The 9.0 magnitude earthquake that hit Japan at 14:46 on March 11, 2011, and the massive tsunami that it produced inflicted the most damage by any disaster in Japanese history. One of the most serious consequences of these events, referred to as the Great East Japan Earthquake, was the damage to the Fukushima nuclear power system. The Great East Japan Earthquake disrupted the power supply of the cooling system of a nuclear reactor in the plant, resulting in the release and diffusion of a large quantity of radioactive particles.
To assist the victims of this complex, wide-ranging catastrophe, 100 000 personnel of the Japan Self-Defense Force (JSDF) were dispatched throughout the nation. This report provides an overview of the medical characteristics of the victims and the disaster relief activities performed in response to the Great East Japan Earthquake. It also describes the lessons learned from a review of the response to the disaster. These findings, in turn, have become the basis for the expectations of the JSDF medical section and recommendations for the improvement of its response in future disasters.
DISASTER RELIEF FOLLOWING THE GREAT EAST JAPAN EARTHQUAKE
Medical Characteristics of the Victims
Of the fatalities sustained during the Great East Japan Earthquake, 92% were due to drowning, and individuals 70 years or older accounted for approximately 50% of all fatalities. Thus, the elderly was the age group most affected and drowning was the most common cause of death.Reference Nagamatsu, Maekawa, Ujike, Hashimoto and Fuke1 In total, 19 824 people died and 6121 people were injured during this disaster, yielding a death: injury ratio of 0.31. In contrast, 6437 people died and 43 792 were injured during the Great Hanshin-Awaji Earthquake, yielding a ratio of 6.80. Compared to the Great Hanshin-Awaji Earthquake, the Great East Japan Earthquake had many fewer injuries occurring than fatalities, and the number of fatalities due to serious trauma, such as crush syndrome, was relatively low.Reference Fuse and Yokota2, Reference Ueda, Hanzawa, Shibata and Suzuki3
Because the massive tsunami destroyed many homes, a large number of victims were accommodated in shelters, leading to overcrowding. Many elderly victims experienced a worsening of their existing physical conditions. This decline was caused by the loss of the community where they had resided for many years and their relocation to the shelters.Reference Ichiseki4 A notable consequence of the overcrowding was that many elderly victims refrained from water intake because of a lack of restrooms, resulting in mild and moderate dehydration.
Overcrowding at shelters not only caused physical imbalance due to lack of exercise and nourishment but it also exacerbated endogenous obstacles to health and created boredom. Many patients with hypertension experienced a rise in blood pressure due to the intake of excessive salt contained in preserved food and/or the interruption of their antihypertensive medication.Reference Nishizawa5 Also, the onset of acute cardiac syndromes, including acute myocardial infarction and angina and stroke, significantly increased after the earthquake. Research has suggested that living in a cold environment immediately after a disaster increases the risk of cardiovascular disease.Reference Yamauchi, Yoshihisa and Iwaya6
In addition, an increase in infection with communicable pulmonary diseases and infection with an unidentified respiratory illness was commonly observed. This increase was likely due to the inhalation of dust that is created when large quantities of mud and sludge brought up from the sea bed by the tsunami dried and scattered during the post-disaster repair of structures.Reference Ohkouchi, Shibuya, Yanai, Kikuchi, Ichinose and Nukiwa7 A significant increase in chronic obstructive pulmonary disease also was observed, but its cause is unknown.Reference Kobayashi, Hanagama and Yamanda8
The main medical characteristics of the Great East Japan Earthquake were the low number of severe injuries compared to fatalities and the demographics of the damaged area, which had been a medical depopulated zone. This designation defined the area as rural, with limited medical resources, and many elderly residents. Because local medical institutions were destroyed in the disaster, the long-term evacuees experienced a remarkable number of chronic health problems. It was believed that overcrowding at shelters and negative environmental factors in the affected area combined to produce a negative influence on their health.Reference Nohara9 The tsunami also destroyed the local government office of the coastal area, which greatly reduced the provision of health care. In reviewing the response to this disaster, the need to establish back-up systems for coping with public health crises during major disasters was highlighted.
Provision of Medical Aid by the JSDF
After receiving orders from the prime minister, 100 700 JSDF active duty and reserve personnel, 543 aircrafts, and 55 ships were dispatched by March 18, 2011, to conduct disaster relief operations. The JSDF established joint headquarters of disaster management in Sendai, the center of the Tohoku district, and immediately began disaster relief operations. Every base and camp in or close to the disaster area provided logistic support and large quantities of supplies and resources, such as water, food, fuel, and sanitary needs to assist the dispatched units.
In total, 850 medical personnel, including doctors, nurses, emergency medical technicians, and other medical specialists, were deployed to the disaster area. These specialists performed a wide range of medical support activities, including patient transportation, chronic disease management, health consultation, mental health care, infectious disease prevention, and emergency medical care, in cooperation with the Disaster Medical Assistance Team (DMAT), local public health workers, and volunteers. Similar to the US National Disaster Medical System, the DMAT is a temporary disaster medical relief system that currently consists of 4000 trained doctors and nurses familiar with emergency medical care who work within 400 teams. Based on the massive demand for emergency medical services after the Great Hanshin-Awaji Earthquake in 1995, the Japanese government established the DMAT for rapid response to reduce preventable death.Reference Kondo, Koido and Morino10
A major challenge during relief operations for this disaster was that Sendai Hospital, the central hospital of the northeastern army’s JSDF, was at risk of collapse due to damage from the earthquake. In response, the hospital established several patient facilities at air dome shelters, which have been used as field hospitals, and relocated inpatients to these shelters in cooperation with the field medical battalion. By the morning of March 12, a total of 40 injured patients had been transported by air to these shelters from the disaster area. As the air domes were highly insulated for protection from the environment, they proved useful for treating patients with hypothermia.
By April 13, the JSDF for Sendai Hospital had provided medical treatment to 1263 victims. To stabilize the patients’ condition before air evacuation to the Kasuminome Air Field in cooperation with the local health authority, a field medical battalion established the surgical care unit (SCU) as a temporary medical facility. Patients with medium-grade symptoms were taken to the hospital in the northeastern area by JSDF helicopter, while patients with serious conditions or in need of dialysis who required long-range transportation to facilities outside of the northeastern area were transported by JSDF cargo jet.
Seven medical reinforcement units had entered the disaster area by the third day of the disaster’s onset to establish aid stations and provide medical treatment and health consultation. The field ambulance units transported patients and the elderly who experienced difficulty visiting the hospital. Seventeen additional medical teams were organized to provide visiting health consultations at each shelter. The JSDF medical units treated a total of 21 000 survivors in the first 2 months post-disaster.Reference Morisaki and Yamada11
DISCUSSION
Major JSDF Contributions to Relief Aid
The first major contribution of the JSDF to relief aid was the nearly total provision of prompt lifesaving support. After the earthquake, live information regarding tsunami damage was provided from the air by helicopters equipped with photographic-transmission devices, facilitating the transportation of rescue teams on the ground. Based on this reconnaissance, rescue helicopters were dispatched to transport victims from the isolated coastal areas to the inland aid station. The 27 157 rescuers who conducted these operations consisted of 19 286 JSDF staff, 3749 police, and 5064 fire department personnel. The JSDF played an important role in search and rescue activities during the acute phase.
The second JSDF contribution was the provision of a wide range of health services to evacuees at the shelters. To assist in establishing a medical support system, the local government officials adjusted the number of JSDF and relief units at each region 1 week after the disaster. Ishinomaki, which had sustained severe tsunami damage, maintained outreach shelters at 300 areas within the city.Reference Ishii12 In cooperation with the private sector, the JSDF provided health management of victims, improved sanitary conditions at the shelters, and monitored the medical situation.
For many elderly victims, receiving nutritional support, opportunities for exercise, and the ability to continue their usual life activities were important for maintaining physical and mental health. Comprehensive care by specialized medical staff, including pharmacists, nurses, and psychotherapists, was also effectively provided.
The third JSDF contribution was to coordinate and provide transportation. The JSDF played a major role in evacuating patients to hospitals, transporting patients to regional facilities by air, and allocating and transporting hygienic necessities and medications from the hospital by the DMAT to affected areas throughout the country. The DMAT began dispatching staff across the country almost simultaneously with the initial earthquake. On the first day after the earthquake, the DMAT dispatched 377 emergency medical care specialists from throughout the country by C-1 air cargo transport to Hanamaki Airport, northeast of the disaster area, to serve as the first medical team.
The JSDF then transported a second medical team to replace the first team, ultimately transporting a total of 20 240 DMAT specialists by air throughout the relief assistance period. In addition, the JSDF transported many patients, including 19 patients requiring dialysis therapy and intensive care, to hospitals outside of the disaster areas. To transport critically ill patients by air, the JSDF formed an aeromedical evacuation unit containing intensive care monitoring equipment. At the request of Miyagi Prefecture officials, the northeastern army medical battalion established 12 surgical care units (SCU) in the Kasuminome Air Field over a wide area of the site. By March 16, 2011, patients had been transported to the Kasuminome SCU for further care at medical aviation institutions outside of the affected areas.
In the aftermath of the disaster relief efforts, the JSDF dispatched a liaison officer to a conference regarding disaster reduction in the local community to support annual joint training with the police, fire department, and private medical teams, including the DMAT. Since then, the JSDF has been strengthening its close cooperation with other authorities regarding disaster countermeasures.
Lessons Learned From the Great East Japan Earthquake
The Development of Human Resources
Three important lessons learned during the provision of disaster relief after the Great East Japan Earthquake should be considered when planning for future response to large-scale disasters. The first lesson is the need for the development of human resources. When facing a catastrophe in which demand greatly exceeds supply, the ability to use limited medical resources effectively to minimize secondary damage is necessary. Building this capacity requires training specialists who can perform medical techniques in dangerous situations.
By providing treatment at many shelters and first-aid stations, the JSDF physicians filled a wide range of roles, including the coordination of public health activities such as environmental hygiene control, radiation protection, and disaster-incident command system preparation, with the disaster medical team in the private sector. The school gymnasium was usually specified as a shelter when a disaster occurs. However, the tsunami damage was so widespread that unpredictably large numbers of evacuees were accommodated at shelters (Figure).
Figure Changes in the Number of Evacuees and Shelters After the Great East Japan Earthquake.
Prevention of influenza outbreak at shelters was performed by a military medical officer who had been educated at the Japanese National Institute of Infectious Diseases (NIID), in cooperation with health care stakeholders in the disaster area. They collaborated with the community health office and the NIID surveillance center to exchange predictions regarding epidemic influenza outbreak and provided recommendations (eg, room ventilation, wearing a mask, and early counseling) to prevent an outbreak. They also diagnosed disease by syndrome surveillance of general fatigue and fever and conducted rapid testing of suspected cases.
A physician with experience working at the International Atomic Energy Agency contributed to safety management after radiation exposure by the nuclear accident response team. Furthermore, military experts who had undergone training in incident medical management, such as disaster management and emergency preparedness, played a key role in the organization and management of many disaster aid teams. The roles that all of these professionals were required to assume indicated the need to train experts in the JSDF medical staff by providing opportunities for them to work with various professional organizations domestically and internationally during non-disaster times.
The JSDF provides education and training based on the principles of disaster medicine that emphasize command and control, safety, assessment, triage, treatment, transportation, knowledge of the incident command system, primary trauma care, triage for mass casualties, and patient evacuation. Currently, disaster psychiatry and forensic medicine training, including death certification, are also provided.
Providing Aircraft for Transportation
The second lesson learned is the importance of having proper aircraft available and prepared to transport patients and deliver supplies. Because many land routes in the disaster areas were impassable, the use of aircraft was indispensable for transporting the wounded and rescuing victims.Reference Matsumoto13 However, Matsushima Air Force Base and Sendai Civil Airport, the facilities that were closest to the coast, were completely devastated by the tsunami, which hindered the use of large aircraft requiring long runways. Therefore, the use of helicopters was important, but the availability of police and fire department helicopters was limited. Although the JSDF had a helicopter, it was designed for general purpose activities.
The primary lesson learned from this experience is to have available helicopters designed for aeromedical evacuation that are equipped for long-distance transport (ie, containing oxygen cylinders) and patient monitoring. As helicopters have no pressurizing structures, staff that use them must receive special training in caring for patients at high altitudes.Reference Imai14 The JSDF contributed significantly to the establishment and operation of the SCU in stabilizing the conditions of patients for air transportation. In the future, providing them with further training in the means of rapidly forming an SCU is necessary.
Providing Medical Care Through All Phases of Disaster Response
The third lesson learned is to provide disaster medical care throughout all phases of disaster response rather than focusing on the acute phase of response only. Within 24 hours of the disaster, 380 DMATs had been dispatched throughout the disaster areas by JSDF aircraft. Although the DMATs were able to provide specialized emergency medical care, the need for chronic disease management was greater than the need to provide acute life-saving treatment. Specifically, the need to manage chronic disease, including diabetes, hypertension, renal failure, and autoimmune disease, in elderly victims who had been evacuated with only the barest of necessities, was not met. The chronic conditions experienced by these victims were often exacerbated by long-term residence in a shelter, resulting in deterioration in many cases.
A variety of medical services, including geriatric care, nutritional management, and treatment of post-traumatic stress disorder and dementia, had been required for the elderly. In the aging society of Japan, elderly survivors represent a special population at risk for psychiatric disorders. The JSDF experts in clinical psychology were responsible for providing mental health consultation to survivors to detect early symptoms, such as anxiety, insomnia, and anorexia.
A review of the medical response to the Great East Japan Earthquake indicated that medical response during the acute phase had been strengthened, as based on lessons learned during the Great Hanshin-Awaji Earthquake; however, planning for the provision of long-term treatment for chronic health conditions after a disaster had not been addressed. This failure contributed to disaster-related fatalities, such as those from excessive fatigue, insomnia, deterioration of chronic disease conditions, and nutritional imbalance, the incidence of which increased in tandem with the duration of shelter life. The primary lesson learned from this failure was that providing clinical treatment by physicians is not the only consideration in responding to a large disaster; also to be considered is the provision of a wide range of health care services by various specialists who are familiar with local health activities.Reference Matsumoto and Inoue15 To improve disaster medicine in the future, a central consideration must be the provision of comprehensive medical care that also accounts for the sustainability of public health initiatives.
Acknowledgment
International assistance, especially that provided by Operation Tomodachi of the US Armed Forces, was generously provided.
Disclaimer
This report represents the personal views of the author and does not reflect the official position of any governmental agency.
