemed unwell enough to merit testing at that time. So I suspect that back in February, some younger, healthier people had Covid-19, were not diagnosed and recovered spontaneously (as most people do). I'm fairly certain that if larger numbers of older people had been hospitalized with pneumonia then this would have been flagged by doctors (as it was in Wuhan).
Is Japan taking any steps to manufacture ventilators, face shields, masks, etc. on an emergency basis?
I know that the government has requested increased manufacture but unfortunately, I hear that there are supply problems with PPE (personal protective equipment) in hospitals. I'm afraid that I don't have any detailed information on the supply chain or manufacture situation. I do believe that most people overestimate the capacity of any individual country to manufacture complex devices, though - typically manufacturing of something like a ventilator will require a supply chain which crosses multiple national boundaries so importing components from overseas is more likely to be a limiting factor than the capacity of assembly lines here? Maybe someone with a background in medical devices could give a better answer to this question, though, I am not an expert.
Are children who are prone to asthma at greater risk?
Probably yes, they have a higher risk. but maybe not by very much, I don't think that there is enough good data to quantify this accurately yet. I suspect that asthma rates in China are high but despite this, few children were seriously unwell in Wuhan in Jan/Feb. Better data on this is likely to come out of Europe & North America soon, but for now, a good place to start is the early data from Wuhan where there clearly were pediatric cases (not identified as Covid at the time) - it seems that even at the severe end of the disease spectrum, though, full recovery was the norm:
https://www.nejm.org/doi/full/10.1056/NEJMc2003717
What actions can a person take if they know they are high risk and need quick treatment related to COVID-19?
Should anyone who is known to be high risk become unwell with fever and respiratory symptoms, they should seek access to medical care either with their primary care provider, or if more acutely unwell, by visiting an emergency department and with as little delay as possible.
For higher risk individuals who are presently well, careful social isolation for the coming weeks and maybe months is key. Such individuals should ensure that they have good supplies of their regular medications and take whatever steps they can to make sure that their current condition is optimally treated to minimize the risk of developing a medical complication of an underlying problem during the next few months.
How will foreign nationals be triaged in the Japanese system?
My expectation would be that all patients would be triaged equally regardless of ethnicity. I appreciate that in practice this cannot be guaranteed, though. Across the world, studies into equality of access to healthcare have shown that articulate, educated people in their native country are better able to access effective care than those who are socio-economically disadvantaged or do not speak the native language. Many foreign residents of Japan will have heard stories about non-Japanese people struggling to get the health care they seek due to cultural or language barriers so I'd generally advise that foreign residents attend a Japanese hospital together with a Japanese language speaker wherever possible. In my experience, when unable to attend with a Japanese language speaker, in Tokyo St Luke's and the Red Cross hospital generally have plenty of experience in providing for members of the foreign community. To strike a positive note, the feedback I've received from diplomats here who have liaised on behalf of the foreign nationals hospitalized in Japan from the Diamond Princess is that they received good care.
Why does Japan not distinguish HK and Taiwan from China in its travel restrictions? Both have been very successful in controlling COVID 19's spread.
The U.S. Embassy can only speculate that one possible reason that both HK and Taiwan both have airports which are very busy regional transit hubs. In that regard, it may not necessarily be a concern reflective of COVID spread specifically from HK/Taiwan, but rather where travelers went prior to transiting those locations (i.e. China, Korea, Thailand, etc.)
Would it be helpful for individuals/companies to report infections of American citizens to the Embassy?
We are not tracking personal medical or health information regarding U.S. citizens but our American Citizens Services staff is available for those who need assistance.
If commercial flights to the US cease, will the US government provide support if long-term residents need to make a sudden trip to the US to look after family members? The U.S. Embassy has no plans to stage repatriation flights from Japan and strongly encourages those who may need to travel to the United States to depart without delay.
Will the Embassy be working with the Japanese Government to clarify that long term foreign residents with working visas but without permanent resident status can return from the US to Japan as long as they self-quarantine?The U.S. Embassy defers to the Japanese authorities on Japan’s entry restrictions and quarantine requirements. Please consult Japanese Immigration for specific guidance
Is a U.S. hospital ship available for Japan? The U.S. Embassy has confidence in Japan’s health care system and has no plans to deploy a hospital ship to Japan.
