Report on Observation of Korean Ferry Disaster Support Facilities※Source: Journal of Public Health Nursing, Vol. 74, Issue 3, pp 189-193, 2018

SpecialEdition:Reconsidering Disaster Health Work from a Medium-Term Perspective

The Effects of the Great East Japan Earthquake on
Health and the Development of Public Health Activities
Miyagi Disaster Mental Health Care Center, Planning and Research Department, Director

Naru Fukuchi[Grab your reader’s attention with a great quote from the document or use thisspace to a key point. To place this text box anywhere on the page, just drag it.]Introduction

When the Great East Japan earthquake struck the
Tohoku region on March 11, 2011, approximately
400,000 people were evacuated to shelters, many ofthem with special needs, including children and people
with disabilities. Over time, as children were moved
out of the evacuation center and into temporary housing, they reacted in a variety of ways. Even though wealready had experience with such events following theGreat Hanshin Earthquake of 1995, we were still not
prepared for such a large-scale disaster, where support
was provided in such an ad hoc manner 1, 2, 3.
The objective of this manuscript is to create a narrative that can help minimize the chaos that could occur
in the event of another disaster of similar magnitude.

About the author
The author of this manuscript is a psychiatrist thatspecializes in working with children going through puberty. Before the disaster, he worked in a local psychiatric hospital and served as the supervising doctor at achild mental welfare ward. During the disaster, he witnessed children resorting to violence and self-harm toprotect themselves. The local Health Care Center, doctors from the Child Counseling Office, and representatives from the various Boards of Education were all involved; there were many opportunities to work with local specialists. Because he majored in public healthstudies in graduate school, he had always wondered
whether the presence of specialists in disaster-affected
communities could prevent mental illness in children.
Nine months after the Great East Japan Earthquake
occurred, in December 2011, the Miyagi Prefecture
Mental Health and Welfare Council established the
Miyagi Disaster Mental Health Care Center (our center), and the author got involved, as a member of thestaff, almost immediately.
Currently, there are five “disaster mental health carecenters” across the country, in Hyogo, Miyagi, Iwate,
Fukushima, and Kumamoto. One has been built inevery prefecture that has dealt with a large-scale disaster 4. Because these are not legally mandated organizations, they each have different parent organizations andmanagement strategies. Our center’s teams of doctors,
psychiatric social workers, psychologists, nurses, andoccupational therapists have contributed to the processof restoring community mental health.
The special characteristics of this center include (1)a focus on outreach support rather than walk-in counseling, and (2) a commitment to the regional Mental
Health and Welfare Department, and we expand our
support following its guidelines. For this reason, mostof our work involves conducting home visit surveys
alongside regional supporters, including public healthnurses. Public Health Nursing Journal is the translation.
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Special Edition: Reconsidering Disaster
Health Work from the Medium-Term Perspective
Because the author is a psychiatrist of this Center, his
primary responsibilities include offering advice to support teams and visiting residents suffering from various
mental illnesses. Of course, he sees people of all ages,
from children to the elderly. Below, we will focus onchild mental health work; in particular, we will discuss
our medium-term prospects now that several years
have passed since the disaster.
The effects of the disaster on children
In the acute phase, we saw child victims of the disaster in evacuation shelters and temporary housing, but
in the medium-term phase, we tend to see them inschools or counseling organizations. Overall, the mostimportant thing for a specialist is to keep child growthand development at the forefront of their minds at all
times.
The timing needed to accurately understand the current picture In 2012 after a year had passed since thedisaster, the MEXT determined that the health status ofchildren who had changed residences or schools in thewake of the disaster was not very good 5. When one
lives in an area with little human traffic, or about whichvery little information is available, it becomes difficult
to objectively view one’s lifestyle. However, by connecting with external supporters or leaving disaster-affected districts, one can compare one’s own experiences with those of others, enabling us to form a moreaccurate picture of the status quo.
For example, the author supervised a case involving
a middle schooler from a coastal region, who had been
affected by the disaster, and relocated to a more inland
region. While at his new school, there was an aftershock; the student panicked and hid under his desk.
When he noticed that he was the only one that did so,
he realized that his disaster experience was unique.
However, when one does not relocate and instead remains in the same area, a strong sense of unity develops between children that have undergone similar experiences, and this feeling can protect their mind andbody. Unfortunately, the middle schooler I mentioned
earlier had no one to share his experiences with, and hestarted to feel as if he didn’t fit into his school. Basedon these cases, specialists should realize that children
cut off from their communities or tight-knit groups require special consideration.

Stopgap behaviors
After about two to three years had passed since thedisaster, when I was contacted by a parent complainingthat their child “stopped using their allowance money
wisely.” At first, I thought this was a psychological issue, but I wasn’t too sure. After interacting with thechild, however, I was able to form a more accurate hypothesis.
For example, let us say that there was a child who,
before the disaster, deliberately saved his allowance,
perhaps because he wanted to buy a $200 bicycle.
However, when the earthquake occurred, all his hardearned money was swept away by the tsunami, and he
was left with nothing. After going through such an experience, a child might think “Something like that canhappen at any time. Better to just spend my allowance
when I get it.”I also dealt with a case in which a child’s school mentioned that he wouldn’t pass food around to everyone
and that he’d only eat his favorite foods. I immediately
thought of the same mechanism as in the previous case.
When they cannot believe in a stable and reliable future,children become unable to adopt planned, calculated
behavior, and they instead revert to stopgap behavior.
However, this phenomenon does not persist for very
long; it slowly disappears as safety and security return
to a child’s environment. As professionals responsible
FY 2018 Bulletin, Issue 7 for giving children the psychological support that they need, it is our responsibility to create safe societies and communities for children to grow up in.
Children who Tend to Talk
After about five to six years had passed, I was contacted by an elementary school teacher regarding a“lower-grade child in poor condition.” That same child
had been flagged in a survey conducted by the Boardof Education in that area. However, this evaluation was
an impartial measurement and had been carried out at
the request of a teacher.
Upon hearing more of the case details, I learned thatthe child in this particular case was prone to telling thestory of his disaster experience to other children. His
teachers were worried that this tendency indicated that
he was having “flashbacks” or something else of thesort.
After observing the children involved in these cases,
I learned a couple of things. They were all in the early－134－

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elementary school years, which meant they were between the ages of 1 and 3 when the earthquake hit. Like
it would be for almost anyone, they found their experience of a natural disaster to be a terrifying and overwhelming one. However, because they did not have theverbal ability to express what was happening to them,
they simply screamed or sat transfixed. Now, five to six
years later, their memory of the incident remained, albeit slightly blurred. However, because they now possessed the verbal ability to discuss what happened tothem, they began to tell everyone they knew
While these children might, at first glance, appear tosuffer from mental or physical instability, their tendency to talk about what they have gone through is evidence of them having reached the developmental
phase where they can organize and categorize theirmemories.

The effects of a child’s environment
Around the same time, approximately 5-6 years after
the disaster, I heard from public health nurses in coastal
areas who were complaining of an uptick in worrisome
children. However, because they hadn’t used any
scales or other instruments to evaluate the developmentof these children, the PHN’s complaint was still verymuch their subjective impression of the situation andwas not reflective of any longitudinal trends.
Upon listening to them for a while, it became clear
to me that while there was no apparent bias in the students’ development, this PHN had the feeling that there
was a sudden increase in children who could not stay
still and had poor impulse control. A teacher at a nursing school shared the same opinion, telling me thatthese kids had “a lot of cavities” and “often forgot
things.”As these nursery school teachers and parents continued to pile on observations and diagnoses, I was struckby the thought that these children’s home lives might
be affecting their behavior. Their parents were probably far too involved in reconstruction to give their children the time of day. Rather than the disaster contributing to an increase in patients with ADHD or someother developmental disorder, there had instead been
an increase in the number of parents that were too busy
to provide a stable living environment to their kids andfailed to notice them developing a loss of impulse control or an inability to sit still.
Thus, one thing we must be aware of in the medium
term is not to get so caught up in judging a child’s developmental trajectory that we forget to account for theeffects of their environment as well.

Community changes
In my disaster support work, I have seen countlesscommunity transformations, and I have come to realizethat these changes can affect a child’s mental and physical development. A child’s community is the “vessel”
in which he or she is raised. Specialists that work to
support childcare and parenting must remain acutely
aware of changes to this vessel and must respond in atimely fashion. Here, I will describe a few examples ofthis phenomenon. How a community opens and closes
its doors
As time passes, changes occur in a community’s attitudes towards external support, and we can makesense of many of them as community defense mechanisms. Immediately after a disaster occurs, a community keeps its doors wide open and tends to accept supporters without reservation. Disaster-affected regions
are always short-handed, and the supporters that flowin are always in high spirits. The support that a community is looking for often requires backbreaking work,
like mud scraping, and there is no harm in supporters
coming and going every few days.
But, after several months have passed, the community has begun to notice problems that come with accepting supporters without limit, and its doors are shuttightly. The support such a community then begins tolook for requires the ability to communicate, someone
who can take charge of the conversation in a salon. Relationships based on trust and a sense of safety become
important, and supporters must be able to stay for several months, at the very least.
After some more time passes, that sense of warinessslowly recedes, and the community’s doors begin toopen once more. The community is now able to accept
supporters that fit with its long-term plans.
I have seen how communities open and close theirdoors in this way, and I believe external supporters
must be able to provide time-appropriate support.
Wariness as a defense mechanism
If a threat to the community manifests itself, it is notuncommon for a community to formulate defense strategies to prevent such a thing from happening again.
One inadvertent side effect of this process is that thecommunity can become overly wary.
For example, if an individual dies from loneliness incontainer-type temporary housing, people become mutually attentive to changes in one another, to prevent
such a thing from happening again. Neighbors check－135－

Report on Observation of Korean Ferry Disaster Support Facilities

each other’s electricity meters and mailboxes, andalarm systems designed to broadcast emergencies outside the home are even installed in every house. Families with disabled children, having experienced how
difficult it was for people to be sympathetic to their situation in an evacuation shelter, work overtime to gettheir neighbors to understand their child’s condition by
telling them about it 6. I have seen all this myself.
Nevertheless, like a super-levee, community residents soon grow uncomfortable with this excessive
level of wariness, and they realize their community
doesn’t need such a high level, so to speak. They switch
over, as it were, to the opposite tactic. I, therefore, believe that as time passes, residents grow uncomfortablewith such a high level of wariness, and the community
slowly trends back towards normal levels.
Thus, in response to threats that jeopardize the survival of the community, it activates its unique defense
mechanisms, and as time passes, the community’s wariness waxes and wanes.

Gatherings and the recovery of autonomy
Different kinds of gatherings were spontaneously organized in disaster-affected regions. Most of them occurred in container-type temporary housing, and they
incorporated a variety of techniques to help the community tide over its crises and experience happinessonce again. From simple tea parties to elaborate oncrafts activities, these gatherings took many forms.
For example, to get hikikomori-Esque men to meetwith one another, some communities planned Sunday
carpentry classes, cooking lessons, mahjong meetups,
and fishing expeditions. There is a long-standing tradition of celebrating festivals in many communities.
Some have used it as an occasion to allot odd jobs tofellow residents, as the entire community comes together to put on the event. Many festivals are significant because they involve worship of gods or ancestors
out of gratitude, for one’s edification, or to comfort thedead. When each resident has their role, everyone cansee quite clearly the effects of a strong, home-based resource.
From these cases, we can see that when in danger,
communities will organize events that are in line with
their own culture, and while confirming each other’sroles, community members will have a chance to witness their community’s inner strength, and can slowly
move towards regaining the autonomy they lost at thehands of an overwhelmingly powerful external entity.
When specific organizations or regions bear significant
trauma, determining how to make use of their uniqueculture can be the first step to recovery.

Necessary support systems
Although it is often discussed, it is nevertheless truethat the most important thing in regional mental healthwork is to “connect” entities. After experiencing theGreat East Japan Earthquake, while it is of course important to prepare oneself for future disasters, we mustalso consider equipping individuals and communities
to respond to whatever happens.
When large-scale disaster damage occurs, the organizations that oversee a community are themselves destroyed, and until they regain their usual functions,“connections” come to play a large role. Rather thanfocusing on charismatic leaders, communities should
prioritize developing an institution that can play a hublike role. This hub is responsible for very freeform
work during peacetime. They ought to go out into thecommunity, get acquainted with each other, and essentially wander from place to place. If two organizations
do not normally collaborate, even under challenging
circumstances, arranging such a collaboration is not aseasy as simply saying “let’s collaborate!” An ideal situation would be a complex network of connections thatspontaneously form and fall away, much like a living
thing.
When it comes to child mental health, I believe that
individuals that should bear this responsibility are public health nurses and school social workers.
The mental health welfare system of this country iscentered on hospitals, and the expectation that specialists should simply wait for patients to come to themremains strong. For this reason, I believe that psychiatry has not been sufficiently developed as a publichealth good. However, since the Great East Japan
Earthquake, this trend has flipped. We now use publicfunds to carry out large-scale screening initiatives, andspecialists have begun to travel out to communities toprovide support. At first blush, this seems like the sortof change we have wanted for so long, but factors driving this pattern can include a strong sense of wariness,
as well as a desire to erase one’s anxiety. Of course,
as time passes, screening parameters and response rates
will fall, meaning that the number of flagged high-risk
individuals will also decrease.
We cannot merely focus on “flagged” high-risk individuals. We must also consider population approaches
that target specific demographics and groups. To that
end, we have collaborated with an epidemiologist to
develop theories and carry out repeated analyses. We
continue to believe that mental health welfare practice－136－

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is an essential feature of public health.

Conclusion
If nothing else, my current work has taught me thatrather than consider each individual as a separate entity
and then attempt to employ the appropriate support andtreatment techniques, we must consider entire communities as one unit and aim for health promotion techniques that target the entire group. These will not be
psychological, psychiatric, or psychopharmacological
techniques, but efforts that facilitate public healthminded thoughts and work.
Finally, more important than all of that are the techniques required to connect community residents and2) Fukuchi N. How the disaster affected childcare
environments. Child Abuse and Neglect, 14(1):14-19, 2012
3) Fukuchi N. The earthquake disaster and childcare.
The Science of Childcare.
4) Sakai A, et al., ed. Disaster Mental Health. Igaku
Shoin, 2016.

organizations that provide the same sort of support.
The willingness to make the effort to understand another person, to respect their wishes, and to cooperatewith them without critique. We must confirm what isnecessary for building effective communities. Once wedo, I fervently hope that we can turn the aftermath of
this horrible disaster into a turning point in the historyof public mental health work.
References
1) Fukuchi N, Hayashi M. The status of child mental
health in disaster-affected regions. Child Psychiatry and Neurology in Japan. 51 (2): 126-132,2011
http://www.mext.go.jp/a_menu/kenko/hoken/1337762.htm(accessed
1/10/2018)
6) Fukuchi N. “Support for Developmentally Disabled Children in Disasters.” Furusho J et al., ed.
The Progress of Developmental Disorder Medicine. 25, 36-42. Shindan to Chiryo Corp., 2013.
Naru Fukuchi
Miyagi Prefectural Mental Health and Welfare Council,
Miyagi Disaster Mental Health Care Center
T 980-0014 2-18-21 Takeda Sendai Bldg 3F,
Honmachi, Aoba, Sendai, Miyagi, Japan

5) MHLW: FY 2012 Emergency Disaster Child
MentalHealthSurveyReport.
2012.
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