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Nursing and Health Sciences (2014), 16, 26–30

Research Article

Medical relief for the 2011 Japan earthquake: A nursing account* Satoko Mitani, RN, PhD,1 Mayumi Kako, RN, PhD, MACN2 and Lidia Mayner, RN, BSc, BScHons, PhD2 1 Graduate School of Medicine, Kyoto University, Kyoto, Japan and 2Disaster Research Centre, Flinders University, Adelaide, South Australia, Australia

Abstract

In 2011 the east coast of Japan experienced a massive earthquake which triggered a devastating tsunami destroying many towns and killing over 15 000 people. The work presented in this paper is a personal account that outlines the relief efforts of the Humanitarian Medical Assistance team and describes the efforts to provide medical assistance to evacuees. The towns most affected had a large proportion of older people who were more likely to have chronic conditions and required medication to sustain their health. Since personal property was destroyed in the tsunami many older people were left without medication and also did not remember which type of medication they were taking. Some evacuees had brought a list of their medication with them, this assisted relief teams in obtaining the required medication for these people.The more successful evacuation centers had small numbers of evacuees who were given tasks to administer the center that kept them occupied and active.

Key words

evacuation center, humanitarian relief, Japan earthquake, older people, public health nursing.

BACKGROUND The event On March 11, 2011 a megathrust occurred off the coast of Japan and caused the Great East Japan earthquake, which triggered a massive tsunami that damaged many towns and villages on the coastline. The total area affected by the tsunami was 561 km2 (Geospatial Information Authority in Japan, 2011) and the death toll was recorded at 15 883 (National Police Agency of Japan: Emergency Disaster Countermeasures Headquarters, 2012). The affected area is located in the northeast of Tokyo. The earthquake and tsunami also caused the Fukushima Daiichi Nuclear Plant meltdown, which resulted in the compulsory evacuation of local residents living around the 20 km radius of the plant. Many medical facilities were destroyed and many were rendered not operational due to the earthquake.

Type of injury and cause of death from the earthquakes In 1995 the Great Hanshin-Awaji earthquake caused much damage in Hyogo and there was a high presentation of

Correspondence address: Mayumi Kako, Disaster Research Centre, School of Nursing & Midwifery, Flinders University, GPO BOX 2100, Adelaide, SA 5001, Australia. Email: [email protected] *The authors report no conflict of interest. Received 23 July 2013; revision received 23 October 2013; accepted 23 October 2013.

© 2013 Wiley Publishing Asia Pty Ltd.

people with injuries caused by collapsed buildings. In contrast, over 90% of deaths in the 2011 earthquake were due to drowning from the tsunami (Nagamatsu et al., 2011; Ushiyama & Yokomaku, 2011). The Disaster Medical Assistance Team (DMAT) was operating from the Ishinomaki Red Cross Hospital, a 402-bed hospital, situated in the Miyagi Prefecture. The majority (63.1%) of patients who presented at the Ishinomaki Red Cross Hospital had green tags, they were ambulatory, and their medical conditions included pneumonia from aspiration of seawater or cellulitis from wounds. Yellow tags were used for patients (27.1%) who were transferred to the hospital with serious injuries (Nagamatsu et al., 2011).

Aging population The affected areas were located in the northeast of Japan, where there are increasing numbers of older people. Three prefectures were involved and affected in this disaster, namely Fukushima, Miyagi, and Iwate, which all have an ageing population. An example of this was recorded in 2005 when 30.5% of people in Japan were over 65 years old, but in the Iwate Prefecture this was 40% (National Institute of Population and Social Security Research, 2012). The people who died in the 2011 disaster who were aged 60 years and over accounted for more than 65% of the total death toll (Ushiyama & Yokomaku, 2011). In comparison with the 1995 Hanshin-Awaji earthquake in which the age of the people that died was: 58.3% were aged over 60 and within this figure 39.3% were over 70 years old (Kobe City Department of doi: 10.1111/nhs.12112

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Fire and Emergency, 1995). The more recent earthquake therefore affected a higher proportion of older people. The study by Nagamatsu et al. (2011) pointed out that for many old people their health deteriorated because they were unable to obtain medication to manage their chronic medical conditions.

Disaster relief There was an increase in the capacity for medical needs during the super acute period (from onset to 48 h after the disaster) in the affected areas, and the DMATs were deployed to meet this need. Lessons learned from the Great Hanshin-Awaji Earthquake in 1995 prompted officials to establish the Tokyo DMAT in 2004, this being the first prefectural medical assistance team in Japan. Following the establishment, DMAT member trainings and workshops were launched in 2005 by the Ministry of Health and Labor. The current total number of DMAT teams in Japan since its inception has grown to 380 with a total of 1800 members throughout Japan (Yamaguchi & Tanshou, 2012). Thus, the interest in, preparedness and standardization of the disaster medical assistance after the 1995 disaster has gradually increased in numbers. The DMAT activities are generally completed within 48 h of the disaster onset due to its objectives to provide acute medical support and logistics for patients who cannot have appropriate medical treatment in the affected area (DMAT: Japan Disaster Medical Assistance Team, 2012). The follow-up support for those who need further medical attention was provided by various short-/ long-term disaster-recovery support organizations, including government and nongovernment agencies. The Humanitarian Medical Assistance (HuMA) is a medical nongovernment organization established in 2002, but is not registered as a DMAT. It has approximately 500 members, some of whom have been involved in international humanitarian activities since the 1980s. The organizational objectives are to provide humanitarian support including medical support and care to those who are victims of various disasters (Humanitarian Medical Assistance, 2013). Each disaster is different and requires different needs for affected people and damaged communities. One of the authors of this paper is a team member of HuMA and participated in the medical relief activities after the 2011 disaster in Japan. The following is a description of the activities of the HuMA organization, as well as personal accounts of the humanitarian work carried out by the team, including that of a nurse’s experience, and a summary of lessons learnt.

PERSONAL OBSERVATIONS AND ACCOUNTS Deployment to the affected area, Minami-Sanriku town, Miyagi prefecture The area of deployment was one of the three prefectures that had been severely damaged by this disaster (Fig. 1). After the initial inspection of the affected area and, based on the decision by three members including the director of HuMA,

Figure 1. Map of Japan showing significant town and prefectures.

seven members from this organization were deployed to Minami Sanriku Town on March 21, the tenth day after the disaster. The following section will describe the nurse’s experience of the deployment from March 21 to March 26, 2011, especially focusing on the dates March 21 and 22, 10 and 11 days after the tsunami.

March 21, 2011 The team left Tokyo at six in the morning on March 21. The first team deployed left in two buses, one for personnel (2 medical officers and 5 nurses) and the other for equipment. The team joined a logistics group from the Japan Mountain Association. It usually would take 8 h to travel to the destination, however, the arrival was significantly delayed due to the severely damaged conditions of the highways. The Service Area, a designated rest place was closed. Although the highway was closed at the time on March 21, rescue-related vehicles were allowed to use the highway. Petrol transport to the affected area was commenced on the same day. When the vehicles transporting petrol to the affected area were seen, it signaled the importance of these trucks in that they were carrying vital provisions that would save people’s lives. We stopped at several rest areas, but the toilets were not functional. Even if some of the rest areas were open, we did not see anything on the shelf in the shop as there was no transport to bring any supplies. Temporary toilets were prepared since the toilets facilities did not work due to insufficient water supply.The team then had lunch brought from Tokyo. After this rest stop, the team set off again but had to take a number of detours due to the damaged roads. We finally arrived at the Sizugawa Bayside Arena around 1500 that day. © 2013 Wiley Publishing Asia Pty Ltd.

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Figure 2. Temporary toilet facility brought in by the HuMA team for their use.

Shizugawa Bayside Arena was the central emergency management headquarters for the region. Approximately 1500 people were evacuated there and the supply of relief items was stored inside the gym. Next to the Arena, there was a Self-defence Force Base. Docomo (Japanese Telecommunication Company) was setting up the mobile telecommunication station and people could see the national news on a giant TV set. The HuMA team were allocated to five sites by a medical officer working at the Arena. There were already some medical assistance teams working in the area. The HuMA team had set up an office at the nursing hostel called Utatsu Azalea Garden and then went to visit the other four nearby sites.The medical equipment brought from Tokyo was unloaded. An empty room at the hostel was used as a drug store. The hostel accommodated residents, their family, and evacuees from the neighborhood. The staff at the hostel took care of the residents. Other displaced people were looked after by the volunteers. It appeared that the care responsibilities were designated as required. Although residing under the same accommodation (Utatsu Azalea Garden), only the residents at the hostel had meals provided, the other evacuees were not provided with meals. Other humanitarian organizations provided for other evacuees and the nursing home provided for their residents. Due to the early departure on the day, the HuMA team had completed their duty by 1800 then drove about one and half hours to their accommodation, at an inn located near the mountains. I was surprised to see a town where water and electricity was functioning only one and half hours away from the affected area. All shops were closed and there were no vehicles to be seen since there was no petrol.

March 22 The HuMA team left the inn at 0700 hours and went into the Nursing Hostel in Minami Sanriku Town.While setting up the base control for the clinic, the HuMA team divided themselves into four groups to visit the evacuation centers, at the following locations: © 2013 Wiley Publishing Asia Pty Ltd.

1. 2. 3. 4. 5.

Utazu Azalea Nursing Hostels (250 evacuees) Minato Shingi Kaikan (community hall; 35 evacuees) Yosegi Residential House (15 evacuees) Chive Beach House (accommodation; 30 evacuees) Ishiizumi Community Center (80 evacuees) Activities at each clinic were as follows.

Utazu Azalea Nursing Hostels Morning: outpatient clinic run by Kokushikan University medical team and medical round for residents at nursing hostel (health check for 39 residents), intravenous fluid (IVF) treatments for people with chronic condition and patients with enteritis. Afternoon: outpatient clinic by Nagasaki DMAT. Checked seven patients, provided prescriptions for three patients who were residents there, but the team did not know whether the residents knew about the HuMA clinic. This was reported to the director of the nursing hostel who was asked to publicize the clinic. Toilet facilities: a bucket of water was used to flush the toilet as the sewage system was not functional. The team brought temporary toilet facilities from Tokyo for their own use so as to be self-sufficient and not be a further burden on an already overextended system, see Fig. 2. These facilities were cleaned every morning by the logistics people from the Mountain Climbing Association.

Minato Shingi Kaikan (community hall) There was a retired public health nurse (PHN) and a registered nurse who use to work at the Shizukawa Hospital, which was destroyed by the tsunami. They kept the health assessment notes including the regular medication needs of patients. This information helped the team to supply the necessary medication obtained from the Bayside Arena, where the regional disaster management headquarters were located. Although evacuees had cars, they could not drive due to insufficient petrol supplys. Health assessments were carried out by the HuMA team workers and point of care was

The 2011 earthquake medical relief

used for pathology testing. Thirty-five patients were checked for chronic health problems, with hypertensions, hyperlipedemia, backache, and hay fever being the main health issues. No febrile patient was observed and it was suggested that the weekly medication supply be distributed by the PHN to evacuees.The evacuees were advised that medical appointments were available at 10 am every second day so that they could prepare for an appointment. The existing toilets (four restroom stalls) were functioning, because they were pit latrines. Cleanliness of the toilet was maintained.

Yosegi Residential House and Chive Beach House At both Yosegi Residential House and Chive Beach House the Nagasaki DMAT was in charge. The HuMA team visited these centers but did not have involvement in the medical activities.

Ishiizuki Community Center The Center was located on the top of a hill. People at this center were found to have colds and laryngitis, which was recorded. Another nurse who evacuated from the Shizugawa Hospital was also staying there and was very supportive. Local residents and a local welfare commissioner also helped the evacuated people but on a voluntary basis. For example, the volunteers would inform the evacuees about the medical clinics at the venue. Toilets were maintained for cleanliness and sullage was controlled by humanitarian volunteers so as to not cause further health concerns. The damage caused by the tsunami was not seen in this area and some of the residential houses remained intact. Both welfare volunteer officers at the community and community leaders were looking after evacuees who had lost homes. “Due there being no communication facilities available, people were having difficulties getting food, clothes and medication for their chronic medical conditions” personal account.

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Town through the activities of HuMA. The relief activities were to visit evacuation centers and houses where frail older people were living and to check their health status and needs. There were two important findings to highlight from this experience. Firstly, due to the large numbers of people with chronic conditions in the centers, medication management was important and difficult. There were many difficulties encountered in supplying necessary medication to people due to the loss of their property and hence information. Evacuees did not remember the type of medication they were taking and there was no way to confirm their prescription due to the damage caused to hospitals and pharmacies. Even if medication was available, self-managing was difficult for those who stayed at evacuation centers because of irregular meal times, unbalanced diet, and the stressful living environment. These negative factors especially affected people with chronic conditions, particularly people with diabetes and hypertension. However, there were also some positive aspects. Some people had kept a medication booklet, which was encouraged by the General Practice clinics. This was very useful to gain information about their medication. Secondly, environmental management differences in large- and small-size evacuation centers were noteworthy.At the large-sized evacuation center such as sports centers and concerts halls, it was too crowded and there was no provacy. Due to the large area of the evacuation center the number of evacuees entering increased. The room temperature in these large areas was not kept at an appropriate level: mainly it was too cold. Furthermore, evacuees had nothing to do throughout the day. In contrast to this, at the small-sized evacuation centers, evacuees knew each other since they were from the same community and evacuees and volunteers were designated the maintenance role of the center. Some health professionals were themselves evacuees in the smaller centers.This was another factor which improved the environment quality of the smaller evacuation centers and these were better managed.

CONCLUSION

Tokushu-kai medical team supported staff from the Shizugawa Hospital, which had an outpatient clinic. There was only one entrance and an administration office at the disaster management office. Furthermore, there was not enough space for evacuees and it was packed with people. Medical teams had a clinic at the athletic gymnasium within the Arena, however, behind this space, more evacuees and bedridden people were lying on the floor. There was a toilet for people with disabilities at the front of the clinic. The layout of the clinic was disappointing and it was not functional at all.

The characteristics of an area affected by a disaster will influence the length of the recovery phase. Through this disaster relief experience in 2011, a large aging population in the affected area was one of the considerations. Medication management in particular was important due to the numbers of people with long-term health problems. Lack of medication and knowledge about individual’s medication was problematic. In the evacuation centers the designated role for evacuees, including older people, was purposeful and they were able to maintain their daily activities and sense of selfesteem. The concept of health promotion as well as healthrisk prevention at evacuation centers should be considered. Promotion of medication awareness for those people with chronic conditions should be an important issue for local officials as part of disaster preparedness.

IMPORTANT LESSONS

ACKNOWLEDGMENT

The team’s purpose was to support the disrupted health service system in the damaged areas, particularly in Sanriku

We would like to thank Dr Takashi Ukai for providing information and sharing important work and experience.

Bay Side Arena (evacuation center and emergency management center)

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CONTRIBUTIONS Study Design: MS, MK, LM. Data Collection: MS. Manuscript Writing: SM, MK, LM.

REFERENCES DMAT: Japan Disaster Medical Assistance Team. Japan DMAT office home page. 2012. [Cited 5 May 2013.] Available from URL: http://www.dmat.jp/index.html. Geospatial Information Authority in Japan. The fifth report of the area of tsunami affected area (estimated count). 2011. Humanitarian Medical Assistance. Humanitarian medical assistance. 2013. [Cited 19 Jul 2013.] Available from URL: http://www .huma.or.jp/. Kobe City Department of Fire and Emergency. Report of the department of fire and emergency during the Hanshin Awaji earthquake. Kobe, 1995.

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Nagamatsu S, Maekawa T, Ujike Y, Hashimoto S, Fuke N. The earthquake and tsunami – observations by Japanese physicians since the 11 March catastrophe. Crit. Care 2011; 15: 167. National Institute of Population and Social Security Research. Table 12-17 Prefectural ageing population between 1920 and 2005. 2012. [Cited 15 Mar 2013.] Available from URL: http://www.ipss.go.jp/ syoushika/tohkei/Popular/Popular2012.asp?chap=12&title1=%87 %5D%87U%81D%93s%93%B9%95%7B%8C%A7%95%CA %93%9D%8Cv. National Police Agency of Japan: Emergency Disaster Countermeasures Headquarters. Damage situation and police countermeasures associated with 2011 Tohoku district – off the Pacific Ocean earthquake, 3 October 2012. [Cited 17 July 2013.] Available from URL: http://www.npa.go.jp/archive/keibi/biki/higaijokyo_e.pdf. Ushiyama S, Yokomaku H. The death and missing persons characteristics in the Great East Japan Earthequake in 2011 (Express report). Tsunami engineering research report, 2011. Yamaguchi J, Tanshou K. Saigai to iryou: Saigaiji no DMAT katudou to yakuwari (Disaster medicine: the role and activities of DMAT). Nichidai Igaku Zasshi 2012; 71: 10–13.

Medical relief for the 2011 Japan earthquake: a nursing account.

In 2011 the east coast of Japan experienced a massive earthquake which triggered a devastating tsunami destroying many towns and killing over 15 000 p...
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