Notebook From Japan: After The Earthquake

Following the earthquake and resulting tsunami that rocked Northern Japan March 11, PharmAsia News has published more than 50 articles on how biopharma and medical device companies are dealing with the financial, infrastructure, manufacturing and distribution impacts of the disaster.

Many have been reported by the PharmAsia News Tokyo-based staff, who share offices with editorial staff of other Elsevier publications serving Japanese business audiences. Several weeks after the disaster, reporters for Elsevier's Monthly Mix magazine, a Japanese-language publication on the pharmaceutical industry, visited the hardest hit regions of Japan to interview health care leaders on the early days of the response and ideas for rebuilding. Parts of their chronicle, "Learning From The Great East Japan Earthquake," are excerpted and translated below to provide a closer look on how the larger Japanese healthcare system is faring.

Creative First Response Strategies

In Japan, emergency medical care is provided by Disaster Medical Assistance Teams (DMATs) immediately following serious disasters. However, nearly all local core hospitals in the coastal areas of Iwate Prefecture were severely damaged by the earthquake and tsunami, and some of the health care professionals who worked at them lost their lives. The situation in the disaster area was grim: local health care had to be provided by medical professionals who were themselves victims.

The health care scene in the disaster area changed daily and hourly. Several days after a disaster, the emergency care required in the first response shifts to a secondary response focusing on chronic diseases, health management, and public health measures at emergency shelters. However, the gasoline shortage prevented trucks from transporting drugs and food supplies to the isolated Iwate coastal region, and hindered the dispatch and support of medical teams as well. It was only 10 full days after the disaster that Japan Self-Defense Forces and U.S. Armed Forces could airlift supplies to the region.

Many individual practitioners found new ways to deliver needed drug treatments despite the disrupted health care infrastructure. For example, Professor Nobukazu Nakasato, a specialist in epilepsy at Tohoku University School of Medicine, on March 17 began publishing updates via a merumaga, or e-mail magazine. He revealed that a number of epilepsy patients had suffered seizures and been transported to hospitals due to the sudden shortage of epilepsy medications following the disaster. Some doctors who read this went as volunteers to the Iwate coast and other areas battered by the disaster to provide care.

In an interview, Nakasato said: "I also considered using mixi [a Japanese social networking website] or Facebook, but elderly people don't read them. Websites provide information only to people who go there, so I finally decided to use a merumaga. Since merumaga let people forward information freely, a lot of information came in, including quick responses from a division director at Korosho's Health Insurance Bureau. He quickly provided support from Korosho."

Nakasato also commented: "People with epilepsy and psychiatric diseases have long faced prejudice and discrimination. The recent disaster has brought this out into the open. There are some epilepsy patients who are so afraid of being seen having seizures that they live in their damaged homes instead of going to emergency shelters."

Others say Nakasato's merumaga reflects the blur of action on the part of doctors struggling to obtain drugs in short supply. Some turned to Twitter and online blogs to share information.

Professor Etsuro Mori, Department of Behavioral Neurology and Cognitive Neuroscience at Tohoku University, drew upon his experience during the Great Hanshin Earthquake of 1995 to provide quick support in the disaster area.

After a few days, "the situation had become clearer and I decided to act, because there were a number of things I regretted not doing" after the Hanshin Earthquake, Mori said. "At that time, we were still unable to take drugs out from Tohoku University Hospital, but I contacted Kobe University Hospital, and the nurses and administrators were kind enough to send us drugs. Taking these drugs, we went to a police station and filled out the forms necessary to use our cars as emergency vehicles. As a team of six including two doctors, at our own expense, we went to Ishinomaki Red Cross Hospital in Iwate Prefecture to offer our support."

Ishinomaki Red Cross Hospital was "jammed with people. Most of them seemed to be patients with minor conditions like hypertension and insomnia," he reported. "After delivering our drugs, we examined patients with various conditions such as psychiatric diseases, hypertension, and diarrhea. We stayed the night and then went around to emergency shelters and hospitals the next day."

Reviving Health Care Services In New Ways

Before the disaster, small cities and towns like Miyako, Rikuzentakata, Minamisanriku, and Yamada had already been facing rising demand for health care services due to their aging populations and lack of resources to provide services locally.

Akira Ogawa, president of Iwate Medical University, spoke with passion on this subject, saying "Reconstruction after a disaster doesn't mean going back to the state of things prior to the disaster. Local communities will need to rebuild their towns and remake their health care systems based on fresh ideas."

Mental health care has taken on greater importance due to post-disaster stress. Prolonged living in emergency shelters also greatly affects health management.

"A great number of people lost their lives, so just bringing towns and neighborhoods back to life will not be simple. Nevertheless, I consider this a good opportunity to radically review Iwate Prefecture's health care supply system," Ogawa said in an interview.

Iwate Medical University Hospital is a disaster treatment center, and a critical and emergency care center all in one.

When the earthquake happened, Ogawa said, "at Iwate Medical University Hospital, doctors and nurses not busy treating patients were told to remain on standby at the Advanced Critical Care and Emergency Center. After the earthquake, we initially expected a few hundred injured people to be transported in from the coast. In fact, however, very few were brought in. They lost their lives in the tsunami. The ones who survived were healthy people who hurried to higher ground without changing clothes or packing bags."

Asked what were the biggest problems faced initially, he said, "The lack of food and gasoline. The gasoline shortage was a particularly serious problem. Without gas we couldn't transport doctors or supplies to the disaster area."

"Another major problem was that we had no means of communication with emergency shelters or other hospitals. On top of that, we couldn't even send support supplies."

The Ministry of Internal Affairs and Communications set up an emergency mobile phone base station for us, so things have improved, but they're still not 100%, perhaps because the terrain is so mountainous.

Regarding steps for rebuilding the health care system, Ogawa noted, "Iwate Prefecture is notorious for its shortage of doctors. It's a large area with a low population density. For example, the Miyako health care zone covers twice the area of Tokyo's 23 wards and 1.2 times the area of Tokyo Prefecture as a whole, but the only general hospital there is Iwate Prefectural Miyako Hospital. Patients who can't be treated by Miyako Hospital are sent to Iwate Medical University Hospital, but the distance is 100 kilometers and it takes two hours by car. This is a big difference from Tokyo, where patients can usually get from home to a hospital within 30 minutes.

"It would be difficult to build a general hospital in every area with a population of a few tens of thousands or thousands," the university official noted. "It would also be a minus from the perspective of improving doctors' skills, and therefore a minus for patients as well from the standpoint of advanced health care. The centralization of functions is necessary. Specifically, it will be necessary to build core hospitals that serve wide geographical areas and that permanently employ doctors from all fields including pediatrics and OB/GYN in addition to satellite clinics in surrounding areas that would see patients two or three times a week. Patients with chronic conditions should be able to receive remote health care services using the Internet after the first examination."

Professor Nakasato envisions a healthcare network spanning the entire Tohoku region that would provide highly rational health care.

"Though Japan has a universal health insurance system," he said, "there are also regional differences in the quality of services people receive, the so-called "treatment gap. ... Since before the disaster, I've been making medical visits to outpatients along the Tohoku-Shinkansen line from as far north as Aomori all the way down to Fukushima. I was considering constructing a network of epilepsy treatment for the entire Tohoku region over the next five years. Following the recent disaster, however, I am feeling that I am forced to hurry up. If it's successful, I'd like to see this model exported to the rest of Japan, even to other countries."

Commenting more broadly, Ogawa concluded, "One thing this disaster has taught us is that it's possible to shift to an efficient healthcare system that gets maximal results from minimal resources. I believe we need to revitalize regional healthcare by returning to the starting point of health care, putting aside political and other considerations. There's a proverb, 'Turn calamity into good fortune,' and I agree - it would be a tragedy to waste this opportunity."

- Yoshiyuki Numata ([email protected]) and Eri Mochizuki ([email protected])

[Editor's note: This story also ran in 'The Pink Sheet,' June 13, 2011.].