Looking to the Future
Healthcare Reform and Disaster Preparedness Planning in Japan
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. Makoto Aoki about the healthcare needs and care coordination for affected populations, and ideas for subsequent reforms and disaster planning. Dr. Makoto Aoki is Scientific Executive at Sakura Seiki Co. Ltd., a Japanese company that specializes in the design and manufacturing of medical and laboratory equipment. A Member of the American College of Physicians, Dr. Aoki’s primary research interests include hospital infection control, HIV medicine, and education in the field of clinical infectious diseases. For this interview, Dr. Aoki also reached out to fellow colleagues in Japan, who helped provide valuable opinions and firsthand descriptions from the disaster areas.
Immediately following the earthquake and tsunami, media coverage reported dire shortages of supplies and lack of access to medical workers, water, and electricity in many parts of northeast Japan. Can you describe the supply situation and the most pressing needs confronting the Japanese healthcare system in the first several days?
Both supply and medical needs changed over time. During the first 24 to 48 hours following the quake, clean water and food were the most needed supplies in the evacuation centers. In some areas, shelter was also needed, as the tsunami destroyed buildings that had been intended to serve as evacuation centers, such as schools, city halls, and fire stations. After a few days, most evacuation centers began receiving enough water and food. Sewage disposal was also a challenge; there was a need for a standardized disposal method.
During the first several days following the disasters, the most desperately needed item that was continuously in short supply was fuel. Gasoline was essential for the transportation of the sick to the outlying hospitals, for search and rescue missions in the disaster region, and for electricity generators for hospitals, etc.
What is your general assessment of the level of preparedness and the response of Japan’s central and local governments and the medical community in the immediate aftermath of the disaster?
Neither central nor local governments were prepared to deal with a disaster on such a large scale. In the first few days of the disaster, the central government seemed especially slow to respond, almost stunned and paralyzed. Local government officials were supposed to manage logistics for a variety of things, but they themselves were also victims. In many places, nobody took charge.
I heard from one local physician in the disaster area near Sendai that the disaster had an upside. After dealing with significant local government inefficiency for many years, the necessity of post-disaster infrastructure rebuilding offered the locals a chance to create community improvements themselves, such as local communication networks and other projects.
It is worth mentioning that local physicians, who themselves were also victims of the tsunami, played major roles in providing care for their local populations, though fatigue among medical personnel has now become a problem. In Japan, there are not enough physicians, even in the absence of a disaster. The shortage of medical personnel, including physicians and nurses, is a continuing challenge.
One friend of mine felt that in the absence of a strategically well-designed evacuation plan or a well-executed rescue operation, the very patient and tolerable nature of the Japanese people led to an extremely harmonious handling of the disaster. He believes that when assessing the key reasons for such a relatively calm and smooth evacuation, we should keep in mind the patience of the people being evacuated rather than only the level of preparedness of the disaster plan for handling the evacuation.
Could you elaborate on this point about preparedness and coordination? How would you rate Japan’s overall preparedness?
Japan gets a big Yes and No for preparedness. A big “yes” for the earthquake-resistant construction: the number of victims would have been much higher had Japan not had seismic technologies in its housing and building construction. Only 10% of the casualties were due solely to the earthquake. On the other hand, for the tsunami, the story is completely the opposite. Many lives were lost due to the tsunami. The regions struck by it were well-known, “high risk” areas for centuries. People, however, tended to forget about the danger that a tsunami poses and built their houses in risky areas.
I have heard repeatedly from some friends of mine involved in risk management planning that Japanese preparedness for the disaster and its plan were deeply flawed in that the government had a limited contingency plan: If the earthquake was within the size of what they expected, there would have been no problems; if the tsunami’s height was less than what they expected, it would have been less severe.
Also unanticipated in the government’s plan was the nuclear problem, for which there was a shortage of emergency physicians who were knowledgeable in radiation emergencies as well as insufficient numbers of inspectors willing to provide accurate assessments of the situation that might have reassured the public when rumors of radiation problems spread.
One of the most frequently heard words this time from the government, TEPCO [Tokyo Electric Power Company], and other authorities was “unexpected”: An “unexpectedly high tsunami” destroyed people’s lives, despite the fact that these events have been known to happen for centuries. Japanese bureaucrats are afraid of doing new things, which is imperative in a disaster of such unexpected magnitude. New rules are needed that will allow more freedom and protection for bureaucrats so that they can do things that are not in the routine manual.
How were medical needs addressed in the immediate aftermath, both by the government and by the private sector?
The government dispatched special medical teams specifically designated to handle disaster. The Japan Disaster Medical Assistance Team (DMAT) was established in 2004 to cope mainly with major earthquake events. These teams are capable of rescuing heavily traumatized patients, transporting them to outlying tertiary care centers, and providing on-site minor surgeries and other medical care. As of 7:00 A.M. on March 12, within 24 hours of the earthquake, 25 DMAT teams of about 130 medical personnel were already operating in the Sendai temporary medical headquarters. By March 13, the number of DMAT teams had reached 77, totaling about 390 medical personnel. These teams were allocated to remaining medical centers, search and rescue mission teams, and staging care centers for the Japanese Self Defense Forces.
In areas where Japanese DMAT teams were able to set up local headquarters in regional city halls, they were the ones coordinating medical needs. Local pharmacists voluntarily visited hospitals to find out which medical supplies and medications were most needed, and they traveled back and forth between these hospitals and their warehouses until the usual supply system started working again. The Japanese Ministry of Health and Labor established a special rule that temporarily allowed patients to get their medications without prescriptions from their doctors.
Some private sector healthcare providers were also very quick in responding. One example is the Tokushukai Hospital Group, which sent 30 ambulances, 1,000 physicians, 1,800 nurses, 200 pharmacists, and even a tanker truck with 16,000 liters of fuel into the disaster areas. They used ambulances not only for the transportation of patients, but also for shipping medical and general supplies. They were in the disaster zone within 24 hours of the event. They also helped foreign rescue teams get to requested areas.
How did the medical care needs of those affected only by the earthquake differ from the needs of those who also experienced the tsunami firsthand?
The disaster of the tsunami was much different from the earthquake in that it left mainly two kinds of populations in its wake: those who escaped and those who did not. There was almost no one in between, which was the targeted group for most of the trauma teams that were sent. The people who did manage to escape from the tsunami were brought to hospitals, suffering mainly from hypothermia, blood clots in legs, and pieces of the clot entering the lungs, all of which resulted from sleeping in small cars with flexed legs or being crouched in other confined spaces. Acute medical problems were also found in the elderly, many of whom died from lack of intravenous fluids and electricity-dependent, life-sustaining machines.
Two weeks following the disasters, the constant and desperate shortage of fuel remained a major obstacle hampering the delivery of materials that were necessary for the maintenance of sanitary daily life in the evacuation centers. People who escaped from the tsunami also needed fuel to drive their vehicles in order to rebuild their lives, for tasks such as shopping, and for transportation to and from evacuation centers and their homes. Large numbers of tanker trucks were dispatched, but many had difficulties driving into the disaster zone due to damaged roads.
What other health issues were of most concern in the evacuation centers? Was the spread of infectious diseases an issue considering how many people were displaced and living in temporary shelter?
About two weeks after the earthquake and tsunami, the primary medical needs transitioned to managing infections. Influenza and Norovirus infections (also known as stomach flu or viral gastroenteritis) became problems. In areas with outlying hospitals, patients were transferred so as not to become new sources for subsequent infections in other patients. In areas where there were no hospitals to accept these patients, isolation was used as much as possible. But it was not easy to do in crowded evacuation centers. Medical personnel prescribed Oseltamivir (Tamiflu) for patients with influenza and those who needed protection against it. Fortunately, Japan had a large stock of Oseltamivir on hand for addressing H1N1 influenza A. The strategy used against Norovirus was not much different from the usual healthcare setting, which is basically the practice of good hand hygiene.
The type and level of medical needs evolve over time following a major disaster, as you mentioned. What was particularly notable a month or more after March 11? What is the current situation for those still living in the evacuation centers?
Continuation of care for chronic illnesses, such as hypertension and diabetes, has become the major concern. Physicians have had a hard time identifying patients’ medications since patients often remember their medications only by their shape or color. Of course, most of the hospitals that patients had attended also lost their medical records as a result of the earthquake or tsunami. It may be a good idea for the future to have copies of this information held in secure distant centers, perhaps in electronic form.
As time goes by, the needs of each evacuation center evolve in different ways. Centers with relatively healthy people need more privacy, while those with more sick and injured people need more experienced medical personnel. There is a definite need for monitoring evacuation centers as needs change.
Also of note, Japan has never had this many people who suffered the loss of their loved ones so suddenly and completely. In 1995, after the large earthquake which struck the western part of Japan, many survivors actually attempted suicide. Mental and psychiatric care is going to be a formidable task for our healthcare system.
Returning to questions of preparedness, what can the government do to improve both its inter-agency coordination and general preparedness for future disasters?
I think it is vital to have medical and non-medical modules at each level of government to support local efforts. In the case of disasters like those we experienced in March, it is usually impossible to receive commands from the central government, from which isolated areas were cut off. We need a better national government disaster coordination agency, as well as improvements at the prefectural, city, and village levels.
In my opinion, there should be a single agency for handling all disasters at every government level, and not separate plans for individual disasters like earthquakes, nuclear accidents, or tsunamis. National and international military assistance and search and rescue organizations should all be coordinated by one agency. In the immediate period following a disaster, search and rescue teams are deployed. A few weeks later, the search and rescue missions are phased out, and recovery and rehabilitation plans are phased in to supply water, food, shelter, and other basic living supplies. For every phase, annual preparedness drills must be conducted at each level of governmental.
How about the military’s readiness?
Of course, the military were best equipped to deal with this type and magnitude of disaster because it can exist without local support for water, food, or fuel. Any medical or non-medical supporters from outside of the disaster zone must be completely independent of local supplies; otherwise, they can become a new burden for the disaster zone. The Japanese Self Defense Forces, consisting of 100,000 men and women, contributed mightily to the rescue and relief efforts.
The Israeli team, which came with everything it needed and set up a completely independent clinic in Minamisanriku, Miyagi, showed us an ideal example of providing aid during the acute phase of a disaster. Also, my strong and sincere appreciation goes to the U.S. military, which contributed much toward every level of relief.
What about other foreign relief aid? How has that impacted the situation and has it been effective?
Here is a story that demonstrates why foreign aid did not make it to the most needed areas. For example, when 100 people were starving in an evacuation center, local government officials decided not to deliver food because they had enough supplies for only 99 people. Donated money did not make it to the regions of the greatest need because local government officials also thought that a thorough and lengthy discussion was needed as to how these monies should be allocated. Again, I believe we should not confuse people’s patience with ridiculous bureaucratic discussion.
When matters come to the allocation of human resources, it gets worse. They tended to be reluctant to accept foreign human aid that did not come without their opinion and permission.
More than 60% of the people killed in the earthquake and tsunami were aged 60 or older. Given Japan’s relatively large elderly population, were any special measures in place to protect seniors? Following the catastrophes, what did healthcare institutions and medical practitioners do to reach and treat this group?
I do not think the plan for the disaster in March was particularly fine-tuned for the elderly population. Many elderly patients died from dehydration or the loss of electricity that caused ventilators and other life support equipment to stop functioning. For the bedridden elderly, the lack of sufficient nutrition and diapers made their bed sores worse. Nevertheless, the prognoses of many of these patients tended to be poor even without the disaster, which, however, still exacerbated their conditions.
Medication supplies for chronically ill elderly patients significantly improved in local hospitals about a month or so after the disaster. But due to the lack of public transportation, many elderly were having difficulty reaching their hospitals. Some regions began dispatching medical teams to each patient’s home to make sure that even bedridden patients could receive needed medications. Sometimes elderly patients were the only remaining members in their families. It will be difficult to find funding to pay for these patients’ medical bills.
In terms of radiation problems and the elderly, finding the right evacuation method was tough for each hospital and nursing home. The transportation of vulnerable people was not well-prepared. It was very difficult even for healthcare workers, who were mostly not well-informed about handling radiation emergencies, to recognize how critical it was to evacuate the area after the governmental evacuation order was issued.
I hope the crisis accelerates the urgency of reforming the current healthcare system to adapt to an aging population. Maybe if properly publicized in the press, the plight of the elderly might accelerate the urgency to reform healthcare.
Before the disasters, Japan was already exploring healthcare reforms to address demographic shifts and manage rising healthcare costs. What is the current state of the Japanese healthcare system and how might the recent tragedies influence the shape and direction of reforms?
I think it is time for the Japanese people to realize that there are some health and medical situations that demand unacceptably high costs, such as USD $3,000 a month for hemodialysis [a kidney dialysis treatment] for 95-year-old vegetative state patients. Very few Japanese realize the fact that most Japanese spend 90% of their lifetime medical costs during the final month of their lives.
At the same time, we have the least coverage for pediatric immunization among developed countries, resulting in numerous preventable illnesses. The enormous amount of the budget deficit, exacerbated by the recent disasters, will force the Japanese government and people to rethink the inefficiency of their medical care.
To answer this particular question, I would also like to share the views of a foreign friend of mine who is now working as a general physician in Japan. He says:
Japanese medicine is far too “specialized,” with a significant lack of emergency physicians and general internists. In a disaster, care by emergency medical services, general medicine, and general surgery are of significant importance. The fact that the government has allowed droves of physicians to enter specialties such as ophthalmology and dermatology with a lack of staff entering core specialties like general medicine, surgery, obstetrics, and pediatrics, leaves Japan without a resource to tap during times of need.
This skewing of specialties so that doctors can have an easier professional life and better pay has led to a medical system bursting at the seams. As an example, remaining medical and surgical generalists see 50 to 60 patients daily in a clinic, sometimes over 100, and can only give them each less than five minutes per consultation because they then must also manage a ward full of sick patients. This situation indicates that the healthcare system is struggling desperately. The government should cap the number of trainees per specialty and provide incentives to doctors to enter the underserved areas of general medicine and the surgery specialties that are deemed less favorable.
Finally, the government needs to make hospitals develop emergency medical services that provide 24-hour care and do not reject patients who do not fall within the specialty of the “on-call” doctor. Patients in Japan can be rejected from every hospital they try to enter, even when they have a true medical emergency, and some die en route to hospitals in ambulances (and that is not even during a time of disaster). These problems show that the medical system is not working.
The government needs to take the entire system by the horns and reform it into a system fit for a developed country with an aging population and its corresponding inherent special needs. This means training more ER physicians, internists, and surgeons, and having paramedical staff who can administer lifesaving treatments rather than their current status of “scrape and run” protagonists.
When another disaster strikes in the future, if some of these reforms are not in place, I am not certain that the Japanese healthcare system will be able to adequately cope with it. Hopefully, we will not be presented with this scenario.
Dr. Aoki would like to express his sincere gratitude to his colleagues listed below who devoted themselves to rescuing people in the disaster zone, some of whom even went near the nuclear facility to take care of the sick and injured there. These first medical responders provided invaluable opinions and plans regarding current problems in Japan, and with the hope that sharing these insights will lead to improved disaster planning for Japan and other developed countries.
Kohei Hasebe, M.D.
Resident, Family Medicine
Teine Keijinkai Hospital
Yoshihiro Takayama, M.D.
Physician, Section of Infectious Diseases
Department of Medicine, Okinawa Chubu Hospital
Hiroyuki Hayashi, M.D.
Professor, Division of Emergency and Family Medicine
University of Fukui Hospital
Shigenobu Maeda, M.D.
Chief, Emergency Department
Fukui Prefectural Hospital
Hironobu Tokunaga, M.D.
Physician, Division of Emergency and Family Medicine
University of Fukui Hospital
Suganami Shigeru, M.D., Ph.D.
President, Association of Medical Doctors of Asia (AMDA)
 Takeharu Yasuda, Keishi Takahashi and Hirofumi Noguchi, “Disaster hits elderly with dementia,” Daily Yomiuri, http://www.yomiuri.co.jp/dy/national/T110514001816.htm.
This interview was conducted by Rebecca Kennedy and Karuna Luthra, interns at NBR.