Chapter 40
Comprehensive Community Care and Disasters
Field of expertise: Disaster Stomatology

Ken Osaka
Translated by Catherine Sachi Kikuchi

SummaryAn analysis of citizen’s situations before the disaster and deaths caused by the tsunami showedthat fewer people who were less independent and were considered to be high-risk died on the dayof the disaster. On the other hand, more people who lived with their families or had many friends
died. The risk of death was found to be 3.9 times higher for those who were severely depressed.
These results show the importance ofTsunami tendenko, the legend that each person flees inisolation to save their own life, but it also suggests what is needed to ensure that vulnerable people
are never left behind in disasters. We believe that the community-based comprehensive caresystem, which the national government is developing in cooperation with regional medical care andlong-term care, will also play a major role in regional disaster mitigation.
Keywords: community comprehensive care system, Iwanuma Project, community disastermitigation, multidisciplinary cooperation

1: Problems Revealed by the Great East Japan Earthquake
The Iwanuma Project: Examining the health and lives of the elderly before and after theearthquake
For more than 10 years, we have been working with Iwanuma City, Miyagi Prefecture,(population: approximately 44,000) to develop a nursing-care prevention program1 for the elderly,
which has been covered by various media and has become a model for the national government.
In 2010, the year before the Great East Japan Earthquake, we were able to conduct a Life andHealth Survey of all elderly people together with Iwanuma City Hall. This was possible becauseIwanuma City agreed to participate in the Japan Agency for Gerontological Evaluation andResearch project, in which we also participate. This project investigates the lives and health ofelderly people in the community, and examines how social capital and social environments affecttheir health. Thirty cities, towns, and villages nationwide participate in the project, which is1

A program that supports maintenance and improved living conditions of elder people in order to prevent
them, as best as possible, from deteriorating health and falling into a long-term care-requiring state.

1conducted every three years, and many researchers from universities and other institutions
participate in the project.
In Iwanuma City, the Great East Japan Earthquake left 187 people dead or missing, 5,428
houses completely, half, or partially destroyed, and 48% of the city area flooded, causing damage
to a lot of farmland and 200 companies in the industrial park. We conducted a survey in 2013,2016, and 2019 in addition to the pre-earthquake data (2010 survey). By combining these data, wewere able to construct a data set that can capture the changes from the pre- to post-earthquake
situation on a yearly basis. This valuable data was funded by the U.S. National Institutes of Health(NIH) through the efforts of Professor Ichiro Kawachi of Harvard University, with whom we had
been collaborating for some time. Together, we launched the Iwanuma Project.
The findings of this project are as follows.
Group housing is good in evacuation sites
In many municipalities, moving into temporary housing, of which there are only a limited
number, was done randomly by lottery or other means in order to maintain fairness (randomizedmove-ins). Based on the experience of the Great Hanshin-Awaji Earthquake, Iwanuma City
implemented a method of moving into temporary housing while maintaining the community byneighborhood associations (group move-ins). A study of the impact of this method revealed thatthose who moved into group housing were 2.5 times more likely than those who moved into
random housing to maintain relationships and to be in good mental health.
The impact of disasters on the mental and physical health of disaster victims is significant.
As for the relationship between the onset of depression after the earthquake and residential
relocation, the risk of developing post-disaster depression was twice as high among those whomoved to temporary housing compared to those who did not move. Losing jobs, and not being able
to receive mental health support immediately after the disaster were associated with worsening
symptoms of depression, in addition to the loss of a home. Two years after the earthquake, there
was still an effect, and the effect of having one's home completely destroyed was more
pronounced in males. The inability to see a psychiatrist immediately after the disaster also had animpact, but various measures were taken, including the opening of a mental health care center. In
the immediate aftermath of the disaster, while everyone is working hard, declining mental healthmay go unnoticed, and it is important to provide mental health care even to those who may appear
to be okay.
Post-traumatic stress disorder (PTSD) is known to be caused by traumatic experiences thatthreaten someone’s safety, such as war, natural disasters, and accidents. A study of PTSD among
survivors found that while loss of relatives or friends and damage to houses increased the chancesof PTSD, social bonds among individuals and local communities prior to the disaster suppressed
PTSD.
Among the elderly, the study found that dementia worsened as a result of the earthquake.
Those whose homes were completely destroyed reported higher levels of dementia (worsecognitive functioning) than those whose homes were not damaged. In our study, we found thatthose who had weakened social ties after the earthquake showed a worsening of dementia due tohousing damage, while those who had improved social ties after the earthquake showed amitigation of the impact of housing damage on dementia.
The loss of a home, a job, and the inability to see a physician immediately after the disasterwere all associated with a reduction of independence in the lives of the elderly about 2.5 years
2after the disaster. The inability to see a doctor is thought to have worsened chronic illnesses due tothe disruption of medication, the loss of human connections, and the decreased frequency of goingoutside due to the absence of outpatient visits.

Figure 40-1. Community ties before the earthquake suppressing the onset of Post TraumaticStress Disorder (PTSD)

2: Paradigms Destroyed by the Earthquake
In the Great East Japan Earthquake, although there was about one hour between theearthquake and the arrival of the tsunami, many people were killed by the tsunami. We
investigated the relationship between the deaths caused by the tsunami and the characteristics ofthe elderly people living in the area before the earthquake. We found that those who were severely
depressed before the disaster had a higher mortality rate of 12.8% and a significantly higher risk ofdeath of 3.9 times. On the other hand, surprisingly, those who had less independence in daily life
and were considered to be at higher risk of death from the tsunami were less likely to die on theday of the disaster. In Iwanuma City, it is reported that on the day of the earthquake, there was abridge that was not destroyed due to earthquake countermeasures that were in place, andevacuating residents of an elderly residence was successful. An unexpected finding was that therisk of death on the day of the earthquake tended to be twice as high for sociable people who often
met with others, compared to those who did not meet with friends often. This means that the moresociable people were, the more likely they were to not leave others alone, going to help them, andunfortunately becoming victims of the tsunami. For those who needed support in the community,
such as those who needed nursing care, various measures were taken in places with close
community relations, which enabled a quick evacuation. On the other hand, those who wereseverely depressed were not necessarily recognized by the people around them, making themhigh-risk people who would delay evacuation. In the Sanriku region, tsunami tendenko has been
passed down from generation to generation, a tradition in which each person flees in isolation tosave their own life. However, for vulnerable people who cannot evacuate on their own, many lives
can be saved by putting measures in place in advance, such as considering a disaster response incare plans.

3Figure 40-2. Risk of mortality during and after the 2011 Great East Japan Earthquake and Tsunamiamong older coastal residents

3: A New Approach
Disaster response utilizing the comprehensive community care system
We think that the community-based comprehensive care system being promoted by thegovernment would be useful in a disaster response. Community-based comprehensive care is aconcept in which medical care, nursing care, prevention, housing, and lifestyle support arecomprehensively secured so that people can continue to live independently according to theirabilities in the communities familiar to them for as long as possible, even if they need medical careor nursing care.

4: Achievements and the Future
A nationwide survey was conducted targeting the Regional Comprehensive Support Centerand municipalities, which play a central role in this comprehensive community care system.
Although few local governments have established a comprehensive community care system as adisaster countermeasure, the number of municipalities and neighborhood associations working on
voluntary disaster prevention in the region is gradually increasing. They are not waiting forassistance from the outside, but rather, they are communities that do what they can on their own
under the leadership of good government and neighborhood associations. In the future, however,
local resources related to home healthcare, such as home care support clinics, home nursing
stations, nursing care offices, and home delivery pharmacies, will be very important for emergency
responses in the event of a disaster. It is necessary to have a system that is organically related todisaster response. In addition to securing power supplies for people using home oxygen andventilators in their individual care plans, it is necessary for community disaster prevention toenvision existing nursing and welfare facilities as emergency evacuation sites and to consider
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disaster response in community care meetings. In addition, it is not enough for individualcompanies and medical institutions to create business continuity plans (BCP), but the entire
community must think about it, because if, for example, a nursery school or nursing home closes, itwill affect many people of working age. While this type of movement seems to be emerging in theindustrial sector, community continuity management (CCM) is needed to sustain an entire region.
In order to achieve this, it is necessary to have a mixture of initiatives in the community, that
include governments and business, children to the elderly, and that see elderly people and people
with disabilities in need of care as valuable community resources.

Conclusion - from the authors
By putting ideas such as mixed disaster responses in which a diverse group of people areinvolved in responding to a variety of disasters in various ways, including the COVID-19 pandemic,
we hope that communities will become more resilient, and that no one will be left behind.

References
Aida, J., Hikichi, H., Matsuyama, Y., Sato, Y., Tsuboya, T., Tabuchi, T., Koyama, S., Subramanian,S.V., Kondo, K., Osaka, K., Kawachi, I. (2017). Risk of mortality during and after the 2011 Great
East Japan Earthquake and Tsunami among older coastal residents. Scientific Reports, 7(1),16591. https://doi.org/10.1038/s41598-017-16636-3
Tohoku University Graduate School of Dentistry. (2017). Ministry of Health, Labor, and Welfare
Promotion Business Report: Constructing a disaster response through the comprehensive
community care system. (In Japanese)
Tsuboya,T., Aida, J., Hikichi, H., Subramanian, S.V., Kondo, K., Osaka, K., Kawachi, I. (2017).
Predictors of decline in IADL functioning among older survivors following the Great East Japan
earthquake: A prospective study. Social Science & Medicine, 176, 34-41.
https://doi.org/10.1016/j.socscimed.2017.01.022

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