The Great East Japan Earthquake, Tsunami, and Fukushima Daiichi Nuclear Power Plant Accident
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The Great East Japan Earthquake,Tsunami, and Fukushima DaiichiNuclear Power Plant AccidentA Triple Disaster Affecting the Mental Health of the
CountryJun Yamashita, PhDa,*, Jun Shigemura, MD, PhDbKEYWORDS
The Great East Japan Earthquake Tohoku region Tsunami Fukushima Daiichi nuclear power plant accident Psychological First Aid
Posttraumatic stress disorder, major depressive disorder, and suicide need to be moni-tored closely in the wake of the Great East Japan Earthquake. Other problems includecompassion fatigue among caregivers and discrimination against Fukushima residents,including workers in the nuclear power plant.
Outreach activities of public health teams (eg, setting up common rooms) in temporaryhousing developments have been found effective in dealing with scarce mental health re-sources in the Tohoku region and in reducing psychological barriers because of stigmaaround receiving treatment. Japan now advocates education of first responders with Psy-chological First Aid.
Future disaster response efforts in Japan should include mental health measures in thenational disaster plans, and a review of subsidized or reimbursed psychotherapy for evac-uees provided by professionals outside doctors offices. Agreement about methods oftraining and supervising mental health professionals should be developed in Japan.In 2011 Japan experienced one of the biggest earthquakes in the last 1000 years. TheGreat East Japan Earthquake was record-breaking itself and caused 2 other seriousdisasters: a tsunami and a nuclear power plant accident. The tsunami destroyed thepast of its victims while the nuclear power plant accident threatens their future, andDisclosure of Interests: None.a Faculty of Letters, Department of Humanities and Social Sciences, Keio University, Tokyo,Japan; b Department of Psychiatry, National Defense Medical College, 3-2 Namiki, Tokorozawa,Saitama 359-8513, Japan* Corresponding author. Department of Drug Informatics, Graduate School of PharmaceuticalSciences, Chiba University, 1-8-1 InoHana, Chuo-ku, Chiba, 260-8675 Japan.E-mail addresses: firstname.lastname@example.org; email@example.com
Psychiatr Clin N Am 36 (2013) 351370http://dx.doi.org/10.1016/j.psc.2013.05.004 psych.theclinics.com0193-953X/13/$ see front matter 2013 Elsevier Inc. All rights reserved.
Yamashita & Shigemura352the earthquake continues to add stress to the present lives of survivors in theFukushima, Iwate, and Miyagi prefectures in the Tohoku region, located 200 to500 km (125310 miles) northeast of Tokyo.1 This article uses the term triple disasterfor the 3 disasters combined. This triple disaster has highlighted the chronic shortageof mental health resources, which had existed in the region. This article outlines mea-sures that have been implemented against the long-term impact of the triple disasteron scarce mental health resources, as well as mental health needs among the affectedpeople and the state of mental health services both before and after the disaster.
BEFORE MARCH 11, 2011Socioeconomic Status in Japan
The 2011 populations of Fukushima, Iwate, and Miyagi prefectures were 2,029,000,1,331,000, and 2,348,000, respectively.2 Younger generations have tended to moveto cities where there are more job opportunities, and the Tohoku region is one ofthe least densely populated areas of Japan. As such, people in these 3 prefecturesare older than in other parts of the country. In 2011, the percentages of peopleaged 65 years or older were 25.2%, 27.3%, and 22.4% in Fukushima, Iwate, andMiyagi, respectively, whereas the national average was 23.3%.3 These 3 prefecturesare more engaged in agriculture, forestry, and fishery than other parts of Japan.Among 2,605,736 Japanese people engaged in agriculture, Fukushima, Iwate, andMiyagi prefectures share 4.2% (109,048), 3.5% (89,993), and 2.7% (70,869), and theseprefectures make up to 10.4% of the total share among all 47 prefectures in Japan.Fukushima, Iwate, and Miyagi prefectures are reported to contain 3.5% (11,322),4.8% (15,685), and 2.0% (6397) of people engaged in forestry in Japan (325,589),totaling 10.3%. The numbers of people involved in fishery in Fukushima, Iwate, andMiyagi prefectures in 2011 were 1743 (0.8%), 9948 (4.5%), and 9753 (4.4%), consti-tuting 9.7% of the total (221,908).4
The Tokyo Electric Power Company (TEPCO) owns Fukushima Daiichi (First) andFukushima Daini (Second) nuclear power plants, which generate 4,700,000 and4,400,000 kW, respectively. The total production of TEPCOs nuclear power plantsconstitutes 28% of the total power for 7 prefectures5 including the Tokyo metropolitanarea but, interestingly, excluding Fukushima prefecture. At the time of the disaster, theFukushima Daiichi and Daini plants employed 1053 and 707 full-time workers,respectively.6
Pre-Event State of Mental Health
NeedsIn 2009, Japans suicide rate was 24.9 per 100,000, whereas the suicide rate of theUnited States was 11.3 per 100,000 in 2007 (age-adjusted).7,8 However, higher suiciderates have been reported in Fukushima and Iwate, and seasonal increases in depres-sion have been reported in the region.9 The Tohoku region is a traditional rural area,and stigma attached to seeking mental health services is common, as in rural areasof other countries. In these areas it is difficult for local people, who have knowneach other since birth, to access mental health care and for mental health profes-sionals to assess their needs, out of concern that their neighbors or coworkers mightfind out that they have mental problems.10,11 It is relatively common for people to takea 2- to 3-hour bus or train ride to visit a university hospital for psychiatric treatment.
Services and system for mental health deliveryIn the affected prefectures of the Tohoku region, there was already a severe lack ofmental health resources before the disasters, such as lack of employment for mental
East Japan Earthquake Disaster 353health professionals and lack of accessibility to services, especially in the sparselypopulated coastal areas.10 It has been reported as of December 2008 that there areonly 8.9 psychiatrists per 100,000 people in Iwate prefecture, with 9.9 in Miyagi pre-fecture and 10.5 in Fukushima prefecture, compared with 12.8 in Tokyo and 16.5 inthe United States.10,12 Although there is reluctance among older people to seekmental health services because of the stigma mentioned earlier, an increasing numberof people who seek psychological counseling or psychotherapy has been reportedacross the country since the mid-1990s, owing to mounting socioeconomic dis-parities and interpersonal conflicts.13 Despite such demand, lack of psychotherapythat is certified and insured by the government poses a further obstacle to care. Nonational licensing system has been established by a governmental organization tocertify psychiatrists and/or clinical psychologists for psychotherapy or even psycho-logical counseling.13 At present, little or no coverage in the health care insurance sys-tem has been established for psychotherapy, although psychiatric medication isinsured in Japan.13THE TRIPLE DISASTER AND ITS IMPACT
The total amount of damage caused by the triple disaster is estimated at U16.9 trillion(approximately US$215 billion), including buildings (U10.4 trillion), public utilities (U1.3trillion), infrastructure (U2.2 trillion), and damage to agriculture, forestry, and fishery(U1.9 trillion).14 The tsunami destroyed coastal highways and railroads, which previ-ously provided the main transportation system in the region, and prevented foodand daily necessities, including drugs, from being delivered for the following weeks.In Fukushima people are still affected physically, mentally, and socially by the nuclearpower plant accident. Rather than repeating detailed descriptions of the triple disas-ters impact that have been already reported elsewhere,9 the rest of this section differ-ently describes the respective impacts of the Great East Japan Earthquake, thetsunami, and accident at the Fukushima Daiichi nuclear power plant.The Great East Japan Earthquake actually comprised 4 magnitude (M-) 7 to 9 earth-
quakes occurring consecutively within a period of 40 minutes.15 The first 3 epicenters,with M-9.0 at 2:46 PM, M-7.3 at 3:08 PM, and M-7.3 at 3:15 PM, were located within anarea 200 km (125miles) wide and 500 km (310miles) long, close to the eastern coast ofthe Tohoku region.15 The 4 earthquakes caused Japans northeastern coastline toshift by as much as 4 m (157 inches) to the east16 while the tsunami also transformedthe landscape, washing away entire towns. Geophysicists estimate that the first M-9earthquake accelerated the spin of the globe, causing the length of a day to become1.8 microseconds (1.8 millionths of a second) shorter.17
Immediately after the earthquakes, a tsunami warningwas reported by the Japanesemedia, estimating that the highest wave of tsunami would land within 30 to 70minutes.18 However, this was not enough time for many people to evacuate to higherground, particularly thosewhowere elderly, bedridden, or unable to take a quick actionfor other reasons. When the tsunami struck, some people were on their way to rescueother members of their family who did not have access to transportation, despite theancient saying Tsunami, ten-den-ko [Tsunami, self-evacuation] being part of localwisdom. Some people managed to reach a local school (often one of the highestelevated buildings in town) in time, but were unable to enter because of the limitedcapacity of the shelter.18 Others underestimated the seriousness of the warning andstayed in their homes. The tsunami was reported to be 17 m (669 inches) in height.The wave reached 10 km (6 miles) inland and 40 m