保健医療科学

2018 Vol.67 No.1 p.71－83

Topics: Lessons learned on public health from the Fukushima Daiichi Nuclear Power Plant accident＜ Review ＞
Secondary health issues associated with the Fukushima Daiichi nuclear
accident, based on the experiences of Soma and Minamisoma Cities
Masaharu Tsubokura
Soma Central Hospital

Abstract
Nuclear accidents and their associated radiation hazards can cause radioactive contamination in thesurrounding areas and health effects associated with radiation exposure for local residents. However, theeffects of radiation disasters on local residents are not limited to those caused by radiation exposure. This
paper outlines the secondary health issues, unrelated to radiation exposure, experienced by residents ofSoma and Minamisoma Cities after the Great East Japan Earthquake and Fukushima nuclear power plant
accident. The most serious problem, during the early stages of the accident, involved the health effects ofevacuation, especially among elderly people. While evacuation is the most effective way to reduce radiationdose, it can have the greatest mid- and long-term health impact, in particular, by exacerbating of chronic
diseases, lifestyle diseases, and motor functions. In fact, the worsening of diabetes can have much moresignificant health effects than radiation exposure. There are also problems related to medical treatment,
consultation behaviors, and nursing care, resulting from the lack of social support, rather than the judgment
or decision-making of individuals. It is therefore necessary to give serious, balanced consideration to a wide
range of health risks and to put in place long-term countermeasures after a nuclear accident.
keywords: Evacuation, diabetes, lifestyle disease, social determinants of health, emergency transport,
decontamination worker(Accepted for publication, 18th January 2018)

I．Introduction
Nuclear accidents and associated radiation hazards cancause radioactive contamination in the surrounding areas;
local residents may have health effects associated withradiation exposure [1]. It is therefore necessary to measureradiation doses from the early phase of an accident.
Environmental monitoring and countermeasures to reduceradiation dose, such as evacuation and decontamination, areessential. However, the effects of a radiation disaster on
local residents are not all caused by radiation exposure.
Studies of Three Mile Island and the Chernobyl nuclear
power plant accidents have revealed that evacuation andmigration can themselves cause danger in the short term,compounded by a shortage of human and material resources[2-4]. In the medium term, while evacuation can reduce thedose of radiation local people are supposed to receive, it has
also been reported to cause lifestyle changes and stressleading to lifestyle disease, posttraumatic stress disorder(PTSD), and depression [5-7]. After the Chernobyl nuclear
accident, local people exposed to radiation faced prejudiceand stigmatization, leading to an increase in the numberof abortions, cases of alcohol addiction, and psychosomatic
disorders [8,9]. In the long term, radiation hazards have an
impact on social and cultural transformation and nationalenergy policy.
It is known that radiation hazards damage communities,
not just through radiation exposure, but also throughmultifaceted health, economic, and social impacts. This
paper outlines secondary health issues, unrelated toCorresponding author: Masaharu Tsubokura
3-5-18 Okinouchi, Soma city, Fukushima, 976-0016, Japan.
E-mail: tsubokura-tky@umin.ac.jp

J. Natl. Inst. Public Health, 67 (1) : 201871

Masaharu Tsubokuraradiation exposure, that emerged as a result of the Great
East Japan Earthquake and subsequent Fukushima Daiichi
Nuclear accident (Fukushima disaster). The data come fromthe cities of Soma and Minamisoma in Fukushima, locatedin the range of 10–50 km north of the Fukushima Daiichi
Nuclear Power Plant in Hamadori District.

II．What can be learned by analyzing the longterm mortality rate after the Fukushimadisaster?
Following the Great East Japan Ear thquake andFukushima Daiichi nuclear accident, the health of local
residents was seriously affected by various factors,
including the evacuation immediately after the nuclear
accident, the deterioration of lifestyle habits, and socialchanges. This study asks when the impact on residentsʼ
health was most severe, in the years following the disaster.
One possible answer to that question has been provided byMorita et al. (2016), who have compared the age-adjusted
death rate of residents in Soma and Minamisoma Cities
before and after the disaster [10].
In this 2016 study, Morita et al. used the death-dateand cause-of-death data (ICD-10 code) for all residents ofSoma and Minamisoma Cities between January 2006 andDecember 2015, and compared the monthly mortality risks
between January 2011 and December 2015 with the average
mortality risk before the disaster. The aim of this study
was to evaluate the “secondary” mortality risks associatedwith the nuclear accident. Deaths directly caused by theearthquake and tsunami immediately after the disasterwere excluded from the analysis.
This study showed that the risk of death rose in bothgender and every age group, during the first month after
the disaster, in comparison to the period before the disaster.
Especially for women aged 85 and older, the risk of death
increased during the first three months after the disaster (upto May 2011) (Figure 1).
Three important lessons can be derived from this study:
1. In the five years after the Fukushima disaster, the riskof death for residents was at its highest one month after
the disaster. In other words, even with deaths directly
caused by the disasters excluded, the risk of “secondary”
mortality was at its highest immediately after thedisaster. This was the period of time when the mosthuman lives were lost, during the five-year span. The
rise in the risk of death reflects the worsening of diseases
during evacuation, and the inability of damaged local
communities and medical infrastructures to maintain thehealth of local residents.
2. While the rise in the risk of death among women aged 85
and older was sustained for 3 months after the disaster,
the indirect health risks of the disaster for elderly people
were more serious and lasted for a long time. Most highrisk elderly people were those living in nursing homes,
and their cause of death was “pneumonia.” This meansthat they died as a result of weakness, a decrease in care,and the general deterioration of their physical condition,

Figure 1 Age-specific monthly trends showing the relative risks of indirect mortality pre- andpost-disaster [10](A) 0–64 years. (B) 65–74 years. (C) 75–84 years. (D) 85+ years. The baseline risk was defined as the monthly
mortality rate per year from 2006 to 2010. The relative risks were adjusted by city; the asterisk (*) indicatesstatistical significance at the 0.05 level.

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J. Natl. Inst. Public Health, 67 (1) : 2018

Secondary health issues associated with the Fukushima Daiichi nuclear accident, based on the experiences of Soma and Minamisoma Cities
and not from the onset of any particular disease.
3. The risk of death during the five years after the disaster
was at its highest during the first month following thedisaster; there was no clear rise in the mortality rate after
that. Deaths due to indirect impacts, including disasterrelated deaths, spiked immediately after the disaster,
but then decreased to levels that cannot be statisticallydetected. No statistically obvious or excessive death rate,
associated with disaster-related deaths, can be seen forthe years immediately following the disaster.
Reducing radiation risks among residents is an important
issue that should be given the highest priority after nuclear
accidents. For this reason, evacuation is an unavoidable
necessity and the first procedure to consider. However,a simple analysis of the numbers suggests that the mostimportant category of health damage that occurred after
the Fukushima disaster involved the impact of evacuation
on elderly people. Given the life risk to elderly people innursing homes caused by evacuation (described in the next
chapter), it is necessary to balance the risks associated withradiation and evacuation. Although this is a great lesson
learned from the Fukushima disaster, it is a difficult problem
to solve, with no easy solutions.

III．Health effects associated with evacuation in the acute phase
Emergency evacuation without adequate preparation
forces evacuees to bear the physical burdens of moving,
and the long-term burdens associated with environmental
changes, and with mental and psychological strain.
Evacuation will destabilize vulnerable people in various
social, physical, and economic contexts, creating situations
that will damage weaker people more than others. During
the process of evacuation after a nuclear accident, residents
of facilities such as nursing homes are typical examples of
the types of vulnerable people who need adequate care andcountermeasures [11].
Nomura et al. conducted a survey comparing the death
rate before and after the disaster among a total of 715
nursing home residents in five of the eight nursing homes
forced to evacuate from Minamisoma City [12]. The
relative risk of death among nursing home residents after
the disaster was about 2.7 times higher than before thedisaster. It is worth noting that the risk of death varied fromfacility to facility. At two facilities, there was no change (astatistically significant difference was not observed between
before and after the disaster). In facilities with a high riskof death after the disaster, the mortality rate was about 3.8
times higher than before the disaster. In the facility with thehighest mortality rate, approximately 25% of the residents

Figure 2 Estimated post-earthquake survival rate byfacility among nursing home residents in Minamisoma City [12]died within 90 days of the disaster (Figure 2). Differencesin the actual evacuation distance did not affect the mortality
rate, but the mortality rate during primary evacuations
was 1.98 times higher than during subsequent evacuations(many residents were forced to evacuate several times after
the earthquake.)
Nomura et al. have compared the death rates of evacuatedand unevacuated nursing home residents after the disaster[13]. Evacuated nursing home residents in Minamisoma
City had a higher mortality risk of 1.82 times (95%
confidence interval: 1.22–2.70) than those in Soma City who
did not evacuate (Figure 3).
Interviewing to the staff of each facility, the researchers
noted that the following four factors had a significant healtheffect on elderly patients: (1) the presence or absenceof dietary care after evacuation, (2) the quality of carereceived at the evacuation destination facility, (3) whether
nutrition management before evacuation was sufficient, (4)evacuation measures.
Murakami et al. have used the loss-of-life-expectancy
measure to compare the risks of evacuation with the risksof radiation exposure (caused by staying, without being
evacuated) among nursing home residents and the staff
members who cared for them in Minamisoma City [14].
They have shown that the risk of rapid evacuation
without sufficient preparation (for the action actually
selected during the disaster) was about 400 times higher
than the risk of radiation exposure associated with staying
in the nursing home for 3 months after the disaster. The
risk of rapid evacuation was higher than the risk associatedwith 100 mSv of radiation exposure, which is the reference
index of evacuation (Table 1).
Many factors affect logistics during a nuclear accident.
The size of the accident and the degree of contamination
are not uniform. The extent to which vulnerable people,

J. Natl. Inst. Public Health, 67 (1) : 201873

Masaharu Tsubokura

Figure 3 E stimated pre- and post-disaster survival
rates among nursing home residents in Minamisoma and Soma Cities [13]such as nursing home residents, evacuate early—or at all—is determined on a case-by-case basis. Although Murakami
et al. [14] emphasize the risk of evacuation, not evacuating
is not a zero-risk option. Staying in the contaminated area
creates a mental burden; people also worry about logisticalcrises, a lack of goods, and a lack of human assistance[15,16].
It has been reported that, immediately after the nuclear
accident in Minamisoma City [17], the number of medical
staff members actually working in hospitals decreased
to about one third of those working before the disaster.
It is difficult to choose not to evacuate during such an
emergency. The author of the present paper would not wish
these findings to be used to argue that particular groupsof people should or should not have evacuated after the
nuclear accident. However, there is much scope to reduce
evacuation risks, and it is important to prepare and planfor future possible nuclear power plant accidents. These

610
611
612
613
614

studies present us with a lesson learned: that evacuation
without sufficient preparation is accompanied by a large
health risk, involving the delay of care at the evacuation
destination, and the physical burdens caused by long-term
movement.
The author believes that the main cause of the increased
mortality rate associated with the evacuation was thecollapse of medical care and the eventual lost continuityof care due to a failure of local logistics. For example,
children and living family members tend to recognize slightchanges in the physical condition of their own elderly
parents and relatives better than anyone else. For thisreason, maintaining pre-disaster human relationships after
evacuation is very important to maintaining the healthof frail people. It may reduce the health risk faced byelderly patients if care-home staff members evacuate at
the same time and continue to provide care. In the future,comprehensive measures that take into consideration bothradiation and evacuation risks must be implemented toprotect the weak. Further research is needed in this area.

IV．Medium- and long-term health effects:
the deterioration of lifestyle diseases,
especially diabetes
In discussing the secondary health problems that
accompany nuclear accidents, we have mentioned the
keyword “evacuation,” during the early phase of theaccident. Evacuation-related changes to residentsʼ living
and social environments have a major impact on their healthin the medium and long term. Of these changes, one of themost serious involves the increased severity of chronic
diseases, especially diabetes.
After the disaster, the number of diabetic patients

Table 1 Comparison of LLEs of residents and staff in nursing homes among rapid andTable 5. Comparison of LLEs of residents and staff in nursing homes among rapid and 90-day
90-day delayed evacuation scenarios and 20-mSv- and 100-mSv exposure
delayed evacuation scenarios and 20-mSv- and 100-mSv exposure scenarios (persons-d). Scenario 1,
scenarios (persons-d).
rapid evacuation;
Scenario 2, 90-day
delayedevacuation.
Total
LLEs of evacuation-related
risk in
Scenario
1, rapid evacuation;
Scenario
2, 90-daydelayedevacuation.
Total LLEs of evacuationScenario
1
were
much
higher
than
those
of
avoidable
risks
due
to
radiation
exposure
in
the
other
related risk in Scenario 1 were much higher than those of avoidable risks due to radiation
scenarios.inValues
in parentheses
95% inconfidential
intervals.
exposure
the otherscenarios.are
Valuesparentheses
are 95% confidential intervals [14].

615
Evacuation-related
Nursing home residents
Nursing home staff
Radiation-related
Nursing home residents
Nursing home staff
Total

Rapid evacuation

90-day delayed
evacuation

20-mSv
exposure

100-mSv
exposure

11000 (10000–13000)[880 (730–1200)]a
Not observed

Unknown--

Unknown

-

-

0.01
0.1
11000+ (10000+–13000+)

1.7
26
27+

100
1000
1100

530
5300
5800

616
617
618

a

LLEs due to non-evacuation-related effects (e.g. disaster-shock), as estimated from the data from
Nursing home group B.

619

74

620

J. Natl. Inst. Public Health, 67 (1) : 2018

Secondary health issues associated with the Fukushima Daiichi nuclear accident, based on the experiences of Soma and Minamisoma Cities
increased in Soma and Minamisoma Cities over thefollowing years; in some age groups, the prevalence of thedisease increased by about 5% after the disaster. Nomura
et al. have retrospectively investigated data drawn from thehealth examinations of subjects between 40 and 74 years
old in Soma and Minamisoma Cities (6,406 persons in total).
They have reported that, for several years after the disaster,
the risk of developing diabetes was higher than before [18].
In the evacuated area, the risk of developing diabetes after
2013 significantly increased (by 1.55–1.60 times) from the
2008–2010 baseline. Even outside the evacuation area, anincrease (1.27–1.33 times) was observed after 2013 (Table2). This pattern has also been revealed in the Fukushima
Health Management Survey carried out by the prefectural
government in evacuation areas south of Minamisoma City
[19]. It is worth nothing that a worsening of diabetes wasobserved, not only in residents of the evacuation area, butalso in residents outside the evacuation area.
It is well known that diabetes carries a risk of vascular
events, such as cerebral and myocardial infarction. In
fact, the number of stroke-related visits to Minamisoma
Municipal General Hospital increased after the disaster[20]. In addition, diabetes itself has a carcinogenic risk.
Given the widespread deterioration of diabetes after thedisaster, the “secondary” risk of diabetes was much greaterthan the risk of carcinogenesis associated with radiation
exposure. Although future measures may change theprevalence of diabetes, Murakami et al. have shown that theloss of life expectancy among residents in their 40s and 70s
in Soma and Minamisoma Cities, due to increased diabetes
associated with the disaster, was about 30 times larger thanthat of radiation exposure, even if the risks associated withdiabetes were underestimated and the carcinogenic risk ofradiation exposure was overestimated [21].
The main secondar y health impact, following a
nuclear accident, is a largescale change of peopleʼs wayof life, including work, exercise habits, dietary habits,
and community. In this chapter, we have discussed theworsening of diabetes and its associated risks; this healtheffect was the direct consequence of lifestyle changes
caused by the disaster. Although the most clear-cut
cause of lifestyle change was “evacuation,” the healthof diabetic residents outside the evacuation area also
deteriorated, indicating that evacuation was not the only
cause of worsening diabetes. These findings underline
the importance of having a balanced set of responses tonuclear accidents, taking into considering a wide range ofrisks, from lifestyle diseases to radiation exposure. Rather
than focusing on a single type of risk, it is indispensable torecognize and understand various types of risk, in order toprotect peopleʼs health.

V．Which group of people faces the highest
risk of the development of diabetes?
The worsening of diabetes is one of the most important
mid-to-long-term health effects after a nuclear accident.
Evacuation is one of the most important factors aggravating
diabetes, as discussed above. However, diabetic patientsoutside the evacuation area also experienced worsening
diabetes. The identification of high-risk groups is an
important issue in public health. Although few studies have
explored this issue, the following papers make important
contributions to the discussion and implementation of

Table 2 Age-adjusted pre- and post-incident relative risk of the diseases(versus baseline (2008-2010)) [18]Diabetes
2011
2012
2013
2014
Hyperlipidemia
2011
2012
2013
2014
Hypertension
2011
2012
2013
2014

Evacuees

Non-/temporaryevacuees

P-value of thedifference in row

1.12 (0.70–1.79)
1.21 (0.88–1.67)
1.55 (1.15–2.09)**1.60 (1.18–2.16)**0.94 (0.81–1.10)
1.11 (0.97–1.27)
1.33 (1.17–1.52)***
1.27 (1.11–1.45)***

p=0.5
p=0.6
p=0.3
p=0.1

1.10 (0.94–1.27)
1.16 (1.05–1.29)**
1.30 (1.18–1.43)***
1.20 (1.08–1.32)**

1.00 (0.95–1.05)
1.03 (0.98–1.08)
1.12 (1.07–1.17)***
1.14 (1.09–1.20)**p=0.3
p<0.05p<0.01p=0.6

1.05 (0.91–1.21)
1.04 (0.94–1.14)
1.10 (1.00–1.21)*
0.94 (0.85–1.05)

1.05 (1.01–1.10)
1.03 (0.99–1.07)
1.01 (0.97–1.05)
0.95 (0.91–0.99)*

p=1.0
p=1.0
p=0.1
p=0.8

** p<0.05,**p<0.01,
p<0.01,p<0.001
for givenyear versus(2008-2010),
adjustedp<0.05, ********
p<0.001
for givenyear versus
baselinebaseline(2008-2010),
adjusted forage
for age.

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Masaharu Tsubokura
future health measures.
The first study has examined the relationship between
worsening diabetes and the social determinants of healthin Minamisoma residents. Using data on 404 people over
the age of 20 who were diagnosed as diabetes before
the disaster and attended consultations at Minamisoma
Municipal General Hospital, Leppold et al. investigatedwhether the condition of diabetes worsened after thedisaster, and in which districts the health of diabetic
patients was most likely to deteriorate [22]. They evaluated
HbA1c levels at three points before and two points after
the disaster (December 2011 and March 2012), and divided
Minamisoma City into three areas: suburbs, city center, andmiddle area, based on residential land prices.
Their study has shown that worsening diabetes wasobserved after the disaster among young people andpatients living in the center of the city. In patients who
lived in the center of the city, diabetic symptoms wereapproximately three times worse than those of patientsliving in the suburbs. These findings are comparable to theresults of Ishii et al., which found no apparent worseningof life-style diseases in 2012, one year after the disaster, inTamano District, Soma City, a mountain area with one of
the highest levels of radioactive contamination outside theevacuation zone [23].
The lifestyle habits of young people may have led toa worsening of “secondary” diabetes after the nuclear
accident, in comparison to elderly people. In addition, themore urban lifestyle in the city center may have affected
diabetes control more than the suburban lifestyle.
The second paper to evaluate the relationship between
regular hospital consultations after the disaster and theworsening of chronic diseases is Toda et al., which has
analyzed the data of 563 people who visited a specific healthcheck-up every year for four years (2009–2012) before andafter the Fukushima disaster in Minamisoma City. This
study has examined changes in the cardiovascular diseaserisk score (Framingham score) to discover whether therisk of cardiovascular disease increased and the risk factor
changed after the disaster [24]. No significant change wasfound in the post-disaster cardiovascular disease risk of any
male and female participant; nor was there any change inthe risk factors (Table 3).

Residents who remained in Minamisoma City after thedisaster and regularly received specific health examinations
over four years are an example of a group that did notevacuate or change their lifestyle habits significantly.
In this population, there was no increase in the risk ofcardiovascular disease. This finding is comparable tothe study by Nishikawa et al. (2015), which showed thatthe HbA1c control of 58 diabetic patients who regularly
attended consultations at Soma Central Hospital after thedisaster did not deteriorate [25]. It has been suggested
that chronic diseases such as diabetes do not worsen (atleast, not easily) in groups that continue to receive hospitaltreatment or regular medical examinations.
The treatment of diabetes includes individual behavioral
changes, such as diet and exercise therapy. To predictwhether treatment will be successful, we often focus on
individual problems, such as understanding and a positive
attitude towards treatment. However, the health effects
caused by the nuclear accident should not be attributed
to individual commitment or ability; instead, they reflecta larger change in society—affecting peopleʼs ability tocontinue the same lives they had before the disaster. It
will be important to identify social risk factors and adopt
countermeasures to combat worsening diabetes, rather
than focusing on individual risk factors.

VI．Secondary health effects on newborns andchildrenNewborns and children are two groups that needparticular attention to radiation. The results of radiationdose assessments after the Fukushima nuclear power plant
accident indicate that radiation exposure itself cannot be
expected to have a health impact on newborns and infants.
However, changes in living environment can affect thehealth of neonates and children, as well as adults. Studiesof past disasters have revealed that stress to the motherand environmental changes affected the health of newborn
babies. In fact, problems caused by stress and lifestylechanges, especially obesity, were reported in children after
the Fukushima disaster by various researchers. In thischapter, we will present two papers that discuss this issue.
To clarify the impact of the disaster on mothers andTable 3 Comparison of age-adjusted cardiovascular risk score (Framingham score)
before and after the disaster in male and female [24]Cardiovascular risk score
Male (Ave, SD)
Female (Ave, SD)baseline (2009–2010)
1.36 (3.06)
0.19 (3.19)

2011
1.50 (3.26)
0.37 (3.30)

2012
1.46 (2.96)
0.69 (3.31)

The Framingham score is calculated from the blood pressure value, cholesterol level, presence or absenceof smoking, and presence or absence of diabetes. A higher point indicates that the risk of cardiovasculardisease is higher.

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Secondary health issues associated with the Fukushima Daiichi nuclear accident, based on the experiences of Soma and Minamisoma Cities
neonates in the disaster-stricken area, Leppold et al.
assessed the health status at birth of all newborn babies
born between 2008 and 2014 at Minamisoma Municipal
General Hospital (1,101 people) [26] to see whether rates
of low-birth-weight infants and premature birth changed
after the disaster. They found no statistically significant
change in the rates of low-birth-weight infants or prematurebirths after the disaster (Table 4). On the other hand, theproportion of elderly births (Mothers over 35 years of age
at the time of delivery) increased after the disaster; thepercentage of first-time mothers also increased.
Nomura et al. used school health examination datafrom Soma City in 2010 (before the disaster), 2012, and2015 to analyze weight changes among junior high school
students [27]. In 2012, one year after the accident, theobesity rate for boys increased, while the BMI and obesity
rate for girls decreased. Both boys and girls seemed toexperience weight changes, due to the change in theirliving environment. As no change to the weight of boys or
girls was observed in relation to the restriction of outdoor
school activities, these changes may have been caused by,for example, a decrease in extra-curricular exercise, stress,
or changes in diet. Interestingly, in 2015, there was nodifference in the weight index for either males or females;by that time, the weight index had returned to the samelevel as before the disaster.
However, in 2015, BMI variance increased for boys.
Although the average body weight of children in this cohort
returned to what it was before the disaster, this does notnecessarily reflect the health of individual children, whose
weight may have been increasingly variable after thedisaster.
These studies show that the disaster had little impact(or a temporary effect) on the weight of newborn babies
and children overall. However, the expansion of varianceand diversification in the student weight index provides
important data on the secondary health impacts of nuclear
accidents on children. Although the study data do notdirectly show it, the authors believe that the weight ofindividual children who needed social support, whether
obese or thin, worsened as a result of diminished social

support after the disaster. Although the average value has
returned to the same level, social support continues to beinadequate. We recognize that the impact of the disasteron weak individuals has been masked, in some cases, by
the normalized average value. Weaker children, as well as
weaker adults, are likely to be disproportionately affectedby a nuclear disaster.

VII．Impacts on bone health/motor function
So far, this paper has mainly discussed the impact of thedisaster on chronic diseases and obesity. The deteriorationof lifestyle habits also has a significant impact on motor
function and bone health. This serious secondary healtheffect of the nuclear accident should also be considered.
Ishii et al. have used the health-check data of 1,890
residents of temporary housing in Soma City, aged 65
or above, to evaluate declining rates of motor function.
Deteriorating performances in the TUG (up and go) test
and the standing-on-one-foot test were observed in bothmale and female residents, indicating that their motor
function may have declined in 1.5 years since the disaster.
The percentage of residents who achieved a TUG test of
11 seconds or less, or a standing-on-one-foot test of 15
seconds or less, in temporary and other types of housing,rose (for the TUG) to 6.7% from 2.8% for men and to 9.2%
from 2.8% for women. For the standing-on-one-foot test, itrose to 64% from 31% for men, and to 66% from 30% forwomen [28]. However, no deterioration of bone density,and osteogenesis or absorption markers was evident inpatients visiting Soma Central Hospital [29].
Vitamin D is an important nutrient for bone health, andmushrooms and marine products are an important sourceof vitamin D among Japanese people. These foods werehighly contaminated after the nuclear accident, and the
problem was complicated by waste furnace water pollution.
Many residents therefore refrained from ingesting them[30]. Since peopleʼs post-evacuation conditions havebeen prolonged, with some residents continuing to live in
temporary housing for more than six years, it is possiblethat motor function and bone health are deteriorating in

Table 4 Post-versus pre-disaster risk ratios of low birthweight and preterm birth,
adjusted for maternal age and neonatal sex [26]Birth Outcome
Low Birthweight
2012
2013
2014
Preterm Birth
2012
2013
2014

Risk Ratio

95% CI

p-Value

0.71
0.80
1.28

0.29–1.75
0.42–1.55
0.76–2.17

0.46
0.52
0.35

0.40
1.01
0.52

0.10–1.64
0.49–2.05
0.21–1.30

0.20
0.99
0.16

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Masaharu Tsubokura
these residents. There has not been an adequate longterm assessment of rates of fractures or of residents whoare bedridden. This area needs long-term follow-up in the
future.

VIII．Changes in the clinical behavior of cancer
patients
Previous chapters have introduced secondary healtheffects that are mainly related to lifestyle habits. While thedeterioration of lifestyle habits generally includes a poor
diet and a lack of exercise, these characteristics should not
be seen as individual self-management problems. Rather,
these problems reflect social and environmental changes,
including changed family relationships, a loss or change ofoccupation, and the connections between people known associal capital.
There are many examples of people whose health,previously maintained through human-human relationships,
failed because of changes in the surrounding environment
after the disaster. The change in the medical care of cancer
patients is a good example. Ozaki et al. have targeted
219 breast cancer patients (122 patients before and 97
patients after the disaster) who visited one of two hospitalsdelivering breast cancer treatment in Minamisoma City, tosee whether there was any delay in patientsʼ initial visits(the time period between noticing the first symptoms andhaving a consultation). They also analyzed the relationshipbetween the loss of family support and delayed first visits
after the disaster [31].
This study has shown that the number of patients
who delayed their consultations for more than 3 months
increased from 18.0% before the disaster to 29.9% after thedisaster (an age-adjusted risk ratio of 1.66), and that the
number of patients who delayed their consultations for 12months or more increased from 4.1% before the disasterto 18.6% after the disaster (an age-adjusted risk ratio of4.49). This trend is continuing, even five years after thedisaster. Of the patients who experienced a delay, only a low
proportion lived with children. This suggests that, if youlive with your children, when you notice something unusual
in your physical condition, you have an increased chanceof getting to the hospital. Previous reports have suggested
that it is more important for breast cancer patients to havethe support of their children than their partners, when it
comes to improving the prognosis. The evacuation after thedisaster greatly reduced the number of young people, andchanged the family environment, leading to changes in the
behavior of local residents in need of cancer treatment, andnegatively affecting their health. Although the followings
are case reports, similar changes in consultation behavior

78

have also been noted in relation to other types of cancer,
including colorectal cancer [32,33].
Examples of such changes in the family environment
affecting residentsʼ health are often experienced in daily
practice. In large-scale disasters such as nuclear accidents,
family environment a environmental changes occur
frequently here and there. Although we have currently
focused on the consultation behavior of breast cancer
patients, it is highly likely that similar things will happen,
not only among patients with other types of cancer, but withmany other medical conditions that need long-term follow
up.

IX．The impact of changes in clinical service
areas, due to the closure of hospitals
In the previous chapter, we introduced changes in the
medical treatment behavior of breast cancer patients.
Changes in the family environment can have a serious
health impact on patients, both directly and indirectly. Whenan evacuation area was designated, after the disaster, many
hospitals were closed and movement was restricted. It
seems likely that that residentsʼ consultation behaviors wereaffected by hospital closures and changes in clinical service
areas. To assess the health effects of hospital closures andclinical service area changes on local residents, Morita et al.
have analyzed changes in emergency transportation times,
using post-disaster emergency transportation data in Soma
area (Soma City, Minamisoma City, Shinchi Town, and Iitate
Village) [34].
The number of emergency transportation cases was at
the same level or lower than before the disaster after apeak of 162 cases in the week (Week 0) of the Great East
Japan Earthquake. From Week 1 to Week 11, emergency
transportation times were significantly longer than before
the disaster; they then returned to the same level (Figure4). Delays in emergency transportation occurred not only
evacuation areas but across the entire Soma area. One
possible reason for this is that hospital closures in theevacuation area and the emergency evacuation preparation
area extended the travel distance from the emergency site
to hospitals. In the first days after the disaster, there weremany injuries caused by the disaster itself, and emergency
medical treatment were needed. After several weeks, there
were calls to transport elderly people left behind, dog bites
among returning residents [35], and work-related injuries
among construction workers involved in the reconstruction[36].
In the Soma area, hospitals outside the evacuation zone
managed to sustain medical care, even after the disaster;
However, hospitals in the emergency evacuation preparation

J. Natl. Inst. Public Health, 67 (1) : 2018

Secondary health issues associated with the Fukushima Daiichi nuclear accident, based on the experiences of Soma and Minamisoma Cities

Figure 4 Trends in the number of emergency medical service (EMS)transports and median total EMS time. The week of the earthquake (11-17 March 2011) is defined as week 0 [34].

zone were not allowed to admit patients for months after
the disaster. The extension of emergency transportation
time, which is important for seriously ill patients, wasaffected for 3 months after the disaster. Although it wasessential for patients to know whether medical treatment
could continue or be completed within the area, there
continues to be little available information and resources on
the treatment of chronic conditions, or diseases requiringlong-term continuous care, such as cancer. Local medical
staff must work in cooperation with patient families toprovide such care [37]. Further measures and research areneeded to resolve this point.
Studies discussed above do not cover necessary medical
treatment in the evacuation zone, especially in the Futaba
area. Nishikawa et al. have described the type of outpatient
clinical practice needed in Kawauchi Village after returning
to the village [38]. As residents return to the former
evacuation zone, future research and measures will benecessary to determine what kind of medical treatment isneeded in such areas.

X．Changes in nursing care supply and demand
As a secondary health impact, we have discussed theworsening of diseases, the lack of access to medical
treatment, and changes in medical treatment behavior.
Another very important secondary impact concerns theshortage of nursing care. Most nursing care is targeted at
the elderly; it is a system that depends on the connections
between family and society.

Morita et al. have reported that the cost of nursing
care rose 1.3 times per capita in Minamisoma City after
the disaster [39]. Although a detailed investigation todetermine the cause will be needed in future, this may
reflect an increase in the number of residents who wereforced to rely on systems such as nursing-care insurance
because their families were split and local social support
had disappeared. The number of nursing care insurance
cases also rose among residents needing milder forms ofcare after the disaster. Changes in nursing-care supply
and demand are barometers, revealing the social powerthat protects an areaʼs health. Continual monitoring andcountermeasures will be necessary in the future.

XI．Health issues among decontamination
workers
Many decontamination workers were hired to reduceradiation levels in the contaminated area, following
the nuclear accident. As reconstruction accelerated,workers from inside and outside the prefecture worked inradioactively contaminated areas; many of these workers
lived in Hamadori District. While the radiation dose
received by workers was relatively low (in 2015, averaging
0.6 mSv/year with the max of 7.8 mSv/year), they werereported to have various health problems, including lifestylediseases, infectious diseases, and trauma-related conditions[40].
Sawano et al. have analyzed the health condition of
decontamination workers by assessing the prevalence

J. Natl. Inst. Public Health, 67 (1) : 201879

Masaharu Tsubokura
and treatment of lifestyle diseases in 113 decontamination
workers, who were hospitalized at the Minamisoma
Municipal General Hospital between June 1, 2012 (the day
Minamisoma City began decontamination work) and August
31, 2015 [41]. Approximately 80% of the hospitalized
patients were admitted to the internal medicine department.
There were high proportions of alcohol consumers andsmokers, and a high rate of lifestyle diseases. This study
has also suggested that decontamination workers were at
risk of trauma. Risks posed by bee stings were reported
during decontamination, in areas that people did not enter,
due to radioactive contamination [42].
Decontamination workers have various health risks, apartfrom radiation exposure. For workers, health measures
are often designed to cope with occupational accidents. In
this case, decontamination workers were exposed to more
health risks in their daily lives (including lifestyle diseases)
than at work, due to their low socioeconomic situation.
Although decontamination workers are required to have ahealth check every six months, we believe residents who
engaged in reconstruction work need comprehensive andsustainable health support.

XII．Conclusion
This article outlines the secondary health effects of thenuclear accident based on the experiences of Soma andMinamisoma Cities. In the acute phase of the disaster,evacuation had a significant impact, especially on elderly
people. Many problems, including the worsening of chronic
diseases such as - diabetes, impaired motor function,
inadequate medical treatment behavior, and a shortage ofnursing care, emerged as middle- and long-term issues.
Most of these issues should be seen as social and regional
problems, rather than individual ones. While several
important issues, including mental health problems and theeffect of living in temporary housing, are not covered in thispaper, it is clear that additional measures to address a rangeof different health risks in a well-balanced manner will beneeded for the long term, following a nuclear accident.

Acknowledgments
We would like to show our sincere gratitude to the
local residents who cooperated in the survey, even while
facing their own troubles after the disaster. We would also
like to thank to the medical staff members in and beyond
Fukushima Prefecture, who helped to support our research
activities.

80

Conflict of Interest
The author declares that there is no conflict of interests
regarding the publication of this article.

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Secondary health issues associated with the Fukushima Daiichi nuclear accident, based on the experiences of Soma and Minamisoma Cities

原発事故に伴う二次的な健康課題―相馬・南相馬地区での経験から―

坪倉正治
相馬中央病院抄録
原発事故およびそれに伴う放射線災害は周辺地域の放射能汚染を引き起こし，周辺地域住民へ放射線被ばくに伴う健康影響を及ぼしうる．しかしながら，放射線災害の地域住民への影響は放射線被ば
くによるものだけに留まらない．本稿では東日本大震災および福島原発事故後，放射線被ばく以外の
事故後の二次的な健康課題について，福島県浜通り地区でも福島原発の北10km ～50kmの範囲に存在する相馬市・南相馬市でのデータを元に概説する．
事故初期に最も問題となるのは避難に伴う特に高齢者への健康影響である．避難は放射線被ばくを低減するための最も有効な手段である一方で，震災数年間を通して最も大きな健康影響を持ちうる．
中・長期的には糖尿病に代表される慢性疾患・生活習慣病，運動機能の悪化は最重要課題の一つである．特に糖尿病の悪化による影響は，放射線被ばくの数十倍の健康影響を及ぼしうる．診療行動，受診行動，介護にも多くの問題が存在する．これらの多くの問題は，個人の自己判断や意思決定の問題として考えるより，社会や地域の問題，地域が変容することで社会的なサポートが欠如してしまった
結果として起こったものとして考え対策を行うべきものである．これらの様々な健康リスクをバランス良く考え，対策を長期的に行うことが原発事故後には必要となる．
キーワード：避難，糖尿病，生活習慣病，社会的健康決定資本，救急搬送，除染作業員

J. Natl. Inst. Public Health, 67 (1) : 201883