Medical Examiner

How to Hold the Olympics During a State of Emergency

COVID cases are rising in Tokyo, and vaccinations are low. Health experts weigh in on how to make the events safe.

Protesters hold signs that spell out "No! Olympics."
Protesters take part in a demonstration on May 23 in Tokyo against the forthcoming Olympic Games. Carl Court/Getty Images

The International Olympic Committee is unwavering, even in the face of rising COVID cases and a state of emergency: The games will go on. The question is: Should they?

COVID cases in Tokyo are currently at their highest since May, with 920 new infections reported on Tuesday. A mere 15 percent of Japanese residents are fully vaccinated. Eighty-three percent of the 1,527 Japan residents polled several weeks ago by the newspaper the Asahi Shimbun agreed that the games should be postponed or canceled altogether. Now, with two weeks to go until the Olympic Games officially begin, it seems there is no hurdle high enough to result in a total cancellation of the games.

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On Thursday, the Japanese government announced a new state of emergency in Tokyo, which goes into effect on Monday and will last until Aug. 22—covering the duration of the Olympic Games and ending just two days before the start of the Paralympic Games. Only hours after the declaration, Olympics minister Tamayo Marukawa made another crucial announcement: Spectators will be entirely absent from the Olympic Games.

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In addition to these new measures, the IOC claims that its COVID playbook—which has gone through three volumes trying to respond to the rapidly changing COVID threat—will aid in mitigation. However, some public health experts are calling for more comprehensive measures—including classifying events as low, medium, or high risk depending on the venue and activity, and implementing PCR testing over temperature screenings. These experts worry that the playbook doesn’t properly account for inadequate ventilation in Olympic venues.

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Considering the complex and polarizing nature of the 2020 Olympic Games (yes, they are still officially titled the “2020” Olympic Games), Slate asked a range of public health experts to weigh in on the risk they pose: Monica Gandhi, associate division chief of the Division of HIV, Infectious Diseases, and Global Medicine at UCSF/ Zuckerberg San Francisco General Hospital; Krutika Kuppalli, an assistant professor in the division of infectious diseases at the Medical University of South Carolina; Keiji Fukuda, a director and clinical professor at the School of Public Health, the University of Hong Kong ; plus one infectious disease epidemiologist working for a nonprofit research foundation who wished to remain anonymous as their institution requires clearance to speak to the press. (Their responses, received via email, have been lightly edited for length).

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Grace Woodruff: Let’s get right to the point: Should the Olympics be canceled? 

Monica Gandhi: No, I do believe they should be held. This has been a difficult time for the world. The Olympics are a unifying event watched by the entire planet. The Olympics will bring spirit, unity, and joy after a very difficult time.

Even with lower rates of vaccination in the country, the athletes and the country can be kept safe. Each athlete should be tested prior to arrival—even the vaccinated. The vaccinated can just have one test. The unvaccinated should be tested prior to arrival and then regularly during their time in the country. The athletes should stay in small cohorts while in country and should mask if not competing or practicing when inside with others.

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Krutika Kuppalli: Honestly, the Olympics should never have been planned to be held this year given the current situation with the COVID-19 pandemic. I understand there are thousands of athletes who have worked their entire life toward a goal of competing for their country in the Olympics, years of planning and billions of dollars have gone into planning for this event, however given the global situation with the pandemic, I think it is out of touch to be planning to have this event at this time. We currently have had over 4 million documented deaths from COVID-19, the pandemic is surging in many countries—particularly resource-limited countries—and we are seeing the emergence of increasingly dangerous variants, which have the potential to undermine the efficacy of our vaccine.

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Keiji Fukuda: This is for the Japanese government to decide. But in essence, it is reasonable to go ahead if the major risks for spread of infection from the Olympics have been identified and carefully addressed by the event organizers, government, and visiting delegations.

If the events are conducted in a way that minimizes the risks of infection spreading, then I believe it is reasonable to go ahead. COVID-19 has already spread worldwide and so this event involving vaccinated individuals is unlikely to significantly further spread infections—if the event is managed well. If this was the start of the pandemic, then I would have answered differently, and said it should not be held. But we are at a very different stage than the beginning of COVID-19.

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Anonymous epidemiologist: No [they should not be canceled]. But as always with epidemiology it very much depends on many factors. It may not seem like it, but we do know how to “live with COVID” if we follow very specific protocols. First and foremost every person involved in making the Olympics happen must be vaccinated. Hard stop. If that can’t be guaranteed, then the risk of COVID spread is likely inevitable.

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What do you think is the biggest risk posed by having the games?

Gandhi: I think there is a risk of spreading but not if proper mitigation procedures are kept in place for those who are unvaccinated.

Kuppalli: I think the biggest risk of the games is the potential for superspreader events, which can occur despite having bubbles. It isn’t clear how they plan on enforcing these bubbles. I am also concerned there could be a surge of COVID-19 infections in Tokyo and Japan as a result of the Olympics, which could not only overwhelm the health care system and already exhausted health care staff, but also lead to even more variants—which could further affect the efficacy of the vaccines we have.

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Fukuda: The biggest question and risk is whether adequate planning has been done, and whether the needed operational steps have been taken, both by the competing delegations and the Japanese authorities, to minimize the spread of infection.

Anonymous epidemiologist: The biggest risk is another large surge of COVID, but this time in more countries simultaneously, because athletes are coming together and then returning home and could easily bring COVID with them. Again—vaccinations are our best defense. But we also have tools that include masking and distancing. Athletes can quarantine when they arrive and repeat testing could also be used. If the Olympics can be run with the same rigor as the NBA Bubble, it could go off without issue. But that requires a ton of coordination!

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What do you see as the most important health measures for the games to properly mitigate COVID risk, aside from vaccines?

Kuppalli: In addition to vaccines—which is a very difficult situation due to challenges with vaccine equity across the world—other important public health measures will be ensuring bubbles among the athletes and ensuring they stay within those bubbles to prevent spread of positive COVID-19 cases, if there were to be one. It will also be important that nonpharmaceutical interventions are used, such as social distancing and usage of face masks to prevent spread of infection. Finally, reliable testing with quick turnaround time for athletes, coaches, judges, and staff supporting the events will be critical to ensure that cases are not being missed and that individuals are not accidentally exposing others to COVID-19.

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It will also be important to have the appropriate amount of health care staff and contact tracers to help investigate any cases to ensure individuals who are exposed to cases undergo appropriate isolation and quarantine.

Fukuda:: After vaccination, minimizing situations where unvaccinated individuals congregate in groups is probably the next most important measure. Other important measures are to make sure health systems are ready to handle an increase in cases, that surveillance is in place, and to continue with use of face masks and social distancing.

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Anonymous epidemiologist: It’s a toss-up between ventilation and masking—correct masking. Masking is an individual action, while ventilation is more of a structural protection for large groups, so both could be used. Also, the games limiting attendees is a very smart idea. With fewer people coming together and then going home—the less likely for continued COVID spread if someone happens to become infected.

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What do you think is the extent of the damage that could be caused by a worst-case scenario of COVID spreading at the Olympics? 

Gandhi: I think we know, by July 2021, how to mitigate the spread of COVID-19, aside from the vaccines (and I am hoping most of the athletes will be vaccinated). I think it would be damaging to Japan’s reputation if spread increased, which is why mitigation techniques are essential.

Kuppalli: I think the worst scenario would be a situation where you see the city of Tokyo overtaken by a surge of cases and the health care system overwhelmed without the ability to care for these individuals. I also think a situation where an even more dangerous variant arises as a result of a superspreader event is another extremely concerning situation. Finally, a situation where you have athletes and coaches coming from countries who have not had access to vaccines coming to compete and falling ill due to COVID-19.

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Anonymous epidemiologist: Simultaneous large COVID case surges in countries that require hospitalization and ventilation. This scenario risks the collapse of health care systems for many low-income nations.

Will you watch the games yourself?

Gandhi: Absolutely.

Kuppalli: I am not sure. I will be attending on the inpatient infectious diseases service at the time.

Fukuda: If I am interested in a specific event and it is televised at a time I can watch, then definitely yes. Among all sporting events, the Olympics still stand out, and I really admire the dedication of the athletes and enjoy watching the competitions.

Anonymous epidemiologist: Absolutely! Former competitive gymnast myself so I’ve been following both the women’s and men’s national teams and team selections!

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