On March 24, 2020, Japanese officials and the International Olympic Committee made the difficult decision to delay the Tokyo Olympics for a year. As The New York Times reported, there had been extraordinary pressure—not just from governments, but from athletes and sports organizations—to delay the games after the World Health Organization officially declared a pandemic two weeks earlier. But Japanese officials at first resisted the decision. Having spent huge sums preparing the location and having devoted a decade to planning the event, making any change came hard. And those officials knew that announcing a year’s delay was no guarantee that the games would go on, because pandemics don’t follow a schedule.

Now it’s a year later, and those same officials are facing a terribly difficult decision. Again. 

In the United States, COVID-19 cases are down tremendously from their peak at the start of the year, but they are still four times greater than where they were on the day Japan announced the delay in 2020. And the United States is one of those nations where a moderately high level of vaccination is having a serious impact on the spread of the disease. One of the nations not seeing this benefit happens to be Japan, where not only are rates of vaccination shockingly low, but cases of COVID-19 are near their highest point in the entire pandemic.

After spending over a year as one of the nations that had “handled COVID well,” Japan is now seeing a wave of disease at the worst possible time.

Despite having access to COVID-19 vaccines and having signed up to purchase more than enough of the vaccine to cover the entire population, Japan’s government was both slow to start vaccinations and slow to expand availability. At the end of February, when the United States had given out 70 million doses, the count in Japan was still below 20,000. When Pfizer asked for an emergency approval in Japan, it took weeks before the government even announced a timeline for when the application would be considered. No Japanese officials lined up on television to get their shots publicly or advocate for everyone to get vaccinated. 

This was happening even though the nation had seen a surge of disease in January, and with the Olympics just months away. Japanese officials spent huge amounts of time advocating for the Olympics. They rarely mentioned vaccines. And the reason is … complicated.

Polls have shown that about a third of Americans were skeptical about either the safety or efficacy of the COVID-19 vaccine. A study in the medical journal The Lancet found big differences in general vaccine acceptance between nations. 

Japan ranks at the bottom when it comes to believing vaccines are safe, important, or effective.

This study is just one of several that show an incredible level of vaccine resistance in Japan. The Japanese people questioned didn’t think vaccines were effective, or important, or safe. Less than 20% of Japanese people strongly agreed that vaccines were either safe or effective.

How could a nation as scientifically keen, technologically advanced, and education-focused as Japan also produce the world’s biggest population of vaccine skeptics? As Japan Times wrote in December 2020, the reason dates back decades—but it doesn’t come from some Tuskegee-level horror in the past. Instead, it comes from a case that’s similar to the “vaccines cause autism” mythology that has so long fueled much of the anti-vax sentiment in the United States.

In the 1990s, Japan saw an uptick in cases of aseptic meningitis that was tied to the MMR (Measles, Mumps, Rubella) vaccine routinely given to children. Even though multiple papers were published, and the story of infants suffering convulsions or even death dominated Japanese media, long-term studies were unable to establish any definite link with the vaccine.  

But the the fear over vaccines increased rapidly. In 1992, a court ruled that the Japanese government was responsible for any “adverse effects” caused by any vaccine given under a mandatory vaccine program. The ruling stipulated that this included “suspected” effects. In response, Japan actually stopped given MMR vaccinations. In fact, it dropped all mandatory vaccinations. 

That decisions has since led to numerous measles outbreaks. That includes a 2019 outbreak that The New York Times reported spread to at least 20 of Japan’s 47 prefectures. 

When the HPV vaccine was introduced in the 2000, Japanese media dug in again, with 87% of articles focusing on the potential for adverse effects. Also involved in the effort that ultimately caused the withdrawal of the vaccine: a social media group that called itself the “Cervical Cancer Vaccine Sufferers Organization,” which espoused unsourced and unsubstantiated claims that were given overwhelming attention. Vaccination rates among girls in Japan dropped from 70% to 1%. Eventually, the government suspended availability of the vaccine and remained silent in the face of numerous request from medical and scientific boards recommending that vaccinations resume.

Since the Japanese government dropped its mandatory vaccination program, it’s also been extremely cautious about saying anything that even suggests someone should give a vaccine—out of fear of being sued. The end result of all this can be seen in the table below.

Japan’s level of vaccination is shockingly low, especially when compared to other wealthy nations.

Not only has Japan been reluctant to even hint that its citizens should be vaccinated despite a rising tide of COVID-19 cases, it’s failing to take the biggest step that could protect both its citizens and visitors to the nation.

On Monday, Reuters reported that an organization representing 6,000 primary care physicians in Japan recommended that the Olympics be canceled, saying that doctors in Tokyo “have their hands full and have almost no spare capacity” due to the wave of new COVID-19 infections. Citing statistics showing that hospitals in the area are already feeling the strain from the number of coronavirus patients, the doctors state—forcefully—that the area is unable to cope with an influx of athletes and tourists who will inevitably bring with them other diseases and suffer from issues such as heatstroke. 

The physicians sent their statement as an open letter to Prime Minister Yoshihide Suga. But Suga, who did get his own vaccination in March in preparation for meeting with President Joe Biden, continues to insist that Japan can hold “a safe and secure Olympics.”

Japan has largely avoided the kind of disaster seen in nations like the United States. More than a year into the pandemic, Japan has seen only 5,500 cases per million people—that’s almost 20 times lower than the total in the United States. Japan’s per capita rate of new cases is also only just over half that of the United States. But as other nations are trending down, Japan is trending up. 

A nationwide tradition of wearing masks and a culture that celebrates cleanliness has likely contributed to Japan’s low levels of COVID-19 despite relatively low level of government interventions in 2020. But bringing the world to Tokyo at this point seems like a very bad idea.