Moving Forward: Relief Efforts, Health System Reforms, and Japan’s Role in Global Aid
An Interview with Dr. Kiyoshi Kurokawa
By Rebecca Kennedy
June 16, 2011
The March 11 earthquake off the coast of Japan, followed by the devastating tsunami and an ongoing nuclear crisis in Fukushima, will create long-term challenges for both Japan and the world. This week, NBR spoke with Dr. Kiyoshi Kurokawa about the various relief efforts and responses to the disaster and the state of health systems in Japan, as well as Japan’s important role in global aid.
Dr. Kiyoshi Kurokawa is Chairman of the Health and Global Policy Institute and Academic Fellow of the National Graduate Institute for Policy Studies. He is also Professor Emeritus of the University of Tokyo School of Medicine, and Chairman of Impact Japan. A physician and leader in medical education and healthcare policy, Dr. Kurokawa has held posts in academia and many international and governmental advisory capacities, including Dean of the Tokai University School of Medicine, Commissioner on the World Health Organization’s Commission for Social Determinants of Health, and Science Advisor to Japan’s Cabinet of the Prime Minister.
What was the focus of government relief and medical responses in the first few days and weeks following the Great East Japan Earthquake (Higashi Nihon Daishinsai) and the tsunami of March 2011? Can you describe the most pressing medical needs and how those needs were addressed?
It took time to grasp and assess the magnitude of damage, due to the mountainous landscape of some areas, which restricted access. Relief efforts initially came in locally, nationally, and from abroad. The Japanese government, regional and local leadership, the private sector, and other stakeholders, most notably NGOs, acted quickly on rescue efforts, including medical response. But the scale of the damage was massive, almost beyond control—often communication systems were disconnected and most medical facilities were simply gone, with many staff and patients unaccounted for.
Within a few days, it became clear that the major issues were provision of shelters, food, water and sanitation, and basic living needs. The severely damaged infrastructure made access very difficult. Moreover, the cold and often snowy weather in some of the most affected communities made relief efforts and continued searches for survivors extremely challenging. The most critical medical needs were primary care and counseling, namely for the children and elderly whose family members went lost or missing. Medical societies and communities responded quickly, some through the government’s Disaster Medical Assistance Team (DMAT), the Japan Medical Association (JMAT), and a private medical system called Tokushukai (TMAT). Other notable groups were the Japan Society of Pediatrics, which immediately organized and enlisted psychiatric experts, the Health and Global Policy Institute, and Project Hope from the United States. Additionally, many Japanese bilingual physicians, nurses, and paramedical staff from abroad, many from the United States, joined these relief efforts.
After several weeks, schools began to reopen—good places for children to gather and reconnect with their daily life. According to disaster relief organizations, such as the Public Advice International Foundation (PA International), engaging in normal activities is very important to help traumatized children regain psychological strength.
You mentioned the response from abroad, in addition to national and local rescue and relief efforts. Can you give some specific examples of the ways in which international aid contributed to the disaster response?
The international community was quick to respond. For example, Israel dispatched an entire medical unit consisting of medical professionals with portable facilities and critical equipment. Additionally, the U.S. responded with “Operation Tomodachi” with its military forces in cooperation with Japanese Self Defense Force, and many other countries provided support. 
Very significant help and monetary donations have come to Japan from many countries, including many poor countries which are recipients of overseas development assistance (ODA) from Japan, to help the earthquake and tsunami victims. For example, there was a group of students in Bangladesh who collected and donated money.
How do you think prospective healthcare policy and health system reforms, hot topics of debate in Japan even before the March events, will be influenced as Japan sets out to rebuild the many medical facilities and access to service in devastated areas?
Healthcare policy reform has been a major national political agenda in many countries, Japan included. Calls for reform derive from a paradigm shift that reflects not only advances in science, technology, and engineering, but also evolving social factors that include:
- rapidly aging societies;
- chronic disease becoming a major disease burden, in many cases lifestyle-related, e.g. obesity, diabetes, high blood pressure, atherosclerosis, etc.;
- income disparity; and
- lack of sufficient public funding for healthcare.
As a result, a single national health policy no longer makes the most sense. These four major factors define healthcare not just in Japan, but in most Organization for Economic Cooperation and Development (OECD) countries.
In 2007, the Japanese government mandated that each prefecture develop a 5-10 year healthcare reform plan, shifting from supply-side medical policies to more demand-driven, innovative policies to meet the practical and projected needs of local communities. Implementing and approving these plans has been very difficult, in part because the Japan’s central government and ministries have very strong control over the policies and finance of prefectural governments. In addition, over the past few decades, healthcare has come to embrace a multitude of powerful stakeholders with a weak economy. As a result, negotiations have been complex and in most cases, innovative policies have not yet been implemented.
This massive and widespread disaster may provide a rare opportunity to implement innovative health systems in Iwate prefecture, the second largest prefecture after Hokkaido. Many municipalities in Iwate lost their public hospitals, which had run in the red for many years while serving elderly communities. Along Iwate’s coastline, there are larger cities every 40-60 kilometers and one to three smaller townships in between. Thus, when rebuilding this area’s infrastructure, secondary care hospitals are unnecessary every 10-20 kilometers, as long as paved connecting roads between communities exist.
Furthermore, many hospitals can introduce “open systems” that allow many doctors practicing in their own clinics to take advantage of currently underutilized hospitals for high-tech diagnostics needs, specialists, and surgical procedures, such as computed tomography imaging (CTI) and magnetic resonance angiogram (MRA). This “open system” concept of hospital use has not traditionally been part of the medical delivery system in Japan and certainly not a part of Japanese physicians’ mindsets.
Now in the 21st century, we can reinvent the health system with a more appropriate distribution of tertiary, secondary, and primary care facilities. Iwate prefecture’s capital city of Morioka has two major hospitals. In the short-term, the Red Cross could meet immediate tertiary needs while strategic rebuilding plans move forward for secondary hospitals that connect to primary care and elderly housing. This approach could serve as an innovative new model for other prefectures in the coming decades.
Opportunities to rebuild a more appropriate system are exciting, but implementing such plans requires strong visionary leadership at both the central and prefectural government levels, along with the public and other stakeholders being on board as well. Also note that Japan carries an enormous national debt, almost 200% of its GDP. Large systemic changes are often costly, and such risk, even when such changes may save money over the long term, is not always widely embraced.
The ongoing nuclear crisis at Fukushima (Fukushima Genpatsu Jiko) drew international attention in the days and weeks following the tsunami. What is your assessment of the government’s management of the Fukushima crisis? What future implications do you see for Japan’s energy dynamics as well as for the nuclear energy generation in other countries?
The disaster in Fukushima provides an unfortunate but rare opportunity to look into crises associated with nuclear plants. Nuclear power has been recognized as a major energy source due to its low carbon emissions, and many plants are planned for construction in various parts of the world. The Fukushima situation, however, has triggered real concerns among the public at large on the risks of nuclear energy and many nations have subsequently begun to review their energy policies.
The crisis illustrated that increased use of nuclear power poses several risks. Some examples of these risks include natural disasters (as we saw in March), terrorist attacks, technical and structural failures, and waste products. If the risks become reality, they pose a great threat to our civilization and environment; they could impact our way of life in major and lasting ways. Nonetheless, these risks give us opportunities to innovate in order to minimize and prevent them–such as new clean and renewable energy sources and systems, robotics, and biotechnology.
In my opinion, the Japanese government and TEPCO [Tokyo Electric Power Company, the fourth largest power company in the world] have not responded properly to the situation. In particular, the speed of release and transparency of primary data and decision-making processes have been criticized widely. Considerable amounts of radioactive substances have been released outside the plants, including into the ocean, and subsequent responses have been insufficient and not transparent.
Transparency and recognition of the need for management through sharing and asking for international expertise and technologies should have been central and most critical as the world watched what was going on during the Fukushima disaster. Such principle was lacking by the government, as well as TEPCO, from the outset, leading to the loss of credibility and trust in the leadership of Japan.
You said that Japan’s government has mismanaged the Fukushima situation, a popular opinion held by many Japanese and international observers. Going forward, what actions do you recommend?
It is critical for the Japanese government to establish an independent international taskforce commission to examine and analyze the Fukushima disaster, inviting international experts. Such a commission will also help minimize and mitigate the falling credibility of Japanese government, TEPCO, and other establishments of Japan. The creation of such a commission is vital and will help prevent unnecessary concerns and barriers to imports of products that are made in Japan. A relevant case in point is the handling of BSE (commonly known as “mad cow” disease) in the United Kingdom in the 1990s, where restoring the credibility of the UK’s cattle products took almost two decades.
The Fukushima incident must undergo detailed investigation and research analyses, with involved sectors accepting the latest and best scientific advice. The analyses will provide invaluable lessons to share, illuminating possibilities for better system design, engineering, and materials, all of which will enable the global community to develop safer nuclear energy generation systems in the future.
The set of cataclysmic events in March placed Japan, a country that has traditionally been an active player in advancing global aid, on the receiving end of international assistance. As the longer term economic consequences of the disaster are just beginning to unfold, is it still vital for Japan to continue its notable role in global aid?
Japan was a champion of foreign aid throughout the 1990s, but as its economy has stagnated over the past two decades, its official development assistance (ODA) budget has fallen substantially. At the same time, the world has become more interconnected and interdependent. Japan must remain a significant partner in global affairs, and ODA must remain a critical priority for Japan’s national policy. We cannot allow the March disasters to prevent Japan from engaging more in the global arena.
Japan’s economy is quite dependent upon trade and globalization. Combined with a wide array of stakeholders engaged in global affairs, Japan must create more innovative ways to support poor nations.
For example, through contributions to multilateral organizations like the United Nations and its agencies, and the World Bank, we must deploy innovative programs and projects, which may include debt-for-equity swap financing. Collaboration with various global NGOs is another key element.
Supporting poor nations is crucial even at such a difficult time. In addition to being a moral issue, these continuing efforts will be remembered by the recipient countries. With such support, recipient nations will become healthier, and when their economies begin to improve partly as a result, they will become good business partners, as they will recall how donor countries helped them. The future of Japan will be bleak without close partnerships with emerging economies.
 Operation Tomodachi (トモダチ作戦) is the U.S. Armed Forces operation that supported Japan in disaster relief following the Great East Japan Earthquake and the tsunami. Tomodachi is Japanese for “friend.” See Chronology of Operation Tomodachi for more information.