Author: Masahiro Kami
Executive Director, Medical Governance Research Institute
Editor: Tetsuya Tanimoto
More than seven years after the Fukushima nuclear accident, our medical team has continued to work in the disaster-stricken areas; we have published various research articles based on our own activities at these sites. In March 2018, one of my colleagues, Dr. Tomohiro Morita, of Fukushima’s Soma Central Hospital, published a research article in the journal PLOS One, “Demographic transition and factors associated with remaining in place after the 2011 Fukushima nuclear disaster and related evacuation orders”
The main finding of Dr. Morita’s article is that some residents, particularly those who lived alone, chose to remain in the mandatory evacuation zones, in spite of the evacuation orders that were issued after the nuclear accident. Such studies, along with others we have published, have attracted worldwide attention (especially from researchers associated with the U.S. military); the results of our research have huge implications for preparedness against nuclear terrorism, which is my focus in the following article.
On March 21, 2018, the Israeli government admitted to launching a covert air strike in 2007 on Syria’s nearly-completed nuclear reactors. Those reactors had purportedly been constructed with the support of North Korea. According to the Israeli government, declassification of the 2007 operation prompted the recent disclosure of information, which diplomatic officials seem to regard as a warning aimed at Iran. In the wake of President Trump’s request to reconsider the suspension of sanctions, a condition that the Obama administration had permitted in exchange for cessation of nuclear development, the world is becoming unstable.
In its March 29, 2018 issue, the world-renowned New England Journal of Medicine (NEJM) published an article entitled “Are We Prepared for Nuclear Terrorism?” coauthored by Dr. Robert P, Gale, of London’s Imperial College, and Dr. James O. Armitage, of Omaha’s University of Nebraska Medical Center (http://www.nejm.org/doi/full/10.1056/NEJMsr1714289).
Dr. Gale is not only a prominent hematologist, but also a global authority on radiation disasters. He was involved in the treatment of patients exposed to radiation in the 1986 Chernobyl nuclear accident. In an account published in the July 27, 1989, issue of the NEJM Dr. Gale reported that 13 patients exposed to estimated total-body doses of either 5.6 or 8.7 Gy received bone marrow transplants, and two transplant recipients, exposed estimated doses of radiation of 5.6 and 87 Gy were alive more than three years after the accident (http://www.nejm.org/doi/full/10.1056/NEJM198907273210401).
Furthermore, Dr. Gale visited Japan in 1999, after the Tokaimura nuclear accident happened, the worst civilian nuclear accident in Japan until the nuclear disaster at Fukushima occurred. In the Tokaimura accident, two nuclear workers suffering from acute radiation exposure were under the care of a Professor of Emergency Medicine at the University of Tokyo, Dr. Kazuhiko Maekawa, who invited Dr. Gale to assist him in a special advisory capacity. I also participated in that consultation, but I vividly remember that Dr. Gale’s experience rendered him capable of providing phenomenally appropriate guidance. For example, he provided the following expert prognosis and recommendation: “There will be no serious symptoms soon after radiation exposure. However, in a few days, the skin will break, severe diarrhea will occur, and we will observe the manifestation of bone marrow failure. Therefore, bone marrow transplantation is urgent.” As I had not yet treated patients suffering radiation exposure, I could not even imagine such things as he was describing. Although no workers or residents suffered acute radiation exposure in the Fukushima nuclear disaster, Dr. Gale made another visit to Japan in the wake of that crisis. He was featured in a great deal of the media coverage at the time, although I got the impression that no use was then made of expertise.
So, what have we learned from the Fukushima nuclear disaster? We must regard it as a lesson in preparedness for residents. When should evacuation begin? By what means and to which locations? Who should be evacuated? In this kind of disaster, making the wrong choices would yield numerous victims. In that sense, Dr. Morita and our colleagues’ research article, mentioned at the beginning of this discussion, provides compelling results. I first met Dr. Morita in 2006, when he was a student at Nada High School, one of highest-ranked private schools in Kobe. Subsequently, Dr. Morita joined the University of Tokyo’s Faculty of Medicine, and has since joined our team as well. He graduated from the University in 2012, and married his classmate, Dr. Mariko Morita, who is also a member of our team.
Returning to our subject of interest, Dr. Morita and colleagues aimed to investigate the evacuation of residents from Minamisoma City just after the nuclear disaster at Fukushima. However, nobody generated a precise record of how the evacuation was conducted at the time. Therefore, Dr. Morita and his colleagues used medical questionnaires that had been created and distributed by another member of our team, Dr. Masaharu Tsubokura, to gather data about internal radiation exposure. In the questionnaires, we made inquiries concerning the immediate post-disaster evacuation measures, to generate an accurate assessment of radiation exposure. At the time of the Great East Japan Earthquake, Minamisoma City had a population of 79,919, 12,201 of whom resided in the mandatory evacuation zone that consisted of the area within a 20- kilometer radius of the damaged nuclear power plants. Residents of the designated indoor evacuation zone, within 20-30 kilometers of the plants, numbered 44,773, while those residents living outside the evacuation zone numbered 19,555. Of these three groups, the residents that participated in our examination of internal radiation exposure numbered 3,415 (28%), 13,801 (31%), and 2,993 (27%), respectively.
One limitation of our research was the potential overestimation of the risk involved in evacuation, because the residents we were questioning about internal radiation exposure were already worried about the risks of radiation exposure. In addition, we were unable to examine the evacuated residents who have still not returned to the city, which amplifies the potential for underestimation. That being said, given that past research investigated a mere 1% of the target population, our research still yielded substantial findings with significant implications. In fact, we obtained surprising results from our study. It is worth noting the proportions of the total residents evacuated: 87% of the residents in the designated indoor evacuation zone and 87% of the residents in the zone 30 kilometers from the nuclear power plant were evacuated. This signifies that there were residents who themselves judged it too dangerous to remain at home, and therefore evacuated voluntarily, although the government had informed them that it would be safe for them to stay inside their houses.
On the other hand, what do we know about those residents who elected to stay in their houses? According to Dr. Morita, “They were males in their working age and elderly people.” The former included people who served as city officials, first responders (including firefighters and ambulance personnel), hospital workers, and construction workers. The presence of the latter group reveals a profound implication. Dr. Morita and the team analyzed the households where residents lived alone and households with residents who were aged 70 years or older, and discovered that, respectively, they were 1.7 and 1.2 times likelier to stay, relative to others. Dr. Morita noted, “It would be more appropriate to say that the elderly residents who stayed in their houses were just left behind rather than proactively chose to stay at their own will.”
“The left behind” contingent was not limited to those living in the designated indoor evacuation zone. Dr. Tsubokura, who provided medical care in the zone after the earthquake, said, “I found the residents who stayed at their houses even within the 20-kilometer zone in Odaka district. There were those left behind as well. Some got illness and there were elderly people who got injured and even if they called an ambulance, it was impossible because the government prohibited it to enter the zone.” In the modern societies of developed countries, our daily lives depend on systems that operate on the basis of advanced logistics. Can you imagine a Japanese society with no available or accessible delivery services? Precisely this kind of emergency situation actually occurred in Minamisoma City following the Fukushima nuclear disaster. In fact, the government took various measures to provide the designated indoor evacuation zone residents with substantial emergency supplies, which included including the Self Defense Force. However, such methods were failed to work as intended, and were thus insufficient. Many commodities supplied by private companies simply failed to be transported to their intended destinations.
Dr. Tomoyoshi Oikawa, then the Deputy Director of Minamisoma Municipal General Hospital (now the hospital’s Director) said, “It was only March 16, 2011, that we could obtain various rescue goods including water and foods. During the 5 days before that, we could not get even foods at all. The nurses who did not evacuate began to enter the kitchen in the hospital, and prepared meals for patients using anything available as foods.” [m1]It was very unusual for nurses to enter the kitchen for the purpose of cooking, but this was an exception that owed to the fact that the cooking staff typically provided for patients were assigned to the companies outside of the hospital. After the disaster, all of 14 members of the cooking staff quit their jobs, due to the policies of the companies that had contracted their services. Similarly, 19 medical clerks, 6 custodians, and 6 guards stopped attending work. As a result, the excessive burden of sustaining hospital operations was imposed on the remaining doctors and nurses.
Such was the case at this hospital, so what happened to the remaining populace can be easily imagined. Due to disruptions within the distribution system, most companies and shops were unable to continue operating. In the absence of the daily income required to continue doing business, there were a very few and rare companies that managed to avoid closing and dismissing employees completely. Consequently, elderly persons left behind found themselves totally isolated. Some local doctors observed, “Among those left behind, there were deceased persons, due to isolation. Some people were even suspected of starving to death by necropsy.”
In the wake of the disaster, a huge panic consumed the city, which regained a sense of calm, as the actual situation manifested more clearly a month after the disaster. Ultimately, it was determined that relatively low radiation contamination afflicted the city. The ambient exposure around the hospital that was located in the coastal area of the Fukushima prefecture was 0.4 to 0.5 microSv per hour, which was lower than the levels in Fukushima city, located inland of the prefecture. When the evacuated residents learned this fact, they started to return to their homes, because they had not had time to retrieve anything other than necessities before leaving, they wanted to see their homes with their own eyes, and they had experienced a series of hardships at the evacuations sites of evacuation. The pre-disaster city population of 70,919 decreased to approximately 10,000; however, it the population underwent moderate recovery, reaching about 40,000 by April 2011.
However, it was not until April 22 that the designated indoor evacuation was abrogated by the Government. Dr. Tsubokura remarked, “Usually, it should be cancelled in just a few days.” Meanwhile, the social infrastructure in the area remained dysfunctional. Hospitals were no exception to this rule. The main hospitals in the area are the Kashima Kosei Hospital (outside the 30-kilometer zone) and the Minamisoma Municipal General Hospital (within 20-30 kilometer zone); it was not until May 2 and May 9, respectively, that those hospitals started to admit patients again. Before those dates, patients could not be admitted to either local hospital, even if they were suffering from an acute illnesses.
An acquaintance employed as a part of the bureaucracy composing the Ministry of Health, Labor and Welfare said, “In a case like this, a prefecture has no legal authority to suspend the operation of individual medical institutions.” Nevertheless, managers of the local hospitals simultaneously declared, “At that time, Fukushima prefecture instructed us to suspend hospital admissions to treat patients.” I suppose that they aimed to avoid assuming their due responsibility for transporting many hospitalized patients, in case of any residual effects of the nuclear accident under the continued designated indoor evacuation by the central government. It is impossible to determine their true intention, but the significance is clear: the residents left behind were deserted by them.
It was extremely likely that this policy was effectively fatal for many residents. Another study, published by Dr. Morita in October 2017, revealed that the risk of death in the first month after the disaster (not including the drownings related to the Tsunami) showed an increase of 2.64-fold among males and 2.46-fold among females (http://jech.bmj.com/content/71/10/974.long). In particular, the risk was higher among those aged 85 years and above, and the main cause of death was pneumonia. It is plausible to imagine that the elderly patients simply lacked adequate access to treatment, given how immediately they were isolated after the disaster, and left without sufficient support from the outside of the evacuation zones.
The lesson we must learned from the Fukushima Daiichi Nuclear Power Plant Accident is that, for the elderly members of society, serious damage can derive not only from the direct effects of radiation exposure but also from the indirect effects of dysfunctional infrastructure of post-disaster modern society—which clearly include insufficient access to medical care. Further, this particular case demonstrates the difficulty of predicting the precise impact of a nuclear accident on a modern city. At best, we can perform a dynamic analysis to gauge the damage to a society, by conceiving of a city as a complex and organic system in the event of another nuclear accident. To conduct such analyses, collaboration with experts in the fields of artificial intelligence and big data would be indispensable. If that is so, then what can we clinicians contribute to such complicated dynamic analyses and possible resolutions? In my opinion, we should practice medicine at the level of individual patient care, to obtain primary clinical data as much as possible. Without the consuming work required to accumulate such big data, there will be material for information engineers to analyze.
In that sense, the research conducted by Dr. Morita is highly suggestive. He has lived and practiced in Fukushima’s disaster-stricken coastal area for more than 4 years. He is familiar with the long-term effects of the nuclear accident on the society, and his familiarity is based on his real and personal experience. This is why he has successfully published the research paper I proudly introduced at the beginning of this article. During Dr. Morita’s 4-year stay in Soma city in Fukushima, he has generated more than 30 English publications. Among these, there were 11 papers for which he was credited as the first author. Those publications represent are valuable records, elucidating the impact of the nuclear disaster on the society.
Researchers worldwide pay attention to publications by Drs. Morita and Tsubokura. In fact, interested researchers are not limited to the field of medicine. Researchers in the field of military affairs (specifically, from the US army) have also made contact with them, to establish methods of preparedness for potential nuclear attacks and nuclear terrorism that might strike cities in the United States. As such, the research by Drs. Morita and Tsubokura is associated with publications related to preparedness for nuclear terrorism, as note at the beginning of this essay.
Due to exacerbated levels of global warming, natural disasters are occurring at increasing rates worldwide. In the current political climate, the risks of nuclear terrorism and attacks are also on the rise. Therefore, the experience of the Great East Japan Earthquake is a valuable source of information about how to prepare ourselves for the dangers that lie ahead. We must share the lessons we have learned with the world. How can we do that? As Dr. Morita has done, we must work with patients, practice medicine, and publish research. Instead of espousing armchair theories, but we must encourage and practice the actual behavior we describe.
The Japanese version of the manuscript was originally published in Japan-in-depth, a news website provides interpretation current news in Japan, on April 16 2018, and was reproduced for MRIC Global under the author's permission.