At the Intersection of Health, Health Care and Policy Cite this article as: Parveen Parmar, Maya Arii and Stephanie Kayden Learning From Japan: Strengthening US Emergency Care And Disaster Response Health Affairs, 32, no.12 (2013):2172-2178 doi: 10.1377/hlthaff.2013.0704
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Preparedness By Parveen Parmar, Maya Arii, and Stephanie Kayden 10.1377/hlthaff.2013.0704 HEALTH AFFAIRS 32, NO. 12 (2013): 2172–2178 ©2013 Project HOPE— The People-to-People Health Foundation, Inc.
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Parveen Parmar is an attending physician in the Department of Emergency Medicine, Brigham and Women’s Hospital, in Boston, Massachusetts. Maya Arii is an assistant professor in the Department of Emergency Medicine and Critical Care at Keio University School of Medicine, in Tokyo, Japan. Stephanie Kayden (skayden@ partners.org) is director of the International Emergency Medicine Fellowship at Brigham and Women’s Hospital.
Learning From Japan: Strengthening US Emergency Care And Disaster Response As Hurricane Katrina demonstrated in 2005, US health response systems for disasters—typically designed to handle only shortterm mass-casualty events—are inadequately prepared for disasters that result in large-scale population displacements. Similarly, after the 2011 Great East Japan Earthquake, Japan found that many of its disaster shelters failed to meet international standards for long-term provision of basic needs and health care for the vulnerable populations that sought refuge in the shelters. Hospital disaster plans had not been tested and turned out to be inadequate, and emergency communication equipment did not function. We make policy recommendations that aim to improve US responses to mass-displacement disasters based on Japan’s 2011 experience. First, response systems must provide for the extended care of large populations of chronically ill and vulnerable people. Second, policies should ensure that shelters meet or exceed international standards for the provision of food, water, sanitation, and privacy. Third, hospital disaster plans should include redundant communication systems and sufficient emergency provisions for both staff and patients. Finally, there must be routine drills for responses to mass-displacement disasters so that areas needing improvement can be uncovered before an emergency occurs. ABSTRACT
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mergency departments (EDs) and emergency medical services such as ambulances are the primary providers of emergency health care during disasters in the United States and many other high-income countries. However, experts have raised serious concerns about the ability of EDs in the United States, many of which are already operating at or beyond capacity, to absorb a surge of survivors after a largescale disaster.1,2 In many such disasters, national disaster health response systems are called on to fill the gaps in emergency health services. US disaster health response systems were originally developed to respond to mass-casualty incidents, in which the number of injured or 2172
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sick survivors temporarily overwhelms local resources. When such incidents force people from their homes—for example, after a tornado or hurricane—the disaster response systems can provide refuge in temporary shelters with basic health care for hours or days at a time. Because high-income countries like the United States are relatively resilient to disasters, these displacements are typically localized and short-lived. In 2005, in the Gulf coastal region of the United States, Hurricane Katrina created a mass population displacement disaster—a type of disaster that is relatively rare in the United States and other high-income countries. Disasters causing large-scale population displacement are more common in developing countries,
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where poor building codes, weak governments, and inadequate response systems allow enormous devastation to follow natural disasters.3 International aid agencies have developed guidelines for the care of large populations displaced by such devastation.4 The inexperience of the US disaster health response systems with mass-displacement disasters was evident after Hurricane Katrina. These systems were inadequate to deal with the medical needs of thousands of people displaced not for hours or days, but for weeks or months.5–9 Where can the United States look for lessons on how to better prepare for future mass-displacement disasters? Japan, like the United States, is a high-income country with a relatively robust disaster response system.Yet Japan suffered its own mass-displacement disaster when the 2011 Great East Japan Earthquake caused a tsunami whose waves devastated Japan’s northeast coastal region. The lessons learned from the difficulties Japan faced in responding to the mass displacement are useful for US disaster response planners. This article reviews the Japanese experience following the 2011 disaster in terms of the medical and public health response, with particular attention to vulnerable populations. It also discusses hospital infrastructure and planning. Specific policy lessons for the United States are presented with the aim of strengthening US disaster response systems.
Overview Of The Japanese Earthquake Response The 9.0-magnitude 2011 Great East Japan Earthquake produced a forty-meter-high tsunami that flooded 216 square miles of coastland and caused a leak of radiation from the Fukushima Daiichi Nuclear Power Plant.10,11 The disaster killed 15,883 people and displaced 470,000. Of the dead, 65 percent were over age sixty,12 and 92 percent died by drowning.13 Causing $235 billion worth of damage, this was the costliest natural disaster in world history.14–16 Although careful government planning saved many lives, the sheer scale of the devastation and the resulting mass population displacement tested Japan’s ability to respond effectively. Many of the country’s disaster preparations proved to be inadequate. Medical Response Teams After the 1995 Great Hanshin-Awaji Earthquake (also known as the Kobe Earthquake), Japan established disaster medical assistance teams (DMATs), whose members are trained to rapidly treat and evacuate trauma victims.17–19 Each DMAT has four to five members, including a physician, a nurse,
and logistical support staff, all of whom have disaster response training.20–22 The 1995 Great Hanshin-Awaji Earthquake produced a typical earthquake-related disaster. Such disasters commonly require a robust, trauma-focused medical response to treat crush injuries. The 1995 earthquake caused 6,434 deaths and 43,792 injuries, giving it a high injury-to-death ratio (6.8:1). Earthquake injuries in the 2011 Great East Japan Earthquake were minimized as a result of well-enforced building codes, and most people who escaped the deadly tsunami did so without major injury. The injury-to-death ratio in 2011 (0.4:1) was more typical of tsunamis than of earthquakes: Most of the dead drowned, as noted above, and only 6,130 were left injured.17 More than 300 Japanese DMATs were deployed within twenty-four hours of the 2011 earthquake.18 However, only a small number of survivors met the criteria for emergency treatment or transfer based on traditional traumafocused DMAT criteria. Most of the survivors were elderly, chronically ill people in need of primary care who were living in shelters after the earthquake. The trauma-oriented DMATs were not adequately trained to respond to their needs in particular23 or to address other key needs for the affected population overall, such as radiation screening; the provision of food, water, and sanitation for public health purposes; and the evacuation of large populations.17 The deployments of DMATs were also inadequate. Japanese DMATs are designed to be deployed for a three-day period, because most earthquake-related traumatic injuries require treatment in the first seventy-two hours.21,22 Three days after the 2011 earthquake, there were 120 DMATs active in the disaster area; a week after the earthquake, there were only twelve.24,25 Although some DMATs later returned on a rotating basis, most did not stay beyond their initial deployment. Moreover, DMATs are not designed to interact with local health care providers, and as a result, coordination among health responders in the field was poor.23,26 Other disaster response teams from the Japanese Red Cross; the Japan Self-Defense Forces; public health departments; hospitals across Japan; and local medical, dental, and pharmacist organizations spontaneously arrived to fill the gaps left by the DMATs. The Japan Medical Association organized Japan Medical Association Teams and deployed nearly 1,400 of them to various sites affected by the disaster.27 Coordination efforts by medical staff in the area near Tohoku University and in Ishinomaki City made use of these volunteer teams to fill gaps left by departing DMATs. However, this level of sucDecember 2013
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cessful coordination was the exception and not the rule.19,26 Public Health Response Inadequate provision for the public health needs of displaced and vulnerable populations can increase the demands on limited, and often damaged, medical facilities. In the weeks following the 2011 earthquake, deteriorating hygiene and environmental conditions in shelters caused a surge in the number of patients seeking medical care from the health system. Patients affected by the disaster suffered from allergic skin and respiratory reactions; muscle wasting and blood clots resulting from inactivity; and respiratory illnesses and pneumonia caused by exposure to “tsunami sludge,” a mixture of liquid waste, toxins, and mud containing bacteria that formed as a result of the tsunami.23,28,29 Tokyo University Hospital—180 miles from the primary site of the disaster—reported a 23 percent increase in patient volume as a result of displaced people seeking care for medical and psychiatric complaints.30 This highlights the need for medical, psychiatric, and social services during disasters on a national scale. From the beginning of the 2011 earthquake disaster response, problems arose because of an underlying misconception that basic public health needs—food, water, and sanitation—were less important than medical needs. Japanese responders felt that basic public health needs should be handled by the local governments and municipalities, but these entities had been rendered incapable of doing so by the disaster.31 As a result, many government-designated shelters did not meet international humanitarian standards4 for safe and adequate supplies of water, toilet facilities, nutrition, and privacy even two months after the disaster.32 In Ishinomaki City assessment teams discovered critical public health needs, including insufficient food in thirty-five shelters, inadequate sanitation in a hundred shelters, and insufficient facilities for hand washing in eleven shelters.26 Rapid intervention prevented outbreaks of communicable diseases in shelters in the Ishinomaki Medical Zone.26 However, insufficient food and poor environmental conditions were thought to have contributed to illness, particularly among older people and the chronically ill.23 In other areas, inadequate supplies of water for drinking and hand hygiene at shelters led to cases of vomiting, diarrhea, and dehydration.28 In Iwate Prefecture, public health and sanitation teams worked alongside medical teams to conduct rapid assessments of water and sanitation, provide clean drinking water, and conduct daily surveillance of conditions at the shelters. Their efforts successfully avoided a major outbreak of
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infectious disease in the prefecture.33 Vulnerable Populations The lack of adequate planning for the care of certain vulnerable populations led to additional demands on already overburdened emergency medical providers. Vulnerable populations in the affected region included older people, patients in nursing homes and hospitals, chronically ill people, and people living with mental illness. ▸ OLDER PEOPLE : A quarter of the people in Tohoku who were affected by the disaster were older than sixty-five, and 14 percent were older than seventy-five.34 Older people displaced by the earthquake endured life in evacuation shelters that were not planned to accommodate their needs and lacked heat and running water. Toilets, flushed with buckets of water from school pools, soon became clogged and overflowed. Older people who could not climb stairs or walk to outside toilet facilities were forced to wear diapers and quickly became bedridden and debilitated.35 In Tohoku a group of medical responders established a 362-bed evacuation facility specifically for older people, which treated 13,094 people in its first six months. Responders found that multidisciplinary teams, including social workers and professional caregivers, were needed to care for an older population with limited mobility who were living in shelters.35 By tailoring services to the needs of older survivors, the facility was able to prevent illness and any increased demand for emergency medical care.35 ▸ NURSING HOME AND HOSPITAL PATIENTS : The Fukushima Daiichi power plant radiation disaster that accompanied the 2011 earthquake prompted the government to create a twentykilometer mandatory evacuation zone around the nuclear plant and a voluntary evacuation zone another ten kilometers outside the mandatory zone.36 Among the evacuated were 1,770 older patients who were residents of hospitals, nursing homes, and other care facilities.37 Transfers from the evacuation zones were often haphazard and disorganized. Frail patients were moved long distances without medical attendants, adequate clothing, blankets, or safety restraints—which sometimes resulted in traumatic injuries en route.38 Because these critically ill and immobile patients were left unattended at times for more than twenty-four hours, more than twenty patients died from dehydration, exacerbation of underlying illness, and hypothermia during bus transfers and at abandoned shelters.39 Pneumonia was the most common cause of death, probably a result of poor nutrition and housing conditions.37 Receiving facilities often lacked food and medical supplies to care for evacuated patients, and
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some patients were turned away because staff members feared being exposed to radiation.36,37 One group of older people evacuated from nursing homes suffered a three- to fourfold increase in mortality.36 Not all patients were evacuated. At least 840 of them were left stranded in medical and nursing facilities near the nuclear plant.39 The mortality rate for older people living in the mandatory evacuation zone during 2011 (excluding people who died during the tsunami) was 2.4 times higher than during 2010.37 ▸ CHRONICALLY ILL PATIENTS : Japan has a high proportion of patients with chronic diseases such as diabetes and hypertension. Although traumatic injuries were relatively few, hospital admissions surged in the ten days following the disaster, in part because of complications of uncontrolled chronic illnesses.23 The majority of patients who visited medical clinics in the affected region sought treatment for chronic illnesses. The incidence of acute coronary syndrome, cardiac arrest, and stroke increased shortly after the disaster, presumably as a result of cold and stress.40 Many “drug refugees”—people who lost their medicines in the disaster—suffered complications from the lack of essential medications, including uncontrolled hypertension, high blood sugar, and other problems.23 An estimated 282 people died from exacerbations of chronic illness in the two weeks after the disaster,18 which highlights the need for increasing the capacity of disaster response teams to treat chronic illnesses.17–19,33 ▸ PEOPLE LIVING WITH MENTAL ILLNESS : People living with mental illness are a vulnerable population that experiences both a disruption in necessary services and a growth in numbers after disasters.41,42 After the 2011 earthquake there were increased rates of depression and posttraumatic stress disorder in the population that was affected by the disaster. Those with chronic mental illnesses suffered from inadequate access to medications, the loss of medical records, and destroyed mental health facilities. A strong social stigma against mental illness discouraged many survivors from seeking mental health care.23
Hospital Infrastructure And Planning The 2011 Great East Japan Earthquake illustrates the need to strengthen hospital communications, emergency supplies, and disaster drills. Communications The destruction of communications infrastructure after the 2011 earthquake crippled coordination among regional
disaster responders, making it difficult to assess needs and coordinate patient transports.19,43 There was no functional communication network between hospitals transferring patients and the Japan Self-Defense Forces and fire brigades dispatched from other prefectures44 to transport patients.43 For two days after the disaster, one 1,262-bed hospital in Sendai was dependent solely on satellite phones and disaster multichannel access radios for internal and external communications. Many hospital staff resorted instead to in-person communication via physicians who were dispatched to other hospitals after the earthquake.19 Emergency Supplies Insufficient emergency supplies of food and water threatened patient care at hospitals affected by the disaster. Tohoku University Hospital had stockpiled a three-day emergency supply of food that was intended to be sufficient for patients but not for the hospital staff. However, many staff members were unable to leave the hospital in the days following the tsunami. The hospital was forced to request emergency aid from other hospitals in Japan and to ask its university-employed staff members, who were in Tokyo at the time of the disaster, to send what food they could.19 At the 778-bed hospital at Fukushima Medical University, there was no running water for eight days. The hospital’s water tank held 700 tons of water, normally enough for only one day. Water trucks brought more than 100 tons of water daily, but even with these additional deliveries there was insufficient water at the hospital one week after the disaster. Lack of water prevented the hospital from accepting patient transfers and forced staff to discharge patients until the hospital was at only 70 percent capacity.43 Disaster Drills Unlike the United States, Japan does not require regular hospitalwide disaster drills for hospital accreditation.45 The 582 government-designated “Emergency Base Hospitals” are expected to be prepared to accept influxes of disaster patients and to dispatch medical teams to the scene of a disaster. However, the substance of hospital disaster plans and drills is left to the discretion of each facility.46–48 The 2011 disaster demonstrated gaps between written hospital disaster plans and their actual implementation—gaps that might have been exposed by drills.
2.4
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Times higher
The mortality rate for older people living in the mandatory Fukushima evacuation zone during 2011 was 2.4 times higher than during 2010.
Lessons For The United States Despite extensive preparation, the 2011 earthquake overwhelmed Japan’s medical and public health response systems. Unfortunately, many of Japan’s response problems mirror those seen December 2013
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Preparedness in US disasters, particularly Hurricane Katrina. Lessons should be drawn from these mass population displacement disasters to improve US policies for disaster response. The US Disaster Response System Like Japan, the United States has a generally wellorganized system to respond to health needs after disasters. Small-scale disasters are managed by local authorities with assistance from state and federal entities.49 The Department of Homeland Security’s National Incident Management System provides a comprehensive framework for use by private, local, state, and federal agencies in preparing for, responding to, and recovering from disasters.50 The National Disaster Medical System, part of the Department of Health and Human Services, supplements the medical capacity of state and local authorities during disasters. The system can deploy DMATs, Disaster Mortuary Operational Response Teams, National Veterinary Response Teams, and International Medical Surgical Response Teams.51 As was the case in Japan, the DMATs deployed in Hurricane Katrina were insufficiently prepared to care for the chronic illnesses of people displaced by the disaster.9 Many teams had insufficient medical supplies to meet the needs of overwhelming numbers of patients and were thus able to provide only the most basic care— first aid and triage.52 DMAT members cited inadequate federal deployment logistics, poor communication, and inadequate coordination between DMATs and local providers,5 in addition to lack of training and equipment to manage chronic illnesses. DMATs must be ready to manage large numbers of chronically ill patients for weeks to months during mass population displacement disasters. They also must work with local providers to coordinate care in a way that promotes smooth recovery. Improvements have been made in these areas since Hurricane Katrina, but it remains to be seen whether those improvements are enough. Public Health Response Public health needs in overcrowded and underresourced shelters went largely unmet during the initial days after Hurricane Katrina struck Louisiana, similar to the situation in Japan after the 2011 earthquake. Crowding, insufficient water and sanitation facilities, poor nutrition, and chronic disease— together with Louisiana’s relatively low baseline vaccination rates—made several authorities worry about possible outbreaks of disease in shelters.7,53 It is likely that there will be future mass displacements of US populations as a result of climate-related natural disasters, and displaced 2176
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populations may require shelter for weeks to months. Thus, US authorities must develop and enforce minimum standards for public health needs—food, water, sanitation, and privacy—after a disaster. The Sphere Project’s standards4 are internationally developed guidelines for the care of populations displaced by disaster. Although these standards were created for developing countries, they are a reliable starting point for the development of locally relevant standards. Shelters for populations displaced by a disaster must be improved to meet or exceed international standards for meeting public health needs. Vulnerable Populations Hurricane Katrina displaced a population with high rates of chronic illnesses such as diabetes, renal disease, and hypertension. Thousands of survivors of the 2011 Japan earthquake and of Hurricane Katrina suffered less from the direct effects of the disaster than from the effects of mass displacement, including lack of access to medications or lifesaving treatments such as dialysis.5,9,41,42,54–60 Based on recent experiences in Japan and the United States, it is clear that any plans for mass evacuation, sheltering, and medical response to a disaster must incorporate a robust analysis of vulnerable populations, including older and institutionalized people, the chronically ill, and those living with mental illness. Disaster plans should spell out how necessary medical and psychiatric care will be provided in the absence of local health infrastructure and staff. Provisions for the care of large numbers of displaced people with new or worsened depression and posttraumatic stress disorder should be incorporated into shelter-based health protocols. Mental health services must be a priority in disaster preparedness. The 2011 earthquake in Japan highlighted the dangers of evacuating hospitalized, chronically ill, and older populations. Evacuation and shelter plans for bedridden and nursing home patients should be strengthened to combat the common causes of morbidity and mortality identified by the Japanese experience. Hospital Preparedness Many US hospitals in the areas along the Gulf Coast affected by Hurricane Katrina had inadequate stockpiles of food and supplies for patients and staff and lost the ability to communicate and coordinate with actors in the field, as did Japanese hospitals after the 2011 earthquake.5 Realistic disaster drills at US hospitals, based on the types of disasters most likely to occur, might have uncovered key inadequacies ahead of time. For example, some hospital generators in the lowlying, flood-prone region affected by Hurricane Katrina were located in basements or on ground
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floors. Patients suffered major, but preventable, complications and even death when flooding rendered the generators unusable.5 Hospital disaster plans should include redundant communication systems and sufficient emergency provisions for both staff and patients.
Conclusion The challenges Japan faced in responding to the large-scale population displacement after the 2011 Great East Japan Earthquake provide valuable insights for the United States and other
countries into improving disaster preparedness. US disaster response systems must plan for the extended care of large populations of chronically ill and vulnerable people displaced by disasters. Policies should ensure that shelters meet or exceed international standards for the provision of food, water, sanitation, and privacy. Hurricane Katrina proved that the United States is not immune to climate-related mass population displacement disasters, and that even wealthy nations are vulnerable if these lessons are not heeded. ▪
NOTES 1 Institute of Medicine. Hospitalbased emergency care: at the breaking point. Washington (DC): National Academies Press; 2007. 2 Toner E, Waldhorn R, Franco C, Courtney B, Rambhia K, Norwood A, et al. Hospitals rising to the challenge: the first five years of the U.S. Hospital Preparedness Program and priorities going forward. Baltimore (MD): Center for Biosecurity of UPMC; 2009. 3 Internal Displacement Monitoring Centre, Norwegian Refugee Council. Global estimates 2011: people displaced by natural hazard-induced disasters [Internet]. Geneva: The Centre; 2012 Jun [cited 2013 Nov 8]. Available from: http://www .internal-displacement.org/8025708 F004BE3B1/(httpInfoFiles)/ 1280B6A95F452E9BC1257A22002 DAC12/$file/global-estimates-2011natural-disasters-jun2012.pdf 4 Sphere Project. Humanitarian standards in context [Internet]. Dunsmore, UK: Sphere Project; [cited 2013 Nov 8]. Available from: http://www.sphereproject.org/ 5 Franco C, Toner E, Waldhorn R, Maldin B, O’Toole T, Inglesby TV. Systemic collapse: medical care in the aftermath of Hurricane Katrina. Biosecur Bioterror. 2006;4(2): 135–46. 6 Valas J, Gebbie KM, Irizarry L. Framing emergency and disaster training needs post Hurricane Katrina: a round-table discussion. Int J Public Pol. 2008;3(5–6): 366–77. 7 Greenough PG, Kirsch TD. Public health response—assessing needs. N Engl J Med. 2005;353(15):1544–6. 8 Nieburg P, Waldman RJ, Krumm DM. Evacuated populations— lessons from foreign refugee crises. N Engl J Med. 2005;353(15):1547–9. 9 White House. The federal response to Hurricane Katrina: lessons learned [Internet]. Washington (DC): White House; [cited 2013 Nov 8]. Available from: http:// georgewbush-whitehouse.archives .gov/reports/katrina-lessons-
learned/ 10 Ishida K. [Tsunami reached maximum height of 40.5 meters, experts say]. Asahi.com [serial on the Internet]. 2011 May 30 [cited 2013 Nov 8]. Japanese. Available from: http://www.asahi.com/special/ 10005/OSK201105300115.html 11 Geospatial Authority of Japan. [The area flooded by the tsunami] [Internet]. Tsukuba, Japan: The Authority; 2011 Apr 18 [cited 2013 Nov 8]. Japanese. Available from: http://www.gsi.go.jp/common/ 000059939.pdf 12 Futamura M, Hobson C, Turner N. Natural disasters and human security [Internet]. Tokyo: United Nations University; 2011 Apr 29 [cited 2013 Nov 8]. Available from: http:// unu.edu/publications/articles/ natural-disasters-and-humansecurity.html 13 National Police Agency. [The Great East Japan Earthquake and activities of police, 2011] [Internet]. Tokyo: The Agency; 2011 Jul [cited 2013 Nov 8]. Japanese. Available from: http://www.npa.go.jp/hakusyo/ h23/youyakuban/youyakubann.pdf 14 National Police Agency. Damage situation and police countermeasures associated with 2011 Tohoku district—off the Pacific Ocean Earthquake [Internet]. Tokyo: The Agency; 2013 Jun 26 [cited 2013 Nov 14]. Available from: http://www .npa.go.jp/archive/keibi/biki/ higaijokyo_e.pdf 15 Fire and Disaster Management Agency. [Collection of records from the Great East Japan Earthquake] [Internet]. Tokyo: The Agency; 2012 Dec [cited 2013 Nov 8]. Japanese. Available from: http://www.fdma .go.jp/concern/publication/ higashinihondaishinsai_kirokushu/ pdf/honbun/03-06.pdf 16 Kim V. Japan damage could reach $235 billion, World Bank estimates. Los Angeles Times. 2011 Mar 21. 17 Ushizawa H, Foxwell AR, Bice S, Matsui T, Ueki Y, Tosaka N, et al. Needs for disaster medicine: lessons from the field of the Great East Japan
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186–8. 38 Tanigawa K, Hosoi Y, Iwasaki Y, Kamiya K. Loss of life after evacuation: lessons learned from the Fukushima accident. Lancet. 2012; 379(9819):889–91. 39 Tanigawa K, Hosoi Y, Terasawa S. [Lessons learned from the Fukushima Daiichi nuclear power plant accident; the initial 5 days medical activities after the accident]. J Japanese Assoc Acute Med. 2011;22:782–91. Japanese. 40 Kario K. Disaster hypertension—its characteristics, mechanism, and management. Circ J. 2012;76(3): 553–62. 41 Wang P, Gruber M, Powers R, Schoenbaum M, Speier AH, Wells KB, et al. Disruption of existing mental health treatments and failure to initiate new treatment after Hurricane Katrina. Am J Psychiatry. 2008;165(1):34–41. 42 Sastry N, Gregory J. The effect of Hurricane Katrina on the prevalence of health impairments and disability among adults in New Orleans: differences by age, race, and sex. Soc Sci Med. 2013;80:121–9. 43 Murakawa M. Anesthesia department preparedness for a multiplecasualty incident: lessons learned from the Fukushima earthquake and the Japanese nuclear power disaster. Anesthesiol Clin. 2013;31(1):117–25. 44 Fire and Disaster Management Agency. [Fire department activities during the Great East Japan Earthquake] [Internet]. Tokyo: The Agency; 2012 Jun [cited 2013 Nov 8]. Japanese. Available from: http:// www.fdma.go.jp/neuter/about/ shingi_kento/h23_shingi/01/1-4/ all.pdf 45 Joint Commission. Standards FAQ [Internet]. Oakbrook Terrace (IL): Joint Commission; [cited 2013 Nov 8]. Available from: http://www .jointcommission.org/mobile/ standards_information/jcfaq.aspx? ProgramId=1 46 Kai T, Ukai T, Ohta M, Pretto E. Hospital disaster preparedness in Osaka, Japan. Prehosp Disaster Med. 1994;9(1):29–34. 47 Kai T. [Hospital preparedness]. In: Marukawa S, editor. [Learning from experiences of large scale disaster medical response]. Osaka, Japan: Nagai-shoten; 2007. p. 31–41. Japanese. 48 National Disaster Medical Center. [What is an emergency base hospital] [Internet]. Tokyo: The Center; 2008 Jul [cited 2013 Nov 8]. Japanese. Available from: http:// www.hosp.go.jp/~tdmc/dm/ dm_kyotenbyouin.htm 49 Federal Emergency Management Agency. National Disaster Recovery Framework: strengthening disaster recovery for the nation [Internet]:
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Washington (DC): FEMA; 2011 Sep [cited 2013 Nov 8]. Available from: http://www.fema.gov/medialibrary-data/20130726-1820-250455325/508_ndrf.pdf Federal Emergency Management Agency. National Incident Management System [home page on the Internet]. Washington (DC): FEMA; [last updated 2013 Jun 4; cited 2013 Nov 8]. Available from: http:// www.fema.gov/national-incidentmanagement-system Department of Health and Human Services. Public health emergency: National Disaster Medical System [Internet]. Washington (DC): HHS; [last reviewed 2013 Jan 9; cited 2013 Nov 8]. Available from: http://www .phe.gov/preparedness/responders/ ndms/Pages/default.aspx Lister SA. The public health and medical response to disasters: federal authority and funding [Internet]. Washington (DC): Congressional Research Service; [updated 2007 Sep 19; cited 2013 Nov 8]. Available from: http://www.fas.org/sgp/crs/ misc/RL33579.pdf Harrison JP, Harrison RA, PIermattei HJ. The role of emergency medical planning in disaster response. Int J Public Pol. 2008; 3(5–6):354–65. Centers for Disease Control and Prevention. Tuberculosis control activities after Hurricane Katrina— New Orleans, Louisiana, 2005. MMWR Morb Mortal Wkly Rep. 2006;55(12):332–5. Atkins D, Moy EM. Left behind: the legacy of hurricane Katrina. BMJ. 2005;331(7522):916–8. Berggren RE, Curiel TJ. After the storm—health care infrastructure in post-Katrina New Orleans. N Engl J Med. 2006;354(15):1549–52. Centers for Disease Control and Prevention. Surveillance for illness and injury after Hurricane Katrina— three counties, Mississippi, September 5–October 11, 2005. MMWR Morb Mortal Wkly Rep. 2006;55(9): 231–4. Quast T, Mortensen K. Emergency department utilization in the Texas Medicaid emergency waiver following Hurricane Katrina. Medicare and Medicaid Research Review. 2012; 2(1):E1–16. Rudowitz R, Rowland D, Shartzer A. Health care in New Orleans before and after Hurricane Katrina. Health Aff (Millwood). 2006;25:w393–406. DOI: 10.1377/hlthaff.25.w393. Tsubokura M, Horie S, Komatsu H, Tokiwa M, Kami M. The impact of the Great Tohoku Earthquake on the dialysis practice in the disasterstricken area. Hemodialysis International. 2012;16:320–1.
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Preparedness By Parveen Parmar, Maya Arii, and Stephanie Kayden 10.1377/hlthaff.2013.0704 HEALTH AFFAIRS 32, NO. 12 (2013): 2172–2178 ©2013 Project HOPE— The People-to-People Health Foundation, Inc.
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Parveen Parmar is an attending physician in the Department of Emergency Medicine, Brigham and Women’s Hospital, in Boston, Massachusetts. Maya Arii is an assistant professor in the Department of Emergency Medicine and Critical Care at Keio University School of Medicine, in Tokyo, Japan. Stephanie Kayden (skayden@ partners.org) is director of the International Emergency Medicine Fellowship at Brigham and Women’s Hospital.
Learning From Japan: Strengthening US Emergency Care And Disaster Response As Hurricane Katrina demonstrated in 2005, US health response systems for disasters—typically designed to handle only shortterm mass-casualty events—are inadequately prepared for disasters that result in large-scale population displacements. Similarly, after the 2011 Great East Japan Earthquake, Japan found that many of its disaster shelters failed to meet international standards for long-term provision of basic needs and health care for the vulnerable populations that sought refuge in the shelters. Hospital disaster plans had not been tested and turned out to be inadequate, and emergency communication equipment did not function. We make policy recommendations that aim to improve US responses to mass-displacement disasters based on Japan’s 2011 experience. First, response systems must provide for the extended care of large populations of chronically ill and vulnerable people. Second, policies should ensure that shelters meet or exceed international standards for the provision of food, water, sanitation, and privacy. Third, hospital disaster plans should include redundant communication systems and sufficient emergency provisions for both staff and patients. Finally, there must be routine drills for responses to mass-displacement disasters so that areas needing improvement can be uncovered before an emergency occurs. ABSTRACT
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mergency departments (EDs) and emergency medical services such as ambulances are the primary providers of emergency health care during disasters in the United States and many other high-income countries. However, experts have raised serious concerns about the ability of EDs in the United States, many of which are already operating at or beyond capacity, to absorb a surge of survivors after a largescale disaster.1,2 In many such disasters, national disaster health response systems are called on to fill the gaps in emergency health services. US disaster health response systems were originally developed to respond to mass-casualty incidents, in which the number of injured or 2172
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sick survivors temporarily overwhelms local resources. When such incidents force people from their homes—for example, after a tornado or hurricane—the disaster response systems can provide refuge in temporary shelters with basic health care for hours or days at a time. Because high-income countries like the United States are relatively resilient to disasters, these displacements are typically localized and short-lived. In 2005, in the Gulf coastal region of the United States, Hurricane Katrina created a mass population displacement disaster—a type of disaster that is relatively rare in the United States and other high-income countries. Disasters causing large-scale population displacement are more common in developing countries,
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where poor building codes, weak governments, and inadequate response systems allow enormous devastation to follow natural disasters.3 International aid agencies have developed guidelines for the care of large populations displaced by such devastation.4 The inexperience of the US disaster health response systems with mass-displacement disasters was evident after Hurricane Katrina. These systems were inadequate to deal with the medical needs of thousands of people displaced not for hours or days, but for weeks or months.5–9 Where can the United States look for lessons on how to better prepare for future mass-displacement disasters? Japan, like the United States, is a high-income country with a relatively robust disaster response system.Yet Japan suffered its own mass-displacement disaster when the 2011 Great East Japan Earthquake caused a tsunami whose waves devastated Japan’s northeast coastal region. The lessons learned from the difficulties Japan faced in responding to the mass displacement are useful for US disaster response planners. This article reviews the Japanese experience following the 2011 disaster in terms of the medical and public health response, with particular attention to vulnerable populations. It also discusses hospital infrastructure and planning. Specific policy lessons for the United States are presented with the aim of strengthening US disaster response systems.
Overview Of The Japanese Earthquake Response The 9.0-magnitude 2011 Great East Japan Earthquake produced a forty-meter-high tsunami that flooded 216 square miles of coastland and caused a leak of radiation from the Fukushima Daiichi Nuclear Power Plant.10,11 The disaster killed 15,883 people and displaced 470,000. Of the dead, 65 percent were over age sixty,12 and 92 percent died by drowning.13 Causing $235 billion worth of damage, this was the costliest natural disaster in world history.14–16 Although careful government planning saved many lives, the sheer scale of the devastation and the resulting mass population displacement tested Japan’s ability to respond effectively. Many of the country’s disaster preparations proved to be inadequate. Medical Response Teams After the 1995 Great Hanshin-Awaji Earthquake (also known as the Kobe Earthquake), Japan established disaster medical assistance teams (DMATs), whose members are trained to rapidly treat and evacuate trauma victims.17–19 Each DMAT has four to five members, including a physician, a nurse,
and logistical support staff, all of whom have disaster response training.20–22 The 1995 Great Hanshin-Awaji Earthquake produced a typical earthquake-related disaster. Such disasters commonly require a robust, trauma-focused medical response to treat crush injuries. The 1995 earthquake caused 6,434 deaths and 43,792 injuries, giving it a high injury-to-death ratio (6.8:1). Earthquake injuries in the 2011 Great East Japan Earthquake were minimized as a result of well-enforced building codes, and most people who escaped the deadly tsunami did so without major injury. The injury-to-death ratio in 2011 (0.4:1) was more typical of tsunamis than of earthquakes: Most of the dead drowned, as noted above, and only 6,130 were left injured.17 More than 300 Japanese DMATs were deployed within twenty-four hours of the 2011 earthquake.18 However, only a small number of survivors met the criteria for emergency treatment or transfer based on traditional traumafocused DMAT criteria. Most of the survivors were elderly, chronically ill people in need of primary care who were living in shelters after the earthquake. The trauma-oriented DMATs were not adequately trained to respond to their needs in particular23 or to address other key needs for the affected population overall, such as radiation screening; the provision of food, water, and sanitation for public health purposes; and the evacuation of large populations.17 The deployments of DMATs were also inadequate. Japanese DMATs are designed to be deployed for a three-day period, because most earthquake-related traumatic injuries require treatment in the first seventy-two hours.21,22 Three days after the 2011 earthquake, there were 120 DMATs active in the disaster area; a week after the earthquake, there were only twelve.24,25 Although some DMATs later returned on a rotating basis, most did not stay beyond their initial deployment. Moreover, DMATs are not designed to interact with local health care providers, and as a result, coordination among health responders in the field was poor.23,26 Other disaster response teams from the Japanese Red Cross; the Japan Self-Defense Forces; public health departments; hospitals across Japan; and local medical, dental, and pharmacist organizations spontaneously arrived to fill the gaps left by the DMATs. The Japan Medical Association organized Japan Medical Association Teams and deployed nearly 1,400 of them to various sites affected by the disaster.27 Coordination efforts by medical staff in the area near Tohoku University and in Ishinomaki City made use of these volunteer teams to fill gaps left by departing DMATs. However, this level of sucDecember 2013
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25 percent of the people in Tohoku affected by the disaster were older than age 65.
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cessful coordination was the exception and not the rule.19,26 Public Health Response Inadequate provision for the public health needs of displaced and vulnerable populations can increase the demands on limited, and often damaged, medical facilities. In the weeks following the 2011 earthquake, deteriorating hygiene and environmental conditions in shelters caused a surge in the number of patients seeking medical care from the health system. Patients affected by the disaster suffered from allergic skin and respiratory reactions; muscle wasting and blood clots resulting from inactivity; and respiratory illnesses and pneumonia caused by exposure to “tsunami sludge,” a mixture of liquid waste, toxins, and mud containing bacteria that formed as a result of the tsunami.23,28,29 Tokyo University Hospital—180 miles from the primary site of the disaster—reported a 23 percent increase in patient volume as a result of displaced people seeking care for medical and psychiatric complaints.30 This highlights the need for medical, psychiatric, and social services during disasters on a national scale. From the beginning of the 2011 earthquake disaster response, problems arose because of an underlying misconception that basic public health needs—food, water, and sanitation—were less important than medical needs. Japanese responders felt that basic public health needs should be handled by the local governments and municipalities, but these entities had been rendered incapable of doing so by the disaster.31 As a result, many government-designated shelters did not meet international humanitarian standards4 for safe and adequate supplies of water, toilet facilities, nutrition, and privacy even two months after the disaster.32 In Ishinomaki City assessment teams discovered critical public health needs, including insufficient food in thirty-five shelters, inadequate sanitation in a hundred shelters, and insufficient facilities for hand washing in eleven shelters.26 Rapid intervention prevented outbreaks of communicable diseases in shelters in the Ishinomaki Medical Zone.26 However, insufficient food and poor environmental conditions were thought to have contributed to illness, particularly among older people and the chronically ill.23 In other areas, inadequate supplies of water for drinking and hand hygiene at shelters led to cases of vomiting, diarrhea, and dehydration.28 In Iwate Prefecture, public health and sanitation teams worked alongside medical teams to conduct rapid assessments of water and sanitation, provide clean drinking water, and conduct daily surveillance of conditions at the shelters. Their efforts successfully avoided a major outbreak of
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infectious disease in the prefecture.33 Vulnerable Populations The lack of adequate planning for the care of certain vulnerable populations led to additional demands on already overburdened emergency medical providers. Vulnerable populations in the affected region included older people, patients in nursing homes and hospitals, chronically ill people, and people living with mental illness. ▸ OLDER PEOPLE : A quarter of the people in Tohoku who were affected by the disaster were older than sixty-five, and 14 percent were older than seventy-five.34 Older people displaced by the earthquake endured life in evacuation shelters that were not planned to accommodate their needs and lacked heat and running water. Toilets, flushed with buckets of water from school pools, soon became clogged and overflowed. Older people who could not climb stairs or walk to outside toilet facilities were forced to wear diapers and quickly became bedridden and debilitated.35 In Tohoku a group of medical responders established a 362-bed evacuation facility specifically for older people, which treated 13,094 people in its first six months. Responders found that multidisciplinary teams, including social workers and professional caregivers, were needed to care for an older population with limited mobility who were living in shelters.35 By tailoring services to the needs of older survivors, the facility was able to prevent illness and any increased demand for emergency medical care.35 ▸ NURSING HOME AND HOSPITAL PATIENTS : The Fukushima Daiichi power plant radiation disaster that accompanied the 2011 earthquake prompted the government to create a twentykilometer mandatory evacuation zone around the nuclear plant and a voluntary evacuation zone another ten kilometers outside the mandatory zone.36 Among the evacuated were 1,770 older patients who were residents of hospitals, nursing homes, and other care facilities.37 Transfers from the evacuation zones were often haphazard and disorganized. Frail patients were moved long distances without medical attendants, adequate clothing, blankets, or safety restraints—which sometimes resulted in traumatic injuries en route.38 Because these critically ill and immobile patients were left unattended at times for more than twenty-four hours, more than twenty patients died from dehydration, exacerbation of underlying illness, and hypothermia during bus transfers and at abandoned shelters.39 Pneumonia was the most common cause of death, probably a result of poor nutrition and housing conditions.37 Receiving facilities often lacked food and medical supplies to care for evacuated patients, and
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some patients were turned away because staff members feared being exposed to radiation.36,37 One group of older people evacuated from nursing homes suffered a three- to fourfold increase in mortality.36 Not all patients were evacuated. At least 840 of them were left stranded in medical and nursing facilities near the nuclear plant.39 The mortality rate for older people living in the mandatory evacuation zone during 2011 (excluding people who died during the tsunami) was 2.4 times higher than during 2010.37 ▸ CHRONICALLY ILL PATIENTS : Japan has a high proportion of patients with chronic diseases such as diabetes and hypertension. Although traumatic injuries were relatively few, hospital admissions surged in the ten days following the disaster, in part because of complications of uncontrolled chronic illnesses.23 The majority of patients who visited medical clinics in the affected region sought treatment for chronic illnesses. The incidence of acute coronary syndrome, cardiac arrest, and stroke increased shortly after the disaster, presumably as a result of cold and stress.40 Many “drug refugees”—people who lost their medicines in the disaster—suffered complications from the lack of essential medications, including uncontrolled hypertension, high blood sugar, and other problems.23 An estimated 282 people died from exacerbations of chronic illness in the two weeks after the disaster,18 which highlights the need for increasing the capacity of disaster response teams to treat chronic illnesses.17–19,33 ▸ PEOPLE LIVING WITH MENTAL ILLNESS : People living with mental illness are a vulnerable population that experiences both a disruption in necessary services and a growth in numbers after disasters.41,42 After the 2011 earthquake there were increased rates of depression and posttraumatic stress disorder in the population that was affected by the disaster. Those with chronic mental illnesses suffered from inadequate access to medications, the loss of medical records, and destroyed mental health facilities. A strong social stigma against mental illness discouraged many survivors from seeking mental health care.23
Hospital Infrastructure And Planning The 2011 Great East Japan Earthquake illustrates the need to strengthen hospital communications, emergency supplies, and disaster drills. Communications The destruction of communications infrastructure after the 2011 earthquake crippled coordination among regional
disaster responders, making it difficult to assess needs and coordinate patient transports.19,43 There was no functional communication network between hospitals transferring patients and the Japan Self-Defense Forces and fire brigades dispatched from other prefectures44 to transport patients.43 For two days after the disaster, one 1,262-bed hospital in Sendai was dependent solely on satellite phones and disaster multichannel access radios for internal and external communications. Many hospital staff resorted instead to in-person communication via physicians who were dispatched to other hospitals after the earthquake.19 Emergency Supplies Insufficient emergency supplies of food and water threatened patient care at hospitals affected by the disaster. Tohoku University Hospital had stockpiled a three-day emergency supply of food that was intended to be sufficient for patients but not for the hospital staff. However, many staff members were unable to leave the hospital in the days following the tsunami. The hospital was forced to request emergency aid from other hospitals in Japan and to ask its university-employed staff members, who were in Tokyo at the time of the disaster, to send what food they could.19 At the 778-bed hospital at Fukushima Medical University, there was no running water for eight days. The hospital’s water tank held 700 tons of water, normally enough for only one day. Water trucks brought more than 100 tons of water daily, but even with these additional deliveries there was insufficient water at the hospital one week after the disaster. Lack of water prevented the hospital from accepting patient transfers and forced staff to discharge patients until the hospital was at only 70 percent capacity.43 Disaster Drills Unlike the United States, Japan does not require regular hospitalwide disaster drills for hospital accreditation.45 The 582 government-designated “Emergency Base Hospitals” are expected to be prepared to accept influxes of disaster patients and to dispatch medical teams to the scene of a disaster. However, the substance of hospital disaster plans and drills is left to the discretion of each facility.46–48 The 2011 disaster demonstrated gaps between written hospital disaster plans and their actual implementation—gaps that might have been exposed by drills.
2.4
◀
Times higher
The mortality rate for older people living in the mandatory Fukushima evacuation zone during 2011 was 2.4 times higher than during 2010.
Lessons For The United States Despite extensive preparation, the 2011 earthquake overwhelmed Japan’s medical and public health response systems. Unfortunately, many of Japan’s response problems mirror those seen December 2013
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Preparedness in US disasters, particularly Hurricane Katrina. Lessons should be drawn from these mass population displacement disasters to improve US policies for disaster response. The US Disaster Response System Like Japan, the United States has a generally wellorganized system to respond to health needs after disasters. Small-scale disasters are managed by local authorities with assistance from state and federal entities.49 The Department of Homeland Security’s National Incident Management System provides a comprehensive framework for use by private, local, state, and federal agencies in preparing for, responding to, and recovering from disasters.50 The National Disaster Medical System, part of the Department of Health and Human Services, supplements the medical capacity of state and local authorities during disasters. The system can deploy DMATs, Disaster Mortuary Operational Response Teams, National Veterinary Response Teams, and International Medical Surgical Response Teams.51 As was the case in Japan, the DMATs deployed in Hurricane Katrina were insufficiently prepared to care for the chronic illnesses of people displaced by the disaster.9 Many teams had insufficient medical supplies to meet the needs of overwhelming numbers of patients and were thus able to provide only the most basic care— first aid and triage.52 DMAT members cited inadequate federal deployment logistics, poor communication, and inadequate coordination between DMATs and local providers,5 in addition to lack of training and equipment to manage chronic illnesses. DMATs must be ready to manage large numbers of chronically ill patients for weeks to months during mass population displacement disasters. They also must work with local providers to coordinate care in a way that promotes smooth recovery. Improvements have been made in these areas since Hurricane Katrina, but it remains to be seen whether those improvements are enough. Public Health Response Public health needs in overcrowded and underresourced shelters went largely unmet during the initial days after Hurricane Katrina struck Louisiana, similar to the situation in Japan after the 2011 earthquake. Crowding, insufficient water and sanitation facilities, poor nutrition, and chronic disease— together with Louisiana’s relatively low baseline vaccination rates—made several authorities worry about possible outbreaks of disease in shelters.7,53 It is likely that there will be future mass displacements of US populations as a result of climate-related natural disasters, and displaced 2176
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populations may require shelter for weeks to months. Thus, US authorities must develop and enforce minimum standards for public health needs—food, water, sanitation, and privacy—after a disaster. The Sphere Project’s standards4 are internationally developed guidelines for the care of populations displaced by disaster. Although these standards were created for developing countries, they are a reliable starting point for the development of locally relevant standards. Shelters for populations displaced by a disaster must be improved to meet or exceed international standards for meeting public health needs. Vulnerable Populations Hurricane Katrina displaced a population with high rates of chronic illnesses such as diabetes, renal disease, and hypertension. Thousands of survivors of the 2011 Japan earthquake and of Hurricane Katrina suffered less from the direct effects of the disaster than from the effects of mass displacement, including lack of access to medications or lifesaving treatments such as dialysis.5,9,41,42,54–60 Based on recent experiences in Japan and the United States, it is clear that any plans for mass evacuation, sheltering, and medical response to a disaster must incorporate a robust analysis of vulnerable populations, including older and institutionalized people, the chronically ill, and those living with mental illness. Disaster plans should spell out how necessary medical and psychiatric care will be provided in the absence of local health infrastructure and staff. Provisions for the care of large numbers of displaced people with new or worsened depression and posttraumatic stress disorder should be incorporated into shelter-based health protocols. Mental health services must be a priority in disaster preparedness. The 2011 earthquake in Japan highlighted the dangers of evacuating hospitalized, chronically ill, and older populations. Evacuation and shelter plans for bedridden and nursing home patients should be strengthened to combat the common causes of morbidity and mortality identified by the Japanese experience. Hospital Preparedness Many US hospitals in the areas along the Gulf Coast affected by Hurricane Katrina had inadequate stockpiles of food and supplies for patients and staff and lost the ability to communicate and coordinate with actors in the field, as did Japanese hospitals after the 2011 earthquake.5 Realistic disaster drills at US hospitals, based on the types of disasters most likely to occur, might have uncovered key inadequacies ahead of time. For example, some hospital generators in the lowlying, flood-prone region affected by Hurricane Katrina were located in basements or on ground
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floors. Patients suffered major, but preventable, complications and even death when flooding rendered the generators unusable.5 Hospital disaster plans should include redundant communication systems and sufficient emergency provisions for both staff and patients.
Conclusion The challenges Japan faced in responding to the large-scale population displacement after the 2011 Great East Japan Earthquake provide valuable insights for the United States and other
countries into improving disaster preparedness. US disaster response systems must plan for the extended care of large populations of chronically ill and vulnerable people displaced by disasters. Policies should ensure that shelters meet or exceed international standards for the provision of food, water, sanitation, and privacy. Hurricane Katrina proved that the United States is not immune to climate-related mass population displacement disasters, and that even wealthy nations are vulnerable if these lessons are not heeded. ▪
NOTES 1 Institute of Medicine. Hospitalbased emergency care: at the breaking point. Washington (DC): National Academies Press; 2007. 2 Toner E, Waldhorn R, Franco C, Courtney B, Rambhia K, Norwood A, et al. Hospitals rising to the challenge: the first five years of the U.S. Hospital Preparedness Program and priorities going forward. Baltimore (MD): Center for Biosecurity of UPMC; 2009. 3 Internal Displacement Monitoring Centre, Norwegian Refugee Council. Global estimates 2011: people displaced by natural hazard-induced disasters [Internet]. Geneva: The Centre; 2012 Jun [cited 2013 Nov 8]. Available from: http://www .internal-displacement.org/8025708 F004BE3B1/(httpInfoFiles)/ 1280B6A95F452E9BC1257A22002 DAC12/$file/global-estimates-2011natural-disasters-jun2012.pdf 4 Sphere Project. Humanitarian standards in context [Internet]. Dunsmore, UK: Sphere Project; [cited 2013 Nov 8]. Available from: http://www.sphereproject.org/ 5 Franco C, Toner E, Waldhorn R, Maldin B, O’Toole T, Inglesby TV. Systemic collapse: medical care in the aftermath of Hurricane Katrina. Biosecur Bioterror. 2006;4(2): 135–46. 6 Valas J, Gebbie KM, Irizarry L. Framing emergency and disaster training needs post Hurricane Katrina: a round-table discussion. Int J Public Pol. 2008;3(5–6): 366–77. 7 Greenough PG, Kirsch TD. Public health response—assessing needs. N Engl J Med. 2005;353(15):1544–6. 8 Nieburg P, Waldman RJ, Krumm DM. Evacuated populations— lessons from foreign refugee crises. N Engl J Med. 2005;353(15):1547–9. 9 White House. The federal response to Hurricane Katrina: lessons learned [Internet]. Washington (DC): White House; [cited 2013 Nov 8]. Available from: http:// georgewbush-whitehouse.archives .gov/reports/katrina-lessons-
learned/ 10 Ishida K. [Tsunami reached maximum height of 40.5 meters, experts say]. Asahi.com [serial on the Internet]. 2011 May 30 [cited 2013 Nov 8]. Japanese. Available from: http://www.asahi.com/special/ 10005/OSK201105300115.html 11 Geospatial Authority of Japan. [The area flooded by the tsunami] [Internet]. Tsukuba, Japan: The Authority; 2011 Apr 18 [cited 2013 Nov 8]. Japanese. Available from: http://www.gsi.go.jp/common/ 000059939.pdf 12 Futamura M, Hobson C, Turner N. Natural disasters and human security [Internet]. Tokyo: United Nations University; 2011 Apr 29 [cited 2013 Nov 8]. Available from: http:// unu.edu/publications/articles/ natural-disasters-and-humansecurity.html 13 National Police Agency. [The Great East Japan Earthquake and activities of police, 2011] [Internet]. Tokyo: The Agency; 2011 Jul [cited 2013 Nov 8]. Japanese. Available from: http://www.npa.go.jp/hakusyo/ h23/youyakuban/youyakubann.pdf 14 National Police Agency. Damage situation and police countermeasures associated with 2011 Tohoku district—off the Pacific Ocean Earthquake [Internet]. Tokyo: The Agency; 2013 Jun 26 [cited 2013 Nov 14]. Available from: http://www .npa.go.jp/archive/keibi/biki/ higaijokyo_e.pdf 15 Fire and Disaster Management Agency. [Collection of records from the Great East Japan Earthquake] [Internet]. Tokyo: The Agency; 2012 Dec [cited 2013 Nov 8]. Japanese. Available from: http://www.fdma .go.jp/concern/publication/ higashinihondaishinsai_kirokushu/ pdf/honbun/03-06.pdf 16 Kim V. Japan damage could reach $235 billion, World Bank estimates. Los Angeles Times. 2011 Mar 21. 17 Ushizawa H, Foxwell AR, Bice S, Matsui T, Ueki Y, Tosaka N, et al. Needs for disaster medicine: lessons from the field of the Great East Japan
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