Beyond the day after tomorrow: community health in Japan

The author with a self defence team next to the exclusion zone, Minami-Soma City

When the earthquake, tsunami and subsequent aftershocks hit Japan in early 2011, health systems and staff were tested to the extreme in trying to meet people’s health needs. Ryuki Kassai, from the Department of Community and Family Medicine, Fukushima Medical University, tells the story of what happened and the lessons that he and other medical professionals learned from their experiences. 

On Friday afternoon, 11 March 2011 the first earthquake and tsunami hit us in the Pacific Coast areas of the Tohoku region (the northernmost region of the main island of Japan). The disaster that we now call the ‘Great Eastern Japan Earthquake’ was caused by the strongest earthquake ever recorded in Japan (magnitude 9.0) followed by a 15-metre tsunami and hundreds of aftershocks.

According to the Japan Meteorological Agency, as of 8:00 am on 21 May there have been 459 aftershocks with a magnitude of 5.0 and above, with 76 registering 6.0 and higher and five at the 7.0 level or higher. According to a National Police Agency tally as of 20 May, 15,148 people are dead and 8,881 are missing with 91,484 houses/buildings completely destroyed and 40,454 partially destroyed.

A major lesson from the first few days of the disaster was the need to resume information networks as quickly as possible. The telephone circuits were immediately shut down, due to the overload in the affected areas. Although the Internet was alive, its use was limited by the availability of computers and electricity. It was difficult for us to get a whole picture of what was going on in the prefecture and the region overall.

Hundreds of patients were evacuated from community hospitals and nursing homes in the severely damaged tsunami-hit areas, especially in the towns very close to the Fukushima Daiichi (No. 1) nuclear power plant, and were transferred in chartered buses to facilities in safer places. Those evacuations had to be operated without notice to the receiving facilities. Damage to the electronic medical record systems of the sending facilities resulted in referral/transfer without necessary patient information about their medical condition. We need to invent some innovative telecommunication systems that can survive the acute initial period of grave disasters, by collaborating with the local/national governments, police, paramedics, telecommunication companies, the Internet services, academics in technology etc.

People in Fukushima, especially those who have young children, nursing or pregnant mothers in their families, are very worried about potential risk of thyroid cancer to children after the nuclear accidents. They sometimes complain that they do not know what to do, or what not to do, and that they are not given essential information for their decision-making.

Unfortunately, we still do not have high quality standardised evidence-based information to assist us. By collaborating with people around the world, we need to construct a database of evidence-based information/references on immediate, short- and long-term effects of ionizing radiation, as well as of several kinds of disasters, and interventions and strategies to alleviate the effects. On the other hand, we know that scientific evidence cannot be generated without bias. A gap always exists between scientific evidence and daily practices in reality. In order to apply evidence into our practice/decision-making, we have to take several contextual factors into account.

Another lesson I have learned is the need for good collaboration between specialists in the hospitals and primary care physicians, after the disaster, even in the acute disaster period. If many patients with primary care problems had not been rushed into secondary/tertiary care hospitals after the disaster, the function of the hospitals would not have been affected so much. I found that care of the weak (frail elderly, children, pregnant or nursing mothers, people with chronic illness, mental illness, or multiple co-morbidity) was easily left behind in the acute disaster period without well-functioning primary care providers.

Japan has weak systems of primary care, which have become much more conspicuous since we were affected by the disaster. Many primary care doctors in the communities stopped seeing patients and they did not work within networks to serve communities. Several primary care assistance teams visited the affected areas, but it was often difficult for the local governments and people to coordinate such sporadic aid from several different prefectures in Japan.

During the past two months I have been working as a leader of the teams to help people who cannot move by themselves and still live at home in the zone between 20 and 30 km from the nuclear power plant, next to the exclusion zone. In the first week of the operation, we took care of 299 people at home in three cities, two towns and one village. Identifying who we needed to visit was difficult. We had to make a database of the target people by collecting information from several sources: from registers of several different health services, making many phone calls and by going from house to house. This is another weakness of Japanese primary care; we do not have health register systems for the whole population. We cannot have an accurate grasp of the health status and needs of people in the communities without such health register systems.

It is hard for us to resolve all the difficulties in the aftermath of the disaster. However, it is my hope that we can make good use of what we have experienced and learn to reconstruct at least some systems in better ways.

Ryuki Kassai, MD, PhD, MRCGP
Professor and Chair
Department of Community and Family Medicine
Fukushima Medical University
1 Hikarigaoka, Fukushima
960-1295 Japan

E-mail: ryukikas@fmu.ac.jp

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