The Fukushima Disaster: Lessons Learned from GEJE Catastrophe
By Jun Shigemura, MD, PhD


On March 11, 2011, at 2:46 p.m., a gigantic earthquake struck the northeastern coast of Japan. The quake, along with repeated aftershocks, eventually led to a series of tsunami waves, with more than 18,000 individuals reported killed or missing. The earthquake primarily affected three northeastern prefectures: Iwate, Miyagi, and Fukushima.

These events triggered a series of nuclear accidents at the Tokyo Electric Power Company’s (TEPCO) Fukushima Daiichi Nuclear Power Plant, located on the coast of Fukushima prefecture. These accidents constituted the worst nuclear disaster since the 1986 Chernobyl incident in the former Soviet Union. The Fukushima nuclear accident was rated Level 7 on the International Nuclear Event Scale. Chernobyl was the only previous accident to reach this magnitude.
The 2011 catastrophe led to reactor meltdown, release of radioactive materials, evacuation of the surrounding regions, as well as major disruptions and burdens on affected residents. This combination of earthquakes, tsunamis, and nuclear accidents eventually came to be known as the Great East Japan Earthquake (GEJE).

Effects of the Fukushima Nuclear Power Plant Disaster
No one died from direct radiation exposure, and reports have shown that the adverse health effects of radiation exposure have been remarkably lower than that of Chernobyl (Hasegawa, et al., 2015). However, the nuclear disaster was still a dire calamity for the people of Fukushima. Residents experienced intense fear and uncertainty due to the gradual nature of the disaster. In fact, they continue to struggle from immense psychosocial burdens not directly related to radiation exposure, such as relocation, displacement, and changes in living environment. A total of 89,319 residents were still displaced as of July 2016 (Fukushima Prefectural Government, 2016).
Immediately after the disaster, a mandatory evacuation was ordered for residents within a 20-kilometer radius. The evacuation process was chaotic, as more than 50 hospital patients died during this process, probably due to hypothermia, dehydration, and exacerbation of pre-existing medical conditions (Tanigawa, Hosoi, Hirohashi, Iwasaki, & Kamiya, 2012).

The mortality rate among evacuated elderly people at nursing facilities increased after the accident (Yasumura, Goto, Yamazaki & Reich, 2013). Following the disaster, suicide rates dropped in the affected three prefectures (Iwate, Miyagi, and Fukushima) but rose in 2014 to the pre-disaster level in Iwate and Miyagi; a rate that was exceeded in Fukushima (Ohto, Yabe, Yasumura & Bromet, 2015).

Challenges of Disaster Workers
When a calamity occurs, disaster workers are potentially exposed to a wide variety of psychologically traumatic events, such as witnessing horrific events, experiencing life-threatening situations, and being involved with the injured, dead, and the bereaved. These workers are subject to extreme pressure and overwork.
Furthermore, many of these workers are also local residents and thus survivors of the disaster. They have to protect themselves and their loved ones from danger and make tough decisions on whether or not they should prioritize their work duties over their private responsibilities. Affected workers’ health outcomes are associated with a wide range of mental and behavioral issues, such as post-traumatic stress disorder (PTSD), depression, anxiety disorders, psychosomatic symptoms, and increased alcohol consumption (Brooks, Dunn, Amlôt, Greenberg, & Rubin, 2016).
 
Mental Health Issues of GEJE Disaster Workers
The GEJE raised physical, mental, and behavioral concerns for the workers who responded to these events through rescue, recovery, and support activities. Reports of studies on workers are still emerging. Suzuki, Fukasaw, Obara and Kim (2014) assessed the mental health correlates of 3,743 Miyagi prefectural workers seven months after the GEJE.
The workers were exposed to traumatic experiences such as working in morgues (6.7%) and coastal areas (15.5%). Some of the workers were directly affected by the disaster, such as experiencing family members’ deaths (2.5%), property damage (14.5%), and home evacuation (22.7%).

They were also subject to overwhelming workloads. Roughly one out of four (25.7%) worked overtime, and one out of eight (16.8%) logged ≥ 80 hours respectively. In addition, one-fourth (26.0%) were unable to take a single day off per week. Many of these traumatic and exhausting experiences, along with lower levels of workplace communication, were associated with adverse mental health (≥ 13 on the K6 scale — a six-item screening tool for detecting serious mental illness (Kessler, et al., 2003).
Another report by Sakuma and colleagues (2015) found a high prevalence of mental health consequences among the GEJE disaster workers. In a study of 1,294 disaster relief and reconstruction workers in Miyagi 14 months after the GEJE, proportions of probable PTSD, depression, and psychological stress were as follows:

* municipality workers (n = 610; 6.6%, 15.9%, and 14.9% respectively);
* medical workers (n = 357; 6.6%, 14.3%, and 14.5%, respectively); and
* firefighters (n = 327; 1.6%, 3.8%, and 2.6%, respectively).

In addition, insufficient rest was associated with an increased risk of PTSD and depression in municipality and medical workers. The aforementioned lack of workplace communication was linked with an increased risk of PTSD among medical workers, and depression in municipal and medical workers.
 
Mental Health Consequences
When a public crisis occurs, communication practices are critical to providing safety and stability among affected individuals (Glik, 2007). However, the authorities and TEPCO were severely criticized for their post-management issues such as the ambiguous and untimely release of information.
This practice primarily affected the TEPCO workers responding to the Fukushima nuclear power plant disaster. They suffered not only workplace-related trauma, but also grieving experiences and shame from public criticism (Shigemura, Tanigawa, & Nomura, 2012). These public perceptions took the form of various negative societal responses, such as discrimination and stigmatization of TEPCO workers. These negative experiences made the workers hide their identities from the public to avoid further negative responses.

In the first four years after the disaster, mental health support was provided to the TEPCO workers of the Daiichi and nearby intact Daini nuclear power plants. Support was necessary as part of a comprehensive public health management program. Programs included screening and support schemes for mental and behavioral conditions, assessment of work environment stressors (e.g., radiation protection), as well as collaborations with occupational physicians and nurses, supervisors, and co-workers.
To raise public awareness about the workers’ health issues, it was also necessary to speak with various national and international media on behalf of the stigmatized workers. In this project, entitled “Fukushima NEWS Project” (NEWS is an acronym for Nuclear Energy Workers’ Support), we surveyed 1,495 Daiichi and Daini nuclear power plant workers 2 to 3 months after the disaster (Shigemura, Tanigawa, & Nomura, 2012).
About one-fourth of the respondents (n = 378, 25.3%) reported high post-traumatic stress symptoms (≥ 25 on the Impact of Event Scale-Revised), and their mental health outcomes were significantly associated with experiences of discrimination. A follow-up longitudinal study conducted 14–15 months after the disaster also verified that their experiences were associated with their mental health (Tanisho, et al., 2016).

Summary
When a catastrophe occurs, disaster workers are susceptible to a wide range of mental and behavioral health challenges. In the case of the Fukushima nuclear power plant disaster, the public experienced a massive fear and uncertainty, and exhibited negative responses such as discrimination and stigmatization.
Disaster workers may experience not only workplace trauma, but also trauma associated with a victim as well as various psychosocial changes related to the event. In order to plan disaster management programs, it is critical for each organization to develop comprehensive mental health programs before disaster strikes.

Jun Shigemura, MD, PhD, is an Associate Professor at the Department of Psychiatry, National Defense Medical College, a medical school of Japan’s Ministry of Defense. Following the 2011 Great East Japan Earthquake and the Fukushima nuclear power plant disaster, he has been a mental health consultant for various workers and their agencies, including the Ministry of Defense, Fukushima nuclear power plants, mortuary workers, and healthcare providers. The information and views in this article are those of the author and do not necessarily reflect the official opinion of the Japanese government, Ministry of Defense, National Defense Medical College, or the Tokyo Electric Power Company. Jun may be reached at jshigemura.psy@gmail.com.

The following individuals also contributed to this article: Masaaki Tanichi, MD; and Aihide Yoshinio, MD, PhD, also with the Department of Psychiatry, National Defense Medical College; and Masanori Nagamine, MD, PhD, and Kunio Shimizu, MD, PhD, both with the Division of Behavioral Science, National Defense Medical College Research Institute, National Defense Medical College.

References

Brooks, S.K., Dunn, R., Amlôt, R., Greenberg, N., & Rubin, G.J. (2016). Social and occupational factors associated with psychological distress and disorder among disaster responders: A systematic review. BMC Psychology, 4, 18.
Fukushima Prefectural Government (2016). Transition of evacuation instruction zones: Evacuation zone update. Fukushima, Japan. Author. Retrieved from www.pref.fukushima.lg.jp/site/portal-english/en03-08.html
Glik, D.C. (2007). Risk communication for public health emergencies. Annual Review of Public Health, 28, 33–54.
Hasegawa, A., Tanigawa, K., Ohtsuru, A., Yabe, H., Maeda, M., Shigemura, J., Chhem, R.K. (2015). Health effects of radiation and other health problems in the aftermath of nuclear accidents, with an emphasis on Fukushima. The Lancet, 386(9992), 479–488.
Kessler, R.C., Barker, P.R., Colpe, L.J., Epstein, J.F., Gfoerer, J.C., Hiripi, E., Zaslavsky, A.M. (2003). Screening for serious mental illness in the general population. Archives of General Psychiatry, 60(2), 184–189.
Ohto, H., Maeda, M., Yabe, H., Yasumura, S., & Bromet, E.E. (2015). Suicide rates in the aftermath of the 2011 earthquake in Japan. The Lancet, 385(9979)1727.
Sakuma, A., Takahashi, Y., Ueda, I., Sato, H., Katura, M., Abe, M., … Matsumoto, K. (2015). Post-traumatic stress disorder and depression prevalence and associated risk factors among local disaster relief and reconstruction workers fourteen months after the Great East Japan Earthquake: a cross-sectional study. BMC Psychiatry, 15, 58.
Shigemura, J., Tanigawa, T., Saito, I., & Nomura, S. (2016). Psychological distress in workers at the Fukushima nuclear power plants. JAMA, 308, 667–669.
Shigemura, J., Tanigawa, T, & Nomura, S. (2012). Launch of mental health support to the Fukushima Daiichi nuclear power plant workers. American Journal of Psychiatry, 169(8), 784.
Suzuki, Y., Fukasawa, M., Obara, A., & Kim, Y. (2014). Mental health distress and related factors among prefectural public servants seven months after the great East Japan Earthquake. Journal of Epidemiology, 24(4), 287–294.
Tanigawa, K., Hosoi, Y., Hirohashi, N., Iwasaki, Y., & Kamiya, K. (2012). Loss of life after evacuation: Lessons learned from the Fukushima accident. The Lancet, 379(9819) 889–891.
Tanisho, Y., Shigemura, J., Kubota, K., Tanigwa, T., Bromet, E.J., Takahasi, S., Fukushima NEWS Project Coordinators. (2016). The longitudinal mental health impact of Fukushima nuclear disaster exposures and public criticism among power plant workers: The Fukushima NEWS Project study. Psychological Medicine, 46(15) 3117–3125.
Yasumura, S., Goto, A., Yamazaki, S., & Reich, M.R. (2013). Excess mortality among relocated institutionalized elderly after the Fukushima nuclear disaster. Public Health, 127(2) 186–188.