Domestic spectators will be allowed to attend Olympic events in Tokyo this summer, the president of the Games announced on Monday, ending months of speculation that athletes could be deprived of a live audience in an effort to reduce the risk of coronavirus transmission.
The decision settles the last major logistical issue facing the organizers of the Games, which have been delayed for a year because of the pandemic, all but guaranteeing that the event will go forward despite lingering concerns. Spectators from overseas were barred from attending in March in a major concession to the realities of the pandemic.
The president of Tokyo 2020, Seiko Hashimoto, said that the International Olympic Committee had agreed that crowds would be allowed up to 50 percent of a venue’s capacity, up to 10,000 people. However, if the pandemic situation worsens or if emergency measures are declared by the Japanese government, the Games could be held without spectators.
The decision to allow people in Japan to attend events indicates a growing certainty that the Tokyo Games, which are scheduled to begin on July 23 and run through Aug. 8, will go on, after months of concern that they could become a superspreader event as athletes and other personnel pour into the city from around the world.
Concerns have diminished substantially in recent weeks as Japan’s virus case numbers drop and vaccination rates skyrocket. After a slow rollout, the country is now administering nearly one million doses of the vaccine every day. About 18 percent of the population has received a first dose of a Covid-19 vaccine, and 7.3 percent are fully vaccinated, according to a New York Times database.
Nevertheless, worries remain. Japan’s top coronavirus adviser, Shigeru Omi, has consistently warned against allowing spectators, which he believes adds an unnecessary layer of risk. This month, organizers said that about 10,000 of the 80,000 volunteers who signed up to help with the Games had quit, citing fear of infection among their reasons.
As recently as May, a poll showed that 83 percent of people in Japan disapproved of plans to go through with the event. But those numbers have turned around along with the improvement in the country’s virus situation.
Olympic officials said that more than 80 percent of athletes had been vaccinated. Other groups, including staff members, journalists covering the event and some volunteers, will also receive shots.
Conscious of the public’s concerns, Olympic officials have also agreed to strict conditions on the Games. Athletes will be tested regularly for the coronavirus and their movements will be restricted and monitored. Failure to abide by the rules could lead to disqualification or even deportation.
The Games will have rules for spectators aimed at reducing the risks of transmission, including mask wearing, a ban on shouting, and specific guidelines on travel to and from venues.
A panel of expert advisers to the committee told reporters on Friday that the rules were likely to be stricter than those currently in place for other live sporting events, such as baseball.
There are 11 states in the United States where at least 20 percent of older adults still haven’t received a Covid shot, potentially putting the recovery there at risk.
People 65 and older were given top priority for vaccinations because they are far more vulnerable to serious illness and death from the coronavirus than younger people are. Those 65 and older have the highest rate of vaccination among all age groups, with 87 percent having received at least one dose, compared with 60 percent for people ages 18 to 64, and 31 percent for those 12 to 17.
But in 11 states, seniors who have yet to get a dose of the vaccine pose a risk to their states’ recovery as most places remove restrictions aimed at limiting new outbreaks.
Most of them are in the South: Alabama, Arkansas, Louisiana, Mississippi, North Carolina and Tennessee. Georgia, Idaho and Missouri are at the 20 percent threshold. West Virginia and Wyoming also have more than 20 percent of people 65 and over without one dose.
“The 20 percent lines up pretty well with a group of people, especially in the South, who say, ‘No way, no how am I getting vaccinated,’” said Dr. Michael S. Saag, associate dean for global health and professor of medicine at the University of Alabama at Birmingham.
Among the factors at play, he said: conspiracy theories, a belief in pseudoscience and a libertarian mind-set that says, “You can’t tell me what to do.”
“Convincing them that it is in their own interest is a tough nut to crack,” Dr. Saag said. “For the state of Alabama and other Southern states, this is not for a lack of effort or resources. This is about a population resistant to receiving the message.”
Older people, in general, feel more threatened from the coronavirus and more likely to die from it, experts say, and it’s not surprising that they have been among the most receptive to the vaccines. After older age groups were given priority when the first vaccines were authorized for emergency use in December, the proportion of those dying started dropping immediately.
Across the United States, those 50 and older continue to make up the bulk of Covid-19 deaths, and the virus continues to kill hundreds of people daily.
Death rates remain high in pockets of the nation where vaccination rates are not. Experts are concerned that Southern states, where vaccination rates are lagging, could face a surge in coronavirus cases over the summer.
“All epidemics are local at the end of the day, and transmission is person to person,” Dr. Saag said. “There is going to be a hot pocket of transmission if someone becomes infected and others around them are unvaccinated. This is not Epidemiology 101, this is common sense.”
Last year, a summer surge lasted until September in the South. This year, many people are vaccinated, and there is residual immunity from those who have already had it, Dr. Saag said.
What’s more worrying for him, he said, is the dropping of mask ordinances as the more infectious Delta variant spreads. U.S. health officials this week classified the Delta variant, which was first found in India, as a “variant of concern,” sounding the alarm because it spreads rapidly and may cause more serious illness in unvaccinated people.
“We’re sitting on a powder keg,” Dr. Saag said.
A Kaiser Family Foundation poll found last month that 10 percent of unvaccinated seniors said that they would “definitely not” get inoculated against the coronavirus. But the same poll showed signs that some hesitant people have been persuaded: About a third who had planned to “wait and see” whether they would get vaccinated said that they had made vaccine appointments or planned to do so.
The largest Covid-19 treatment facility in the Maldives has nearly 300 beds and a steady supply of oxygen. But as the country reported some of the world’s highest caseloads per capita last month, Covid wards ran low on another essential resource: employees.
The health care system in the Indian Ocean archipelago depends largely on doctors and nurses from India, a country that is facing its own crushing outbreak. With foreign health professionals unavailable, the Maldives’ only medical school — which opened in 2019 and has a total of 115 students — sent dozens of medical and nursing students to work in Covid wards in the capital, Malé. The government also called nurses out of retirement and drafted volunteers with no medical experience.
“We were always prepared for a possible surge, but a wave this sudden and massive was just unexpected,” said Nazla Musthafa, a health adviser to the government.
Though 59 percent of the Maldives’ approximately 540,000 people have received at least one dose of a Covid-19 vaccine, the recent surge took a heavy toll. Nearly half of the country’s 200 Covid deaths during the entire pandemic were reported in May.
Many people in Malé now have someone in their extended families who has died, said Marjan Montazemi, the UNICEF representative to the Maldives. “Because the numbers are not the same as in other countries, it doesn’t attract that much attention,” she said. “But for the country, it has been quite difficult.”
The number of so-called black fungus cases in India has shot up to more than 30,000 from negligible levels in just three weeks. The deadly disease has sickened former coronavirus patients across the country, and doctors believe that hospitals desperate to keep Covid-19 patients alive made choices that left them vulnerable.
Indian states have recorded more than 2,100 deaths, according to news reports. The federal Health Ministry in New Delhi, which is tracking nationwide cases to allot scarce and expensive antifungal medicine for the condition, called mucormycosis, has not released the number of fatalities.
The pandemic has drawn stark lines between rich nations and poor, and the mucormycosis epidemic in India stands as the latest manifestation. During the second wave of the coronavirus, which struck India in April, its creaky, underfunded medical system lacked beds, oxygen and other necessities as infections and deaths soared.
The mucormycosis epidemic adds even more urgency to the difficult task of protecting India’s 1.4 billion people, only a small fraction of whom have been vaccinated against the coronavirus. They remain vulnerable to a third wave and the consequences that could follow.
“Mucormycosis will tail off and go back to baseline as the Covid cases subside,” said Dr. Dileep Mavalankar, an epidemiologist. “But it may come back in the third wave unless we find out why it is happening.”
Many doctors in India think they know why. The bone-and-tissue-eating fungus can attack the gastrointestinal tract, the lungs, the skin and the sinuses, where it often spreads to the eye socket and the brain if untreated. Treatment for the disease involves complex, often disfiguring surgery and an uncommon and expensive drug, contributing to a mortality rate above 50 percent.
Mucormycosis is not passed from person to person. It develops from commonplace spores that sometimes build up in homes and hospitals. Doctors believe that India’s crowded hospitals, and their dire lack of medical oxygen, left the fungus an opening.
Without enough oxygen, doctors in many places injected patients with steroids, a standard treatment for doctors battling Covid globally. Steroids can reduce inflammation in the lungs and help Covid patients breathe more easily.
Many doctors prescribed steroids in quantities and for durations that far exceed World Health Organization recommendations, said Arunaloke Chakrabarti, a microbiologist and the co-author of a study examining the causes of India’s mucormycosis outbreak. Those steroids may have compromised Covid patients’ immune systems and made them more susceptible to fungal spores.
The steroids may have also dangerously increased blood sugar levels, leaving people with diabetes vulnerable to mucormycosis. They could also increase the chance of blood clots, leading to malnourished tissue, which the fungus attacks, said Dr. Bela Prajapati, who oversees treatment for nearly 400 patients with mucormycosis.
Desperate doctors may not have had the chance to ask patients whether they had diabetes or other conditions before resorting to steroids.
“Doctors hardly had any time to do patient management,” Dr. Chakrabarti said. “They were all looking at how to take care of the respiratory tract.”
FRESNO, Calif. — On a Tuesday afternoon in April, among tables of vegetables, clothes and telephone chargers at Fresno’s biggest outdoor flea market were prescription drugs being sold as treatments for Covid.
Vendors sold $25 injections of the steroid dexamethasone, several kinds of antibiotics and the anti-parasitic drug ivermectin. Chloroquine and hydroxychloroquine — the malaria drugs pushed by President Donald J. Trump last year — make regular appearances at the market as well, as do sham herbal supplements.
Such unproven remedies, often promoted by doctors and companies on social media, have appealed to many people in low-income immigrant communities in places across the United States where Covid-19 rates have been high but access to health care is low. About 20 percent of Hispanic people in the United States lack health insurance, and the proportion is far higher among undocumented immigrants.
What’s more, some immigrants mistrust doctors who don’t speak their language or who treat them curtly — and those concerns have been amplified by harsh political rhetoric directed at Mexicans and Central Americans.
“My community fears that the government might be trying to get rid of us,” said Oralia Maceda Méndez, an advocate at a Fresno-based community group for Indigenous people from Oaxaca, Mexico.
A woman in Fresno recently described how her husband, a farmworker, had fallen so sick from Covid-19 that he couldn’t breathe or walk, but he refused to go to the hospital because he had heard rumors that undocumented immigrants had checked in and never left.
She took him to a wellness clinic, where a doctor gave him injectable peptide treatments, recalled the woman, who requested anonymity because of her immigration status.
She wasn’t prepared, she said, for the $1,400 bill, which included the cost of syringes and vials labeled thymosin-alpha 1, BPC-157 and LL-37. Pulling them out of a cabinet in the kitchen of her mobile home, she said she didn’t know exactly what they were, and she still feels the sting of the price.
“I was shocked, but I was trying to act like it was OK because I had to be strong for my husband and my kids,” she said. He grew sicker despite the injections, but the family had no funds left for care. More than a month passed before he was well enough to return to the fields.
Some unregulated drugs can be dangerous. And even if they aren’t a health risk by themselves, they can lead people to postpone seeking help from doctors, which can be deadly. Delayed treatment is one reason Black and Hispanic people have died from Covid at twice the rate as white people have in the United States.
Alternative therapies can also limit a patient’s treatment options because doctors worry about toxic drug interactions, said Dr. Kathleen Page, an infectious-disease specialist at Johns Hopkins University School of Medicine in Baltimore.
“I’m not upset at patients when they tell me what they’ve taken,” Dr. Page said. “I’m upset about the system that makes it easier for them to get help from nontraditional places than from regular health care.”
Sandy Sirias contributed reporting. This story was supported by the Pulitzer Center.