Disaster Relief Report - The 2011 off the Pacific coast of Tohoku Earthquake

Disaster Relief Report - The 2011 off the Pacific coast of Tohoku Earthquake

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Description: Disaster Relief Report, Hospital and Clinics in Minami-Sanriku City Before the Disaster, Shizugawa Public Hospital, Hyper-acute Phase, Main Evacuation Center in Shizugawa, First-Aid Station Clinic, Acute Phase, Morning Conference and Health Cluster Meeting, Disaster Relief through Education, Overview of Educational Support.

 
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Contents:
4/3/2012

Disaster Relief Report The 2011 off the Pacific coast of Tohoku Earthquake @Minami-Sanriku City in Miyagi Prefecture
Minami-Sanriku City Medical Headquarter Director Miyagi Prefecture Emergency Medical Coordinator Shizugawa Public Hospital Internal Medicine Department Chief Masafumi Nishizawa, M.D.

Minami-Sanriku City, Miyagi Prefecture
Japan


Miyagi Prefecture

Minami-Sanriku City

Miyagi Pref

Minami-Sanriku City

Damages in Minami-Sanriku City
Before � Population: 17,666 people � Number of Household: 5,362 houses After 05/07/2011 � Number of Evacuee: 5,461 peopleMax: 10,000 people � Number of Death: 509 people � Number of Missing: 664 people � Number of Damaged Household: 3,877 houses � Flooded Houses in the City: 48%

Evacuation Shelters and the number of evacuees
Utatsu Area 14 Shelters 1,970 people

Iriya Area 4 Shelters 708 people

Bayside Arena 1,500 people Shizugawa Area 21 Shelters 3,289 people

Outside the Area 2 Shelters 720 people Togura Area 8 Shelters 828 people

Victims in Minami-Sanriku City 49 Shelters 7,515 people

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Hospital and Clinics in Minami-Sanriku City Before the Disaster
Shizugawa Area 5 Clinics Shizugawa Public Hospital 126 beds internal medicine, surgery, orthopedics, pediatrics, otorhinolaryngology, ophthalmology, dermatology, urology, general practice, dental surgery) Utatsu Area 1 Clinic

After the Tsunami Disaster

Shizugawa Public Hospital

Shizugawa Public Hospital

Hyper-acute Phase OnsetDay
Role of disaster medical coordinator
� Set-up First-Aid Station � Triage of many evacuees

Major Disease 3rd Floor 1st Floor
� Multiple trauma � Pneumonia

Tsunami wave came up to 5th floor 300 people evacuated to the roof 74 admitted patients died (out of 109 patients) 3 hospital staff died

Problems
� Lack of everything (medicine, man-power, information, etc) � Limited transport (Only helicopter available)

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Main Evacuation Center in Shizugawa
Bayside Arena (public gymnasium)
Reception Consultation Room Pharmacy

First-Aid Station Clinic (inside Bayside Arena)

Acute Phase Day 2week
Role of Emergency Medical Coordinator � Arrangement of transport destinations of dialysis/in-home O2 care patients � Provide medicine to chronic disease patients � Gathering information from each shelters � Request medical goods including medicine � Arrange medical teams from outside areas Major Disease � Dialysis/In-home O2 care/mental disorder/pregnant � Chronic disease (hypertension/hyperlipidemia/DM etc) Problems � Too many volunteer teams and medical equipment (including meds) in such a short period of time � Arrangement donated medical equipment � Gathering information � Lack of pharmacist, administrations

Morning Conference and Health Cluster Meeting

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Sub-Acute Phase (1week1month)
Role of disaster medical coordinator � Provide Routine Medical Care (traveling clinics and medical teams) Major Disease � Chronic Disease (Hypertension, Hyperlipidemia, DM etc) � Infectious Disease (Influenza, infectious gastroenteritis) Problems � Recovery of lifeline (electronics, water) � Lack of car and gas

Chronic phase
(1month)
Role of Disaster Medical Coordinator � Re-open local hospital and clinics � Secure the transport to hospital/clinics � Gathering shelters and mobile clinics to several places Major Disease � Chronic Disease (Hypertension, Hyperlipidemia, DM) � PTSD � Sleepless Problems � lack of doctors (even in the normal time)

Israeli Medical Team

Shizugawa Public Hospital Temporary Clinic

Pharmacy

Waiting room

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Conclusion
� � � � Centralized controlling the information Centralized chain of command Gathering information in the early phase Cooperating with administration, public health and medicine � Acceptance of foreign medical team (Israel) � Early recovery to the pre-disaster situation

Disaster Relief through Education
Daisuke Yamashita MD Japan Primary Care Association Oregon Health & Science University Family Medicine

Challenges
� � � � Changing nature of the project Changing needs of communities Variety in training background Time limitation
� Preparation of the training and the training.

Overview of Educational Support
� Acute/Subacute Phase (March to July)
� Pre-participation training course � Disaster specific educational materials

� Chronic Phase (July to Current)
� Psychological First Aid (PFA) for all participants � Family Medicine Residents "disaster relief rotation" teaching and formative evaluation

� Differences in nature of disasters � Differences in community needs � Limited human resources
� Volunteer bases

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Training for Relief Personnel
Q2Mos

Disaster Relief Training

Knowledge Assessment Usefulness Assessment Focus Group Self Assessment External Evaluation

� Small group learning � 5 to 10 participants with 1 to 2 facilitators � Half-day long Contents � Information Sharing: Updates � Mission briefing � Case based learning

Feedback

Educational Materials
� Summery of core contents:4 to 5 pages
� Printed as well as stored in iPad � � � � � � � �

Contents Area
Home Care Nutrition Dental Care Care of Children Maternity Care Women's Health Psychological First Aid Mental Health � Infectious Disease � Radiation Damage � Coaching

� Voice over slides show
� Streaming on web and iPad

� Cases for discussion
� Facilitate multidisciplinary approach � Increase communication � Promote in depth understanding

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Case 1
� You are participating in a community health event at a temporary housing. The event provides space for tea and snacks and you are there to listen to residents of the temporary housing units. Your group of volunteers consists of physicians, nurses, midwives, pharmacists, clinical psychologists and judicial scriveners. One of the residents reports that since the earthquake, he has not been able to sleep. It is getting better but he still wakes up in middle of the night with palpitations and vivid images of the day of earthquake. You suspect PTSD but you do not have enough knowledge. What will you do?

Q2Mos

Disaster Relief Training

Questioners Focus Group External Evaluation Self Assessment Knowledge Assessment

Feedback

Feedback and Improvement
� Difficult to attend trainings (time) � Want more updates and increased efficiency for handing over the project Improvement � Increased updates and sign outs � Reintroduced reports from recent workers � Decreased time of contents learning � Utilized case and group learning

Psychological First Aid (PFA) Training
Developed by Intra-Agency Standing Committee � 10 to 15 participants with 1 to 2 facilitators � Whole day: 7 hours Contents � Foundation of PFA � Role play � Case discussion � Self-Care for PFA providers http://www.who.int/mental_health/emergencies/e n/

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Support for Residents
� Provided through 4 weeks � Scheduled reflection and discussion; weekly
� Through internet-conference service � Semi Structured Reflection
� � � � What went well? What could be done better? Emotions around these reflections Next Step

Example of discussion
� How to listen to the patient's disaster experience. � How to manage large outpatient volume. � How to organize home health care. � Feedback for in-service lecture for nurses.

� Participant: Residents, PCAT educational director, supporting community faculties, mental health providers

New Technologies
� Sharing of Resources through the internet
� Web; http://akkie.mods.jp/311care/ � SNS (Social Networking Site; ie Facebook)

� Tablet PC (ie; iPad) � Online streaming

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Disaster Preparation
� What are essential contents? � What are essential skills? � How do we prepare our residents for future disaster response? � How do we prepare our organizations for disaster response?

PCAT ACTVITY REPORT 2011
Japan Primary Care Association Primary Care for All TeamPCAT

� � � � � � �

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� �Missing people were posted all over evacuation centers �Disaster Medical Assistance Team (DMAT) �many physicians specializing in emergency medicine and surgical specialists had been dispatched. �However, there were very few injured patients from the tsunami disaster and the need for these specialists had started to decline �Lost of the Communication between Local Medical Association �Focused on establishing a communication network with members of the local medical association. �20 `au' mobile phones were primarily loaned to the members of the Kesennuma medical association. �Many local medical practitioners themselves had been affected, they had been working tirelessly � In order to relieve the local private-practice doctors �began to manage the evacuation centers including manning the night shifts. �local doctors involved in postmortem inspections � 20 to 40 victims per day (after day 7). Taking over these duties from them � to resume their duties in providing healthcare services in the community and to prepare for the re-opening of their clinics.

� � � � � � � � � � �Re-visited Kesennuma and attended one of the vaccination sessions. For the first time, I felt a little at ease. �However, I still feel overwhelmed with guilt when thinking about Kesennuma. � I feel that when I left, I abandoned those who had been displaced by the disaster. �Among those involved in medical relief efforts and volunteer work, there may be quite a few people who feel the same way. In the face of such devastation, it is a mistake to think that one was at all helpful. � � � � � � �

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Fundamental Policies of PCAT
Through research and support of earthquake victims from March to early April 2011, we decided on the following basic policies for our relief work. They are based on five fundamental ideas: Accessibility, Comprehensiveness, Coordination, Continuity and Accountability. Develop a bottom-up medical and health support system which emphasizes continuity, permanency, and the respect for local people and culture. Involve various kinds of professionals to meet the diverse needs of the victims and provide comprehensive support to the stricken areas. Educate people on medical and health care to prepare for possible future disasters. We put emphasis on continuity and accountability, and drew up a plan that would support victims for at least two years until the local medical and health care system is stabilized.

Features of PCAT Activities 1-i
Organized support for neglected groups
One of the special features of the PCAT's support is its Accessibility to the group/society/service who are neglected by Social Accountability. Examples of the neglected groups that PCAT supports: The physically vulnerablethe elderlythe individuals requiring long-term care, the physically/mentally handicapped. The socially vulnerablethe victims at home (who did not take shelter), womenexpecting and nursing mothers). The suffered aid workers: medical professionalsprivate clinic doctors, doctors, nurses and clerks of municipal hospitals), public officerspolicemen, firemen, emergency life-saving technicians Absolute lack of the medical care service Qualitative (night duty of doctors, obstetric medical care, palliative care and autopsy) Quantitative (The depopulated area which is difficult to access and which initially lack medical care: Motoyoshi district Kesennuma-Shi, Ogatsu district Ishinomaki-Shi, and Kitakami district Ishinomaki-shi. The area: Iidate village, Minami-Souma-Shi etc. where many of the medical personnel and the youth were left despite the nuclear reactors and residual radioactivity.

Features of PCAT Activities 1-
Organized support for neglected groups
-- The support for these neglected groups led to discovering unseen problems. It furthered communication between supporters and neglected groups, involving individuals who can also cooperate with the groups. This enabled larger scale activities and activities which are truly necessary. e.g.) The development of aid work in Kesennuma. Medical personnel, who were disaster victims themselves, worked on autopsies that were neglected by external medical supporters. The PCAT substituted for these autopsies so that they could rest. By supporting doctors in the affected areas to restart at-home diagnosis, we discovered that the victims dependent on residential care have been neglected. For the elderly victims who require long-term care, PCAT established a home-visiting supporting group called JRS, and launched a service which offers at-home diagnosis. In the Motoyoshi district which originally was neglected medical care, PCAT found that there are many people who require long-term care and who are seriously ill. JRS cooperated with the new director of the Motoyoshi Hospital, and started a system to support Motoyoshi Hospital by sending resident doctors.

Features of PCAT Activities 2
Understanding people's needs and extending support through the efficient communication of information
A feature of PCAT activities is that victims in the disaster areas are seen and treated comprehensively. Through the coordination of a multidisciplinary health team, we were able to fully grasp the needs of victims. This also enabled us to effectively exchange information with external associations and further extend support. e.g.) The cause of an increase in pneumonia among the elderly population and the solution The increase of pneumonia among the elderly was reported to the headquarters for disaster control. The reported cause was the abuse of antibiotics by supporting physicians . New bacteria that are strongly resistant may have bred and caused infections to expand. For treatment, disaster countermeasures office gave instructions to prescribe stronger antibiotcs. The problems observed by PCAT's multidisciplinary health team. Dietitians: The meals consumed in evacuee shelters. The lack of consideration for individual needsthe elderly people, pregnant women, children, and those having chronic illness Dentists, dental hygienists: Malfunctioning of artificial teeth caused by the life in shelters, the problem of intraoral hygiene, and the environmental restrictions which made it difficult for evacuees to brush their teeth (the lack of water, tools, and the places). Physical Therapists, Occupational Therapists: the decline of ADL(Activities of Daily Living) caused by insufficient exercise for those who require long-term care in shelters or at home. Posture problems caused by taking meals where there were shortages of chairs, beds, and people for aid. Acupuncturists: Victims as well as aid workers and local medical personnel got stiffness in their whole bodies. Medical personnel who were victims themselves were extremely fatigued. Solution for the problems - The doctors on night duty walk around the shelter, and see the elderly patients with aspiration pneumonitis. - By communicating and collaborating with the multidisciplinary health team, PCAT let the people understand the high risk of pneumonia. - PCAT reported the possibility of an aspiration pneumonitis to be higher than the possibility of a spread of drug-resistant pneumonia. - To PCAT executed these measures and also reported to the disaster countermeasures office to call for aid by other professionals .

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Features of PCAT's activity 3-
Extending continuous support by multidisciplinary professionals and volunteers
It is difficult to carry out the basic idea of Primary Care and to maintain `Continuity' in the practice. However, PCAT has been aiding the stricken areas by valuing the concept of "Kizuna", which means the `link' between people. The organizations that we have linked together The administration and the local medical associations: Ministry of Health, Labour and Welfare, Tohoku Branch office Iwate prefectureIchinoseki city, Fujisawa town, Toono city, Rikuzentakada city. Miyagi prefecture: Kesennuma city, Minamisanriku town, Onagawa town, Ishinomaki city, Higashimatsushima city, Wakuya town. Fukushima prefecture: Minamisouma city, Iidate town, Kooriyama city, Shirakawa town, Tenei town. The medical institutions in the stricken area: Fujisawa Municipal Hospital, Kesennuma Municipal Hospital, Wakuya Municipal Hospital, Kesennnuma city Motoyoshi Municipal Hospital, Shizugawa Munisipal Hospital, Onagawa Municipal Hospital, Ishinomaki Municipal Hospital, Ishinomaki Ogatu Clinic ,Ishinomaki Red Cross Hospital, Higashimatsushima Royal Hospital, Abe Obstetrics Clinic, Narita Clinic, Yu Home Clinic Ishinomaki, Kesennuma Otomo Hospital,Mori Obstetrics Clinic, Muraoka Surgical Clinic Academic and professional groups: The Japan Dietetic Association, Japan Dental Association, The Japan Society of Pediatric Surgeons, Japan Pharmaceutical Assoc iation, Tokyo Medical Association, The Japan Academy of home care physicians, National Center of Neurology and Psychiatry, Japanese Midwive's Association, Chronic care nursing laboratory: Hiroshima University, Rehabilitation nursing: Hiroshima University, School of International Health: The University of Tokyo etc. NGO, enterprises and others: Bare foot doctors, Health and Global Policy Institute, Project-HOPE, AmeriCares, NPO Cannus, ETIC, Care Pro, Care Net, Project Yui, The disaster acupuncture and moxibustion project, NPO JEN, Mediva co, Leading Aging Society Forum, Fujitsu co. etc. Creating a link among the various organizations resonates with the five fundamental ideas of Primary Care: Accessibility, Comprehensiveness, Coordination, Continuity, Accountability. The examples are as follows.

Features of PCAT Activities 3-
� e.g.1: The project of perinatal medical care in the northern part of Miyagi prefecture Through the research conducted in Minamisanriku town, it was revealed that there was no information on the safety of maternity women. PCAT, Primary Care obstetricians and maternity nurses started a search to care for pregnant women. PCAT established a team called PCOT (Primary Care Obstetricial Team) consisting of the gynecologists and maternity nurses, and began health consultations for pregnant women in shelters and at home. PCAT cooperated with Japan Midwives Association and Tokyo Midwives Association to establish the `Tohoku Sukusuku Project', which aims to ensure that women are able to give a birth in safe places. The public health nurse in Higashi-Matsushima city asked PCAT to visit newborn babies. PCAT started health consultations for the pregnant women, puerperants, and newborn babies. PCAT launched a mobile phone website for pregnant women and childcare. It was discovered that over 60% of the facilities for childbirth in the northern part of Miyagi prefecture did not function. PCAT sent obstetricians and gynecologists to Abe maternity clinic where childbirths concentrated. In Kesennuma area, childbirths concentrated in Kesennuma City Hospital. To avoid the concentration of childbirths in one hospital and to enable reconstruction in the area, rebuilding the Mori maternity hospital became necessary. Since PCAT cannot support this alone, our association asked the medical management consultant Mediva to help. `The group for protecting the local medical care in the Tohoku earthquake stricken area' was established and has started work..

� e.g.2: The project to aid people who requiring special care in Ishinomaki city. From previous experience in Kesennuma city, we expected that people requiring long-term care at home are neglected. Thus, we made our decision to intervene in Ishinomaki ciy. We cooperated with the JIMMET (NGO) which had already started the search for people requiring long-term care and investigated with them. To gather those who require long-term care in one place, we cooperated with the Ishinomaki City Hospital team which was finally rescued to establish the largest evacuee's facility for long-term care. In association with the social welfare conference, we started to move the individuals requiring long-term care from the shelters to general nursing facilities. However, the lack of the nursing facilities were realized. Because the Ishinomaki City Hospital was damaged, the patients suffering from terminal cancer concentrated in Ishinomaki Nisseki Hospital. It pointed out the lack of palliative care services. To offer medical and palliative care in temporary housing, we cooperated with Leading Aging Society Forum (NGO), to establish Home-health-care services for temporary housing. PCAT continues to introduce professionals to this Home-health-care services for temporary housing. We also conduct health consultations in temporary housings and diagnostic visits for victims who requiring long-term care or who are terminally ill.

Activity Area of PCAT

PCAT Fujisawa Station PCAT Wakuya Station P

P

Kesennuma Minami Sanriku


Ishinamaki

Onagawa
� � � �

Earth Quake HIT Capital Sendai





Capital Fukushima
No damaga

Capital Morioka
No damage




� �

Poisoned by Nuclear Ash

PCAT TenEi Station

P

Tsunami Hit Nuclear Power Station

Fujisawa P

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Number of the doctors dispatched
Physicians Obstetricians and Gynecologists Midwives Registered Nurses Pharmacists Acupuncturists Medical Students Mite Buster, Mold Researchers Dentists, Hygienists Physical Therapist, Occupational Therapist, Rehabilitation Staff Public Health Nurses Nutritionists Social Welfare Workers Psychologists Emargency Rescues Office staff Volunteers others total 209 15 22 49 27 64 15 13 11 15 4 3 4 19 9 15 11 25 530

Project Details 1
Support for Doctor S's rescue efforts Doctor S is an orthopaedist in Kesennuma whose home and clinic were entirely lost to the earthquake and Tsunami. When he reached the K-Wave gymnasium during the disaster by swimming, he faced a grave situation and saw that people needed him. He immediately started examinations but lacked the necessary medicines and tools. Even though there were many patients in serious condition, there was not a way for him to contact the hospitals to receive aid or to send these patients out. The PCAT group discovered Doctor S's situation and how other medical personnel in Kesennuma also did not have means for communication. The PCAT donated 20 mobile phones through the Kesennuma medical association, so that members contact h headquarters for disaster control and medical associations. (19 March, 2011) In the K-Wave gymnasium, the DMAT and JMAT who were there to help set their regulation hours from 9am am to 3pm. Doctor S had to see the 2000 evacuees during the remaining 18 hours without sleep and rest. Through this, he became physically and mentally fatigued. PCAT helped Doctor S on May 21, 10 days after the earthquake. Following this, PCAT started medical support for K-Wave gymnasium which included night medical examinations. (3 dispatched doctors and 1 voluntary worker)

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The detail of the project -
Support for the K-Wave shelter Medical support in the K-Wave shelter developed into activities which influenced the headquarters for disaster control, D-MAT(national medical team for coping the disaster*1) and J-MAT (The medical team for coping with disaster, made by each prefecture under the instruction of the Japan Medical Association*2). *1 D-MAT's operations are generally done during the 72 hours after the occurrence of a disaster. 72 hours is the amount of time in which a person has a high chance of surviving without food and drink. After 72 hours, the rate of the survival steeply falls. In this disaster, however, their operations were executed for 7-days. *2 The plan for J-MAT existed since 2 years ago, but there have been no educational systems for medical care in disasters and no logistic system. This was the first operation for J-MAT. PCAT started medical support in the K-Wave shelter 10 days after the disaster occurred. When PCAT arrived, the DMAT team had already left and J-MAT was only operating during the daytime. By this time the most serious patients were supposed to be dispatched to hospitals and less serious patients were only to be left in the shelter. However the environment of the shelter after 10 days was not suitable for even the healthy people without problems. Conditions could easily worsen effects of `the patients with mild disease' and `the patients with serious disease requiring the swift medical intervention'. The evacuees continued to complain about the poor physical condition during the 18 hours. The J-MAT's system of fixed daytime hours and the situation of doctors not having the time to research the cause of the symptoms are issues to be considered for the future.

Project Details -
Research and the support in K-WAVE shelter. On the 11th day after the earthquake, a PCAT doctor was asked at night by the J-MAT team to observe a child with dehydration symptoms. On that night, several patients claimed to have stomachaches and asked for examinations. The PCAT doctor speculated that people showing signs of gastrogenic watery diarrhea meant that an infectious disease could be spreading. By doing research, the doctor supposed that the indoor toilets were the cause. Over 2000 people were using the 20 flush toilets that could not be flush. When people tried to flush with the bottled water, dirt scattered. People could not wash their hands because there was no running water, no alcohol and no towels. With cleaning done only one time a day, it was natural that bacteria and viruses spread. Accordingly, PCAT and a group of public nurses called `CANNUS' cooperated and collected high school student volunteers and started to clean four times a day using chlorine. After that, we reported this case to the SelfDefence forces, the person in charge in the shelter, and the headquarters for disaster control. We discussed the fundamental measures such as creating volunteer groups that could be taken and applied it to all of the shelters. On the night of the 13th , patients with fever increased to 30 people. During the daytime, two of these patients were isolated in a private room with doubts of having influenza. To prevent the spread of the flu, there was a need to set up a special medical office for fevers and to communicate the situation among all evacuees to prevent the further spread of the infection. On that night, we set a large secluded space for the patients and started preventive administration to the people who were around the infected patients. We informed this method of infection prevention to the heads of each group in the shelter, and set up a medical office for fevers by the next morning. We reported these methods to J-MAT and the headquarters for disaster control. After this, our methods were followed by many other shelters as a role model.

Project Details -
The point previously mentioned about "The cause of an increase in pneumonia among the elderly population and its solution" draws from observations made by doctors who went around for night duties in the K-Wave shelter. We were able to acquire new knowledge regarding disaster medical care and medical care in shelters. With new accumulated knowledge on disaster medical care and the treatment in the shelters in the aging society, our relief work in the K-Wave was concluded in mid April 2011. By then, supporting physicians from the headquarters for disaster control increased and the medical health environment in the shelters stabilized.

Project Details
The support for Doctor M Doctor M owns a surgical clinic. His house and the clinic were completely destroyed by the earthquake and tsunami. After the earthquake, all of the family members took refuge in Kesennuma high school, Kesennuma junior high school, and the public hall. On the second day, the local residents who found Doctor M complained about their health conditions and their anxieties. Because people took refuge by the unit in the area where M clinic is situated, Doctor M was strongly linked with the local residents and refused outside intervention. However, he gradually came to accept the PCAT's stance which respected the locals. Also, Doctor M started to speak out about the fear, anxieties, and terror of the experiences he and the locals hesitated to reveal until then. PCAT's support gave Doctor M the time to start research his home-visiting patients. With this, the situation of the people requiring care at home was revealed and it led to the establishment of a homevisiting supporting group (JRS) in Kesennuma, as seen in the Features of PCAT Activities 1. (3 Dispatched doctors, 1 beneficiary)

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Relief work in the Kesennuma junior high school shelter. After the initial support for the Doctor M, PCAT took over the night duties and Doctor M's responsibilities. At that time, there were about 1800 evacuees in the coalition of shelters consisting of Kesennuma junior high school, Kesennuma elementary school and the public hall. The three shelters together held the second largest number of evacuees following KWave. Because there were three locations, the issue with public hygiene was not as serious compared to K-Wave. Yet, the PCAT conducted examinations thoroughly at these shelters based on its basic policy of interdisciplinary intervention. The findings mentioned in `Special Features of PCAT 2' were discovered in these combined shelters, except for the discovery of aspiration pneumonitis patients found in K-Wave. Information contributed to swiftly improving shelter administration and the support of victims. Although the shelter was divided into three locations, the symptoms of cough spread among the elderly. While living spaces were divided, condition was very poor and infection tended to spread between the shelters. Therefore, it was necessary to intervene and prevent the weak elderly from infectious diseases. In this case, we concluded that Pneumococcus vaccine was needed to prevent the infection of pneumonia. In Japan, since the rate of people who have received vaccination for measles is very high, we inoculated against pneumococcus. (56 dispatched doctors in Kesennuma area, 10 nurses, dispatched dietitian, 4 physiotherapists and occupational therapists, 55 acupuncturist shared the projects. 1800 beneficiaries)

The search of expectant and nursing mothers and health consultation support. (PCOT Project) PCOT (Primary Care for Obstetrics Team) was established as a special unit of the PCAT. On March 24th , the second week after the disaster, a PCAT doctor was dispatched to help the coordinator in Minami-Sanriku town, Doctor N, take time off to rest. The dispatched doctor and Dr N discovered a lack of information on the safety of expectant and nursing mothers and that mapping was also not done. At that time, none of the doctors sent to Minami-Sanriku town specialized in obstetrics and gynecology. So in response, PCAT dispatched a primary care obstetrician and a midwife to Wakuya hub, where Ishinomaki city and MinamiSanriku town are accessible. PCAT searched the areas where public transportation and telecommunication were stopped, and confirmed the safety of expectant and nursing mothers. Brief medical checks were offered to them. To the foreign mothers who did not speak Japanese, a translator from Tokyo was dispatched for support. (Two dispatched Primary care doctors, One obstetrician and gynecologist, two pediatricians, two midwives)

The support of the shelter in Ogatsu Oosu Junior High School. In Ishinomaki city, even after three weeks after the disaster, there was a lack of aid in distant and less accessible areas. The area which required support was too vast while the area in which the headquarters for disaster control regulated was limited. There were also not enough medical teams dispatched. The request for support from the shelter of Ohtsu primary school came to PCAT through the local hygienist. We moved the PCAT doctors who were at K-Wave in Kesennuma to Wakuya town to support Ohsu junior high school. Initially, the area was mountainous and inconvenient for access. The road condition was also very poor. Furthermore, we received information that a group of people likely to be locals held up and robbed a car which belonged to the supporting group. With extra security precautions, we dispatched additional medical personnel and provided support. PCAT finished the relief work in Ogatsu Ohtsu junior high school after Ishinomaki headquarters for disaster control was reinstated. Although most of our medical team was once withdrawn, we now support Yu-ShinEn, which was once a temporary clinic in the temporary housing area in Ogatsu. (One dispatched doctor, One dispatched nurse, 500 beneficiaries)

The support for Yumoto clinic in Tenei town. The relief work started with supporting the Yumoto clinic in Tenei town, where Doctor Y examined patients. Due to the particular situation with the nuclear power plant accident in Fukushima, we chose to support the clinic in Tenei town which is located a little distant from the disaster area. The PCAT doctors in Tenei contacted the local medical association and the disaster countermeasures office to arrange relief work and support the area affected by the nuclear disaster. We helped Doctor Y, who had been working continuously since the disaster first hit, to take some time to rest. We established the smaller hub in Koriyama city 9 days after the disaster on March 20th. We started medical examination visits in the shelters at Tamura city etc., which are located within 25 km from the Fukushima Daiichi Nuclear Power Plant. The visits for medical care and health consultations in Tenei town continued until May 2009 until the subacute phase of the disaster passed. We terminated the work as the situation stabilized. The above activities were later developed into the project, which provides health consultation for residents living near the nuclear plants. We collaborated with the Kami laboratory of the Institute of Medical Science at the University of Tokyo. 5 dispatched doctors and 1 coordinator)

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Support for the home visiting aid group (JRS) (Reference p.5 Features of PCAT's activities and p.25 The support for Doctor M.)

Shelter health consultations in the area 25km from the nuclear plants.(see project details ) On March 19th, 8 days after the disaster and 1 week after the realization of the nuclear accident, PCAT dispatched a medical team to Fukushima pref. The aim of this team was to measure the radiation dose of the area around the nuclear power plants as well as to support the doctors in` the Yumoto clinic in Tenei town'. We visited the Hamadoori area (Iwaki city in the south, Minami-Souma city in the north, and Tamura town in the west) to measure the radiation levels in these areas and share the information with subsequent health care teams. In addition, we stopped at several shelters along the way to respond to the managers at the shelters who requested their patients to be seen. (8 dispatched doctors, 1 coordinator) �
The condition of the patient who the PCAT had examined for Doctor M deteriorated. Seeing this, Doctor M reported to the headquarters for disaster control in Kesennuma the need for special support for at-home disaster victims requiring longterm care. At the same time, PCAT, which mainly targeted its support for the aged, at home victims requiring long-term care, and the area lack of medical care, were strongly asked from the headquarters for the disaster controlto participate in the team that does medical care visits for the victims in the mountainous area in Kesennuma (Karakuwa peninsula). On 26 March, a PCAT coordinator cooperated with a NY doctor who examines mainly in Matsuyama city in Ehime pref. A nurse who is a professor at the Miyagi University School of Nursing and another nurse in Kesennuma-honcho established a committee to improve medical care for the people requiring long-term care in Kesennuma. Doctor M became the representative of the special committee on the next day. PCAT took on the responsibility of coordinating and dispatching home visiting doctors, and also started mapping these acitivities. Later, the doctors who were researching in the Motoyoshi area in Karakuwa peninsula and `NPO Share' joined in the activities. The team helping the at-home victims requiring long-term care was named as JRS (home-visiting medical supporting group). JRS conducted the relief work, involving the many volunteer medical personnel. The work finished at the end of August and we entrusted the core for people requiring long-term medical care at home to the local revived institution. PCAT has been continuing support by setting the Motoyoshi district as the central area for patients with most serious symptoms. PCAT dispatches Primary care doctors and resident doctors to Kesennuma City Motoyoshi hospital, which is the only one medical institution in the area. (Some of 56 dispatched doctor to Kesennuma area and 10 dispatched nurses joined in the activities. 262 beneficiaries.)

The support for Doctor N and the medical support for disaster victims requiring long-term care at home in Kahoku area. In previous projects (the search for expectant and nursing mothers and the health consultation support (PCOT project) and :the support for the shelter of the Ogatsu-Ohsu Junior High School), it was realized that many victims especially in Ishinomaki city were neglected in terms of medical care and needed support. Since PCAT could not conduct research by itself on the people requiring long-term care at home, we gained information from doctors who were doing home-visiting care. We were able to obtain information from Doctor N, who had been doing home visiting examinations in Kahoku area. This area is the largest in Ishinomaki and it is where population is sparsely spread. Also, the local public care nurse and NGO JIM-NET provided us information. With this, we conducted medical support for the disaster victims requiring long-term care. This PCAT support enabled Doctor N, a pediatrician, to visit Kahoku and Ogatsu area to conduct children's care activities with the local nurses. He offered protective inoculation to new-born babies and children. The PCAT's dispatched pediatricians conducted observations and examinations for children requiring continuous medical care. The medical support for people requiring long-term care and Doctor N's support in children's care were continued until June 2011. Due to the stabilization of the medical environment, projects except children's examinations finished. (102 dispatched doctors, 33 nurses, 32 pharmacists in Ishinomaki city conducted the work together.)

The support for the Yugakukan welfare shelter (see Features of PCAT Activities -,e.g.2 ) Ishinomaki city has the second largest population and the largest area in Miyagi prefecture. There, PCAT's target population is large; there are many elderly people and people who require long�term care. In addition, there were a considerable number of the victims requiring visiting examinations and at-home medical care. In order to provide support effectively, it was necessary to gather these victims requiring long-term care and the specialists offering the medical care. Under this situation, the largest welfare shelter in this area was created using the cultural institution called `Yurakukan', located a little distant from the coast. PCAT established this facility with 120 beds, 20 of which were electrically powered beds. We cooperated with external groups including the Japan Association of Medical Social Workers in Health Services, the health care team gathered by Japan National Council of Social Welfare, the Hokkaido administrative team, and the general volunteer groups such as Peace Boat. The team who contributed most to the establishment was the Ishinomaki city hospital medical care team, whose members critically suffered from the disaster themselves and had finally evacuated after one week of the disaster. Features of PCAT activities such as `the support for neglected people' was seen in this project, as we cooperated with the Ishinomaki city hospital medical care team to support the victims. The first activity at the Yurakukan welfare shelter was repairing the facility. To facilitate care, toilets and slopes were repaired, beds were made out of cardboards, and electric powered beds were introduced. We intervened in various ways: we provided individuals with meals overseen by the nutritionists and introduced rehabilitation programs that would better the ADL of survivors. At the same time, preparation for closing the temporary shelters started. Medical Social Workers, doctors, care workers, care managers, and clinical psychologists contributed to making this process effective, discussing and executing the closings together. As a result, the shelter which held at most 100 people could replace the evacuees to new locations by the end of October. (102 dispatched doctors in Ishinomaki city, 33 nurses, and 32 pharmacists worked together. 100 beneficiaries.)

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Health consultation for evacuees living around the Fukushima nuclear power plants in Koriyama district.(see Project.) PCAT substituted examinations for Doctor Y in Yumoto clinic in Tenei town, and supported the shelters located within the 25km radius of the nuclear power plant. The PCAT research team was also involved in setting a small hub in Koriyama city. As time progressed, shelters were established in the suburban facilities around Koriyama city. In Koriyama city, where the damages from the disaster was limited, medical examination could be conducted normally after several weeks. However, the sufferers in Hamadori area, who had to move to the suburban shelter had difficulty getting transportation to distant medical facilities. Particularly, the aged tended to hesitate asking their families for help because their families had also suffered from the disaster. So although their chronic maladies deteriorated, they tended to keep the fact to themselves. PCAT conducted visiting examinations for evacuees living in the suburbs of Koriyama city, based on the information obtained by the research team. Later, we reported our findings on the lack of transportation for patients and worked with the local medical association to improve the situation. We finished the project in this district with this activity. (3 dispatched doctors)

RHITE Project RHITE is an abbreviation of `Research and Health Improvement and Tohoku Empowerment'. This project was established in collaboration with the School of International Health: The University of Tokyo, and Jichi Medical University. We researched preventive medicine in the stricken area and conducted medical examinations to contribute to the revitalization of the Tohoku area. The process was similar to a mass medical examination, but specifically, we conducted examinations that consisted of an optional blood test and a questionnaire created by the professors with different specialities. We returned the examination results to the evacuees and gave them advise in terms of medical and health care. Based on the mental care related questions in the questionnaire, PCAT doctors conducted medical examination. In early May 2011, approximately 500 people were examined in Kesennuma, Minami-Sanriku, and Ishinomaki.

Check up for new-born babies (PCOT) PCOT Project, which started with the search and medical checkup for the pregnant women and nursing mothers, came to a turning point after two months of the disaster. The initial chaotic situation gradually stabilized, and the information on the safety of maternity women started to become organized and understood by the administrative body and the headquarters for disaster control. The examination for maternity women reached a stage where it was able to be conducted by the government. However, some of the municipalities were incapable of checking the condition of new-born babies and puerperas after the childbirth. In such environment, PCOT started doing visits for new-born babies upon the request of the administration of Higashi Matsushima city. By understanding the physical condition of new-born babies and the mental and physical stress of puerperas, and by also dispatching midwives, we have contributed to the healthy growth of babies.

Vaccination against pneumococcal. From May 12th (three months after the occurrence of the earthquake), we gave pneumococcal vaccinations to 5500 elderly people at the Kesennuma shelter for free. The flu season had already passed at that time, and the pneumococcal was the biggest factor that could cause death for the elderly. We executed this project because the vaccination was the most effective method for prevention. By collaborating with the headquarters for disaster control in Kesennuma, Kesennuma medical association and Juntendo University, we conducted this project. Vaccinations were given on site by J-MAT which were dispatched from each prefecture. The preparation for the cold chain was conducted by the PCAT doctors and coordinators. (5 dispatched doctors and coordinators. 5500 beneficiaries.)

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ealth consultation for child care support.(PCOT project) For mothers who conceive babies and for families raising a child in this time of disaster, it is important that they know how to help children grow under such circumstances. Many families have become stressed mentally, physically and socially due to the loss of many things including property. The parents' stress tends to influence a child's growth, and we have been concerned about this negative influence on children. To support parents who are concerned about raising a child under difficult situations, consultations for were given at the maternity hospitals and the center for child care in each region. PCOT dispatched specialists such as obstetricians, gynecologists, pediatricians, and midwives.

Dispatching medical examiners to the Ishinomaki police. The population critically affected by the Tsunami was 2%, However, the number of medical facilities critically damaged by the Tsunami reached 50% because the medical facilities were concentrated along the coast. Although 98% of the population was not directly affected by the tsunami, people suffered greatly from the 50% loss of medical facilities. General citizens were not only the ones effected, and the survived medical facilities were heavily burdened. Procedures which require professional doctors were also disabled; an example is inquest. In the Tohoku region, the number of the doctors who can conduct inquests is limited, and in Ishinomaki, the work has been conducted in rotation by several private doctors who belong to the Ishinomaki medical association. The inquest work burdened the doctors physically and mentally since they were usually conducted after midnight and also 50% of the medical facilities were not functioning. Until the PCAT responded to the Ishinomaki police's request for aid in May, the inquests of Tsunami victims overwhelmed the work load handled by the local specialized medical examiners. Through these inquests, PCAT witnessed many cases of deaths including suicide. The doctors were shocked that the disaster and mental stress had triggered suicides in adolescents. In response to this, PCAT decided to approach mental care in terms of primary care and family therapy. In addition, PCAT underlined the importance of supporting care for aid workers such doctors and policemen. These things developed into the Project, which have been the starting point of mental care activities led by the PCAT. (102 dispatched doctors in Ishinomaki city, 33 nurses, 32 pharmacists divided the projects.)

Health consultation for residents living around the Fukushima nuclear plants. PCAT conducted various medical activities in Fukushima pref.: locums for the Yumoto clinic in Tenei town, support and research, and medical care for the shelters in the suburb of Koriyama area. PCAT also requested support from the school of International Health at the University of Tokyo to conduct health examinations for residents in Minami-Souma city, Souma city, Tamura city, located in the north of the nuclear plants. It was initially planned to be conducted by the Ue lab: institute of medical science: the University of Tokyo, but the number of the doctors were not enough and thus extra help was requested. This health consultations project is consigned by the local government around the nuclear plants. For areas where all of the residents were ordered to evacuate such as Iidate, health examinations became part of the process for evacuation. Although no physical damages of the disaster to the land could be seen, residents were ordered to shelter indoors and they became highly stressed. Mentally, people were seriously damaged because they had to leave the town in which they have lived in for many years. In addition, the number of the doctors joining in the project was small due to the unfounded rumors. Therefore, the coordinators of this project often took on the work. This project continued until the beginning of August. (5 dispatched doctors)

SSB special shelter support In Ishinomaki, the transition to temporary housings was delayed due to the large number of shelters. The long-term stay in the shelter stressed not only to the aged requiring long-term care but also the general people living in the shelters. Babies, infants, school age children, adolescents, and patients with chronic maladies or mental diseases all could get infected or get stressed easily under these conditions. There were no private spaces and it was difficult to cope with the situation in a communal living. This could cause the expansion of infections and bring about further stress on people. To solve the problem, a special shelter called SSB (Short Stay Base) was established in a vacant hospital ward. There was no water and sewer services because of the earthquake. PCAT was consigned to establish the facility by the headquarters for disaster control of Ishinomaki. It was to be done in June, before the summer season when waterborne infectious diseases and heatstroke would likely break out. At this time, other medical supporting teams were reaching their limits and so the PCAT, which still had the capacity to manage various resources, was requested to aid with human resources and logistical support. PCAT managed the SSB shelter by cooperating with the NGO `Project Hope'. With our request, the NGO dispatched a medical team of Japanese doctors based in America. Although the initial activity was to set up a water purifier, SSB shelter looked after infants with measles, children with an early digestive organ infection and diarrhea, people who were stressed with the life in shelters and got mental disorders, and patients with chronic maladies or other health issues . We conducted adequate medical treatments and moved the patients to suitable medical facilities. By August, many people moved into temporary housings and the necessity of the SSB gradually decreased. Local hospitals became ready to accept the patients and the shelter was closed at the end of July. (102 dispatched doctors, 33 nurses, 32 pharmacists divided the projects.)

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Health consultation support in temporary housing (Health Cafe Project) After several months of the disaster, the number of the people moving into temporary housing increased. The PCAT which took on the responsibility of conducting inquests observed suicide cases in temporary housing. Cases of death by alcoholism and solitary deaths of the aged were also seen. Under these circumstances, Starbucks Coffee collaborated with Canon to open an open-air cafe in the temporary housing at Rikuzen-Takada in July. They requested PCAT to join this project by offering blood pressure checks at the cafe. This was the start of the health cafe project. The temporary housing residents who usually did not come out for health consultations came out interested in the caf�. People were able to come together for casual health consultations without white robes and uniforms. We became busy with people coming to share their sadness, fear, anxieties or their struggles with child raising. People also came concerned about their blood pressure. As the restoration of the local hospitals came underway, the health consultations in this health cafe contributed to linking the people, the hospital, and the community. Since then, PCAT has regularly held `health consultation with tea' sessions as part of the `Health Caf� Project'. It is conducted not only in RikuzenTakada, but also Kesennuma, Ishinomaki, Higashi-Matsushima, and Minami-Souma. In response to the local needs, clinical psychologists and psychiatrists have been dispatched and are collaborating with the department of mental care in PCAT and the Project. (10 dispatched doctors, 100 beneficiaries)

Mite Busters Project
In Ishinomaki city, 7000 evacuees live in 100 separate shelters. As time passed, futons and cardboard boxes containing personal belongings became subjects of mold outbreaks. Hygiene became a serious issue. In response, the Mite Buster Project started to air out futons, exterminate mites, and suppress mold. In coordination with other groups, 1900 people joined this project and assisted in disposing moldy beddings, delivering fresh beddings, and managing the environment of the shelters.

Specific activities 1 Investigating the sanitation environment in the shelter. Lecture on how to remove mites and mold. 2 Disposal of old bedclothes. Providing new bedclothes for the summer. 3 Drying of bedclothes. 4 Disinfecting and cleaning the shelter in cooperation with the evacuees. 5 Providing disinfectants, insecticides, seasoned lumber and beds made by corrugated cardboard. The PCAT in cooperation with government sent specialists to advise the Mite Busters on how to maintain sanitized, clean environments in the shelters.
Fifty-three shelters have been visited in Ishinomaki city, Rikuzentakada city, Onagawa-cho, and Higashi-matsushima city. So far 4300 people have benefited from these activities.

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The project of dispatching an obstetrician and gynecologist for Doctor A.

In this disaster, perinatal medical treatment along the coast of Miyagi prefecture up to the north of HigashiMatsushima were disabled. There were 7 hospitals and clinics that could accept childbirths along the coast of Higashi Matsushima to Rikuzen-Takada: Abe maternity clinic, Ishinomaki Redcross hospital, Aneha maternity clinic, Saito maternity clinic, Honda maternity clinic(in Kesennuma), Kesennuma city hospital(in Kesennuma), and Mori maternity clinic. However, all of these facilites except Ishinomaki Redcross hospital and Kesennuma city hospital were damaged by the Tsunami.

In the middle of April, Abe maternity clinic, which received the least damage, recovered and started to assist in childbirth. However, the other facilities could not restart and so the childbirths concentrated in the few hospitals. In addition, Doctor A, who is the director of the hospital, had suffered from the disaster himself and was highly exhausted at that time. Therefore, PCAT dispatched an obstetrician and gynecologist to oversee childbirth on behalf of Doctor A. (See the details on our report submitted to UNICEF.) Currently, hospitals and clinic for childbirth do not have plans to restart except Saito maternity clinic. Aneha maternity clinic and Honda maternity clinic have decided to shut down. Mori maternity clinic needs their boiler, service room, operating room and interior furnishing restored as soon as possible.

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