Healthcare Challenges in a Disaster Zone

Bukit Brown Cemetery

Nahoko Harada is a PhD nursing student from Tokyo. She has been traveling back and forth between Boston, Tokyo and the Tohoku region helping tsunami survivors and healthcare providers cope with the new reality of healthcare in the Tohoku region. I spoke with Nahoko, together with Robin Low of Relief 2.0 to find out what are some of the challenges facing the tsunami survivors.

Tell us about your work in the Tohoku region.

I do not directly provide healthcare to the afflicted. I provide support to the healthcare providers through the organization I work with. My duties include: ensuring safe accommodations for health care providers, keeping their morale up and problem solving.

I also work with the Yamato-shi hospital, a municipal hospital in Kesennuma, which is in the process of moving to a new location. The hospital itself might soon reopen, but it will only offer limited services and a limited number of beds. To make up for this service shortfall, the hospital will start providing home visiting care.

The hospital receives numerous grants and subsidies to provide this service but the hospital staff is feeling a certain level of anxiety; they worry if they are competent enough to adequately provide home visiting care because they were all trained and practiced in a hospital setting.

I am also in the same dilemma, so instead of training health care providers in visiting care, I prepare education packages for them. I plan and organize workshops at Wakuya (near Ishinomaki) with home visiting care specialists from Tokyo. These specialists come and share their expertise with the staff of the Yamato-shi hospital.

I do all this while making sure the hospital staff is not too stressed from work. The Yamato-shi hospital is in a unique situation. When it first reopened, it only had two full time physicians and they actually quit within the first week of the reopening. Patients were coming to a hospital that had no doctors!

The nurses, technicians and administrators all carried on working despite the absence of physicians. The hospital had no advanced nursing practitioners or doctor assistants who could at least fill in for the departed doctors. This is because under Japanese law, only licensed doctors are allowed to perform medical procedures, write prescriptions and do diagnostics.

As a result, the organization I work with has to keep sending physicians to the hospital so it could stay open. We managed to successfully recruit one full time physician and he is now the hospital’s medical director. But the Yamato-shi hospital is still short handed. It needs to have at least two to three working physicians on staff because of the heavy patient load. Unfortunately, the hospital has to make do with the resources it has now.

I am also doing psychological first aid, where we actually educate first responders to help minimize their own trauma when they work in a disaster zone. We conduct monthly meetings where we teach fifteen to sixteen people how to cope with trauma. I am tracking and measuring the physical and mental health of first responders as part of my research work.

What are some of that concerns that have come up during your multiple visits to the disaster stricken areas?

Most of the social welfare dispensed by the government and NGOs goes to the residents who live in temporary housing shelters. But there are survivors who are living in their partially destroyed homes instead of moving to a shelter. These people, because of their living conditions, actually fit the UN definition of an internally displaced person (IDP)(http://ochaonline.un.org/OchaLinkClick.aspx?link=ocha&docId=1112013) and should be moved into a temporary shelter. But because they are living on their own means, the government does not consider them IDP or in need, so they fall through the cracks and are not covered by the social safety net.

Yes, when we were walking around Ishinomaki, taking in the view of the devastation, the question of who pays for all the rebuilding kept coming up.

The survivors have some reimbursement from the government, but between rebuilding their homes and staying afloat with other expenses, sometimes the reimbursement is not enough to cover what the survivors need. The recovery is not all inclusive now because of the IDP situation. And unfortunately with the social workers are so tied up with helping the shelter dwellers, the social workers are unable to visit the homes of the IDP to assess if they need further help from the state.

What about on the medical side? Are there any post tsunami medical problems that might occur in survivors?

Psychological conditions such as post traumatic stress disorder (PTSD), depression, and anxiety disorder are prevalent amongst the tsunami survivors. The March 11th date itself has a lot of profound significance for survivors. As the date draws closer they may start having vivid flashbacks that return them to the scene of their trauma. The flashbacks may even become increasingly frequent as the anniversary of the disaster draws closer and passes. And these are considered normal responses from survivors of a traumatic event.

What worries me more is whether these patients have adequate access to proper healthcare and treatment. The current access to healthcare has room for improvement. You might have noticed that the temporary housing shelters are all situated into remote locations. Some of them are in fact in the middle of nowhere.

Yes, we happened to travel past one that was in the middle of nowhere.

Exactly! How is an eighty year old woman with a chronic illness, supposed to be able to see her doctor every other week for check ups or prescription refills, when it takes her two hours to travel from the shelter to the clinic by public transportation?

I have seen shelters located in places where there is no real access to public transport; where the bus frequency is literally only four times a day. So hypothetically to see your doctor, you would have to leave home and board the 7:30 am bus, ride for hours to arrive at the clinic, wait for hours to see your doctor, then wait for hours again to collect your medication. All this while you are hoping that you are done at the doctor’s in time to make it for the last bus ride home, which again takes another couple of hours. It is very likely that elderly patients in this situation end up spending an entire day on just visiting the doctor. For someone who is really tired with a chronic medical condition, this causes additional needless stress that does not help their well being.

Prior to March 11, life in the Tohoku region was similar to living a suburban lifestyle. Everyone had a car, which is a necessity to getting around in suburban living. Post March 11, many residents lost their only means of transportation. Without family members who could ferry them to the doctor, the elderly residents have become even more dependent on an overstretched public transportation system that is struggling to meet the needs of the Tohoku residents.

There is someone who is trying to start a car sharing program but it is really difficult to get off the ground. People are unable to afford a new car because of financial hardship and a lack of jobs in the devastated regions. If the program can be initiated then there would be some job creation because there would be a demand for drivers. The program can then help ease the transportation problem a little.

What about in terms of waste? We heard that the smell of decay was pervasive and there was an infestation of flies in the disaster region last summer. Does this pose a public health risk and could it happen again this summer?

I am not a public health specialist so I cannot give you a 100% certain answer, but the situation probably might repeat itself again this year on a smaller scale. As you might have noticed, the debris that was deposited by the wave has mostly been gathered and piled up in certain areas within the disaster zone. I am assuming that if the incident from last year occurs again this year it will not be as widespread thanks to the clean up.

What about the impact on medical facilities? Were there any hospitals that were washed away by the tsunami? We learned that the hospital we visited in Ogata, which happened to be on a cliff face, was flooded on the first floor and suffered some damage because of the tsunami. Are other hospitals around the Tohoku region similarly affected?

Did you see the Ishinomaki municipal hospital? It IS gone. Most of the hospitals in the affected regions are 100% destroyed. The future plans for rebuilding the hospitals that survived are mostly unknown.

The first floor of the Yamato-shi hospital in Kesennuma was flooded despite the hospital being located four kilometers away from the tsunami epicenter. And that is the only hospital in Kesennuma that has managed to resume partial services in its original location. Another hospital, the Kesennuma city hospital will be relocated to higher ground within the next couple of years.

In Ogatsu, there are many financial constraints to rebuilding a hospital. So instead they have opened temporary day clinics that provide outpatient services. At least with these day clinics operating, the residents are assured of a continuity of healthcare. But even with these temporary clinics operating together with the surviving hospitals, the healthcare system in the Tohoku region is under tremendous strain.

Japan was already experiencing a huge medical professional shortage prior to the Tohoku tsunami. After the disaster, the shortage has worsened and the healthcare system in the Tohoku region is now under incredible strain. We really have to think about where we go from here. We should not rebuild the same system back to what it was.

The methods of recruiting and retaining medical professionals in remote areas have to change to ensure continuous care for the people. The sheer amount of government regulations and restrictions on the medical field has immobilized the healthcare industry and it is stopping us from rebuilding the medical care system. It is so bad that the regulatory system is actually stopping people from entering the medical profession and that needs to change otherwise the nation’s most vulnerable will suffer.

What about the municipal facilities within Ishinomaki? We noticed that the train line between Sendai and Ishinomaki is still out of service, while the line between Ishinomaki and Kesennuma has resumed operations.

Do you know if people in Ishinomaki are badly affected by the train stoppage? Has public transportation in the area been badly affected by the disaster?

Public transportation definitely affects people’s mobility. But I cannot tell you how much its effect has been aside from what I have already mentioned.

How badly affected has Iwate prefecture been by the disaster? About 30% of Ishinomaki’s businesses have reopened and it looks like there are signs that most of the remaining businesses are slowly working towards reopening. How is the recovery progressing in Iwate?

It is really bad. Rikuzentakata…it is not a ghost town by any means but you can really see how the people struggling to recover are limited by the complete lack of infrastructure and resources right now. You can really see the difference when you compare Rikuzentakata to Sendai. Sendai was the fastest city to recover from the disaster. Sendai looks like Tokyo; it has new stores and businesses opening. While on the other hand, in Ishinomaki or Kesennuma or Rikuzentakata, no one is out on the streets after 7pm.

It seems that there are a few Japanese corporations that have relocated their corporate headquarters to the disaster zone to help create jobs and pump money into the devastated economies; Gindaco Takoyaki is one such example. So it seems that private businesses are also trying to do their part in helping the people recover. But there remains more work to be done does it not?

Yes, the Tohoku region still has a long way to go before it can fully recover from the tsunami. I think new businesses/ jobs will be really beneficial for the younger generation. But it will be hard for middle aged people who have had their businesses and livelihoods destroyed to adjust to a different line of work.

The problem of uneven demographics existed prior to March 11: The younger generation that wanted to work in metropolitan areas such as in Sendai or Tokyo, moved away from Ishinomaki. The ones who stayed behind are mostly old people.

Demographically, it is the old people that remained behind who are most affected by the disaster’s fallout. So from a logistical point of view, you really have to think hard before you initiate a new business: Where is your human resource going to come from? And how are you going to train your local employees?

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