Health in Disasters
A Science and Technology Studies Practicum for
Medical Students and Healthcare Professionals

Editors:
Rethy Kieth Chhem

Gregory Clancey

Formerly Division of Human HealthInternational Atomic Energy Agency
Vienna, Austria

STS Cluster, Asia Research InstituteNational University of Singapore
Singapore

Editorial team:
Pisith Phlong, IAEA
Azura Z. Aziz, formerly IAEA
Ryan Crowder, IAEA
Penelope Engel-Hills, CPUT
Agustina Grossi, IAEA
Joanne Heng, IAEA

Disclaimer: The views and opinions expressed in this handbook belong solely to the authors and are
not representative of the views and opinions of the International Atomic Energy Agency, National
University of Singapore or any other institution involved. This book is intended for educational andinformational purposes only and does not constitute legal, technical, medical or fiscal advice.
Information in this book should not be used as a substitute for professional expert advice given
individually regarding a specific situation. We decline all responsibility for any decisions taken byreaders based on the topics covered in this book.

ACKNOWLEDGEMENT
This STS handbook has been produced as the result of several technical meetings at IAEA in
Vienna, Austria, that gathered international experts and Japanese medical doctors who havebeen involved at the frontline of the Fukushima nuclear power plant accident to respond to
medical emergencies. Through a series of intense discussions with these concerned Japanesephysicians and scientists, and in consultation with a panel of experts in social sciences, theparticipants of the meeting reached the conclusion that only a multidisciplinary STS approach
could help in addressing a complex situation such as the Fukushima Daiichi accident.
The preparation of this STS handbook is in line with the educational needs of Fukushima
Medical University and other Japanese institutions and has been possible through thecontributions and expertise of many experts, especially Japanese medical doctors from
Fukushima Medical University, Hiroshima University, Nagasaki University and National
Institute of Radiological Sciences (NIRS). Special thanks go to Dr Shunichi Yamashita, Dr
Tetsuji Okamoto, Dr Kenji Kamiya, Dr Akira Ohtsuru, Dr Koichi Tanigawa, Dr Arifumi
Hasegawa, Dr Atsushi Kumagai, Dr Hirooki Yabe, Dr Kenneth Nollet, Dr Noboru Takamura,
Dr Tomoyoshi Oikawa, Dr Makato Akashi, Dr Hideo Tatsuzaki, Professor Hideyuki Matsuiand Dr Jun Shigemura. We would also like to thank Dr May Abdel-Wahab and Dr Ahmed
Megzifene for their inputs and editing of this handbook.

PREFACE
Historically, the main concern of medical professionals was the symptom. The patient was acarrier of symptoms to which observation, medical reasoning, and techniques were applied.
Therefore, the medical concern did not extend much farther than the biological body. Even
when operating in a public health capacity, it was not seen as the responsibility of medical
professionals to understand socio-cultural factors, even when they had an obvious influenceon outcomes.
The Fukushima nuclear power plant accident of March 11, 2011 has challenged theseassumptions.
Through technical support by the International Atomic Energy Agency (IAEA), a number of
meetings between international and Japanese experts were organized by the Department of
Nuclear Sciences and Applications, the Division of Human Health (NAHU) with thecollaboration of the Fukushima Medical University in 2013-2014. The international experts
were impressed and moved by the attempts of Japanese health professionals to mitigate thedamage caused by the compound disaster – the earthquake, tsunami, and nuclear power plant
accident. However, many responders would be the first to admit that they were greatly
disadvantaged by their limited training in the social dimensions of disaster. Thus, items notcovered in the education and training of these professionals impinged on the efficacy of theJapanese medical response to the Fukushima Daiichi accident, and by extension, on thegeneral health of the Japanese population.
There is a persistent need for medical professionals, educators, and aspiring medical students
to acquire a broader understanding of the tightly bound relationship between patient andsociety. This requirement becomes only greater when facing disaster, as knowledge of thesocial is increasingly important in establishing and maintaining a relationship between
professionals and citizens during catastrophic events.
This handbook has emerged from this need to better understand the social dimensions ofdisaster. International and Japanese experts in Science and Technology Studies (STS) andmedical education gathered in a meeting in October 2013 to discuss the most relevant needsof the medical curriculum as expressed by faculty members of Fukushima Medical
University, Hiroshima University, Nagasaki University and the National Institute ofRadiological Sciences. The expert knowledge presented within the following pages urgesiprofessionals and students alike to assume responsibility beyond that of the traditional care ofpatients, and to acknowledge the complexities of culture which persist beyond theexamination room.
Of course, writing is a form of understanding. This handbook attempts to create and cultivate
a relationship between the reader and the academics represented within their field ofexpertise. These chapters seek to illustrate the many areas of importance associated withdisaster often neglected in the education of medical professionals. Each chapter will include
important case studies to aid the medical students and health professionals in exploring andapplying relevant STS concepts throughout the handbook.
We begin with an overview of general radiation history and the historical shaping of culturalexperience surrounding disasters in the Japanese context. Following this we address the crisisin expertise often inherent to the onset of disasters and the nature of contested diseases,
especially with regard to psychosomatic afflictions. Next, the topics of coping with disasters,
risk communication, and social determinants of health address the issues of risk perception
and communication within society, and between medical professionals and their patients.
Finally, we discuss the interrelated topics of professionalism, law and ethics with regard toconceptions of value-based practice, and conclude with a general discourse upon disasterstudies as a topic of analysis.
Although the primary context of this handbook is the Japanese experience, all medical
professionals, students, and educators working within the medical sector would benefit
greatly from the breadth and acuity of expertise presented within these pages. Disaster is acontextual matter, but its effects are universal, and arming medical professionals with theknowledge presented herein will provide strong aid to communities plighted by disaster.

Rethy K. Chhemformerly IAEA, Vienna, Austria

Gregory K. Clancey
Singapore, SingaporeiiContents

Guide to the Handbook: Promoting Learning through Curriculum
Penelope Engel-Hills ............................................................................................................................ 1

Introduction
Gregory Clancey and Rethy Chhem ..................................................................................................... 8

1

Techno-natural Disaster and the Role of Expertise
Ulrike Felt and Rethy Chhem...................................................................................................... 13

2

Disease, Illness, and Sickness: A contested boundary
Heiner Fangerau, Azura Z. Aziz and Rethy Chhem.................................................................... 25

3

Perception of Radiation Risk: The Ethical Dimensions of Coping with Disaster
Deborah Oughton and Penelope Engel-Hills .............................................................................. 40

4

Risk Communication
Yuko Fujigaki and Kwan-Hoong Ng .......................................................................................... 62

5Social Determinants of Health
Laurence Monnais ....................................................................................................................... 77

6

Professionalism, Law & Ethics
Tamra Lysaght and Satoshi Kodama .......................................................................................... 91

7

Learning across Disaster: Rebuilding Health
Kim Fortun ................................................................................................................................ 102

Glossary ................................................................................................................. 113

iii

GUIDE TO THE HANDBOOK: PROMOTING LEARNING THROUGHCURRICULUM
Penelope Engel-Hills1

Introduction
The compound disaster in Fukushima alerted the medical community to the need for all healthcare
practitioners and educators to engage with the complexities and dynamics of patients as integral tosociety. The need for awareness and understanding of the social aspects of health, disease andhealthcare, in disaster, has been exposed. This handbook is one response to this acknowledged needand is prepared for medical students and all healthcare practitioners. Each of the chapters of thehandbook draws on the valuable lessons learnt from the Fukushima Daiichi nuclear accident andincorporates applied case studies of this and other disasters. However the goal of the handbook is toprovide a platform to stimulate discussion and further reading that goes beyond the particular disasters
referred to, in order that the learning can be contextualized and applicable to all in any situation where
there is planning and preparation for possible disasters.
The aim of this chapter is to present an introduction to applied educational theory in order to promotelearner and educator engagement with the content in the handbook in a way that encourages deeplearning. Through optimum use of this handbook it is expected that there will be enhancement of theunderstanding of the social dimensions of disasters within a range of different thought collectives orcultural environments that inform the interpretation of and response to disasters.

1. Applied Educational Theory
1.1 Pedagogy
The assumption is that adult learning is different from learning in childhood because maturity brings
with it the resources of life experience together with an approach that is more inclined towards thesolving of problems than the learning of subject content. The word, andragogy, is frequently used forthe learning strategies that are specifically focused on adult learners (Davenport and Davenport 1985).
In order to avoid the confusion and debate that at times accompanies the use of andragogy, the genericterm, pedagogy, will be used in this handbook for the theories and approaches to teaching andlearning.

1 Deputy Dean, Health and Wellness Sciences, Cape Peninsula University of Technology

e-mail: EngelhillsP@cput.ac.za

1

1.2 Taxonomy of Learning
Pedagogical research has entrenched the recognition of learning as a process that takes place at anincreasing level of complexity. Learning in its simplest form is the recall of facts while higher level
learning involves more complex processes such as analysis and evaluation. Bloom (1956) developed ataxonomy to describe this order of learning and his classification of the levels of thinking during thelearning process remain widely accepted. Bloom’s taxonomy was based on the premise that you firstneed to understand something before you can evaluate it or apply the knowledge in another context.
This implies that prerequisite knowledge and competencies need to be in place before there can belearning at the higher level (Table 1). Anderson and Krathwohl (2001) revised the taxonomy torepresent the current approaches to teaching and learning (Table 1) but retained the concept oflearning according to the level of complexity.

Table 1: Bloom’s taxonomy revised
Bloom’s taxonomy (1956)

Anderson and Krathwohl (2001)

Evaluation

Creating

Synthesis

Evaluating

AnalysisAnalyzing

Application

Applying

Comprehension

Understanding

Knowledge

Remembering

In Bloom’s taxonomy, “knowledge” is the ability to recall or remember facts, and “comprehension” isthe ability to understand and interpret the information. Based on Bloom’s taxonomy, health care
professionals or students, in environments where a nuclear disaster is a possibility, should be able todisplay knowledge and comprehension of the topics related to the disaster/s under discussion. So for
example, the professionals should have relevant knowledge of the natural sciences (e.g. radiation
physics, radiobiology) and the applied social sciences (e.g. social health, stigmatization). The topics
covered in this handbook are the key components that underpin development of health care
professionals to function effectively and efficiently in a disaster.
The revised model (Anderson and Krathwohl 2001) lays out the components of learning as cognitive
processes that can be applied to lesson design. These verbs have the potential to enable teaching,learning and the assessment of learning.

2

1.3 Learning Outcomes
The educator or study leader can incorporate the content of this handbook into the design of a lesson
covering the topic of any particular chapter or a combination of chapters. It is a good idea to start by
specifying the learning outcomes for a particular lesson or series of teaching, and learning activities as
the main aim of professional education is to promote the achievement of high level learning outcomesin the learners (Trigwell and Prosser 1991). Learning outcomes shift the emphasis from teaching as an
input process to a focus on the learner and their learning (Allan 1996). They are statements of what
the learner will know and be able to do following

Table 2: Classification of learning (Anderson & Krathwohld, 2001)
Remembering

retrieving information from long-term memory

Understanding

constructing meaning from instructional messages including oral, written and graphic
communication

Applying

use of knowledge to carry out a procedure in a new situation

Analysingdeconstructing the information into its constituent parts and determining how theparts relate to one another and to the overall structure or purpose

Evaluating

making judgements based on criteria and accepted standards or protocols

Creating

putting elements together to form a coherent whole or reorganising elements into newpatterns of structure

participation in the lesson. Bloom (1956) identified three domains of learning; cognitive, affective andpsychomotor. These domains each have a level of complexity of learning that can be achieved
through participation in an educational activity. According to Bloom the use of the correct verb is the
key to the successful writing of learning outcomes and the revised model of Anderson and Krathwohl(2001) provides helpful verbs for this purpose (Table 2). An example therefore might be that
following this lesson the learner will; 1) demonstrate understanding of the historical shaping of thecultural experiences of the disaster in Japan and 2) be able to apply this knowledge to their local
context in order to plan appropriately for possible disasters of that region.

1.4 Competencies in Professional Education
In the education of a healthcare professional it is helpful to determine the competencies that thelearner should achieve through the course being offered. The competencies that need to be identified
include the core competencies, that are specific to the course and profession, and the genericcompetencies that cut across occupational and academic contexts. Mielke and Weber (1989) identified
seven generic competencies; working cooperatively, learning effectively, communicating clearly,
3

working productively, acting responsibly, valuing self and thinking critically and creatively. These areuseful competencies to keep in mind when designing a course on disaster planning and management
and although they are not generally taught in lessons the learning activities should be planned todevelop these generic competencies. So, for example, communication skills are essential for all
professionals working in a disaster environment and the curriculum activities should enable thelearners to develop the competencies with regard to the types of communication that are relevant andpossibly specific to the context e.g. the communication of risk or the communication needed for
advocacy and shaping changed attitudes following a disaster. The core competencies are identifiableabilities that must be achieved for the particular professional (e.g. doctors, nurses, x-ray technologists)being educated. When designing the course or particular lesson they can be described in terms oflearning outcomes thus defining the appropriate content and professional practice related to disastermedicine.
The educational shift from a focus based on theoretical knowledge and skills to competency based
education provides for a learning environment that prepares the learner for the integration ofknowledge, abilities and attitudes. An example of competencies identified for medical doctors arethose described by the CanMEDS system as the seven roles of a physician that were developed by theRoyal College of Physicians and Surgeons of Canada in order to implement postgraduate specialist
programs that appropriately respond to needs of society (Sherbino and Frank 2011). In the context of
education for a disaster, a competency and outcome focus will enable the professional to practiceadequately and adjust to the abnormal situation effectively.
1.5 Active Learning
The lesson design should include tasks and activities that allow the learner to be an active participant
rather than a passive recipient of information. It has been shown that learners retain information betterand develop problem solving, critical thinking, attitudinal change or motivation for further learning
through active learning, such as discussion, rather than from passive input lecture methods (Bonwell1991). A lesson design with a balance of formal lectures and appropriate activities and tasks that
promote active learning, will facilitate learning of the specified learning outcomes.

2. Designing a curriculum for learning
A professor in the Department of Physics at the Imperial College of Science, Technology andMedicine in London, stressed that teaching and learning in professional education should draw on theacademic disciplines that form the knowledge base of the profession, and on the workplace for which
the learners are being prepared (Barnett 2006). In this case the medical students or health care4

professionals are being educated for the specific work environment of disaster-medicine; however the
principles of general professional education remain relevant. The educators should use the chapters of
the handbook, with content based on both disciplinary knowledge (theory) and knowledge forprofessional practice (situated or applied knowledge and competencies or professional abilities), toguide the selection of what to teach and how to plan activities that enable learning. The learners will
benefit from engaging with the disciplines, having facilitators who are experienced educators and or
experts in the field of disaster-medicine and where possible having direct exposure to the real worldof professional practice in a disaster situation. The latter can be through videos, interviews, theinternet or other media that brings the realities of a disaster into the learning environment.
Work-integrated learning (WIL) is an educational approach that seeks to actively build connections
between the world of teaching and learning, and the workplace or environment of professional
practice (CHE 2011). Figure 2 shows how the three knowledge dimensions of the curriculum can bealigned; the dotted line in figure 2 implies that the separation between the disciplinary or academic
and professional components is not rigid but rather the relevant elements of professional practice canbe drawn on when designing a curriculum for a specific purpose. The focus of WIL is professionallyoriented education, as shown by the grey areas and is therefore a suitable basis for the design of acurriculum directly linked to professional practice within the context of a disaster.

5

The academic
dimension

The educational dimension
Professional(directed by the learning outcomes)
practice
DisciplineProfessionallyorientedoriented education
education
Faculty (academic
Faculty select theFaculty determine
Professionals arestaff), develop new
relevant areas forthe professional
educated to be able
knowledge andthe course (theconcepts to be learnt
to transfer/apply thethinking in the fieldhandbook can help and competencies tolearning from theof disaster-medicine
with this process). be achieved.
course into theirthrough research and
The selected
Teaching andfield of practice.
other academic
activities arelearning activities
The learners areengagement. This
planned to promote and assessment tasks
well prepared for
handbook is anactive learning and are designed thatthe unexpected at
example of
to enable thewill facilitate thethe time of aknowledge building
learners to engage professional
disaster.
in this area.
with the material
development of thein ways that arelearners.
appropriate to thelearners’
conceptual
development.
Figure 2: A knowledge system for a curriculum for professional development in disaster-medicine(Adapted from CHE 2011)

3. Concluding comments
This handbook provides material to guide educators in healthcare programs to enhance therelationship between the student/professional and the experts speaking through the chapters they havewritten. An awareness of relevant applied educational theory will allow for the planning ofappropriate teaching and learning activities to enhance high level learning and the achievement ofcompetencies. The content of these chapters is concise information on key social dimensions ofdisaster-medicine that can be incorporated into existing programs or be used to prepare new programs.
Educators and students are encouraged to use this handbook as a tool to stimulate discussion andreading that will go beyond the content of the chapters in order that the learning is relevant to theparticular environment of the students and potential disaster.

6

References

Allan, Jo. 1996. “Learning Outcomes in Higher Education.” Studies in Higher Education 21(1): 93-108
Anderson, Lorin W. and David R. Krathwohl, eds. 2001. A Taxonomy for Learning, Teaching, andAssessing: A Revision of Bloom’s Taxonomy: Complete Edition. New York: Longman.

Barnett, Michael. 2006. “Technology, Science and the English Tradition of Liberal
Education.” Australian Journal of Teacher Education 7 (1): Article 4. Accessed 17
December 2013 http://ro.ecu.edu.au/ajte/vol17/iss1/4
Bloom, Benjamin S., ed. 1956. Taxonomy of Educational Objective: The Classification of
Educational Goals. Handbook I: Cognitive Domain. New York; Toronto: Longmans. Green.
Bonwell, Charles C. 1991. “Active learning: Creating Excitement in the Classroom”. In Youth
Development and Agriculture Education. Accessed December 14, 2013.
http://www.ydae.purdue.edu/lct/hbcu/documents/Active_Learning_Creating_Excitement_in_t
he_Classroom.pdf

CHE (Council on Higher Education). 2011. “Work-Integrated Learning: Good Practice
Guide.” Higher Education Monitor No. 12, August 2011. Pretoria: IeCommunications.
Davenport, Joseph and Judith A. Davenport. 1985 . “A Chronology and Analysis of theAndragogy Debate.” Adult Education Quarterly 35 (3): 152-159.
Mielke, Anne and Dave Weber. 1989. Core Ability Project. Fond du Lac: Moraine Park
Technical College.
Sherbino, Jonathan and Jason R. Frank, eds. 2011. Educational Design: A CanMEDS guide for thehealth professions. Ottawa: Royal College of Physicians and Surgeons of Canada.

Trigwell, Keith and Michael Prosser. 1991. “Improving the Quality of Student Learning: The
Influence of Learning Context and Student Approaches to Learning on Learning
Outcomes.” Higher Education 22: 251-266.

7

INTRODUCTION
Gregory Clancey2 and Rethy Chhem3,4Large-scale disasters tend to re-structure groups of people, objects, and institutions, so thatthe world after the event is never quite the same as the one before. The compound disaster ofMarch, 2011 in Japan followed this pattern. An earthquake triggered a tsunami, which in turntriggered a nuclear power plant accident. While the tsunami was by far the most serious
disaster in terms of lives lost and property destroyed, the nuclear power plant accident led toa crisis of communication and public trust which exacerbated recovery from both. The
breakdown in trust led to political, social, and psychological problems, some with medical
consequences. Any one of these events would have been serious, but taken together and intheir multiple severities, they shook the nation and the world beyond. Fundamental changes
have followed in their wake, and are ongoing as we write.
This handbook is a product of one such change. The Japanese medical community was afront-line responder to the tsunami and nuclear accident, and its role in providing after-care in
the stricken areas has not lessened with time. Even in a country as well-prepared for disasteras Japan, however, and one with a uniquely tragic experience with nuclear radiation, healthprofessionals were strained by the scale and complexity of the 2011 events and theiraftermath. In 2012-13, doctors associated with Fukushima Medical University (FMU) begana series of meetings with social scientists (mainly STS5 scholars), through the initiative of theInternational Atomic Energy Agency (IAEA), in order to both report and work through someof the difficulties they were facing. They hoped that their experiences might be madeavailable to other health professionals in Japan and around the world, in order to preparethem for similar situations.

Hence the current handbook, which is likely the firstcollaboration ever attempted between doctors, social scientists, and humanities scholars on
the issue of radiation-related disaster.

2

Associate Professor, Dept. of History and Asia Research Institute, National University of Singapore (NUS)e-mail: hisgkc@nus.edu.sg
3
formerly Director, Division of Human Health, International Atomic Energy Agency (IAEA)
4 Distinguished Visiting Professor, University of Nagasaki, Hiroshima University and Fukushima Medical
University
e-mail: bengmealea@yahoo.com
5
STS stands for “Science, Technology, and Society” or in some constructions “Science and Technology
Studies”, which is a well-developed interdisciplinary field of inquiry dating from the 1970s.

8No two disasters or accidents are exactly the same, so this handbook is not a ‘how-to’ manualor template for managing a crisis. One of many lessons learned from Fukushima is thatflexibility, creativity, and the ability to cope with limited or conflicting information are
essential qualities to have when protocols break down. Doctors and nurses are already highly
experienced at dealing with emergencies by virtue of their regular training, so there is little
we could write here to supplement or expand on this inherent medical skill-set or instinct.
Our focus is rather on a state of crisis outside the highly controlled space of the hospitalemergency room, a place for which medical curricula usually offer little preparation.
Large-scale disasters produce landscapes of chaos, which societies usually attempt to set rightthrough acts and ceremonies of ‘recovery’, presaging a return to normality. The ‘return tonormal’ is problematic even with relatively cyclical natural events, but when radiation
leakage or fallout is added as an element, the task of recovery becomes much harder, much
more prolonged, and perhaps impossible in highly-contaminated areas. The invisibility ofradiation, its longevity in the environment, its complex and controversial (i.e. not entirely
understood) effects on the human body, the often obscure technical language which experts
use to discuss it, its historical legacy (particularly in Japan), and the politics surrounding
nuclear energy all contribute to a very different doctor-patient relationship following aradiation-related accident than in the aftermath of a typhoon, earthquake, tsunami, or evenother classes of industrial accident. In attempting to discuss health effects of radiation,
doctors may find themselves on very uneasy ground, either having to admit to inadequate
knowledge or even being accused of conspiring with those who may have been responsible
for the accident in order to downplay its impact. These problems are often classed byphysicians and others under “health communication” or “science communication”, but suchterms are inadequate to describe the post-disaster situation in which what previously seemed
like ‘solid’ knowledge is itself compromised or tested.
The doctor-patient relationship relies on trust. After the Fukushima nuclear accident,
however, suspicion of authority replaced trust among many victims and their families, not tomention the general public. Skepticism was entirely natural, as an earthquake of suchmagnitude, and tsunami of such height, had not been predicted by government seismologists.
Official hazard maps had also not pinpointed the likely location of the event. Neither had anuclear accident of that type and scale been anticipated or prepared for by the plant’s
designers, owners, or regulators. Ambiguities surrounding the geography of the subsequentevacuation zone, combined with conflicting information from experts and government
9

officials following the event, added further confusion and mistrust. In an atmosphere inwhich expertise itself, both scientific and bureaucratic, seems to break down, medical
expertise is not immune. Physicians’ attempts to explain the effects of radiation to the public,
and to individual patients and their families, were thus met with far more confusion,
skepticism, and resistance than prevails in a normal diagnostic process. Trust needed to berestored for communication to re-open and be productive, a process that is even now
continuing in Japan.
While the fear, trauma, and even the ‘existential crisis’ which settles over society following aradiation-related disaster may be beyond the control of individual physicians and nurses,
disaster and post-disaster scenarios can be anticipated and prepared for. The situation as
described in the paragraph above is not unique, but close to typical following large-scaledisasters the world over. The field of Disaster Studies provides many lessons as to what
happens to societies and individuals when previously reliable structures and frames suddenly
collapse. These effects are too wide-ranging and complex to be fully explained with medical
descriptors, such as “Post-traumatic Stress Disorder” (PTSD), as useful as these might be indiscussing individual responses. A proper understanding requires going beyond even thepsychological dimension, as important as that is, to the social, cultural, historical and evenphilosophical – what might be called a ‘humanities perspective’; one that takes lessons from afull range of disciplines and combines them to form a broader, fuller, and more textured
image of disaster and post-disaster scenarios. This is one challenge of the present book.
Besides Disaster Studies, the interdisciplinary field of Science, Technology, and Society(STS), also known as Science and Technology Studies, has many lessons to teach about
expertise under stress or crisis. Publics often under-estimate the amount of uncertainty,
debate, and simply differing contexts or frames that exist amongst communities of scientists,
engineers, doctors, and related technical experts. Citizens and government officials often look
for and indeed expect a unified and authoritative “scientific voice” even when none exists.
The press may be more conditioned to accept, indeed actively seek out, disagreement anduncertainty, but in so doing may pathologize or sensationalize what are actually normative
disputes. While consensus is certainly a goal of scientific and medical debate, and closure isregularly achieved around crucial issues, large-scale disasters and accidents tend to re-open
questions, or foster new ones, in the most awkward, sudden and hence dramatic ways.
Moreover, they increase the numbers of ‘relevant social groups’ or stakeholders, and multiply
the numbers of voices engaging questions that a day or two before were the province of a10

small number of experts, technicians, or regulators. The rise of social media makes thepossible number of such voices nearly infinite. Add to this the element of liability, theassortment of blame, and the very real damage to bodies and societies, and the result is muchmaterial for social scientists to weigh and ponder. Indeed, disasters and accidents can upset
even social scientific consensus, which is more usually constructed around ideas of howsocieties behave under ‘normal’ circumstances.
What all of this means is that the present handbook is a spur to discussion and thought rather
than a guide as to how one should behave, or what one should do. It is not an emergency
manual, but a book to prepare students for the eventuality of emergency by opening theirminds to probabilities, uncertainty, and possibilities they may not have considered in ‘normal
times’. It is also, we hope, a spur to greater curiosity; a sign-post pointing toward a large,
rich, and growing literature on disasters and accidents spanning more fields, and visiting
more examples, than we could include between its covers.
While the contributors to this handbook come from many countries, and offer examples andperspectives from around the world, they are also acutely aware that Japan’s relationship withthe disastrous effects of radiation is singular in world history. The string of events from theatomic bombings of Hiroshima and Nagasaki, to the Lucky Dragon 5 Incident, to the
Fukushima nuclear power plant accident

itself, cannot be adequately chronicled andanalyzed in a book of this nature, and readers are strongly encouraged to engage the larger
literature which explains, debates, and draws connections within this history. Likewise, thestring of global nuclear power plant accidents which include Three Mile Island, Chernobyl,
and now Fukushima Daiichi provide another context very relevant to the current project, andone with its own extensive literature. Many of the contributors to this volume have had direct
or indirect experience with these cases, as well as other disasters and industrial accidents nothaving to do with radiation. This is the larger context which frames the handbook.
We should also remind readers that Fukushima Daiichi, like Chernobyl, is an ongoing crisis.
The victims and potential victims still require care, and, at least around Fukushima andChernobyl, contamination will continue to affect the natural environment and society’s
relationship to it for a long time to come. Medical professionals should thus approach the
topic of radiation exposure not only from the standpoint of an emergency, bounded in time. It
is a situation needing to be actively managed over a long period, not only for those exposed,
but their families and communities. Evacuated populations, who may not have been exposed11

to any radiation at all, or to very small amounts, also require understanding, engagement, andcare. While each crisis or event has ‘phases’, one should also not think of these too rigidly or
concretely, as different populations and individuals can experience the same phase atdifferent times, or skip over some of them altogether. This is another reason why a criticalrather than a programmatic approach to disaster is crucial, one that constantly questions thetools and methods one is using rather than accepting them blindly or considering them
unproblematic tools in a box.
Lastly, let us never forget that anyone exposed to high levels of radiation is a victim ofhuman and societal error (or in the case of bombing). That means that those who become
victims through no fault of their own could carry legitimate feelings of anger toward
societies, governments, industries, and policies, which they might also legitimately seek tochange. Controversies surrounding nuclear energy, nuclear weapons, and even the use ofradiation in medical procedures do not have to be resolved by every health professional, butevery one of us should be aware of them as a context in which encounters with patients takeplace. Fear of radiation and anger about exposure are not pathologies, and should thus not be
medicalized, even as psychological disorders. Understanding when to apply medical
terminology on the one hand, and social and philosophical language on the other, is indeed
one of the skills medical students should cultivate as they grapple with the issues in thishandbook. This raises larger questions about the limits of science, the risks of technology, therole of citizens, and ethics, which extend beyond the scope of the present book but are
fundamental to a fuller understanding of ‘radiation and society’ as a compelling modern
theme.

12

CHAPTER 1TECHNO-NATURAL DISASTER AND THE ROLE OF EXPERTISE
Ulrike Felt6 and Rethy Chhem7,8

Summary
In contemporary industrialized societies, scientific and technological expertise has come to play anincreasingly central role ranging from policy decisions to questions of personal choice. This isparticularly true in extreme situations such as techno-natural disasters. Yet, at the same time, it is inthese situations that people feel unsure about which expertise to trust, and medical professionals
express the feeling that their authority is called into question. To discuss these issues, this chapter
starts by reflecting on the specificities of a techno-natural disaster and how this situation challenges
health professionals in particular ways. In a second step, the question of what an expert is and what
holding expertise means is addressed from different perspectives. We then shortly point out how,through the omnipresence of mass media in contemporary societies, new kinds of experts andexpertise gain visibility and challenge existing authorities. Finally, the chapter reflects on the different
kinds of expertise medical professionals would need to develop in order to better contribute tohandling major technical or techno-natural crises.

Learning Objectives
After reading this chapter the reader will be able to:(1) Define and explain expertise(2) Locate distrust in health professionals’ expertise within a broad understanding of thechallenges during situations of crisis(3) Understand the paradox of expertise in crisis situations(4) Recognize the different actors involved in the public arena in a techno-natural disaster such as
Fukushima(5) Recommend how the education system for health professionals could respond to this paradox
Keywords: Expertise, techno-natural disaster, communication, trust

6

Professor, Head of Department of Science and Technology Studies, University of Vienna
e-mail: ulrike.felt@univie.ac.at
7
Formerly Director, Division of Human Health, International Atomic Energy Agency (IAEA)
8Distinguished Visiting Professor, University of Nagasaki, Hiroshima University and Fukushima Medical
University
e-mail: bengmealea@yahoo.com

13

Introduction
In contemporary industrialized societies, scientific and technological expertise has become aubiquitous source of authority. Almost all policy decisions rely on expert advice. In the realm of oureveryday lives, scientific and/or technological expertise has also become of greater significance suchas when people have to take individual and collective choices regarding their health, the consumptionof some products (such as genetically modified food), or energy privilege. To behave like a “rational
citizen” is nowadays often seen as synonymous with following the advice of experts. The latter are
perceived as more knowledgeable and thus better equipped to provide the support for an informed
decision. Thus, we could say: Expertise and experts are omnipresent in contemporary industrializedsocieties.
While this unquestioned dominance of experts is true across many areas of our lives, “they tend to betalked about only when things go wrong” (Stilgoe, Irwin and Jones 2006), e.g. in the context ofdisasters and even more so when health issues play a central role. This is definitely the case for the
Fukushima Daiichi accident (for a case study after Chernobyl, see: Wynne 1992). Sociotechnicalproblems in general, and techno-natural disasters in particular, are complex and fraught withuncertainties and information is generally scarce and unstable; yet decisions need to be made quickly.
Thus, expertise is highly challenged. In such situations, people’s ambivalence towards the role ofexperts becomes visible: expertise is simultaneously longed for and distrusted as well as tested andcontested by citizens.
In such extreme situations, people working in health-related professions have to face the limits of
their own professional self-understanding. Their expertise is immediately called upon yet
simultaneously challenged to a degree unimagined when engaging in their daily profession under‘everyday’ circumstances. Health professionals are accustomed to being trusted, to holding
unquestioned authority, to being able to provide a diagnosis or some relief, as well as to having thecapacity to offer guidance for possible actions. Yet, in such exceptional situations, when a feeling ofstability is of utmost importance – as is the case in disasters – they are often confronted with the limitsof their expertise and have to face people expressing doubts or questioning recommendations.
We are thus confronted with a classical paradox of expertise9: While expertise is increasingly sought
for and used as a source for making choices, it is simultaneously contested (Nelkin 1975; Weingart
1999). This can be due to a multitude of reasons. Not admitting the limits of expert knowledge is one.
A lack of transparency in the way expertise is selected and used might be another. Thirdly, citizens
ask for more of a voice and want to contribute their own expertise in making choices, be it
9 Bijker, Bal and Hendriks (2009) speak more generally of a paradox of scientific authority.

14

individually or collectively. The latter is particularly true when decisions impact on the livelihood ofthemselves or their family or when they feel that they hold considerable experience with the issues atstake. Finally, it is often the case that the more a person becomes an expert in a specific (all too often
quite narrowly defined) domain, the more s/he is likely not to perceive wider issues and changes
palpable to those possessing less specialized knowledge.
In the following we will approach these questions of expertise in four steps. We will first look at the
specificities of techno-natural disasters (Perrow 2007; Steinberg, Sengul and Cruz 2008) and how
they challenge the way we classically analyse health related problems, and how to deal with experts
and to identify solutions. We will then look at the very idea of what it means to be an expert and to
hold expertise in the medical domain. In a third part, we will reflect on the multiplication of expertisein public space and on the role the media plays in this. Finally, drawing these reflections together, thechapter offers a way to rethink health related expertise.

1.1 Techno-Natural Disasters and Their Challenges for Expertise
Nations are “imagined communities”, Benedikt Anderson (1991) argued; they are imagined and held
together through political and cultural activities. Science, technology and medicine are core culturalactivities and therefore national identities, i.e. conceptions, meanings and ways of being Japanese,
have to be understood as closely tied to these developments (see Hecht 2001). A national identity
links a mythologized past with a collectively imagined future, which often “appears as the inevitablefulfillment of a historical legitimated destiny” (Ibid.). In one way or another “the nuclear” was and is
an important part of Japanese national identity, be it through the memory of the dramatic experiences
ending World War II or through the more techno-optimist realization of nuclear power as a peacefulsource of energy. In the second half of 20th century “the nuclear” has thus become an integral part ofJapanese techno-political culture (Felt, Fochler and Winkler 2010). Viewed as part of technologicaland societal progress, there was a widespread belief that it could be managed and contained in favourof the nation’s development. A cross-road sign at the entrance to Futaba, now a deserted town inside
the 20-kilometer evacuation zone of Fukushima Daiichi power plant, brings this belief to the point:“Nuclear Power: Energy for a brilliant future”.
Any disaster, natural, technological or techno-natural, is an event causing a substantial disruption of
the economic, social and cultural life of people. It causes significant physical and psychologicaldamage and dramatically destroys our living environment. Every society has had to endure and learn
from disasters in the past – mostly “natural” ones – be it floods, fires, earthquakes. Throughout its
history, Japanese society has managed to accommodate major natural forces such as earthquakes ortsunamis with broader cultural, technological and economic developments (Clancey 2006). Ways of15

handling and organizing response have been developed, technological and social early warning
systems have been put in place, and procedures to swiftly restore public life, even under severe
conditions, have been set up.
But even though nation states have embraced technological progress and learnt to respond to natural
disasters, techno-natural disasters, such as the hybrid earthquake-tsunami-nuclear disaster ofFukushima, pose completely new challenges. Well-functioning articulations between thetechnological and the social are dramatically disrupted, and both knowledge and experience arelacking about how to reinstall order in such a new and complex situation. This might explain why
actors involved in the aftermath of the disaster almost unanimously complained about the scarcity andthe low quality of the information flow. Much rather than acknowledge the full complexity of theissue at stake, many seemed to hold the strong belief that “the right information” is available, and thatgetting it in time would thus automatically lead to the finding of appropriate solutions.
Yet, while one can express critique of the information politics of different actors, ranging fromgovernment institutions to those running the power plant, it is important to consider several aspects. In
the case of techno-natural disasters (1) it is utterly difficult to put together a reliable set of data which,from hindsight seems most relevant; (2) data gathering has to happen under extreme circumstances
and in a swift manner; (3) skilled persons capable of reading and interpreting this data are often not
widely available; and (4) a balance has to be found between adequate information and overflow of
information, as the latter can do more harm than good and create a situation of disinformation.
Techno-natural disasters have their own timing. The necessary expertise has to be assembled quickly,
data interpretations have to be performed under constantly changing boundary conditions, choices
have to be made about what information is to be disseminated and to which audiences, and, finally,
derive from the knowledge acquired which corresponding actions need to be taken. While this is true
for virtually all disasters, it takes a particular turn when human health is at stake. Collins and Pinch(2005) have addressed this in the following quote: “Medicine is a science, like other sciences, but it isalso a source of succor — a source of relief or assistance in times of distress. The two faces of
medicine often conflict. One dimension of that conflict is urgency: medicine as a science has to try to
get things right however long it takes, but medicine as succor has to provide an answer here andnow.” Indeed, in many situations of choice related to broader scientific and technological issues
people can adopt a “wait and see” position and often do not feel pressured to make choices; in healthrelated issues this is usually not the case. Medical practitioners, but also citizens, have to take action
immediately, often under conditions where information is difficult to collect and scarce; classicalexpertise cannot be directly applied to the new situation, and knowledge about potential consequencesof any action taken or not taken is low. Here the question of expertise becomes a particularly
challenging one and needs reconsideration.
16

1.2 Expertise, Crisis and Contestation
Let’s start by posing two seemingly straightforward questions: What is expertise? Who is an expert?
While the notions of expert and expertise seem evident, the more we reflect on them the less this is
the case. There are at least two kinds of answers we propose. The first draws on the fact that in many
situations we tend to connect expertise with a high degree of scientific/formal knowledge a person
holds on an issue. While this is surely one way to define it, it makes us overlook that formal
knowledge is only part of what we know. Indeed, we often do not sufficiently consider the importanceof tacit knowledge (Polanyi 1958/1998), i.e. intuitions, personal insights or hunches which are an
important part of the knowledge any expert – as any other member of a given society – holds. Thisdraws our attention to how the experience, values, or ideals researchers hold always nourish and shapescientific knowledge. This tacit knowledge is shared, when we learn from each other throughinteraction; it is thus an outcome of social relations within knowledge communities but also withinsociety at large (see also Collins 2010). As responding to situations of natural disasters is notuncommon in Japanese society, we can claim that there is an important degree of tacit knowledge
available. People are often not aware of the knowledge they possess or how it can be valuable to themand others.
We want to argue alongside Fleck (1935/1979) that any knowledge – both tacit and explicit – isalways related to communities of people – communities he calls “thought collectives”; the productionof any knowledge is thus an essentially social process. Thought collectives share a specific way ofseeing and understanding the problems at stake – which Fleck calls a “thought style” – and ofdeveloping solutions. Being educated and working as a health professional thus always means
belonging to such a “thought collective” and having acquired a specific way of addressing issues atstake. The expertise acquired through belonging to such a collective could predominantly be seen as akind of “routine expertise” (Hackett and Rhoten 2009). This means that members of any thoughtcollective learn to solve familiar problems by using a set of tools, techniques and approaches which
are shared by its members. This works perfectly well in the health system, where patientsacknowledge this expertise most of the time and are embracing and accepting this kind of expert
advice to make choices.
However, particularly in complex and hitherto unexperienced situations – the situation in postFukushima being such a case – this well-arranged way of understanding expertise is challenged. Herea second perception of expertise enters the scene. Expertise can no longer simply be a message fromexperts to patients or wider publics; it is no longer a set of statements uttered by experts in a routine
manner. Expertise becomes “the result of collective learning and assessment” (Limoges 1993), the17collective no longer being solely fellow health professionals, but now also including affected people –be they patients or their relatives, or simply members of society. Therefore, the interaction between
the different participants in such tense and controversial situations “in the end defines the status ofexpert knowledge and sets the limits of its efficacy” (Ibid.). This fundamentally changes the very ideaof expertise outlined in the beginning of this subchapter. In this understanding, expertise is not solely
the property of a person acquired through learning in a thought collective, but something that needs tobe developed and re-established in every fundamentally new situation. “When this fails,” Limoges
highlights, “expert knowledge as knowledge of experts is largely discounted and ignored or, evenworse, it becomes dysfunctional, a part of the problem rather than a part of the solution” (Limoges
1993).
In particular, in techno-natural disasters, it is very difficult for professionals to provide the clarity andunambiguity of expertise we seem to long for. More than ever, they need to find answers to questions
they have not chosen – which is a situation contrary to that in classical research. As a consequence,
they are pushed to constantly transgress the limits of their competence (Nowotny 2003), e.g. as
defined in purely medical terms. Thus, in these exceptional situations, statements of experts are quasinecessarily partly contradictory and change over time; standards of expertise are blurred, posing thequestion of whom to trust; expertise appears as utterly fragmented, the partiality of perspectives oncomplex problems renders this visible. As a consequence, there is a call to open up the question ofexpertise to public debate and to make expertise more transparent (Jasanoff 2003). Such a critical
public debate of technoscientific issues and of who counts as expert should be seen as “an expressionof confidence in its potentiality” within science and technology, and “not [as] a loss of trust”(Nowotny 2003). The importance we attribute to science and technology in contemporary societies,
the authority we generally grant to these fields of expertise, however, brings along the right of citizens– in democratic societies – to express their own views of what is at stake and to question expert
statements.
For the health domain, the situation takes a rather specific form. While people have learned to build
personal trust relations to a small number of medical practitioners when it comes to their own and totheir family’s health, in situations of crisis these intimate relationships cannot be easily upheld.
Doctors are not only called on to care for individuals, but they are often pushed to make statements
outside the realm they usually work. They are expected to make statements pertinent to the general
population and provide public counsel – all of which goes well beyond the degree of expertise ofclassical health professionals. Furthermore, health-related issues are very intimate ones, deeply
imbued with cultural values where people thus develop their own perspectives and have their own
body of experience and expertise. Therefore the issue of the limits of expertise is raised over and overagain.

18

1.3 Multiplication of expertise and framing of the disaster in the public space
In particular in situations of public crisis surrounding technoscientific disasters, health professionals
are not the only actors that play an important role when patients and their families try to make senseof their situation. We live in a media-oriented society where much of what we know about the worldcomes from media in various forms. Media contributes to creating collective memories about similar
situations in the past, strongly shapes perceptions of what happens in the present and, through that,
also projects potential futures. Media plays an essential role in framing our understanding of what the
problem is, how it develops and what is at stake (Lewenstein 1995). News about health and medicine
generally rank very high in media attention (Bucchi and Trench 2008) which explains theirimportance in situations of disaster where health related issues matter. With social media and theinternet as additional information sources, we also see a multiplication of sources people can turn totowards getting informed. These latter media, however, are open to all kinds of information, and thus
multiply the voices and interpretations available. Diverse members of society – as experts of everyday
life – report in much detail about their perceptions of the world; they produce, collect or distributeinformation and put forward their own analysis of potential dangers but also of possible solutions.
Thus, they play an important role in the trust relations people can develop with classical experts.
It is therefore not only important to judge whether or not health-related news are reported correctly byjournalists and others who report news, but to also consider how media reports make choices whendescribing, quoting and portraying health professionals when they refer to scientific evidence or when
they offer interpretations of scientific studies and their consequences (Malone, Boyd and Bero 2000).
Through narrating the disaster story in specific ways and through selecting and showcasing evidence,
journalists (and other writers) construct specific accounts of health issues at stake and propose –sometimes implicitly – potential actions to be taken. The media thus identifies issues, validates
information and shapes our views on matters to be addressed. They contribute to the production of“counter-expertise” (Topçu 2008) and become important players in developing collective andindividual responses to techno-natural disasters. Furthermore, they also unfold moral narratives anddistribute responsibilities.
For health professionals this means that they need to grasp the presence of such public narratives as
they shape the interaction with (potential) patients. They need to acknowledge the multiplicity ofavailable expertise and consider how relevant these are in their own domain of expertise. It is thus
essential to not simply discard media reports on the grounds that they do not comply with the thoughtstyle of the community of health professionals, but to analyze them as alternative forms ofunderstanding what is at stake – even though one might not share the view.

191.4 Conclusion: Rethinking expertise – a way out of crisis?
The reflections made so far point to the fact that the techno-natural disaster of Fukushima is notnecessarily a crisis of expertise – as often highlighted. Instead, health professionals need to develop
different kinds of expertise in order to adequately respond in such complex situations. It is no longer
sufficient to solely rely on routine expertise, in the sense of being able to perform health-related
professional work by the book. Instead, health professionals need context-specific, situated forms ofexpertise, and to be capable of responding to complex real-life situations which often comes with alack of validated information, non-knowledge (i.e. admitting that medicine cannot answer certain
kinds of questions), uncertainty, and contingency. This would mean to consider and specificallyembed the training of these necessary skills in the education of health professionals.
Rethinking expertise means devoting more attention to three kinds of expertise. The first would beinteractional expertise10, meaning that medical professionals have to engage with people and theirexpertise well beyond their peer group. This notion draws attention to the need that healthprofessionals have to master communication across many different fields, but above all, with different
groups in society. In situations of disaster, new extended “trading zones” emerge where the healthrelated issues are discussed, negotiated and dealt with. This means that health professionals have todevelop new kinds of “language skills”, i.e. learn how to express their views in context-sensitive
manners as well as learn to listen to the ways in which people think and express their concerns (seeGorman 2010). This in turn would allow them to gradually acquire an expert position in suchsituations. It also means acknowledging that under new circumstances expertise cannot be regarded
simply as a given, but needs to be established over and over again. These processes should not be seenas throwing the validity of medical authority into question, but rather as opportunities for widening a
medical professional’s view on the problems at stake. Patients and their families also hold specificforms of expertise and it is essential to find creative ways of using these different kinds of expertise inorder to develop solutions to health related problems.
The second kind of expertise to be developed is contributory expertise. Health professionals,
particularly in situations of disaster, cannot expect to obtain a straightforward, ready-made overview
of all necessary information in order to be able to act. They will have to work with incomplete, often
shaky information, engage with local forms of knowledge and be imaginative in developing potential
solutions. In that sense, they are expected to become active contributors to developing a bettercollective understanding of the socio-technical problem at stake – on both a technical and social level.
Health professionals hold a reservoir of expertise – be it tacit or explicit – about what such a disaster
10

Collins and Evans (2007) in their extensive analysis of expertise use thes notion of interactional andcontributory expertise in a different way than the one outlined here.

20

means for the many individuals they have encountered and for the nation as a whole. This means thatthey have to learn to transgress their classical areas of expertise and become co-investigators of thetechno-natural disaster.
Finally, health professionals have to develop adaptive expertise, i.e. the capacity to address new andcomplex problems “by creatively transferring and transforming elements of diagnoses, interpretations,and solutions across contexts” (Hackett and Rhoten 2009).
Overall, situations of disaster should remind us that (1) living in a techno-scientific world also needs
new ways of dealing with expertise, and that (2) health is not only a medical phenomenon, but needs
to be understood as a complex socio-medical phenomenon. This means that medical education shouldbe open to new ways of learning, allowing not only to reproduce previously acquired knowledge, butalso explicitly invite health professionals to think in terms of new and unexpected situations, notcaused from within the system but by the societal context in which they work. It calls for a broadeningof education of health professionals with a critical review of their understanding of expertise whilst
also focusing more on the development of these new forms of expertise. This will allow a better
response to challenges posed in complex situations such as techno-natural disasters.

Questions and Answers(1) What different kinds of expertise can be distinguished?
i.

Adaptive expertise requires an individual to develop a conceptual understanding thatallows the "expert" to invent new solutions to problems and even new procedures for solving
problems; demonstrate flexible knowledge handling; understand the types of learning
trajectories that may allow practitioners to break free from routines when necessary.
ii.

Contributory expertise is the ability to contribute to analysing and solving a specificproblem by drawing together different sets of information from research as well as from otherinformation sources.
iii.

Counter expertise is constructed by members of civil society in order to control

classical expertise as well as to allow for alternative interpretations of risk and of theinformation collected by classical institutions.
iv.

Interactional expertise emerges through complete immersion in a specific problem

context; an expert community learns to use the language of another expert community (e.g.
medical practitioners and lay-groups engage in an exchange); describes the capacity toactively engage with the knowledge and experience available in another community.
v.

Routine expertise means the mastering of well established procedures of finding

solutions in such a way as to become highly efficient and accurate.
21

(2) What is a thought collective and what a thought style?
A thought collective is a group of people who share a specific way of seeing the world –inscience, thought collectives are equivalent to scientific communities. A thought style refers tomethods and theories which organise the way we see and try to explain the world. Every
person can be a member of different thought collectives, e.g. a person can be part of a medical
thought collective, but also a thought collective of environmental activists.
(3) What is meant by “paradox of expertise”?
In exceptional situations, when a feeling of stability is of utmost importance as is the case indisasters, expertise is increasingly sought for and used as a source for making choices, yet it issimultaneously contested.
(4) What role do media play with regard to expertise?
Media plays an essential role in framing our understanding of problems, and the stakes thatare associated with them. Social media and the internet are important information sources that
amplify the voices and interpretations available, thus playing an important role in trust
relations. Furthermore, the media becomes an important player in developing collective andindividual responses to techno-natural disasters, unfolding moral narratives and distributing
responsibilities. It is thus essential not to simply discard media reports, but to analyze them asalternative forms of understanding what is at stake – even though one might not share theview.
(5) What is special about a techno-natural disaster with regard to the question of expertise?
In techno-natural disasters, well-functioning articulations between the technological and thesocial are dramatically disrupted, and both experience and knowledge are lacking about how
to restore order in such a new and complex situation. In addition, information is generally
scarce as well as unstable; yet decisions need to be taken quickly, thus challenging expertiseto a great extent.
The challenges of expertise in techno-natural disaster are as follows:i.

It is difficult to put together a reliable set of data which seems from hindsight themost relevant.

ii.

Data gathering and interpretation has to be performed under extreme circumstances
and in a swift manner.

iii.

Skilled persons capable of reading and interpreting this data are often not widely
available.

iv.

A balance has to be found between adequate information and overflow of
information, as the latter can do more harm than good and create a situation ofdisinformation. Decisions have to be made about what information to disseminate and22

to which audiences, and finally, derived from the knowledge acquired, whichcorresponding actions need to be taken.

References
Anderson, Benedict. 1991. Imagined Communities: Reflections on the Origin and the Spread of
Nationalism. London: Verso.
Bucchi, Massimiano, and Brian Trench, eds. 2008. Handbook of Public Communication of Scienceand Technology. London; New York: Routledge.
Clancey, Gregory. 2006. Earthquake Nation: The Cultural Politics of Japanese Seismicity, 18681930. Berkeley: University of California Press.
Collins, Harry M. and Robert Evans. 2007. Rethinking Expertise. Chicago: University of Chicago
Press.
Collins, Harry M. and Trevor J. Pinch. 2005. Dr. Golem: How to Think About Medicine. Chicago:
University of Chicago Press.
Felt, Ulrike, Maximilian Fochler and Peter Winkler. 2010. “Coming to Terms with Biomedical
Technologies in Different Technopolitical Cultures: A Comparative Analysis of Focus
Groups on Organ Transplantation and Genetic Testing in Austria, France, and theNetherlands.” Science, Technology & Human Health. 35 (4): 525-553.
Fleck, Ludwik. Genesis and Development of a Scientific Fact. 1935/1979. Chicago; London:
University of Chicago Press.
Gorman, Michael E. 2010. Trading Zones and Interactional Expertise – Creating New Kinds ofCollaboration. Cambridge, MA: The MIT Press.
Hackett, Edward J. and Diana R. Rhoten. 2009. “The Snowbird Charrette: Integrative
Interdisciplinary Collaboration in Environmental Research Design.” Minerva. 47 (4): 407440.
Hecht, Gabrielle. 2001. “Technology, Politics, and National Identity in France.” In Technologies ofPower: Essays in Honor of Thomas Parke Hughes and Agatha Chipley Hughes, edited byMichael T. Allen and Gabrielle Hecht, 253-294. Cambridge, MA: The MIT Press.
Jasanoff, Sheila.2003. “(No?) Accounting for expertise.“ Science and Public Policy, 30 (3), 157-162.
Lewenstein, Bruce V. 1995. "Science and the Media." In Handbook of Science and Technology
Studies edited by Sheila Jasanoff, Gerald E. Markle, James G. Petersen and Trevor Pinch,
343-360. Thousand Oaks: Sage.
Limoges, Camille. 1993. “Expert Knowledge and Decision-making in Controversy Contexts.” Public
Understanding of Science. 2 (4): 417-426.

23

Malone, Ruth E., Elizabeth Boyd and Lisa A. Bero. 2000. “Science in the News: Journalists'
Constructions of Passive Smoking as a Social Problem.” Social Studies of Science. 30 (5):713-735.
Nelkin, Dorothy. 1975. "The Political Impact of Technical Expertise." Social Studies of Science 5 (1):35-54.
Nowotny, Helga. 2003. “Democratising Expertise and Socially Robust Knowledge.” Science andPublic Policy. 30 (3): 151–156.
Perrow, Charles. 2007. The Next Catastrophe: Reducing our Vulnerabilities to Natural, Industrial,
and Terrorist Disasters. Princeton, N.J.: Princeton University Press.
Polanyi, Michael. 1958/1998. Personal Knowledge: Towards a Post-Critical Philosophy. London:
Routledge.
Steinberg, Laura J., Hatice Sengul, and Ana Maria Cruz. 2008. “Natech risk and management: anassessment of the state of the art.” Natural Hazards 46 (2): 143-152.
Stilgoe, Jack, Alan Irwin, and Kevin Jones. 2006. The Received Wisdom. Opening up expert advice.
London: Demos.
Topçu, Sezin. 2008. "Confronting Nuclear Risks: Counter-Expertise as Politics Within the French
Nuclear Energy Debate." Nature and Culture 3 (2): 225-245.
Weingart, Peter. 1999. "Scientific expertise and political accountability: paradoxes of science inpolitics." Science and Public Policy 26 (3):151–161.
Further Reading
Bijker, Wiebe E., Roland Bal and Ruud Hendriks. 2009. The Paradox of Scientific Authority: The
Role of Scientific Advice in Democracies. Cambridge, MA: The MIT Press
Collins, Harry M. 2010. Tacit and Explicit Knowledge. Chicago: University of Chicago Press.
Wynne, Brian. 1992. "Misunderstood misunderstandings: social identities and public uptake ofscience." Public Understanding of Science. 1 (3): 281-304

24

CHAPTER 2DISEASE, ILLNESS, AND SICKNESS: A CONTESTED BOUNDARYHeiner Fangerau11, Azura Z. Aziz12, Rethy Chhem13,14

Summary
Defining health is a difficult task. According to their intentions, institutions like the World
Health Organization (WHO), health insurance carriers or persons like employees or
employers use different definitions. These range from global concepts to narrow,operationalized classifications. Similarly, different, sometimes contradicting concepts of
disease, illness and sickness exist. Whereas illness is often defined as the subjective
experience of feeling ill, the term disease is often used to describe the application of objective
criteria in attempts to demarcate health from disease. What counts as objective criteria isaxiomatically stated by science and medicine. It is inherent to scientific approaches that thelimits of concepts, such as concepts of disease, are steadily under discussion. Sometimes,
however, even basic understandings of either a disease or models of a disease’s etiology arecontested. We will use the example of discourses about radiation and its effects on health anddisease in order to illustrate the cultural and historical dimensions of disease concepts which
affect the alleged objectivity of scientific definitions of disease and illness.

Learning Objectives
After reading this chapter the reader will be able to:(1) Describe the concept of disease - disease, illness and sickness(2) Explain substantial and gradual disease concepts of medicalization(3) Discuss discourses on radiation safety
11

Director, Institute for the History of Medicine and Medical Ethics, Cologne University
e-mail: heiner.fangerau@uni-koeln.de
12Formerly Division of Human Health, International Atomic Energy Agency (IAEA)
e-mail: noor.azura.zuhairah@gmail.com
13
Formerly Director, Division of Human Health, IAEA
14Distinguished Visiting Professor, University of Nagasaki, Hiroshima University and Fukushima Medical
University
e-mail: bengmealea@yahoo.com

25

Keywords: Disease concepts, low doses of radiation, hormesis
Introduction
It remains an unresolved question whether health, according to the definition by the WHOfrom 1946 as “a state of complete physical, mental and social well-being and not merely theabsence of disease or infirmity,” can ever be fully achieved (Grad 2002). Although there
appears to be transnational agreement that health is far more than the absence of illness, any
concept of health is in some way still linked to concepts of illness and disease (Rothschuh1975), and what is understood as “not well-being” has several cultural determinants subject tochange over time. According to the German social law focusing on health insurance, forexample, unhealthiness is an irregular physical, psychological or mental condition resulting
in an inability to work (Niehoff 2008, 37). Of course, from a subjective perspective a person
who is able to work does not necessarily feel healthy. Thus, it is difficult to come to auniversal definition of unpleasant conditions such as “illness” or “disease”. The different
facets of health, or more accurately “unhealthiness”, have been thoroughly discussed byseveral authors like Christopher Boorse, Lennart Nordenfelt, Hans Georg Gadamer or Talcott
Parsons to name but a few (for an excellent bibliographic overview see Hofmann 2002).
These discussions have led to different―and still disputed―concepts of human ailment.
Nevertheless, a triad of illness, disease and sickness proposed by Andrew Twaddle in the late1960s, and defended in an influential analysis by Björn Hofmann (2002), has proven to bevery useful and intuitively intelligible.
In the following we will refer to this triad in order to describe a four-dimensional concept ofdisease, which results in frontiers of the normal and the pathological that may change overtime (the fourth dimension) with the consequence that these borders need to be negotiated in
medical and social discourses. In doing so we (like the other cited authors) are well awarethat this model is based on a western tradition of reasoning about medicine. We will use theexample of discourses about radiation and its effects on health and disease in order toillustrate the cultural and historical dimensions of disease concepts which affect the alleged
objectivity of scientific definitions of disease and illness. After a short introduction into the“concept of disease”, we will sketch the historical development of disease concepts related toradiation. One has to be aware that historical nuclear narratives may imply responsibility andthat their contents can be challenged by different perspectives (Hamblin 2012). These
different perspectives may be brought about by conflicting concepts of disease, illness and26

sickness as we will illustrate with this short historical sketch and finally a case study about
the hormesis concept as an example of a contested boundary of disease and health.

2.1 A Concept of Disease
Following the post-war debates surrounding the concepts of health and illness, the subjective
notion of feeling unwell in physical or psychic terms is usually referred to as “illness”,
whereas the objectively diagnosed illness is called a “disease”. The objective diagnosis in thisunderstanding is performed by professional medical scientists or physicians according tocertain, axiomatically defined medical criteria that establish a nosology. An “illness” needs tobe acknowledged as a “disease” in order to result in other people’s actions to help in
overcoming the unpleasant status or to recognize it as a status in which another person mightneed help. This social perspective on human suffering/ailment is often referred to as“sickness”. To put it in Hofmann’s (2002, 657) words: “Disease is negative bodily
occurrence as conceived by the medical profession. Illness is negative bodily occurrence asconceived of by the person himself. Correspondingly, sickness is negative bodily occurrence
as conceived of by the society and/or its institutions. Occurrence here means process, state or
event.” We would even extend this definition to mental occurrences as well.
Concepts of illness, disease and sickness in this sense might be contested by representativesof either of the systems involved in demarcating unhealthy states (medical profession,individual patients, society at large), especially if their interpretation is considered as unstablefrom a cultural and temporal (historical) perspective. Not only taxonomies of diseases orsocial (hidden or apparent) institutions but also several personal physical and psychologicalexperiences are bound to cultural and historical contexts (Stolberg 2003, 29). As aconsequence, we need to add a diachronic perspective, a temporal dimension to the threeperspectives on unhealthiness (cf. Fangerau and Martin 2011).
If people feel ill due to an occurrence, state or event and parts of the society also
acknowledge this state as (resulting in) sickness, pressure is put on physicians to discuss theirconcepts of the disease and to do research on the classification of the disease (nosology). In
this case the medical system is only able to fulfill its task if it at least tries to find disease
criteria that fit and explain the feeling of illness and sickness in order to stabilize andharmonize the ‘illness, disease, and sickness’ triad. The same is true for the opposite situation27

whereby a disease has been defined by the medical profession according to certain criteria
which is generally not accepted by patients or society at large (cf. Brown 1995).
As a consequence, medical scientists are urged to arrive at definitions of diseases. In doing
so, two dominant directions of disease concepts seem to have been prominent in the past.
They can be classified as either substantial or gradualistic approaches to diseaseclassification. Far more terms for this dichotomy exist and other dichotomies like ontologicalvs. nominalistic or realistic vs. constructivist have been discussed, but essentially they
address the same problem (Hofmann 2001). Diseases are either understood as substantial:
consistent, fixed entities similar to botanical taxonomies (like in Thomas Sydenham’s
nosology), or they are understood as gradualistic: a historically contingent demarcation of atransition phase or point on a gradual scale which ranges from the normal to the pathologicalat each end (cf. Cohen 1953; Cutter 2003). These two extreme views can be reconciled, orthey at least share common features: whereas health and disease are clearly defined on bothends of such a scale, the transition point at which a condition becomes a disease needs to be
defined; whereas a broken bone clearly belongs to the pathological end of the scale, thequestion of when usual drinking transgresses the diagnostic border to alcoholism is such a
gradualistic problem that needs to be negotiated. The definition of where the normal andpathological spaces are on this scale (cf. Canguilhem 1978), including the nosological criteria
for making a condition a disease, however, relies on medical knowledge, medical technology
and contexts of illness and sickness in a given era. Scientists do not define diseases in an
open space: their methods, their reasoning and their results are embedded within a social andtechnological context. As with other individuals they are driven by interests, resources andpublic demands. As a consequence, some authors coined this interdependence of medical
science and society “the social construction of medical knowledge” (Jordanova 1995).
A gradualistic understanding of disease can especially result in dispute. If conditions definedby medical scientists as diseases are not generally accepted by patients and the society as
such, some authors refer to the model of medicalization to describe these situations.
“Medicalization” is basically a value free term to explain the extension of the medical sphere
into areas which have been previously outside of its realm (Conrad and Angell 2004).
Nevertheless, several critics of medicine and its approaches have used the term with negative
connotations, hinting to the potential danger of defining diseases as conditions which they
regard as normal (see e.g. Illich 1975a, b). If conditions are generally accepted as
pathological but the medical definitions are disputed or the transition point is under attack or28

medical science does not offer a disease definition at all we tend to speak of “contested
diseases” (Figure 2.1). Generally, what is considered a disease is contested in somesituations.

Figure 2.1: Dimensions of Unhealthiness (modified from Brown 1995)

Applied Examples using Figure 2.1
 Scenario 1: A person feels ill 24 hours after exposure to high amounts of ionizing
radiation, the society acknowledges him or her as sick and a physician is able todiagnose the disease as acute radiation syndrome. The three aspects of unhealthinessare in agreement and no conflict about what is pathological arises. In this case, one canpresume that even from a diachronic perspective the harmony of the three aspects
might be quite stable. If, however, one aspect is not in accordance with the others, a
dispute might occur, which results in processes of adaptation or persuasion triggeredby the representatives of the perspective on unhealthiness not met.
 Scenario 2: Society does not acknowledge the ill-being of a person. The person tries tofind an ally in the medical profession, asking for a disease concept that backs his or her
claim of being sick. An example might be offered by discussions about compensation
for delayed effects of radiation, when institutions or political authorities contest theillness claims of individuals after exposure (Cable, Shriver and Mix 2008).
 Scenario 3: At the same time society might define a person to be in a state of sickness
which does not result in the person’s ill-being. In the context of radiation, neighbors
might tend to avoid contact with nuclear scientists because they fear to be “infected”
with radiation received by these scientists. Another illustrative example are so-called“social deviances” (what counts in a certain culture at a certain point of time as such):
for instance, historic interpretation of lifestyles like homosexuality resulted in changing
frontiers and blurred borders within and between these aspects of human suffering(Conrad 1980; Conrad and Angeli 2004).

29

The history of debating the effects of radiation on human health offers various examples of
the negotiations surrounding “contested diseases”. In the following we offer a brief, general,“standard” narrative of discourses on radiation safety. However, one has to be aware that
historical nuclear narratives may imply responsibility and that their contents can bechallenged by different perspectives (Hamblin 2012). These different perspectives may bebrought about by conflicting concepts of disease, illness and sickness as we will illustratewith a case study. Additionally, we will illustrate how experts disagree about what a disease
is by using the example of current debates surrounding the concept of hormesis.

2.2 Discourses on radiation safety – a historical overview of disease concepts related
to illness and sickness
A short time after Wilhelm Conrad Roentgen had reported his discovery of x-rays in 1895 thefirst reports highlighting serious side effects from exposure to ionizing radiation were
published. Over the next few decades, reports continued to implicate the extensive use of xrays in such somatic responses of skin irritations, sterility, leukemia and cancer. In 1927
Herman Joseph Muller added his findings that genetic mutations could be induced by x-rays
in Drosophila. His results also indicated that there was no threshold level of radiation below
which no damage was observed (Walker 1989; Seelentag 1985, xiii). The possible hazards
resulting from radium in the 1920s and 1930s entered the public domain when there werereports on cases of women who died from the damaging effects of radium that they had
ingested by licking the tips of brushes they used to paint the luminous dials of alarm clocks.
In a further example, in 1932, the media informed the public about radium poisoning
associated with the death of a well-known playboy from Pittsburgh who had tried to
rejuvenate himself by ingesting large amounts of radium enriched water over a period formore than four years (Piispanen 1995, 97; Macklis 1990). At this time, against first hopes ofradiation having healthy effects, evidence was such that it was accepted that high doses ofradiation would result in severe radiation effects.
However, from early on the contested boundary was found to be related to assumptions
regarding low levels of ionizing radiation. A first attempt at defining a “tolerance” dose of30

radiation which could be received without evidence of damage – meaning the dose below
which there is no evidence of a transition from a physiologically tolerable condition to adisease – was made by the American Arthur Mutscheller. He defined a “skin erythema dose”
to quantify biological radiation effects in man and added a safety factor which resulted in him
concluding that a dose not exceeding 1% of the “skin erythema dose” within a month would
be “tolerable”, meaning, that it had no sustainable biological effect (Seelentag 1985, xiii).
However, there was immediate disagreement among experts regarding this tolerance dose andduring the following years several radiation protection groups and committees on aninternational level suggested different tolerance doses (Brodsky, Kathren and Willis 1995).
Due to limited empirical evidence no group “claimed that its suggested tolerance dose wasdefinite.” What was agreed was “that exposure below the recommended limit would be
unlikely to cause permanent damage to an individual in normal health” (Walker 1989, 665).
In the middle of the 20th century, Hiroshima and the consequences of the atomic bomb
brought a “new era for radiation safety”. Radiation safety issues became more complex
because many new, ‘man-made’ radioactive elements and isotopes were created throughnuclear fission. There was the realization by scientists that, even if nuclear weapons were
never again used in warfare, the civil use of nuclear energy in power plants would mean an
exposure of a large number of people to low dose levels of radiation. As J. Samuel Walker,
the historian of the US Nuclear Regulatory Commission, stated: “Radiation protection had
broadened from a medical issue of limited proportions to a public health question of,potentially at least, major dimensions” (Walker 1989, 665). In response to these premises theinternational boards and committees lowered their exposure limits in an attempt to establish
protection guidelines for the general public. The fallout controversy during the late 1950s
again highlighted the significance of radiation protection of the public.
Atmospheric bomb testing by the USA, the Soviet Union, France and Great Britain produced
radioactive fallout that reached populations far away from the areas of testing, with an impact
on health and the environment in North America, Siberia, Australia and the Pacific Islands(World Uranium Hearing 1993). A public controversy followed, supported by the media withnews reports and magazine articles. Radiation hazards became a political issue and became acomponent of political campaigns. To quote Walker’s narrative again: “As a subject of publicconcern, radiation moved from the rarified realms of scientific and medical discourse to thefront page” (Walker 1989, 666). Scientists and medical experts disagreed about the risks, andthe possible risks were balanced against possible benefits beyond the scope of biological31

radiation hazards. In the Western discourse the risks of fallout were juxtaposed with the risksof being behind the Soviet Union in the arms race. National security was the dominantdiscourse that overshadowed conversations about nuclear hazards and scientists defended
their actions on that basis. To add to this, contradictory notions of tolerance doses, “linear nothreshold” and “threshold” models of the relationship between radiation damage and dosewere under discussion. Nuclear scientists were unable to give clear accounts of the resilienceor repair functions of human cells after exposure to radiation.
This crisis re-emerged when, after the establishment of nuclear power plants, questions of thehealth effects of low-level radiation entered the public discourse again with a long sustained
drive. However, the fundamental difficulty remains that a rather low radiation-induced cancer
is almost never pathologically distinguishable from a cancer due to other causes and that the
numbers of radiation-induced cancers that might be due to low level radiation are often too
small to distinguish from those occurring ‘naturally’. As a consequence in most cases it isunclear whether any particular cancer was caused by radiation, although recent findings
support the idea long-term exposure to low dose radiation increases the risk for leukaemia(Abbot 2015). This is why it is so difficult to understand and explain the risks. Resulting
latent public anxieties and the associated dissension among scientific experts are nurtured by
the debates accompanying the use of nuclear energy per se and this continues until today. The
yet-unsolved problem of nuclear waste and the recent disasters of Chernobyl and Fukushima
with their global public impact brought this crisis to center stage.

Case Study: Radioactive fallout and local populations – Nuclear testing in the Soviet
Republic of Kazakhstan (Werner and Purvis-Roberts 2007)“…One of the scientists we interviewed suggested that radiation is just a small factor affecting
public health. From his perspective, local health patterns in the villages are best explained by poor
diets and psychological stress associated with radiophobia. He added that he himself had been
exposed to more radiation than most villagers without any harmful impacts on his health. Since it
is still impossible to acquire health data for the residents of Kurchatov, it is difficult to state
whether this population has also experienced health problems associated with radiation exposure… the USSR Ministry of Health collected data through a series of medical expeditions to thevillages surrounding the test site (Shkolnik 2002: 100-114). With all of this data, doctors andscientists investigated the correlation between radiation exposure and certain health problems,
including cancer and birth defects. Due to the need for secrecy, however, patients could notactually be told that their doctors were studying the impacts of radiation exposure. The scientists
who prepared the Shkolnik volume indicate that the Soviet government was very interested inmonitoring the health of the local population, but they fail to indicate the extent to which thegovernment provided effective treatments for these populations.”
This is a clear case of a contested boundary whereby the local population is facing an illness that is
associated with radiation exposure, yet the illness is not recognized as a disease by doctors and 32
scientists, or as a sickness by the State due to the need for secrecy in the name of national interests.

33

2.3 Hormesis and the equivocal low level radiation effects
The 2011 Fukushima Daiichi accident revived a scientific discourse that paradigmaticallyreflects the example of a crisis in expertise which is caused by inconclusiveness of scientificfindings and the varied interpretation of these findings – in the form of contested diseases.
This is the scientific and public discourse about a phenomenon named “hormesis”, which
defends a favorable biological response to low level toxins and describes the possible
stimulating effects of low level radiation.
A few days after the Fukushima Daiichi accident the American commentator, Ann Coulter,
stated on TV and on her homepage: “With the terrible earthquake and resulting tsunami thathave devastated Japan, the only good news is that anyone exposed to excess radiation fromthe nuclear power plants is now probably much less likely to get cancer. This only seems
counterintuitive because of media hysteria for the past 20 years in trying to convince
Americans that radiation at any dose is bad. There is, however, burgeoning evidence that
excessradiation

operates

as

a

sort

of

cancervaccine”(http://www.anncoulter.com/columns/2011-03-16.html. Last accessed 2014-02-24). The
evidence she is referring to, however, is highly contested and not linked to excessive dose but
to low doses. Particularly, the interpretation of “stimulating effects” of low dose radiation
effects as positive, neutral or negative is under discussion. Opposing the currently mostly
accepted linear no-threshold model of radiation effect, hormeticists believe that low levels ofradiation have positive effects on human health, an effect also observed (in relation to an
intended effect) with some chemicals and alcohol.
Possible stimulatory effects of radioactivity have been examined since studies on ionizing
radiation began. Studies in plants and animals very soon suggested these effects (Calabreseand Baldwin 2000). Attempts were made to use ionizing radiation to synthesize life frominorganic matter. The above mentioned radium therapy for rejuvenation practiced during the1920s was a result of these reports. In popular culture this idea was, for example, highlighted
in the 1930s serial called “The Phantom Empire”, in which a dead woman was “brought backto life in a ‘radium reviving room’” (Piispanen 1995, 96).
As discussed by Macklis and Beresford, the politicization of medical and industrial uses of“nuclear energy and radioactive materials” resulted in a shift of “the radiation hormesis
controversy … to disagreements over the positive or negative implications of the putative‘stimulatory effects’… for the ecosystem or for the population as a whole” (Macklis and34

Beresford 1991, 351). Even among the hormeticists there is disagreement about the medical
consequences of their conjectures. Generally they propose hormetic effects on the molecularand cellular level as well as on the level of organism as a whole. Explanations for hormetic
effects of low level ionizing radiation include the stimulation of DNA repair, the stimulationof immune responses, its function as a vital life force, the selective inactivation of senescentparts of an organism, and the production of an evolutionary favorable selection pressure that
benefits a species (Macklis and Beresford 1991, 352).
While critics of hormesis state that “there exists no credible epidemiological evidence for”
the conjecture that “exposures to low doses of naturally present or man-made ionizing
radiation must have beneficial effects on human health” (Nussbaum and Köhnlein 2003, 706;
Nussbaum and Köhnlein 2011) hormeticists offer several epidemiological case studies thatseem to prove hormetic effects. They say for example that “1) incidence of solid cancers
decreased in 21,500 exposed workers at Mayak, a Russian plutonium production complex in
Chelyabinsk oblast’/Ural region. 2) The total cancer deaths in 8,600 cleanup workers at
Chernobyl (who received an average of 5 cGy) were 12% lower than that of the general
Soviet population. 3) The leukemia death rate in 96,000 nuclear workers (in three countries)
exposed to over 40 cSv was only half of that predicted. 4) No increased cancer was found in
222,400 radiologists and radiation technicians who received more than 20 cGy in 20 years,”
etc. (Luckey 2006, 173). The critics of hormesis counter these findings with contradicting
examples and/or different interpretations. They are either “struck by the paucity ofconvincing data and by the lack of expert consensus concerning the health implications ofwhat data are available” (Macklis and Beresford 1991, 357), or they summarize: “All the‘proofs’ and ‘studies’ the crusaders for increased allowable radioactive exposures havecontinued to cite represent either invalid or misleading interpretations of flawed
epidemiological studies” (Nussbaum and Köhnlein 2000, 6).
It may be the case that this example of a contested disease concept has two intertwined
reasons. On the one hand there is no consensus because the data collected are contradictory,
inconclusive and contingent. On the other hand non-scientific values and politicalconsiderations guide the interpretations (Elliot 2011). Both parties accuse the other ofanswering selective interests and following lobbies other than those of science. Hormeticists
argue that the linear no-threshold model has resulted in fear, radiophobia and increased costs,
all of which could be overcome by the acceptance of the hormesis model (Kauffmann 2003;
Jaworowski 1999; Jaworowski 2010), and that psychological warfare during the Cold War,35

lobbying by fossil fuel industries or the interests of the media in public fear fuelled therejection of hormesis. In their eyes “efforts to minimize exposures to humans to the lowest
achievable level or to a level below regulatory concern are counterproductive to health,diverting resources from more worthy endeavors” (Kauffmann 2003, 405). At the same timescientists arguing for the linear no-threshold model accuse hormeticists of being influenced
by interests of the nuclear power industries and governments trying to calm their citizens
after man-made nuclear accidents (e.g. Nussbaum and Köhnlein 2011).
These multi-layered controversies surrounding the idea of hormesis reflect a crisis ofexpertise in knowledge of radiation health effect, leading to contestation of the definition of
diseases associated with radiation. In addition to the concept of hormesis, the Fukushima
Daiichi accident has also resurrected scientific debates about health effects of low levels of
ionizing radiation. Although the citizens of the Fukushima region are monitored, andalthough scientists are trying to get results regarding low dose radiation effects as aconsequence of radiation in Fukushima, a report by Normile (2011, 910) in the journal
Science laconically stated that “some researchers doubt that any study in Fukushima, nomatter how well devised, will reveal much”. A researcher is quoted in this report that he“[doesn't] think anything [done in Fukushima] is going to resolve” the debate about the linear
no-threshold model. However, this also means that the “gnawing fear” of many Japanese“that low levels of radiation could harm their children” cannot easily be alleviated.

2.4 Conclusion
Negotiating the contested boundary of disease, illness and sickness is an ongoing process,especially in situations as highly sensitive and politicized as nuclear energy and the
Fukushima Daiichi accident. As such, various stakeholders along with their social, cultural,political and historical implications must always be considered: the individual(s),physicians/scientists, publics and the state. This has been illuminated by the cultural andhistorical discourse of radiation health effects, which have affected and continue to affect thealleged objectivity of scientific definitions of disease and illness. Care must be taken to avoid
medicalization of conditions in defining contested diseases because of possible inadvertent
implications in social and medical policy. At the same time the leveling or trivialization ofpotential health risks from radiation for the sake of political or public interests should be
avoided in the interest of potentially affected individuals.
36

Questions and Answers(1) How can we term “unhealthiness” or lack of health?
The different facets of “unhealthiness” are disease, illness and sickness – dependingon the perspectives of medical professionals, patients and society, respectively – overtime.
(2) What are the two main directions of disease concepts?
The two approaches to disease classification are substantial or gradualistic.
Gradualistic understanding of disease – under which radiation diseases are
categorized – can result in dispute and medicalization. This is especially the case withthe growing role of social media and the internet, which can be explored further.
(3) How can we approach low levels of ionizing radiation from a historical point ofview?
The multitude of approaches includes “tolerance” doses, “linear no-threshold” and“threshold” models, and radiation hormesis. Each approach has been influenced bycultural, political and historical concerns.
(4) What other contested diseases apart from radiation can we apply this framework to?
This can be applied to physical or mental diseases associated with environmental andoccupational exposures in disasters and events which include but are not limited to
toxic chemicals, gas leaks, heavy metal poisoning and fossil fuels.
(5) Why is there no consensus among scientists about the effects of low doses of radiation
on human health?
Scientific long-term studies on the consequences of radiation in Chernobyl and
Fukushima among others are on-going. However, health effects of low dose radiation
are likely to continue to be contested due to the inconclusive etiology of radiationdiseases, differing interpretations of epidemiological data and political/economic
interests influencing the selection and presentation of data.

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40CHAPTER 3
PERCEPTION OF RADIATION RISK: THE ETHICAL DIMENSIONSOF COPING WITH DISASTER
Deborah Oughton15 and Penelope Engel-Hills16

Pain is inevitable; suffering is optional.
Haruki Murakami, What I Talk About When I Talk About Running

Summary

The objective of this chapter is to address the factors that influence risk perception anddiscuss recommendations for how a holistic understanding of these factors can help healthcare practitioners in disaster and risk management. One important message is that it is a
mistake to assume that public aversion or fear of radiation risks is due only to amisunderstanding of the probabilities of harm. Risk perception is complex and many factors
have strong ethical relevance. We will consider three values that influence the way people
perceive risk: autonomy and respect for personal control; justice and the distribution of risks
and benefits; and community values and societal impact. With respect to control, in addition
to a fundamental ethical respect for dignity, there is an important psychological andphysiological link between coping and stress. Hence management practices need to be awarethat enabling personal control and empowerment will positively influence the response of anindividual to a disaster. The consideration of justice with regard to the distribution of risks
and benefits must include awareness of the challenges of discrimination and victimization as
well as the need for the protection of the vulnerable members of society, such as children and
15

Professor and Research Director, Centre for Environmental Radioactivity (CERAD), Norwegian University ofLife Sciencese-mail: deborah.oughton@nmbu.no
16
Deputy Dean, Health and Wellness Sciences, Cape Peninsula University of Technology
e-mail: EngelhillsP@cput.ac.za

41

the elderly. In addition, community and societal impacts extend the notion of well-being toencompass not only individual physical health but also mental health and social well-being.
Therefore in a holistic approach to disaster risk management there would be the reduction of
the risks of physical harm, and in addition, measures will be taken to address psychologicalheath and societal recovery.
Learning Objectives
After reading this chapter the reader will be able to:(1) Recall some of the societal and ethical factors impacting on the perception of risk
(2) Express relevant societal consequences of radiation accidents(3) Recognize that public aversion to radiation risk is not only due to misunderstanding of
the probabilities of harm
(4) Defend management of radiation risk beyond the reduction of exposure
Keywords: risk perception, disaster management, risk management, ethics, justice,uncertainty, personal control

Introduction
In 1971, Professor Jay Weiss carried out what are considered to be classic experiments on thelinks between stress, control and coping (Weiss 1972). In one experiment, electric shocks
were administered to pairs of caged rats. Both cages were linked to the same circuit, but in
one cage the rat could switch off the electricity by turning a wheel. Even though the samelevel and duration of shock was administered to both rats, the group having no “control” overthe stress showed significantly higher levels of distress (ulcers, loss of hair, weight loss, etc.).
The experiments are seen to be a demonstration of the powerful physiological andpsychological link between personal control and stress-related illnesses.
The objective of this chapter is not to elaborate on the link between control and stress, butrather to argue that these issues also have strong social and ethical relevance to the way
people perceive risks. Furthermore this chapter does not intend to comprehensively cover the
topic but aims to provide a stimulus for debate, discussion and further reading on perceptionsof risk from a disaster, with specific reference to radiation accidents but allowing application
to other forms of emergency. Risk is in part quantifiable but also a social construct that is
42interpreted differently by people in various situations and environments (cultures) – we needto recognise this to achieve effective management (including community participation). The
main objective is to demonstrate that radiation protection, as well as health education, must
address societal and ethical issues as part of the holistic understanding (and holistic approach
to risk management) of factors that impact on radiation risk perception and associated mental
health and recovery from nuclear and radiological emergencies.
3.1 Risk Aversion, Public and Expert Perceptions of Risk
Rational Emotive Behavior Therapy (REBT) is based on the premise that psychological andemotional problems are due to irrational and illogical thought processes about an incident
rather than being a result of the actual event (Banks 2011). Analysis of the Chernobyl and the
Fukushima Daiichi accidents have suggested that fear of radiation and the resultant
psychological stress lie behind the major health impacts seen in affected populations (IAEA
1991; Brumfiel 2013; Yasumura 2014), and that these effects are far greater than the direct
health impacts of the radiation exposure. It is not uncommon to hear claims that this fear isdriven by an irrational perception of the risk, as well as public misunderstanding of the risks
associated with radiation exposure. The public accepts risks associated with driving cars,
drinking alcohol or eating seafood containing heavy metals, but rejects the relatively low
risks associated with radiation exposure largely because they interpret risk without any
personal benefit as unacceptable. People also tend to be more tolerant towards naturalradiation exposures (e.g. radon) or medical uses of radiation than man-made sources(Oughton and Howard 2012). Similar accusations of irrationality have been made against the
public perception of biotechnology and genetically modified organisms. Other experts havesuggested that the fear is fuelled by poor communication, mismanagement of radiation risks,or media hype (Jaworowski 1999; Ng and Lean 2012).
It is true that people misunderstand the probabilities; however, numerous studies of thepsychological and psychometric factors that influence risk perception show that the situation
is more complex than this alone. Public or lay perceptions of risk vary widely between
people, and can differ from the calculated, technical approach to the assessment of risks.
Whereas an expert will often tend to rank risks as being synonymous with the size orprobability of harm, risk tolerance or aversion is dependent on many additional
characteristics (Slovic 1996; Drottz-Sjöberg and Sjöberg 1990). Many of the characteristics
have strong psychological as well as societal and ethical relevance (such as control,
43

voluntariness and distribution of risks and benefits). The conclusion is that it is a mistake todismiss public anxiety towards radiation risks as being “irrational” or “wrong” (DrottzSjöberg and Persson 1993). Irrational beliefs can result in emotional disturbance such asanger, guilt, aggression and withdrawal (Banks 2011). This is an important message formanagement and health care practitioners in order to counteract the assumption by many
experts that the education of the public about the risks is all that is required in order to reduce
aversion to the exposure.
3.2 Factors impacting on Risk Perception
3.2.1 Autonomy, Personal Control and Consent
People tend to be less tolerant of risks that are imposed without their choice or personal
control. The phenomenon applies to a range of different risks and actions, such as driving a
car compared with flying, and why comparing risks of radiation exposure to smoking is not arecommended form of risk communication. Personal control is closely related to thefundamental ethical value of autonomy (i.e. respect for the free-will of individuals), dignity,
integrity and individual rights. It is also linked to the requirement for free informed consent
related to medical risks (Table 3.1).
Uncertainties are an important aspect of radiation risk perception. More people have diedfrom earthquakes and tsunamis than from exposure to radiation. But after a tsunami people
could start the process of rebuilding their life. In contrast after a nuclear power plant accident
the situation is more ambiguous and uncertain. The levels of contamination can be initiallyvery unclear, and the long term risks associated with the onset of a detrimental effect, in thiscase cancer, can take decades. Anxiety is raised by the lack of answers to questions such as:
how long before I can return home—if at all? Would I want to? In the case of the Bhopal
accident—with about 3000 immediate fatalities and more than 100,000 people with medical
problems—the effects were quickly identifiable, and the accidental exposures mainly acuterather than chronic (Broughton 2005; Dhara and Dhara 2002). After a release of high levelsof radiation, the time for recovery is longer and the feeling of helplessness greater than after
most chemical or natural catastrophes. The immediate devastation and loss of lives may be
far worse from the earthquake and tsunami, but the uncertainties, protracted duration of the
problems and lack of autonomy can be greater in the case of a radiation incident.

44

Radiation risks represent a class of environmental risks over which people feel a particularlack of control (Slovic 1996), and particularly those associated with exposures following
accidents. The public is dependent on information from authorities or media, and has little
personal choice or control over the situation. The public has to deal with the risks from theexposure and in addition they must cope with the effects of the measures imposed to reduce
exposure such as relocation, bans on agriculture or access to amenities. The latter represent
decisions taken at central level. They are disruptive and infringe upon liberty and free choice.

45

Table 3.1: Overview of ethical values impacting on risk perception and links to other biomedical
ethical principles.

Ethical Values

Impact on Risk
Perception

Autonomy(dignity,
integrity)

Personal
control orconsent over
the risk.
Public or
patient
empowerment
over thesituation

Welfare(consequences
andcommunity
values)

The size of therisks, harms
and benefits
Impact on the
broadersocietal
aspects such ascommunity
structure or
demographic
changesThe
distribution ofrisks andbenefits withinsociety or overtime

Justice (equity,equality)

Links to
Biomedical
EthicalPrinciples1
Respect forautonomy (anorm ofrespecting thefree-will anddecisionmaking
capacities ofself-governing
persons)

Main Underlying
Ethical Theories2

Other areas ofrelevance for
medical ethics

Deontology,
Kantian ethics,
rights-based
theories

Patient free
informed
consent;
Doctor or
health worker
integrity

Nonmaleficence(a norm of
avoiding thecausation ofharm)
Beneficence (agroup of norms
for providing
benefits)

Utilitarianism,
consequentialism,
teleologicaltheories, virtue
based ethics

Avoidance of
causing harm
to patients.
Duties to help
and reduce
suffering.
Ethics of care.
Communityand publichealth ethics

Justice (agroup of norms
for distributing
benefits, risks
and costs
fairly)Contractarianism3 Distribution ofhealthcare
resources
Costseffectivenessof various
treatments
1 – The four main biomedical ethical principles as proposed by Beauchamps andChildress (1979). See chapters 5 and 6 for further discussion.
2 – The principle ethical theory associated with the ethical value. Note that ethicaltheories can find other values ethically relevant. For example utilitarians recognize theimportance of autonomy or freedom, but this is because of the welfare of utility it brings
to society, rather than respect for autonomy as a fundamental ethical value in itself. The
description of ethical theories can be found in Beauchamps and Childress (1979), or
Sandel (2010)
3 – For example, Rawls (1971).

Control is part of the reason why people are less concerned over medical radiation exposures(which are largely voluntary and for an obvious personal benefit). It is also why actions that46

increase personal understanding, such as provision of dosimeters or counting equipment areconsidered positive and can help populations in coping with disaster (see case study on
personal dosimetry projects in Chernobyl and Fukushima, and discussion on risk
management and communication below).
Informed consent is also important for workers that might be exposed to chemical and/or
radiation risk. This is particularly significant if lower paid workers are employed to carry out
remediation or decontamination, as it has been suggested that the necessary conditions forfree-informed consent are often violated for these groups (Bullard 1990). The increased risk
may justify some form of compensation via higher wage premiums, but compensation itself
can raise questions of whether or not this may coerce people into taking risks they would
otherwise not have (Bullard 1990; Shrader-Frechette 2002). Both ethically and legally, mostpeople would agree that affected persons have a right to some form of compensation fordamages; either those resulting directly from the disaster or as a result of remediation.
Experience from Chernobyl illustrates the problems of compensation in promoting the“victimization” of affected populations (Oughton et al. 2004; UNDP 2002; IAEA 2005). In
Fukushima, higher levels of compensation were paid for evacuees of the nuclear accident ascompared to the tsunami, leading to reports of resentment between the different groups.

Case Study: Chernobyl and Fukushima – personal dosimetry projects
Provision of counting equipment and independent monitoring are methods that have beensuccessfully applied in Chernobyl affected communities. A study carried out in Belarussianvillages concluded that the approach not only resulted in reducing exposures with minimalsocial and psychological side effects, but was also more economically cost effective than thestandard “top-down” management procedures (Dubreuil et al. 1999). A stakeholder study
following up on Norwegian farming communities most affected by Chernobyl fallout
indicated that access to local food monitoring stations was particularly important (Liland etal. 2010).
The interest for access to personal dosimeters and information on personal doses has been
widespread in Japan following Fukushima. When combined with access to experts to help
interpret results, such actions can help empower populations. Ethically, procedures thatinvolve the populations themselves can help promote the principle of informed personal
control over radiation risks. However, it should be noted that in some cases, information
policies that reduce anxiety over radiation might actually lead to an increase in exposures,
since people may eat food that they would have otherwise avoided. In all cases, acommunication strategy needs to be a central part of accident management.
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3.2.2 Distribution of Risks and Benefits
While the actual costs, risks and benefits may vary with the environment and even between
members of the same community, it is universally accepted that these criteria havesignificance to the fundamental ethical values of equity, justice and fairness (Oughton 1996).
The doses received by individuals due to the Fukushima Daiichi accident varied widely. The
risks of exposure also varied with additional factors such as age, because children are deemed
to be more vulnerable to the effects of ionizing radiation. Furthermore, the consideration ofrisks and benefits go beyond direct exposure and must include such aspects as theconsequences of the radiation contamination on lifestyle for different members of thecommunity. So for example, some lost their livelihood, while others were able to continue
more or less as before the accident. Linked to the issue of consent discussed above, it has
been suggested that the less-advantaged members of society often bear a disproportionate
burden after accidents (Shrader-Frechette 2002, 2012). Examples after Fukushima include thesituation for the elderly evacuees, and particularly those living in temporary housing who
experience greater isolation from family and communities (NRA 2014).

The potential for increased health risks from radiation in children mean that the risk
perceptions go beyond consideration for personal risks, as is seen by anxiety over thyroid
cancer in Fukushima populations (UNSCEAR 2014; McCurry 2014). The fear that your childcould be affected in the future can overshadow any personal concern (Bay and Oughton2005). These concerns extend to pregnant women, as exemplified by the rise in voluntary
abortions after Chernobyl (Knudsen 1991). This may seem irrational, since many otheractivities have a statistically greater probability of harming children, such as traffic or evenother sources of exposure to radiation. The explanation is in part due to feelings of blame,
guilt and responsibility, and questioning—have I really done enough to reduce the chance of
my child being harmed? Even with strong epidemiological evidence to the contrary, if a childgets cancer or a baby is born with a disability, the parents will always wonder if this was dueto the radiation exposure.
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Justice has been discussed in this chapter as a biomedical principle (Table 3.1) and withreference to the distribution of risks and benefits, the challenges of discrimination andvictimization and the need for the protection of the vulnerable in society. For thedetermination of whether there is distributive justice; the distributive norms of the group must
be considered (e.g. group norms of equity, equality, need, responsibility). In this way the aim
is the fair distribution of the benefits, risks and costs. The concept of distributive justice insocial psychology can be defined as what is perceived as a fair sharing of costs and rewards
to the members of the affected group. in the context of a radiological emergency the notionof distributive justice adds another layer of complexity in that some measures to reduce
exposures could result in an equitable distribution of cost and exposure reduction, such as
investment by taxpayers to the levels of radionuclides in public areas . On the other hand
there are examples ofless equitable measures, such as, when a reduction of exposure to themajority is only possible at the expense of a higher exposure, cost or welfare burden, on aminority (e.g., banning all farm production in a small community). This is exemplified in acase study on Norway reindeer herders (also see Figure 3.1).

Case Study: Norway reindeer herders
Norway was one of the European countries outside the USSR experiencing the largest
radiological impact after the Chernobyl accident. High levels of deposition, especially inmountain and semi-natural areas, led to radiocesium concentrations in foodstuffs above thosedeemed acceptable for consumption. Many farmers had to endure monitoring andcountermeasures to reduce levels in their produce. The lichen-reindeer food chain wasparticularly vulnerable, with more than 90% of reindeer meat in 1986/7 having Cs-137
concentrations much higher than the 600 Bq/kg limit at the time. In order to protect theminority reindeer herders, and on the grounds that the majority of the Norwegian population
only ate reindeer rarely, the authorities raised the acceptable limit of Cs-137 in reindeer meatto 6000 Bq/kg. At the same time, limits were raised in freshwater fish, mushrooms and othersemi-natural produce. The move had broad acceptance in the Norwegian public, and no
discernible impact was seen on sales of reindeer meat.

49

Figure 3.1 Norwegian Reindeer (Photo: LavransSkuterud)

3.2.3 Community Values and Societal Consequences
The Chernobyl and the Fukushima Daiichi accidents are both examples of incidents that
resulted in a wide range of social and economic consequences. In Chernobyl many of theevacuees lost their jobs, social network, and connection to places of particular community or
historical value like graveyards or places where they played as children (Bay and Oughton2005). Resettlement and long term evacuation in Fukushima have changed the social
structure of the villages and city districts. After Chernobyl, the Gomel region lost about 43
per cent of its population between 1986 and 2000, and demographic parameters, like
mortality- and birth-rate have changed dramatically as elderly people in particular did notwant to leave their villages, while young people did. The emigration of young people
impeded the whole social and economic development of the region, including a shortage ofteachers and doctors (UNDP 2002). Similar demographic changes have been seen after
Fukushima, with young families more likely to evacuate and less likely to return. In somecases, this led to splitting of families with mother and children leaving and fathers remaining
to work (NRA 2013; National Diet of Japan 2012). These lead in turn to a variety of socialand health effects such as alcoholism, obesity and depression in affected populations(Yasumura, 2014; Yasumura et al., 2012).
The economic costs of accidents are complex and wide-reaching. However much one
stresses the small physical risks, actual or potential radioactive contamination of food is one
50

of the fastest ways of losing consumer trust. This means that the economic and social impactof a radiation accident can be enormous, and overshadow the actual health risks. It might beeasy to attribute this to yet another example of public irrationality, but people’s livelihoods
and income depend on consumer choice. Stress, ill-health and even suicide can accompany
job loss and bankruptcy. Loss of consumer trust can have profound consequences both for arange of industries (particularly food or tourist industries) and for the local identities ofpeople and groups (Flynn et al. 2001; Bowley 2011). This has been well-documented in
Fukushima with price drops for produce from the entire region, including areas not affectedby the accident, as well as impacts on tourism (Consumer Affairs Agency Japan 2013).
Negative economic side effects can arise from rural breakdown, and stigma of contaminatedcommunities. Discrimination and stigmatization of the Hiroshima and Nagasaki hibakusha
and their children has an important historical dimension in Japan (Hersey 1985), and is aparticular concern for Fukushima evacuees. TEPCO workers also cited discrimination as oneof the main causes of psychological stress (Shigemura et al. 2012).
The aftermath of an accident can also be economically beneficial to parts of the community,
for example through generation of local employment opportunities. This may lead to some
sections of the population making a profit from remediation (such as selling or hiring
equipment), which can lead to further social inequity and division. As a parallel case, this wasseen in the aftermath of the foot and mouth outbreak in the UK, when a minority of theaffected communities made a large profit from the disaster (DEFRA 2002). Likewise, after
hurricane Katrina, price increases in certain commodities led to outrage and calls forlegislation to prevent such profit-making (Sandel 2010).
3.3 Risk Management
Doctors and public health workers can be expected to be confronted with a variety of views,
perceptions and concerns associated with the public’s perceptions of risks following adisaster. Medical workers need to recognize that risk perception is complex and that manymembers of the public will have concerns that go beyond their personal risk of harm.
Radiation risks are a particularly challenging type of risk. Three important lessons learnt fromprevious accidents will be discussed.
Don’t assume that the public’s aversion to radiation is due to misunderstanding. People willoften turn to general practitioners and public health officials for information and advice, andbeing able to provide the correct information on the potential health risks is important.
51

Doctors need to be prepared to answer such questions from patients, the media and public
advocacy groups. There is a tendency for experts to simply repeat the size of the health risks,
compare them with lower background or higher medical exposure, and assume that any
residual fear of radiation or remaining aversion to the risk is fuelled by phobia, irrationality,
inappropriate thinking patterns and psychological problems of the patient (for a rebuttal ofthis view see Drottz-Sjöberg and Persson 1993). Many people would be concerned at theradiation exposure to their child from a CT scan, but be willing to accept the risk on the basisof the perceived benefit. However while communication can be aided by putting the risk into
perspective with other risks, including other radiation exposures, explaining everything interms of natural or medical exposures will not relieve all errors in risk perception. While notblaming irrational thinking for risk aversion it is also important to focus any intervention ormental health program on increasing rational thinking (Banks 2011).
Many people will be reassured by comparisons, but others are seeking different types of
information. Communication therefore needs to be tailored to different needs and provided
through different media and sources. Experts are good at telling what they know, but theyshould also try to be sensitive to what the public are actually asking.
Recognize the importance of personal control and public participation. Actions that can help
people and communities gain control over their lives (i.e. information on actions that can betaken to reduce exposure) are an important part of coping with disaster (Dubreuil et al. 1999;
Oughton et al. 2004; ICRP 2006). Choice, control, familiarity, closeness and numerous othersocial and psychological factors play an important role in shaping perceptions towards
hazards. Measures that take these factors into consideration may stand a greater chance of
success. So for example, centralized office and desktop assessment of exposures and risks
should be supplemented by individual measurements and personal assessments for thosepeople who request this type of information. Medical staff can play a role in gathering andinterpreting data, and providing advice. Personal measurements can be an important stimulus
to dialogue and communication between public and experts, and not only in the most affectedareas. People may also need reassurance in areas that have been declared clean.

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Case Study: Coping style, psychological distress, risk perception, and satisfaction in
subjects attending genetic counselling for hereditary cancer (Nordin et al. 2002)“As a result of the recent developments in DNA testing and the knowledge that cancer canbe hereditary, it is now possible to offer genetic counselling to people within identified“cancer families”, and to inform them about their assumed increased risk for developing
cancer. One of the most important components in genetic counselling is the provision of
information. Extensive research was performed on principles for providing patient
information in a general medical setting. This type of information is usually fairly simple
and concerns mainly the patient him/herself. In contrast, the information in genetic
counselling is often highly complex, including risk estimates and aspects of heredity
involving family members. … Theories of coping postulate that a person’s reaction to a
stressful situation is moderated by his/her ability to handle the threat and the resulting
reactions. An important aspect of the ability to cope with a potentially serious illness is thedesire for information about its various facets. Some people, referred to as Monitors, have atendency to search out information and focus on health threats, whereas others (Blunters)
have a tendency to avoid information.”
See also: Rothemund et al. 2008; Young 1998

Realize that technical solutions are not enough on their own. Recognizing the enormous
social and ethical consequences of a nuclear or chemical accident means that coping with thatdisaster needs to go beyond simple decontamination and reduction of the physical risks(Howard et al. 2004; Howard et al. 2005; Oughton et al. 2004; Oughton and Howard, 2012;
Oughton, 2013). For nuclear accidents this will require a multidisciplinary approach where
the technical, medical and radiation protection experts need to work with communication andsocial scientists (Howard et al, 2005; Oughton 2013). Also, actions need not be limited tothose that reduce the exposure to radiation, and for example, for some, medical check-up andfollow-up might help to relieve anxiety (Morrey and Allen 1996). Furthermore, psychologicalsupport and mental health should receive particular attention (Bromet 2014). The need forstakeholder engagement is recognized in all areas of risk assessment and management as animportant mechanism of public empowerment (United Nations Economic Commission for
Europe 2001). In practice, this would mean that discussions of coping with disaster should be
extended to a wider group of stakeholders and experts, including medical professions, but
53

also consumer organizations, farmers, fishermen and so forth, many of whom have relevant
technical and lay knowledge (Wynne 1989).

3.4 Conclusion
Public reaction to disasters is the result of complex and intrinsic features of risk perception,
many of which have strong ethical and societal relevance. A holistic approach to disastermanagement should integrate economic, ecological, and health measures. Intervention
strategies should be designed to accommodate the varied needs. For nuclear accidents, it is
not sufficient to simply focus on the dose reduction aspects of radiation protection as societal
aspects will play a major role in how individuals cope with and communities recover fromthe disaster. Engaging with the affected population with regard to increasing theirunderstanding and personal control, and involving them in decision-making processes
respects people’s fundamental right to shape their own future. In addition to increasing trustand compliance, such approaches can lead to significant improvements in the effectivenessand acceptability of disaster management in communities. This chapter should beincorporated into curriculum activities of medical students to facilitate them being receptive
to mental health awareness with particular reference to coping with radiation and other typesof emergencies.

Question and Answers
The learning objectives and terms from the glossary can be transformed into questions thatcan be used by the educator to stimulate discussion and further research by the students.
There are also examples of the sort of questions that can be prepared in order to extend
thinking and discussion on the topic. All these questions are examples of the sort of questions
that can be set for class or small group discussions in order to achieve deep learning andunderstanding of the topic in this chapter. These questions (questions 2, 3, 4 and 5) can begiven as part of an individual or group assignment that can be incorporated into thecurriculum as a formative or summative assessment. Question 1 is an example of a different
task to demonstrate that there are a variety of ways in which the educator can incorporate thechapter into learning activities that encourage student participation and increase engagementwith the material and thereby enhance learning. The answers to these questions are not54intended to be complete or to provide a comprehensive outline of possible discussion. The
intention is that the answers provide only a guide to the type of information that would be
included in the discussion or written response.
(1) This is a group exercise. In a large class it is appropriate to divide the class into
small groups of 6-8 students. This is not an exercise based on reality but because of
the extreme situation presented it raises important messages about values anddecision making. It is a good introductory exercise before discussion on radiation
incidents and will usually capture attention and ensure students attend the classes.
There can be variations on the theme and this is only one example.

NUCLEAR FALLOUT SHELTER EXERCISE
You are a member of an Ethics Committee that is trapped in a fallout shelter. The
information you have is that it will not be safe for your group to leave the shelter for six
months. There is adequate food, water, and other essentials to sustain the group for therequired period.
In the shelter there is a telephone and one member of your group has spoken to someone in
another shelter. The report is that there are nine people in the other shelter and that there are
only enough provisions to keep four members of that group alive for the six months.
The other group has decided that five of its members will have to leave the shelter so thatthose remaining will have a chance to live. However, they have been unable to make thedecision as to who will be put out of their shelter. The group has asked your Ethics
Committee to make the decision and has agreed that your decision will be implemented
without question.
The people in the other shelter are:
1. A male physician (General Practice), 72 years old.
2. A male scientist (medical research), 50 years old.
3. A male patient with mild depression, 48 years old.
4. A female attorney (criminal law), 40 years old.
5. An Imam, 40 years old.
6. A pregnant college student (business major), 28 years old.
7. A male carpenter (union), 25 years old.
55

8. A female college student (engineering major), 18 years old.
9. A female child, 6 years old.

The group task is to:(Note that task 1 should be completed before tasks 2-4 are asked but all tasks are completed
before feedback from each group is given to the class).
1. Reach consensus on a list of four people who will remain in the other shelter.
2. Provide at least 5 criteria that were used by the group to determine who would stay in the
shelter.
3. State what issue you were trying to resolve.
4. Mention any assumptions the group made.
The answer to this exercise is not pre-determined. Most groups will do the exercise
and provide the four people who will remain in the shelter. However there will be avariety of answers and all are ‘right’. There may also be groups that come up withsomething quite different and that makes for an interesting discussion. The classdiscussion can become quite heated and interesting as the groups argue for why theirdecision is the right one. At the end it is important to discuss values, the value of lifeand how culture impacts on what each individual values. It is also an opportunity tolead into ethical decision making and the use of tools in this process of reasoning andcoming to the best possible answer for the circumstances. Question 2 addresses
ethical decision making.

(2) Are models for ethical decision making helpful in a disaster situation?
Models for ethical decision making are used in health care and can be useful more
broadly in disaster management. These models provide a framework forunderstanding expectations and responsibilities. There will be reasons for choosing amodel or a combination of models. These reasons will include what is appropriate forthe cultural, social and individual preferences as well as the specific circumstances.
Models can be helpful to guide decision making as they provide a philosophicalframework (e.g. covenant model based on agreement grounded in traditional values)
and a problem solving approach (e.g. the DOWD model of steps in decision making).
Although health care practitioners will at first need to follow a process quite rigidly
56

they will later develop an ethical problem-solving process that works for them. In a
disaster there is no time to find a model and follow it. Therefore all health carepractitioners should be trained to consciously think about ethical decision making andapply this. The use of scenarios and case studies is a useful way of allowing students
the opportunity to work through various models.
The development of a disaster plan can in itself be an ethical decision making process.
The steps might include something like; full assessment of the potential problem,
identification of the many issues, analysis of the information gathered, preparation ofan action plan for a given situation. This would be a good group exercise for students
to engage in. They could then compare disaster plans they developed with the national
disaster plan. The learning would be multi-faceted and the students are more likely toremember core elements of the disaster plan when they need it in the future.
(3) Why do different people make different estimates of the risk or the anticipated dangerof radiation?
A complex problem in risk analysis and risk management is why individual andpublic concern can follow patterns that are not aligned to the expectations of theexperts in the field. Some relatively minor risks can result in extreme concern that canhave a major impact on mental health and even the economy. Risk perception in thecontext of ionizing radiation is a subjective judgment made by a person about the typeof harm that radiation can cause and the severity of the risk in the given
circumstances. The term ‘risk perception’ is often used in reference to nuclear power
and following nuclear accidents and some of the societal and ethical factors impacting
on the perception of risk were covered in this chapter. The risk perception of anindividual will include threats to the environment but will mainly be focused on risks
to their own health and the health of their family members (living, unborn and future
generations). There are a number of theories regarding the reasons why people makedifferent estimates of the risks and how dangerous they are. These theories include
psychological, sociological, and multidisciplinary approaches that can all be exploredby the students. One theory is the Social Amplification of Risk that is a conceptual
framework that integrates the assessment of risk with cultural, psychological andsociological perspective of risk perception and behavior related to risk. The central
aspect of this theory is that the public responses to the risks of the incident (forexample radiation emergency) are amplified because of the interaction between theemergency and the social, institutional, community, psychological and cultural57

processes. Communication of information is a critical component of this amplificationand connections can be made to the chapter covering communication.

(4) How does the concept of autonomy and informed consent align with disastermanagement in different cultural contexts?
To answer this question there needs to be understanding of the construct ‘autonomy’within disaster management in the specific environment. In some communities andcultures the medical community shifted from a situation in which the physician took
on a parental role to their patient and their opinion was rarely questioned. As patients
became more aware of their rights the health care practitioners changed their practiceand took on a more ‘equal’ relationship with an emphasis on education, information
and a collaborative decision making process that included the patient. This approach
respects the definition of autonomy that no person should have authority or powerover another person. In the medical interpretation, this translates into the situation thatno patient will be treated without informed consent. Autonomy and informed consent
profile the right of the individual and as such this fits the western culture of medical
practice today. However some cultures honor a community or group value system inwhich the enforcement of individual informed consent is uncomfortable. The African
value of ‘ubuntu’ is a philosophy that is not based on the individual. In this culture aperson is a person because of other people and humanity is therefore not embedded
entirely in the individual. In this situation, there is still the need for respect for the
person but there may be the need to adjust the strict interpretation of autonomy andinformed consent. The students could explore this and other examples of cultures that
may be different to the western culture in terms of the application of autonomy andinformed consent. Then also consider how informed consent varies in a disastersituation. Does the medical model of informed consent have to change in a disastersituation and when is the person’s right to information and informed consent for aprocedure not possible or appropriate? These questions do not have a single rightanswer and this is therefore an opportunity for discussion and learning throughlistening to the views of others.
(5) What is important in the care of people affected by a nuclear or radiologicalemergency ?

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This question will draw directly on this and other chapters of this handbook but will
also need to go beyond the confines of the information presented to include researchand publications on the topic of care as relevant in emergency situations. In thinking
about the societal and ethical dimensions raised in the chapter the student will
understand the importance of reducing exposure in a radiation emergency but will
also grasp the key message that this is not sufficient for the management of risk andharm in such a situation. The sort of information that might be included would be a
discussion on: care and risk perception, physical health, mental health, the impact onfamilies, care during and after evacuation, management of social and economic
consequences of the nuclear or radiological emergencies, care of vulnerable groups(children, elderly, seriously ill, etc.), managing stigma, dealing with discrimination,
radiation risks.

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Further Reading
Rothemund, Yvonne, Stefan Paepke, Herta Flor. 2001. “Perception of Risk, Anxiety and
Health Behaviors in Women at Risk for Breast Cancer.” Int J Med Genet 8 (3): 230–
239.
Young, Elspeth. 1998. “Dealing with Hazards and Disasters: Risk Perception and Community
Participation in Management.” National Centre for Development Studies, Australian
National University. Australian Journal of Emergency Management 13 (2): 14-16
http://www.em.gov.au/Documents/Dealing_with_hazards_and_disasters_risk_percept
ion_and_community_participation_in_management.pdf

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CHAPTER 4
RISK COMMUNICATION
Yuko Fujigaki17 and Kwan-Hoong Ng18

SummaryThis chapter consists of three parts. Part I describes the characteristics of radiation risk. First,
we will explain “risk concept” in relation to probability, uncertainty, and the meaning of Risk
Society. Then characteristics of radiation risk are explained using classifications by Solvic
and that by Renn. The notion of evidence is also shown in the comparison with other risks inthe epidemiological framework. In Part II, risk communication is analyzed in the “framing”
analysis. First, we will contrast the deficit model and the two-way communication model inthe research stream of science communication. Risk communication based on the deficit
model and those based on the two-way communication model appear differently. Second, we
will compare the role of information interpreter with information transmitter. Most scientists
desire to perform an information transmitter role, whereas the public wants to have an
information interpreter after the disaster; therefore, there is a discrepancy between what
scientists think of as their responsibility and what the public thinks is the responsibility ofscientists in risk communication. At the same time, we should pay attention to the difference
between doctor-patient communication and doctor-public communication. Utilizing theresults from social psychology and STS, we will show these differences especially for risk
communication on radiation risk. Finally, in Part III, the effect of media, both traditional
media and social media, in risk communication is discussed further.
Learning Objectives:
After reading this chapter the reader will be able to:(1) Define risk
(2) Recall the characteristics of radiation risk
(3) Explain the deficit model and the two-way communication model(4) Distinguish between an information transmitter and an information interpreter

17

Professor, Graduate School of Arts and Sciences, University of Tokyoe-mail: fujigaki@idea.c.u-tokyo.ac.jp
18
Professor, Department of Biomedical Imaging, University of Malaya
e-mail: ngkh@ummc.edu.my64

(5) Differentiate between doctor-patient communication and doctor-public
communication(6) Discuss the roles of media in risk communication
Keywords: Risk, deficit model, two-way communication model, doctor-patientcommunication and doctor-public communication, risk-communication

Introduction
Risk communication is highly important in disaster; however, there is a dichotomy between
what experts and publics consider as the best form of communication. Using the STS
concepts and research streams in science communication and social psychology, we will
explain several useful concepts for medical experts to overcome the problems after disaster.

4.1 Radiation Risk
4.1.1 Risk Concept
What is “risk”? If you look up “risk” in the Longman Dictionary of Contemporary English(1987), you will find these items: (a) danger and (b) possibility that something harmful orundesirable may happen. Also you can find examples of sentences as follows: Firemen
wouldn’t allow anyone back into the building because there was a risk of the fire breaking
out again. / Fishermen face a lot of risks in their daily life. / The disease is spreading, and all
young children are at risk. Therefore, the concept of risk is always related to a “possibility”
or “likelihood”. Specifically, risk relates with “probability”, for example, the probability ofan earthquake occurring, probability of occurrence of severe accidents, or probability of adangerous dose.
When the concept of “probability” turns to the concept of “risk”, it refers to the need toprotect something. For example, probability of dose turns to “risk” when we want to protect“health”. Agrichemicals turn to “risk” when we desire to protect “nature”. Therefore, humanbeings have had the concept of “risk” since they have had something that should be protected.
Radiation risk is considered to become a risk since we want to protect our health.
Beck (1986) described in his famous book, “Risikogesellschaft” or “Risk Society” that wehave to face a task on the “distribution of risk”, whereas sociology had been engaging thetask on “distribution of welfare” before. He also pointed out the difference between scientificrationality and social rationality (p. 38), and stressed that the borderline by which the load is65

endurable or not is determined not only by scientific rationality but also by social rationality.
Therefore, in consideration of radiation risk, we have to think about social rationality.
4.1.2 Characteristics of Radiation Risk
In consideration of social rationality, we should think about the public perception of “risk.” In
his famous paper, Slovic (1987) classified the risk perception of U.S. citizens as seen in
Figure 4.1. As shown in this figure, radiation risk is located in the two different quadrants.
The first, in quadrant I, is “unknown and uncontrollable”. Examples are radioactive waste andnuclear power plant accident. The other in quadrant II, is “unknown but controllable”. An
example is X-ray.

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Figure 4.1: Location of 81 hazards on factors 1 and 2 derived from the relationships among
18 risk characteristics (Slovic 1987).

67Based on this classification, radiation risk is considered by the public as “unknown” and“uncontrollable” in relation to nuclear power plants accidents.

Figure 4.2: Risk classes (WBGU 2000)

Another classification is by WBGU (2000) as quoted in Klinke and Renn (2006). Risk isclassified using two axes: “Extent of damage” and “Probability of occurrence”. A nuclear
power accident is classified as a “Damocles” type, whereby probability of occurrence is low,
but the extent of damage is high.
These classifications reveal that the radiation risk is perceived as “uncontrollable” when it
has a relationship with nuclear power plant accidents, which has low possibility and highdamage. These are the characteristics of radiation risk.
4.1.3 Notion of Evidence
Then, for construction of social rationality on radiation risk, we accumulate evidence on
health effects of radiation risk. ICRP Publication No.111 (2009) indicates as follows:

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The reference level for the optimisation of protection of people living in contaminated areas
should be selected in the lower part of the 1–20 mSv/year band recommended in Publication
103 (ICRP 2007) for the management of this category of exposure situations. Past experiencehas demonstrated that a typical value used for constraining the optimisation process in longterm post-accident situations is 1 mSv/year. [emphasis added by author]
What is “past experience”? The ICRP report (2009, 14) summarized past experiences withlong-term contaminated areas resulting from either nuclear tests (Bikini, Maralinga), nuclear
accidents (Kyshtym, Palomares, Chernobyl), or a radiological source accident (Goiânia).
There is a presence of acknowledged uncertainty, and the scientific evidence cannot provide
societal judgements about what is considered acceptable. The “experience” refereed to isexperience regarding the judgements that different societies have made in thosecircumstances.

In addition, we cannot perform experiments using human beings to gather evidence on theeffect of radioactivity on human health. When we have to gather data from experiences
instead of experiments, we cannot control the “cause” variables on the effect; for example,
exposure level, exposed dose, and accuracy of exposure estimate. At the same time we cannot
control the “effect” variables; for example, incidence of cancer and cancer death rates, bothunder consideration of spontaneous cancer, incidence of other disease, a decrease in mathscores, and so on. Therefore, there are discrepancies between cause variables and effectvariables when comparing with past experiences.
In summary, in the case of radiation risk we do not have clear “evidence” throughexperiments in which cause variables and effect variables are strictly controlled. We only
have “past experiences” from which we can infer the effect of radioactivity on human health.
We are still on the way gathering data.

4.2 Framing of Risk Communication
4.2.1 Communication Disaster
After 2011’s triple disaster―that is, earthquake, tsunami, and nuclear power plant
accidents―Japanese society experienced a “communication disaster.”

The National Diet

Official Report of Fukushima Nuclear Accident Independent Investigation Commission(2012, 406-407) stated that there was a communication failure in protecting public health. It
69also indicated that risk communication on radiation was not informative enough to residents.
In the communication disaster, there was an information-deficit between citizens who wanted
to know and professionals who were providing the information. Citizens wanted to know
“impartial, non-partisan, wide-ranging information”, however, professionals wanted toprovide “decisive action guidelines and limited, absolute information”. The Science Councilof Japan insisted on “unique” or “unified” knowledge while the Japanese government andprofessionals were hung up on “unique, decisive action guidelines”, and they disclosed only
“safety” information. Consequently, Japanese citizens began to develop distrust towards thegovernment and professionals. There were also differences in anxiety with regard to
information. Citizens (or residents) had anxiety related to the limited information andanxieties of distrust towards authorities. On the contrary, professionals had anxiety related to
the non-unique voice and public unrest.
One of the reasons why these gaps arise is the different models by which professionals andcitizens base themselves. Professionals and the government have a “one-way communication
model”, which shows that there is plenty of knowledge for specialists, whereas citizens are
ignorant. Knowledge is therefore conveyed from specialists to public: that is, one-way.
Therefore, professionals desire to provide “decisive action guidelines and uniqueinformation” to the ignorant public. On the contrary, there is another model: two-way
communication model. It recognizes that publics or residents have their local knowledge, so
specialists convey scientific knowledge and publics convey local knowledge to thespecialists. If we adopt this two-way communication model, publics wish to receive“impartial, non-partisan, wide-ranging information”, and want to decide the next action bythemselves based on this information. ICRP reports also insist on the importance of
involvement of habitants. That includes two-way communication.
In dealing with a communication disaster, there is another model known as a doubleinterpreter (Sakura et al. 2013). Sakura and their colleagues conducted interview surveys andshowed that there is a need for a two-interpreter system, i.e. a local interpreter and a specialist
interpreter. Local interpreters can be high school teachers or public health professionals andthey describe the situation to local residents. In addition, there are specialist interpreters who
communicate expert knowledge. He asserts that the communication between local interpreterand specialist interpreter is important. This form of two-way communication resembles thetwo-way communication between specialists and public.

70

4.2.2 Information Interpreter and Information TransmitterTo specify the requirements for specialists by public under communication disaster, one of
the important notions is the difference between information transmitter and informationinterpreter. In this “communication gap” between scientists and citizens, scientists andmedical professionals tried to convey “right information”, and to be good “informationtransmitters” and they think that to be a good transmitter is one of the responsibilities ofscientists. On the contrary, the public needs an “information interpreter” and they asked
scientists, “What would you do if you were me”?
On this point, Prof. Fassert, a researcher at IRSN (Institut de Radioprotection et de Sûreté
Nucléaire) had written a report in 2013 stating that “being an expert during a crisis is much
more than delivering information”. This means that the public requires not only an
information transmitter, but also an information interpreter. It is a very difficult question to
ask whether being an “information interpreter” is a responsibility of scientists or not. There
are huge gaps between what scientists believe is their responsibility and what the public
thinks is scientists’ responsibility. Since medical doctors and scientists have only been
educated as “information transmitters”, they face many problems in risk communication.
4.2.3 Difference between Doctor-Patient Communication and Doctor-Public
Communication
In this section, the concept of “information interpreter” is considered further focusing on the
difference between doctor-patient communication and doctor-public communication. For
example, doctors and patients share a higher goal. That is, to battle with disease, and to raise
the quality of life. When they share the higher goal, then they can “trust” each other.
Therefore, due to the higher goal they share with their patients, doctors can be good
information interpreters.
Based on this model, we can raise the next question: How does doctor-public communicationdiffer from doctor-patient communication? To answer this question, the key point is thedifference between the higher goals. As noted above, in doctor-patient communication, theyshare higher goals. On the contrary, in doctor-public communication there are many higher
goals. For example: to ease public’s worry, to collect scientific data, to open neutral data, orto abolish nuclear power. These higher goals are not all necessarily shared between doctors
and publics. Since interpretation differs when doctors and publics have different higher goals,
71doctors cannot be good information interpreters. In some cases, they are referred to as
information distorters.
To summarize, when doctors and patients share a higher goal, doctors are found to be good
information interpreters based on feelings of “trust”. On the contrary, where they do not share
the higher goal, doctors cannot be good information interpreters, and distrust arises.
The “higher goal model” in information interpretation can be linked to “social trust.” It can
explain segregation in Japanese society. First, we will explain SVS (Salient value similarity)model in social psychology. In social psychology, it is said that there are two components inconstructing “social trust.” One is competence, and the other is fairness in motivation.
Competence means ability, experience, and qualification. Fairness in motivation means
impartiality, integrity, and honesty in motivation of research. The theory is that if a personwith competence does something with fair motivation then others will trust him/her.
However, after 3.11, statements by persons with both competence and fair motivation had
have instead generated mistrust. Why? SVS model will explain these situations better.
SVS model postulates that shared values determine social trust in institutions and persons
related to a technology. In this model, if one thinks that the person in front of them shares
similar salient values with him/her, then he/she will trust that person. One has trust in people
holding similar salient value. The “salient values” resemble “higher goals” in the previously
mentioned concept. At the same time, when doctors and patients share “salient values”,
doctors can be good information interpreters based on their “trust”.
To summarize, one has trust in people with competence, with fair motivation, and who holdsimilar salient values. Therefore, one who holds salient values to ease the public’s worry hastrust in other people holding salient values to ease the public’s worry. One who holds salient
values to open neutral data has trust in people holding salient values to open neutral data. In
addition, one who holds salient values to abolish nuclear power has trust in people holding
salient values to abolish nuclear power. In this way, one has trust in people holding similarsalient values, and this tendency accelerates the segregation of groups which have different
salient values.
This salient value model can better explain the difficulties in doctor-public communicationcompared with those in doctor-patient communication. When doctors and patients share thehigher goal or salient values, for example, to battle with disease, and to raise the quality of72

life, then doctors can attain trust and can be good information interpreters based on their“trust”. On the contrary, in doctor-public communication, doctors rarely share the same
higher goal or salient values as there are a variety of higher goals and different salient values.
This leads to difficulties of trust between doctors and publics. Doctors will have troubles withpublics, especially with groups who have different salient values, and groups who cannot
share salient values with doctors.
Currently there is a high demand for doctors to deal with this communication disaster.
Doctors have learned medical science, and learned communication with patients, but they
have not learned communication with the public. In the construction of different salient
values, the media will play an important role in bridging this divide. We deal with the roles of
media in the next section.

4.3 The Roles of Media on Risk Communication
The media (also known as mass media) – including radio, television, newspapers, magazines,
and the Internet – is the largest source of information in society today. Many of us form ourgeneral opinions about health, environment, food and safety by what we read online or bywatching TV news. In communicating risk-related information, health professionals (andothers) often have to deal with the media as the key information provider, or channel of
information.
Media can be defined as any channel (broadcast media, namely TV & radio; print media,
outdoor media e.g. billboards; new media e.g. Internet & text messages; social media e.g.
Facebook, Twitter, YouTube, etc.) that is used to communicate or transmit information.
Media is now no longer used in one-way communication but is interactive involving multiple
stakeholders.
Scientists and doctors can present their research and innovation in conferences but to a large
extent their messages that reach the public are channeled or mediated by traditional media as
well as social media. Media often plays a central role in public health campaigns. Suchcampaigns are aimed to promote long-term changes in life-style, attitudes, behaviors andknowledge. For example, some encourage people to stop smoking, exercise regularly, wear
seatbelts, reduce risk of AIDS, and handle raw food safely.
There have been many studies on understanding how media coverage influences public
perception of risk issues. We want to know the extent to which news coverage affects public
73

opinion but also how the particular contents of news messages affect this opinion. However,such studies are very difficult to carry out.
The Internet has given birth to social media that is becoming a valuable tool for risk
communication. It not only provides instantaneous distribution channels to a wider audiencebut it also gives organizations almost instant feedback as to what people are thinking about
the risks and the concerns that they are sharing. It allows the organizations to respond quickly
according to rapidly changing scenarios. In this respect, social media has certain advantages
over traditional media. Social media can offer a platform for representatives or experts from
regulatory bodies and international agencies to come forward and make their messages more
personalized through the use of social utilities like Facebook, Twitter, and especially
YouTube where the messenger can be seen clearly. Kaplan’s and Haenlein’s (2010)
definition of social media as a means of allowing ‘‘the creation and exchange of User
Generated Content’’ illustrates the potential of using social media as an important means for
producing and trading information on a large scale.
The proliferation and ubiquity of social media communication channels have made it easierfor most people to seek and find information on almost any health related topic, and theinformation that they obtain from the search is often diverse and divergent in perspectives. As
a result, people have an increasingly difficult time judging the accuracy and credibility of
information coming from ‘experts’ and are turning instead to peers and ‘friends’ throughonline social networks to inform their health-related decision making. Thus we must be very
cautious regarding the authenticity of the information provided by social media sites, as mostof them do not have proper quality control and the source of information is questionable.
During the 2009 H1N1 influenza pandemic, the US Centers for Disease Control andPrevention (CDC) harnessed the potential of social media to provide health and risk
information to consumers (Bernhardt 2010). The CDC employed many social media tools
such as weekly tips by email, text messages by Widget, e-cards, mobile phones, RSS (Rich
Site Summary, also known as Really Simple Syndication), Twitter, Facebook, WordPress, ablog, Flickr, and YouTube to disseminate information to the general public.
Social media has also been deployed during the Fukushima Daiichi accident to communicate
risk-related issues to varying degrees of success. The Fukushima nuclear accident is a global
issue, and given its characteristics of complexity, uncertainty, and ambiguity, risk
communication should be improved. This will be accomplished by conveying complex
74

subject matter, such as radiation and its effect on human beings, in language that laypeople
can understand. At the same time, support of the international agencies and organizations touse plain and consistent language wherever possible would be particularly useful. Indeed, thisis a lesson from which health authorities all over the world should learn (Ng and Lean 2012).
From this and other experiences, we have learned that social media could help in “(i)increasing the dissemination and potential impact of rapid public communications inincidents involving life threatening illnesses, acts of terrorism, or other potentially major
threats to public health; (ii) use emerging channels of communication to reach diverse
audiences with tailored and personalized health messages; (iii) facilitate interactive
communication and community engagement; and (iv) empower people to make healthier andsafer decisions in protecting public health” (Nall 2010).
There is a need to improve public information especially in the event of a crisis and the callfor educational efforts and action to improve risk communication. We should consider
seriously incorporating social media (in addition to traditional media) as an important tool inrisk communication. Additionally, research should be carried out to evaluate the extent of theeffectiveness of the use of social media in risk communication and risk management.

4.4 Conclusion
In this chapter, we have learned about the concept of “risk.” When the concept of“probability” turns into the concept of “risk”, we now understand that something should beprotected; for example, health or nature. The primary characteristic of radiation risk is“uncontrollability”.
In addition, one-way communication model assumes that there is plenty of knowledge for
specialists, and citizens are ignorant. Knowledge is conveyed from specialists to the public,that is, one-way. Experts explain this model of communication as the “deficit model”: thepublic is deficient in scientific knowledge whereas scientists are knowledgeable. Therefore,
professionals desire to provide “decisive action guidelines and unique information” to theignorant public. On the contrary, there is another model: the two-way communication model.
It shows that publics or residents possess local knowledge, so specialists ideally convey
scientific knowledge and publics convey local knowledge to the specialists. If we adopt thistwo-way communication model, publics want to receive “impartial, non-partisan, wideranging information”, and want to decide the next action by themselves based on thisinformation.
75

We also learned the difference between information transmitter and information interpreter.
Whereas doctor-patient communication is sufficient for good information interpreting, since
they often share higher goals or salient values, doctor-public communication is much moredifficult since they cannot share higher goals or salient values. In the construction of higher
goals and salient values, the media plays a very important role.

Questions and Answers(1) What is risk?
Risk means the possibility that something harmful or undesirable may happen. The
concept of risk is always related to a “possibility” or “likelihood” that something bad
may happen to protect our environment or our health.
(2) What are the characteristics of radiation risk?
Radiation risk is perceived as “uncontrollable” when it has a relationship with nuclear
power plant accidents, which has low possibility and high damage. These are thecharacteristics of radiation risk.
(3) What is the deficit model and the two-way communication model?
Deficit model shows that there is plenty of knowledge for specialists, whereas citizens
are ignorant. Knowledge is therefore conveyed from specialists to public. On thecontrary, two-way communication model recognizes that publics or residents havetheir local knowledge, so specialists convey scientific knowledge and publics convey
local knowledge to the specialists.
(4) What is the difference between doctor-patient communication and doctor-public
communication?
In the case of doctor-patient communication, they can share the higher goal or salient
values, for example, to battle with disease, and to raise the quality of life, therefore,
they can build trust with each other. On the contrary, in doctor-public communication,
doctors rarely share the same higher goal or salient values as there are a variety ofhigher goals and different salient values. This leads to difficulties of trust between
doctors and publics.
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(5) What are the roles of media in risk communication?
The role of media on risk communication is a rapid dissemination of information
related to public health and the media influences public perception of risk issues. It
promotes interactive communication with stakeholders and personalized healthmessages. The media can engage with public and empower them.

References
Beck, Ulrich. 1986. Risikogesellschaft. Frankfurt am Main: Suhrkamp Verlag
Bernhardt, Jay M. 2010. “Communication 2.0: increasing information reach and impact
through new media and public engagement”. Abstract in the Forty-Sixth Annual
Meeting of the National Council on Radiation Protection & Measurement, Bethesda,
MD, March 8-9. Accessed February 13, 2014.
www.ncrponline.org/Annual_Mtgs/2010_Ann_Mtg/2010_Electronic_Program.pdf.
ICRP. 2009. “Application of the Commission's Recommendations to the Protection of People
Living in Long-term Contaminated Areas after a Nuclear Accident or a Radiation
Emergency. ICRP Publication 111.” Ann. ICRP 39 (3).
Klinke, Andreas, and Ortwin Renn. 2006. “Systemic Risk as Challenge for Policy Making in
Risk Governance.” Forum: Qualitative Social Research 7 (1) Article 33.
Nall, Janice. 2010. “Social Networking: How It Can Be Used to Improve Public HealthCommunication”. Abstract in the Forty-Sixth Annual Meeting of the National Council
on Radiation Protection & Measurement, Bethesda, MD, March 8-9. Accessed
February 13, 2014.
www.ncrponline.org/Annual_Mtgs/2010_Ann_Mtg/2010_Electronic_Program.pdf.
National Diet of Japan, The. 2012. The Official Report of the Fukushima Nuclear Accident
Independent Investigation Commission: Executive summary.
Ng, Kwan-Hoong and Mei-Li Lean. 2012. “The Fukushima Nuclear Crisis Reemphasizes the
Need for Improved Risk Communication and Better Use of Social Media.” Health
Phys 103 (3): 307-310.

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Kaplan Andreas M. and Michael Haenlein. 2010. “Users of the World, Unite! The Challenges
and Opportunities of Social Media.” Business Horizons 53 (1): 59-68.
Sakura, Osamu, Nobuhiko Ban, Yoshitaka Kohayagawa, et al. 2013. “Toward Communitybased Participatory Risk Communication: A Proposal for a Double Interpreter
System.” Paper presented at the Annual Meeting of Society for Social Studies of
Science, San Diego, October 9-12.
Slovic, Paul. 1987. “Perception of Risk.” Science, New Series, 236 (4799): 280-285.
WBGU, German Advisory Council on Global Change. 2000. World in transition. Strategies
for managing global environmental risks. Annual Report 1998. Berlin: Springer.

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CHAPTER 5
SOCIAL DETERMINANTS OF HEALTH
Laurence Monnais19,20

Summary
The social determinants of health (SDH) perspective is based on a disparate public health and social
science literature and grounded in the ‘McKeown thesis’ (1976) which suggests that the mostimportant antecedents of human health status are not medical care inputs. Instead they are social,economic and cultural characteristics of individuals and groups (Evans, Barer and Marmor 1994).
There is no definitive list of SDH; they range from racism to poverty, from lack of education to living
in a violent neighborhood. Health systems are a SDH when access to efficient public-funded and‘culturally accessible’ care is an issue. In 2005, the WHO established the Commission on Social
Determinants of Health on the premise that action on SDH is the most effective way to improveglobal health and promote social justice, thus reasserting the 1978 Alma-Ata ‘health for all’ motto and‘modernizing’ 19th century social medicine movements. In a context of disaster, SDH must be taken
into account when it comes to medical intervention since some of these determinants might have an
important incidence on the survivors’ physical and psychological well-being and since thevulnerability of specific groups might increase (in relation to edible food scarcity, destruction ofdomestic spaces, relocalisation of refugees, and stigmatization of the victims). Sanitary crises arealways and everywhere socially disruptive. SDH also vary in time and space: although Japan has thehighest life expectancy in the world, from a SDH perspective gender inequities and the weight of apatriarchal society have consequences on local health disparities (Lock 1994). Recalling the SDH
actions taken in different historical contexts of crisis and identifying specific Japanese SDH will help
medical students address future disasters in the country.

Learning Objectives
After reading this chapter the reader will be able to:(1) Explain a SDH and describe the use of a SDH approach
19 Professor, Department of History, University of Montreal
20 Canada Research Chair in Health Care Pluralisme-mail: laurence.monnais-rousselot@umontreal.ca

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(2) Apply the SDH approach to medical intervention in situations of crisis(3) Identify specific SDH in a given/local situation(4) Discuss the use of a SDH approach in disaster zones or situations of crisis(5) Mobilise tools to develop a SDH approach in a disaster context that is sensitive to
local realities
Keywords: Social medicine, social justice, social determinants of health, ecological approach

Introduction
The social determinants of health (SDH) approach is one based on a disparate public health and social
science literature that suggests that the most important antecedents of human health status are notnecessarily medical care inputs. It is an ecological approach to human health. In situations of crisis,
SDH must be taken into account when it comes to medical intervention as some of these determinants
may have an important impact on survivors’ physical and psychological well-being and on society as
a whole. Recalling SDH actions taken in different crises and identifying, more specifically, Japanese
SDH (social capital in particular) will help medical students address future disasters in the country.

5.1 Using SDH approaches for human health
The current SDH perspective is grounded in the ‘McKeown thesis’ (1976). The historian McKeown
postulated that the improvement of human health from the 18th century onwards was due to economic
growth, rising living standards, and improved nutrition. In the wake of his seminal work, health policy
specialists Robert Evans, Morris Barer, and Theodore Marmor (1994) emphasized the role that social,economic, and cultural characteristics of individuals and groups played in the betterment of health. In
March 2005, the World Health Organization (WHO) established the Commission on Social
Determinants of Health (CSDH) on the premise that action on SDH is the most effective way to
improve global health and promote social justice; it aimed to draw the attention of governments to
SDH as well as promote the creation of better social conditions for health, particularly among theplanet’s most vulnerable people. The commission delivered its report to the WHO in July 2008 before
ending its functions. The CSDH made three recommendations: improve daily living conditions; tackle
the inequitable distribution of money, power, and resources; measure and understand the problem andassess the impact of action. These recommendations led to the endorsement by WHO member statesof the Rio Political Declaration on SDH (WHO 2011).

80However, perceiving SDH as fundamental in tackling health care issues is hardly novel. By thesecond half of the 19th century social medicine movements were participating in the formation of
public health discourses and actions. This was reflected in an increased awareness of the powerfulrelationship between a person’s social status, their living conditions, and their health outcomes. In
Japan, advances made by statesman Goto Shinpei’s (1857-1929) in public health, precluded thematuration of social medicine (shakai igaku) during the Interwar period thanks to the work andadvocacy of some Japanese doctors including Sato Sho, Mizobuchi Tadao, and Komiya Yoshitaka
who hoped to better fight TB (Johnston 1995, 252-65). Public health tends to consider a specificpopulation as a sum of individuals (characteristics such as sex, age, education, income and ethnicity
permit the classification of these individuals into groups); in contrast, work in social medicine
envisions populations, as well as social institutions, as totalities whose characteristics transcend thoseof individuals. Social medicine therefore defines problems and seeks solutions with a social unit ofanalysis rather than an individual one. Social medicine also conceptualizes the duality of ‘healthillness’ as a dialectic process rather than a dichotomous category (Waitzkin et al. 2001, 1593-94).
Epidemiological research has since confirmed the centrality of social factors in the impressive
improvement to the health of populations in industrialized countries. The development, in the context
of the Cold War and decolonization, of scientific medicine and its therapeutic breakthroughs(vaccines and antibiotics in particular) put greater emphasis than before on health technologies
delivered through ‘vertical programs’. This was especially true after 1945 despite the fact that the
failure of the WHO’s campaign for the global eradication of malaria would soon lead to the rise ofcommunity-based approaches. Such initiatives emphasized community empowerment and the role ofcivil society, defined as the “organized non-state, non-market sector that exists above the family andindividual” (Kawato, Pekkanen and Tsujinaka 2012, 78) in health decision-making as well as
linking—once again—health to political, economic, social, and environmental demands. It wasthought that locally recruited health workers might be well positioned to assist their neighbors in
confronting a majority of health issues; health education and disease prevention were at the heart ofthese strategies (Irwin and Scali 2007, 238). These initiatives shaped a new WHO strategy better
known as the 1978 Alma-Ata ‘health for all by the year 2000’ declaration. The new primary healthcare model it presented was not only creating a new fundamental level of care within a given healthsystem (putting the emphasis on the basic health needs of the majority); it was also a philosophy ofhealth work as a part of the ‘overall social and economic development of the community’ (WHO and
UNICEF 1978). This approach was to be applied mostly to developing countries, since the collapse of
welfare systems in developing countries at a time of increased neo-liberalism and free market
capitalism led to a wider rethinking about the impact of socioeconomic inequities on population
health.
In some cases neoliberal thinkers were able to turn emerging findings on SDH to their own
advantage by framing non-medical influences on health in terms of individual ‘lifestyle choices’.
The influential 1974 report issued by Canadian Health Minister Marc Lalonde lent itself to such a81reading. Lalonde’s emphasis on the effects of environmental and behavioral factors on healthprovided ammunition to ideologies promoting ‘personal responsibility’ (Lalonde 1974).

Health experts have since asserted that a SDH approach to health cannot be separated from welldesigned public health interventions, health care professionals, and their relationship with national
policies, ideologies, institutions, and, more broadly, social change (Szreter 2002, 724). Moreover a
SDH perspective is an ecological one that emphasizes both individual and contextual systems and theinterdependent relationship between the two in regards to health. However, the relative importance ofinvestments in health care vs. investments in other determinants of health remains up for debate.
It is important to note that although Japan has the highest life expectancy in the world, its healthexpenditure is only 8.5% of GDP, which places it in 20th position in terms of expenditure among
Organisation for Economic Co-operation and Development (OECD) countries.

5.2 Identifying specific SDH in a given/local situation
What’s more, there is no definitive list of SDH. These can range from racism and genderinequality to poverty, from lack of education to living in a violent or polluted neighborhood;by contrast, living in a democratic country where economic disparities are low and social
capital high (both at the structural level: resources embedded in social networks and social
structure and at the cognitive level; trust and reciprocity in actions within the structure andnetworks or social cohesion: Putnam 2000) is considered good for your health. However,health systems become a SDH when access to efficient public-funded and ‘culturally
accessible’ care is an issue. SDH is thus a flexible and multilayered concept. For instance,
several studies have recently shown that cognitive social capital has an impact on health inJapan both positively (trust and mutual aid promote longevity) and negatively (enforce
conformity and intolerance for diversity, within the context of the Japanese school system for
instance) especially on a local scale (Takao 2009, 509-511). The relative ranking of multiple
SDH is also hard to establish. One of the reasons has to do with the fact that SDH vary acrosstime and space. Therefore, when a local study of SDH is conducted, it had to be done in
relation to a given “political, socioeconomic, cultural, geographic and historical context”(Cook, Bhattacharya and Hardy 2009). Locality matters on many different levels: macro andmicro contexts intertwine, as do history and geography, further reinforcing the complexity of
SDH mapping.

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Studies conducted in Japan have emphasized the positive impact of a healthy lifestyle and acollective attention to hygiene (that might be attributable to a complex interaction of culture,
education, climate, environment and the Shinto tradition of purifying the body and mind before
meeting others), ‘health consciousness’, and food (Ikeda et al. 2011). Cockerham et al. (2000)
have found that Okinawans in particular rank highest in health and life expectancy and at thebottom in socioeconomic indicators. This ‘contradiction’ might indicate that the most important
contribution to good health in Okinawa is a healthy lifestyle, especially diet and social support.
In parallel, although the egalitarian nature of Japanese society (shown in terms of strong
educational policies, regulations that ensure employment security, and universal access to healthcare) might account for the country’s high life expectancy, there are documented healthdisparities that may have increased in the aftermath of the 1997 economic crisis. The suicide
rate has increased among working-age Japanese males as well as TB incidence in poor urbanneighborhoods. At the same time the enduring weight of a patriarchal society has consequenceson gender inequality, affecting the psychological well-being of Japanese women and leading togreater rates of depression.

5.3 Using an SDH approach in disaster zones or situations of crisis
Disasters, natural or otherwise, notwithstanding social organization or geographic location, remain
disruptive; they affect the physical health (injuries, contamination, worsening of previous pathologies)
and psychological well-being (PTSD, major depression disorders, generalized anxiety disorders, andpanic disorders (Norris et al. 2002) and cause increased rates of substance abuse, violence and suicide(Otani 2010, 73) in individuals of affected communities. They also tend to affect specific sub-groups
more acutely, notably previously vulnerable populations (the elderly, youth, women, ethnic
minorities, or poor people). Thus a country that had not already addressed SDH such as poverty,
unemployment, housing, transportation, nutrition, and social support will likely be more affected by adisaster (Johnson and Stoskopf 2010). A ‘social autopsy’ of disasters would improve further disasterrecovery interventions (Klinenberg 1999), as well as reveal what had previously been hidden by the
daily functioning of a given community (Otani 2010).

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A revealing illustration of the need for a social autopsy of a disaster is 2005 Hurricane Katrina.
Most of those who could not escape the storm were poor, living in historically economicallydeprived areas and predominately African-American communities. The disaster may have beennatural in a meteorological sense but it was the ‘unnatural’ social forces—specifically class andrace—that determined who lived and who died (Holtz et al. 2006).
A SDH approach is also fundamental when it comes to dealing with the disaster itself and its
outcomes. In fact, the vulnerability of specific groups might also increase in the aftermath of the crisis
due to edible food scarcity, pollution, destruction of domestic spaces, re-localization of refugees,
unemployment, economic instability and new forms of competition for resources, stigmatization of
the survivors—in the case of Chernobyl or Minamata survivors for instance—and loss of social
support. These local vulnerabilities could potentially lead to increased health discrepancies in the longrun, as well as to new health issues.
Studies on the ice storm that took place in Quebec, Canada in the winter of 1998 found that prenatal
maternal stress due to extreme living conditions during the catastrophe (absence of electricity andheat for several weeks, up to two months in some remote areas of the province) led to lower
cognitive and language abilities in children at 5½ years of age (Laplante et al. 2008).
Japan has overcome huge disasters in the past; a number of serious sanitary crises involving naturaland nuclear disasters, environmental pollution (Minamata, 1956-), food-borne diseases (such as theMorinaga Milk co. arsenic poisoning, 1955) and health hazards due to pharmaceuticals (Yakugai)
have occurred since World War II. Earthquakes in particular are historical objects of knowledgemaking in Japan, restructuring disciplines, institutions, and even individual careers (Clancey 2006, 5).
The Japanese have learnt from their past experiences and, in this regard, they have developed a‘catastrophe cultural memory’ (Duus 2012, 175), even a ‘catastrophe collective resilience’ (Kingston
2012, 2) that participated in the forging of the nation. After the Kobe earthquake of 1995, which wassoon christened ‘year one of the volunteer age’ (borantia gannen), the Japanese quickly learned torely more on overseas assistance and local civil society, a fact demonstrated in the initial response to
the humanitarian crisis in Tohoku (Avenell 2012, 53-55). Also ‘Kokoro-no-care’, a concept
encompassing mental health care and psycho-social support, has become a watchword for helping
post-disaster communities recover, thanks to the results of longitudinal surveys that have shown
increased social problems (alcohol dependency, nutrition and diet issues) in the aftermath of theearthquake (Otani 2012, 247). Still, approaches to reconstruction remain mainly top-down. This canbe explained by the weight of history, as can some reactions to the Chernobyl catastrophe inhistorically ‘brutalized Ukraine’ (Petryna 2003). Since the early Meiji period (1868-1912), Japan’s84

development has been achieved via top-down programs of purposeful accelerated socio-politicalmodernization and economic expansion. This required the development of a set of institutions that
could execute the government’s vision through a coordinated mobilization of the nation’s resources
and people. In the post-war era, the ‘iron triangle’ of political, bureaucratic, and corporate elites
became institutionalized: the nuclear industry (what some call the ‘nuclear village’), TEPCO in
particular, symbolizes this co-dependent network of relations (Matanle 2011, 838-41).
When the Minamata disaster occurred in the 1950s, industrialization had priority over public healthin Japan. Private companies demonstrated a lack of ethics and failed to manage the disclosure of
information to the public, worsening the management and recovery of the survivors. Imamura, Ide
and Yasunaga (2007)’s study shows that insufficient social recognition of environmental pollution,
inadequate inspections and faulty diagnoses (the disease was initially called an endemic disease of
unknown cause) together contributed to delays in the identification of the real cause of the illness,
resulting in continuing damage. In this particular case, long-term effects on human health were notconsidered, and insufficient help was deployed to both sick and unaffected citizens of Minamata,leading to long-term discrimination to the region’s population.
We can certainly learn from the past but Fukushima Daiichi accident is no Kobe redux; there is no
way to prepare for every contingency and a disaster is always a surprise to some extent. The
Fukushima Daiichi accident has drawn attention to enduring institutional problems, notably the factthat the agency supposed to act as the nuclear watchdog is part of the ministry responsible forpromoting nuclear energy, as well as a generalized low level of trust in governmental institutions(Hommerich 2012). The weakness of civil society advocacy organizations may also have been acontributing factor in the nuclear accident since they were largely ineffective in their monitoring ofgovernment policies and industry excesses (Avenell 2012, 79). The nuclear meltdown also exposed
the fragility and contradictions in Japan’s energy policy, potentially leading to greater internal
scrutiny of Japan’s economic development model (Matanle 2011, 837) in the post 1997 era. The
Fukushima Daiichi accident is a critical event that is embedded in what historian Peter Duus (2012,178) calls Japan’s ‘lost decades’. This concept is expressed by a country facing fundamental questions
as it witnesses economic stagnation, a demographic problem of herculean proportions, the collapse of
the social welfare system, and growing inequality. By contrast, the huge impact of social media both
positive—on the reinforcement of civil society’s role through Social Networking Services—andnegative—leading to possible more cases of PTSD because of shinsai hai or ‘disaster high’ (Slater,
Nishimura and Kindstrand 2012, 103)—could not be foreseen. Moreover, the Fukushima Daiichi
accident was a ‘compounded catastrophe’ that occurred in a ‘shrinking region’ (Matanle 2011); it
occurred in rural, even remote areas with a high proportion of elderly people (an estimated 30% ormore of the population in the tsunami affected areas was over 65 years old) where the economic
situation had been in an almost constant state of degradation since the 1950s. In terms of per capita
GDP, Miyago ranks 32 out of Japan’s 47 prefectures with Iwate ranking 39 (Curtis 2012, 21). These85

are several reasons why a SDH approach to medical intervention in the aftermath of a catastrophe isfundamental to improving both individual lives and helping communities recover.

5.4 Importance of SDH approach in medical interventions
But what do these specificities and realities concretely mean for clinicians who participate in therecovery of the Tohoku region and who will eventually intervene in further disaster recovery
missions? Firstly, it means following an ecological approach when evaluating a given situation, taking
both global (political, economic, social) and local realities into account, as well as the relationshipbetween the local and the global. For instance, in the case of Fukushima and its surrounding area, thiswould concretely mean to take into account the fact that local farm products and fisheries were very
quickly stigmatized due to fears surrounding radiation, which only reinforced the risk of having the
local economy collapse, with potential repercussions on the country’s economy as a whole. In the caseof the broader Tohoku region, this would also mean acknowledging the fact that the region is ahistorically ‘silent’ one, perhaps even stigmatized (Morris 2012, 42). Thus, identifying andmonitoring the local vulnerabilities and social problems that existed before the disaster is crucial.
Secondly, clinicians would have to nurture and reinforce social capital. What’s more, we must give
particular attention to reinforcing social capital when such a destructive and disruptive disaster occurs
in a region where social and economic vitality has been weakened in the past decades (Kingston 2012,5). For instance, re-localizing elderly people is not a simple matter; it threatens to reinforce preexisting vulnerabilities related to age and to the local erosion of traditional family living arrangements(Otani 2010, 237-42). Therefore, there is a need to engage as quickly as possible with local
community leaders and organizations, with local Neighborhood Associations (NHAs), associations
that generate social capital and whose importance is particularly salient in rural areas and in efforts toimprove disaster preparedness and response (Avenell 2012, 83-84). Relying on local associations’knowledge regarding local needs—what some social scientists call learning ‘from below’—could help
mitigate isolation and anxiety in order to avoid kodokushi of elderly people as it occurred on a quite
disturbing scale after the Kobe Earthquake (Curtis 2012, 21). Instead, one could promote, with thehelp of such associations, locally-adapted reconstruction, in terms of housing, but also in helping
forge a new community with a potential for future economic development. Clinicians could also
participate in increasing survivors’ empowerment by helping them develop a strong voice in publicdebates (Holtz et al. 2006). Bedside manner should thus be extended to an informed ‘community-sidemanner’ that considers all social factors contributing to human health. Thirdly, this ecologicalintervention, sensitive to local specificities and issues, requires interdisciplinary research (on the longterm, before and after disasters) and interdisciplinary action that takes into account work that has beenaccomplished in social sciences and in ethnography such as the works I have quoted in this chapter, as
86

well as works that concentrate on previous Japanese disasters and foreign ones such as Katrina or
Chernobyl. From a SDH perspective, both epidemiological statistics and personal experiencescollected through (medical) interviews with survivors (i.e. both quantitative and qualitative data) are
fundamental; personal narratives and clinical facts matter equally especially when pre-disastersocioeconomic vulnerabilities are salient.

5.5 Conclusion
Interaction with survivors needs to be a continual process, as is giving them a platform to speak about
their identities and give an ‘unsterilized’ version of what they perceived happened. This includes
sharing their own physical and psychological experience of the catastrophe. Asking for their own
interpretation of the(ir) future matters as well since such a disaster might have an impact on the wholeof Japanese society, generating unnecessary anxieties regarding the future of a country, its economic
growth, and its political and social stability.

Questions and Answers(1) What is a SDH?
A SDH is a social, economic, cultural, and/or historical factor which is recognized to
be a determinant in the improvement or deterioration of human health.
(2) What does using a SDH approach mean?
Using a SDH approach means to use an ecological approach to health that involves
paying attention to a wide and locally specific range of socio-cultural and historicalrealities and economic disparities.
(3) Why is having a SDH approach important when it comes to medical intervention insituations of crisis?
Having a SDH approach is important when it comes to medical intervention insituations of crisis since:i.

This kind of situation is socially disruptive;ii.

These determinants might have an important incidence on the survivors’
physical and psychological well-being; andiii.

The vulnerability of specific groups might increase.

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(4) How does one identify specific SDH in a given situation?
Identifying specific SDH in a given situation implies paying attention to bothcollective and individual local needs in terms of health and well-being and working
closely with local community leaders and organizations.
(5) How does one use a SDH approach in disaster zones or situations of crisis?
Using a SDH approach in disaster zones implies interactions with the survivors andproducing qualitative studies regarding their own experience, anxieties, andexpectations for their own future.

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edited by Jeff Kingston, 94-108. London & New York: Routledge.
Szreter, Simon. 2002. “Rethinking McKeown: The Relationship between Public Health and Social
Change.” American Journal of Public Health 92 (5): 722-725.
Takao, Soshi. 2009. “Research on Social Capital and Health in Japan. A Commentary on Ichida andon Fujisawa.” Social Science & Medicine 69 (4): 509-511.
Waitzkin, Howard, Celia Iriart, Alfredo Estrada, and Silvia Lamadrid. 2001. “Social Medicine Thenand Now : Lessons from Latin America,” American Journal of Public Health 91 (10): 15921601.

90

World Health Organization (WHO). 2011. World Conference on the Social Determinants of Health,
Rio de Janeiro, Brazil, 19-21 October 2011. http://www.who.int/sdhconference/en/
WHO and United Nations Children’s Fund (UNICEF). 1978. Primary Health Care, Report on theInternational Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978.
Geneva: WHO.
http://www.unicef.org/about/history/files/Alma_Ata_conference_1978_report.pdf

Further reading
Cook, Harold J., Sanjoy Bhattacharya and Anne Hardy, eds. 2009. History of the Social Determinantsof Health. Global Histories, Contemporary Debates. Hyderabad: Orient Blackswan Private
Limited.
Evans, Robert G., Morris L. Barer, and Theodore R. Marmor, eds. 1994. Why are Some People
Healthy and Others Not? The Determinants of the Health of Populations. New York: Walterde Gruyter Inc.
Holtz, Timothy H., Seth Holmes, Scott Stonington, and Leon Eisenberg. 2006. “Health Is Still Social:Contemporary Examples in the Age of the Genome,” PLoS Med 3 (10): e419.
doi:10.1371/journal.pmed.0030419
Kingston, Jeff, ed. 2012. Natural Disaster and Nuclear Crisis in Japan: Response and Recovery after
Japan’s 3/11. London & New York: Routledge.
McKeown, Thomas. 1976. The Modern Rise of Population. London: Edward Arnold.
World Health Organization (WHO). 2011. World Conference on the Social Determinants of Health,
Rio de Janeiro, Brazil, 19-21 October 2011 http://www.who.int/sdhconference/en/
WHO and United Nations Children’s Fund (UNICEF). 1978. Primary Health Care, Report on theInternational Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978
Geneva: WHO.
http://www.unicef.org/about/history/files/Alma_Ata_conference_1978_report.pdf

91

CHAPTER 6
PROFESSIONALISM, LAW AND ETHICS
Tamra Lysaght21 and Satoshi Kodama22

Summary
Major disasters are public emergencies that tend to demand significant medical resources andexpertise. These demands may be greatest in situations where medical professionals areunable to access their workplace, which may result in hospital facilities being understaffedand unable to cope with the influx of patients requiring assistance. While physicians who
work outside the affected area may wish to offer their assistance, the lack of reliable
information and uncertainty that often follows a disaster can make it difficult to assess
whether it is safe enough to enter an affected area to provide medical assistance. These
challenges are compounded when the immediate risks are unknown but the need for medicalcare may be critical. In this chapter, we discuss the legal and moral obligations of physicians
to provide medical care to patients affected by disasters; both for doctors who live in or near
the affected areas, and for those who live away from the disaster zone.

Learning Objectives
After reading this chapter the reader will be able to:(1) Describe the legal and moral duties of a doctor who works in or near the disasterzone, in relation to his/her patients and others in need of help in public emergencies(2) Discuss the legal and moral duties of a doctor who works away from the disasterzone, in relation to those in need of medical help in public emergencies(3) Apply ethical reasoning to decisions on whether doctors should provide medical
assistance in a public emergency
Keywords: Medical law and ethics, duty to treat, professional codes of conduct, virtue ethics

21

Senior Research Fellow, Centre for Biomedical Ethics, Yong Yoo Lin School of Medicine, National
University of Singapore
e-mail: tlysaght@nus.edu.sg
22
Associate Professor, Department of Ethics, Kyoto University Graduate School of Letterse-mail: kodama.satoshi.4v@kyoto-u.ac.jp92Introduction
Public emergencies are typically characterized by the pressing need for medical assistanceand doctors working in or near an affected area may be called upon to care for injured people.
Physicians with specialist training may be required to diagnose and treat disaster-related
injuries. In addition, patients with unrelated illnesses and conditions may still be in need of
medical attention and physicians may have existing fiduciary duties to care for them. Thus,
physicians may be legally and ethically required to remain in or around disaster zones despite
the risks of harm to themselves. To help physicians understand these duties, this chapter willconsider two scenarios: 1) where a physician works in or near a disaster zone, 2) where aphysician works away from the disaster zone.
See relevant laws and guidelines, local reports


Medical Practitioners Act (1948, as amended 2008)



Japan Medical Association (2009) The JMA Guidelines for Physician’s Professional
Ethics 2008. Japan Medical Association Journal 52, 75-91.



News

reportabout

theshortage

of

staff

at

Fukushima

hospitals

http://www.youtube.com/watch?v=6h6OXqch3O8
Before discussing the legal and ethical obligations of physicians in public emergencies, it isimportant to make clear some of the differences between the law and ethics.23 In many ways,
the law and ethics require the same kind of conduct from individuals, such as not harming
others and respecting the privacy of others. However, there are different expectations forindividual conduct.
First, the law expects us to behave toward others in a way that is reasonable, while ethics
demands a higher standard of acting for the good of others. For example, while we might
agree that doctors should show compassion to their patients, we might also accept that it is
not reasonable to require a doctor to do so in all circumstances – that expectation is better left
as a moral ideal or aspiration. Second, the law enforces its rules by means of sanctions, suchas fines and imprisonment, whereas ethics has either one’s conscience or social influences,such as praise and criticism from others, to guide behavior. So, for example, a doctor who
23 This explanation has been sourced from the Health Ethics, Law and Professionalism (HeLP*) Phase I Course

Book 2013 – 2014. MBBS Programme of the Yong Loo Lin School of Medicine, National University ofSingapore. Centre for Biomedical Ethics. Page 37.

93

commits an act that is legally prohibited may face criminal charges and lose their license forpracticing medicine. However, doctors who do not show enough compassion to their patients
may be criticized by their colleagues and patients but whether they change their behavior is
ultimately up to them.
Professional codes of conduct are different again. Oaths and codes typically describe theidentity of a profession – who they are, what they should do, and what they aspire to be. For
example, the Japan Medical Association has the JMA Guidelines for Physician’sProfessional Ethics (2008). Although they are sometimes referred to as code of ethics, theseguidelines sometimes have closer affinities with the law because their rules are enforceable
by the threat of disqualification or marginalization from the profession. However,professional codes are not the law because they are created and enforced by the profession
themselves and not by the state. In addition, although the code of ethics can encompass morethan-minimum duties and aspirations for its members, it is up to individual members to makeefforts and aspire to be a “good doctor”.
In summary, while the law and ethics create obligations to individual doctors that may often
overlap, it is important to keep them separate and think clearly about what kind of obligations
doctors are under. Whilst there is arguably an ethical obligation on a doctor to respond tosomeone in an emergency, the question needs to be asked: is there also a legal obligation?

6.1 The Legal Obligations of Medical Professionals
The obligations that physicians have under the law to provide medical assistance in public
emergencies can vary in different countries and across jurisdictions. For example, somecountries have ‘Good Samaritan’ laws that reduce the liability of bystanders who come to theaid of others in need of assistance. While no such law exists in Japan, the liability ofphysicians who provide voluntary medical treatment in emergency situations may be reduced
under the Civil Code (1896, as amended 2006) in Article 698, which set rules on “urgent
management of business”. Under this rule, physicians shall not be liable for damages
resulting from their voluntary assistance in an emergency situation unless “he/she has acted
in bad faith or with gross negligence”. However, it is important to note that this law does notcompel physicians to act in an emergency situation.
Under the Medical Practitioners Act (1948, as amended 2008), physicians working in Japan
have legal duties to respond to requests for medical treatment. According to Article 19(1):94No medical practitioner who provides medical treatment shall refuse any request
for examination or treatment without just cause.
This law may apply to physicians in relation to the patient(s) whom he/she is currently incharge of, although no penal sanction is attached in the case of abandonment where aphysician flees or resigns from his/her place of work. In these cases, Article 218(Abandonment by a Person Responsible for Protection) of the Penal Code (1907, as amended
2007) may apply:
When a person who is responsible for protection of a senile, immature, physicallydisabled or sick person, abandons, or fails to give necessary protection to such
person, the person shall be punished by imprisonment with work for not less than
3 months but not more than 5 years.
However, this Article may not apply if the patient is transferred to some other physician or
hospital for their care although, in general, this responsibility would likely fall onto theinstitution rather than an individual doctor. As for the duty of doctors who are not located inor near a disaster zone, there are no specific laws in Japan that would force physicians totravel to an affected area and offer assistance.
Outside the law, further guidance is provided in the JMA Guidelines for Physician’sProfessional Ethics (2008). Interpretation of Article 19(1) of the Medical Practitioners Act is
expanded in Section 2(8), which states that, where possible, a physician must comply with apatient’s request to provide medical care, particularly “when there is an urgent need fortreatment”. However, a physician may refuse to treat where there is “justifiable reason”. Suchreasons may include “working outside a specialty, working outside business hours, and thepast nonpayment of medical fees”, although controversy surrounds their use as “just causes”
for refusing treatment. If the situation permits, the JMA recommends that medical treatment
should be provided even if outside duty hours. If a specialist is required and the situation is
not urgent, then the patient should be referred to an institution with specialists. However, inemergency situations, physicians should provide first aid as far as possible after informing
patients that they are not specialists.
The World Medical Association has issued a Statement on Medical Ethics in the Event ofDisasters (1994, as revised 2006), although no specific guidance is offered on the obligationsof doctors to assist in or near disaster zones. Annotations to the JMA Guidelines do, however,95

make reference to guidance from the American Medical Association (AMA). According to
the AMA’s Code of Medical Ethics (1957, as revised 2001), physicians working in the UnitedStates are privileged with the autonomy to be “free to choose whom they serve”, except inemergencies. In other words, the autonomy of physicians to pick and choose their own
patients, at least in the United States, may be overridden by societal obligations during apublic emergency. Opinion 9.067 on Physician Obligation in Disaster Preparedness andResponse in the AMA Code of Medical Ethics (Ibid.) states:
Because of their commitment to care for the sick and injured, individual physicians
have an obligation to provide urgent medical care during disasters. This ethicalobligation holds even in the face of greater than usual risks to their own safety, healthor life.
Therefore, even though physicians may not be required by law to enter into a patient-doctor
relationship with people injured in a disaster, or remain in and around the affected area, it isregarded as a matter of professional ethics to assist when possible. Indeed, Section 2(9) of the
JMA Guidelines states that in emergency situations, “the physician should voluntarily
provide care to the extent possible”. The ethical justifications that support these obligations
are discussed in the following section.

6.2 The Ethical Obligations of Medical Professionals
Few scholars, if any, would agree that physicians should be ethically or legally obliged totreat patients in public emergencies without any regard for their own safety. For example,
physicians would not be expected to place themselves in immediate danger of injury or death
during the acute phase of a disaster. However, what are their moral obligations to remain with
their patients and offer assistance? For instance, what about physicians who work in hospitals
that are admitting patients with a highly contagious and virulent influenza virus, or are
located in the vicinity of an area exposed to radiation contamination? Should they stay andassist in spite of the potential health hazards to themselves?
While some scholars would answer ‘yes’ to these questions, not all agree that physicians’
professional obligations should always take precedence over their personal commitments (tofamily/children etc.) or that they should be obliged to practice in places that might be unsafe.

96Some of the main ethical arguments that are offered in the literature for and against suchobligations are shown in Table 6.1 and summarized in the following.
In support of an ethical obligation to treat, it is generally reasoned that physicians havespecial training in medicine that is essential to disaster management and that they, either
expressly or implicitly, agree to provide care during public emergencies as part of theirchosen profession. It is also posited that physicians receive significant societal benefits, suchas high social standing and opportunities for wealth creation that are given on a reciprocal
basis: the social contract requires physicians to render their expertise in times of need. Others
point to the oaths and codes of ethics that physicians agree to observe when entering theprofession and the need to show solidarity with work colleagues and support the wider
medical community in challenging times.
A number of objections have been made to these arguments. While certain risks may be
intrinsic to the profession, it is argued that the types of harms that may arise during a public
emergency are often uncertain and may be unknown when a physician enters the profession.
The societal benefits that physicians receive may vary between individuals meaning that
greater burdens could be placed on some physicians who have not enjoyed the same
privileges as others, which may be unfair. Some scholars have also argued that the concepts
employed in codes of ethics and oaths are too vague and imprecise to impose a moral duty on
physicians working under extreme conditions.

97

Table 6.1: Ethical justifications for/against physicians assisting in or near disaster zones
Ethical Justification

For

AgainstSpecial Training

The specialized knowledge,
skills and access to resourcesthat physicians have creates aduty to respond and provide
care in public emergencies asothers in the community maylack this ability.2

The ability to provide care does
not create a special duty torespond in a public emergency
as others in the community may
be more able to assist without
incurring significant risks tothemselves.1

Expressed Consent

Physicians consent to expose
themselves to risks of harm
associated with emergencies aspart of their job description in
employment contracts.1

Significant risks to one’s
welfare are not routinely
specifiedin
employment
contracts.1

Implied Consent

Physician’s consent to expose
themselves to risks of harm
associatedwithpublicemergencies is implied when
they enter the profession.1

Consent cannot be implied
when specific risks of a public
emergency are not an essential
part of a specialized field.1

Reciprocity (Social Contract)

Society gives physicians special
privileges with high social
standing,
education
andeconomic opportunities, and theability to self-regulate. In returnfor these benefits, physicians
are obligated to provide theirexpertiseinpublicemergencies.2

The social contract is made withthe profession as a group, notindividuals. The acceptance ofbenefits, which may differ withindividual physicians, does not
generate a duty to significantly
risk their own welfare in orderto aid another.1

Oath & Codes

The codes of ethics and oaths
that physicians make whenentering the profession toprovide care whenever required
creates an obligation to respondin public emergencies.2

Codes of ethics and oaths are
symbolic and too imprecise to
create obligations for physicians
to respond in specific public
emergencies.2

Solidarity

Physicians are part of a wider
medical community that must
respond in public emergencies.
Physicians who refuse to
assume risks of harm tothemselves impart this risk onto
colleagues.3

The concept of solidarity is toovague to serve as a standard forphysician behavior in times of
emergency.4

1

Malm et al. (2008)
Wynia (2007)
3
Anantham et al. (2008)
4
Akabayashi (2012)
2

98

The decision to assist in a public emergency, or not, may therefore be very difficult. On the
one hand, the physician may feel a strong desire to remain in, or travel to, a disaster zone toprovide medical care. They may feel strongly about supporting their employers andcolleagues, who will surely be under strain if fewer physicians are available to assist. On theother hand, physicians who have young children or elderly parents to care for may worry
about their welfare and feel an even greater need to ensure their safety over the wellbeing of
unrelated patients.
In arriving at a decision to stay or go, it may be helpful to look beyond questions of risks andbenefits and ask what it means for a physician to be a ‘good doctor’ (Akabayashi, Takimotoand Hayashi 2012). This question can be addressed within the framework of virtue ethics.
This approach considers the embodiment of values and character that determine ethicalbehavior. For example, brave, compassionate and selfless might be considered ascharacteristics of a virtuous doctor acting in public emergencies. Recognition that thedecision to assist in a disaster may go beyond what is ordinarily expected from the social
contract might help physicians to reconcile the many conflicting obligations they are likely toface when needed in a public emergency.

Case Study: Dr. N (Akabayashi 2012)
Dr. N is an internist working at a hospital a little more than 20km away from the Fukushima
Daiichi Nuclear Power Station when the Great East Earthquake struck and news spread about ameltdown. When the Japanese government issues an evacuation notice to those living within a
20km radius of the power plant, her parents plead for her to return to the family home in
Hiroshima. She is reluctant to leave because she has patients at the hospital and cannot referthem to other doctors due to the loss of staff who were affected by the tsunami. However, as
the United States had issued directives advising its citizens residing within an 80km radius toevacuate, she is uncertain about the risks of radiation exposure. Her parents are also concerned
about the potential impacts of radiation exposure on her reproductive health and insist theyneed her support in Hiroshima. She asks the head of internal medicine if she may leave to bewith her parents.
Questions:
1. What are Dr. N’s legal obligations to her patients at the hospital where she works?
2. Should she be allowed to resign from the hospital and return home?

99

Case Study: Dr. U (Reilly et al. 2003)
Dr. U is an Italian epidemiologist who specializes in infectious diseases. In February 2003, hereceives a request from the World Health Organization to investigate several patients who havepresented with unusual influenza-like symptoms at a small private hospital in Vietnam. Upon
arrival, Dr. U swiftly determined that the patients were infected with a previously unknown
virus. The hospital immediately sets up an isolation ward that is kept under guard. The virus isshortly revealed to be highly contagious and virulent, and would become known as severe
acute respiratory syndrome (SARS). His wife was concerned about his exposure to the deadly
virus and pleaded for him to return to Italy. However, Dr. U felt it was important that heremain with the medical staff to contain the virus and ensure it did not spread beyond thehospital. While managing to contain the spread of the virus, he and five other health care
professionals died from the pathogen several weeks later.
Questions
1. What were Dr. U’s obligations to remain at the hospital?
2. How should the professional duties of physicians be weighed against their personal
obligations?

6.3 Concluding Remarks
Physicians in Japan are not legally obliged to assist in public emergencies, nor are they
obliged to travel to a disaster-affected area. If a physician wishes to leave an affected area,
they are unlikely to be penalized for abandoning their patients if other arrangements are madefor their transfer to another physician or hospital. As for a physician’s ethical obligations,while there is broad agreement that physicians should continue to provide care during public
emergencies, and assist when possible, there are limits to how much risk physicians can be
expected to assume during a major event. However, what is considered as an acceptable levelof risk for the societal benefits that physicians receive is disputed and may vary according to
the circumstances of individual physicians. Thus, rather than limiting the question tobalancing risks and benefits, consideration may also be given to the virtues that reflect thecharacter of a good doctor.

6.3.1 Key Learning/Take Home Message
The law and ethics may create different obligations for the conduct of individual
doctors in public emergencies.
100

Doctors working in or near a disaster zone in Japan do not necessarily have a legal
duty to provide medical assistance to people in public emergencies.



Doctors working away from a disaster zone in Japan do not have a legal duty toprovide medical assistance to people in public emergencies.

Physicians may be ethically required to assist in disaster zones.

Questions and Answers(1) What are two main differences between the law and ethics?
i.

The law expects us to behave toward others in a way that is reasonable, while
ethics expects us to act for the good of others.

ii.

The law may be enforced with sanctions, while ethics relies on one’s conscienceand social influences.

(2) Are physicians in Japan legally obliged to travel to disaster zones to provide medical
assistance?
No. There is no law in Japan for ordering doctors to travel to an affected area to offer
assistance.
(3) Will physicians be penalized under Article 19 of the Medical Practitioners Act if theyrefuse to remain in or near a disaster zone to treat patients?
No. There are no penal sanctions attached to the Medical Practitioners Act.
(4) What are pros and cons of Implied Consent argument for doctor’s obligation to assist
in or near disaster zones?
Pro: Physicians implicitly consent to expose themselves to risks of harm associatedwith public emergencies when they enter the profession.
Con: Consent cannot be implied when specific risks of a public emergency are not anessential part of a specialized field.
(5) How would you characterize a good or virtuous doctor in public emergencies?
This is an open-ended question where students must come up with their own answers.

101

Acknowledgements
Many thanks are owed to Ms. Hiroyo Ando from the Division of Human Health, International
Atomic Energy Agency, for English translation of the JMA guidelines.

References
Akabayashi, Akira. 2012. “Must I Stay? The Obligations of Physicians in Proximity to the
Fukushima Nuclear Power Plant.” Cambridge Quarterly of Healthcare Ethics 21 (2):392-395.
Akabayashi, Akira, Yoshiyuki Takimoto, and Yoshinori Hayashi. 2012. “Physician
Obligation to Provide Care During Disasters: Should Physicians Have Been Required
to Go to Fukushima?” Journal of Medical Ethics 38 (11): 697-698.
American Medical Association. 1957, as revised 2001. “Code of Medical Ethics.”
http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medicalethics/opinion9067.page
Anantham, Devanand, Wendy McHugh, Stephen O'Neill, and Lachlan Forrow. 2008.
“Clinical Review: Influenza Pandemic - Physicians and Their Obligations.” Critical
Care 12 (3): 217.
Civil Code of Japan (民法). 1896, as amended 2006.
http://www.japaneselawtranslation.go.jp/law/detail/?ft=2&re=02&dn=1&yo=civil+co
de&x=68&y=10&ia=03&ky=&page=4
Japan Medical Association. 2009. “The JMA Guidelines for Physician’s Professional Ethics
2008.” Japan Medical Association Journal 52 (2): 75-91.
Malm, Heidi, Thomas May, Leslie P. Francis, Saad B. Omer, Daniel A. Salmon, and Robert
Hood. 2008. “Ethics, Pandemics, and the Duty to Treat.” The American Journal of
Bioethics 8 (8): 4-19.
Medical Practitioners Act (医師法). 1948, as amended 2008.
http://www.japaneselawtranslation.go.jp/law/detail/?re=02&dn=1&x=0&y=0&co=1&
ia=03&yo=penal+code&gn=&sy=&ht=&no=&bu=&ta=&ky=&page=1

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Penal Code of Japan (刑法). 1907, as amended 2007.
http://www.japaneselawtranslation.go.jp/law/detail/?re=02&dn=1&x=0&y=0&co=1&
ia=03&yo=penal+code&gn=&sy=&ht=&no=&bu=&ta=&ky=&page=1
Reilley, Brigg, Michel Van Herp, Dan Sermand, and Nicoletta Dentico. 2003. “SARS andCarlo Urbani.” New England Journal of Medicine 348: 1951-1952.
World Medical Association. 1994, revised 2006. “WMA Statement on Medical Ethics in the
Event of Disasters.” http://www.wma.net/en/30publications/10policies/d7/
Wynia, Matthew K. 2007. “Ethics and Public Health Emergencies: Encouraging
Responsibility.” The American Journal of Bioethics 7 (4): 1-4.

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CHAPTER 7
LEARNING ACROSS DISASTER: REBUILDING HEALTH
Kim Fortun24

Whenever we pride ourselves upon finding a newer, stricter way of thought or exposition; whenever
we start insisting too hard upon "operationalism" or symbolic logic or any other of these very
essential systems of tramlines, we lose something of the ability to think new thoughts. And equally, ofcourse, whenever we rebel against the sterile rigidity of formal thought and exposition and let ourideas run wild, we likewise lose. As I see it, the advances in scientific thought come from a
combination of loose and strict thinking, and this combination is the most precious tool of science.

Gregory Bateson, "Culture Contact and Schismogenesis"

Explanatory pluralism, I suggest, is now not simply a reflection of differences in epistemologicalcultures but a positive virtue in itself, representing our best chance of coming to terms with the world
around us.
Evelyn Keller, Making Sense of Life: Explaining Biological Development with Models,Metaphors, and Machines

SummaryThis chapter will introduce readers to research by historians and social scientists that identifies
recurrent issues in disaster response in different settings, focusing on challenges in efforts to rebuild
health. The chapter will highlight recurrent challenges faced by disaster survivors, and by technicalprofessionals (including medical professionals) responsible for aiding disaster recovery. The chapter
highlights the need for conceptual and operational innovation in disaster contexts, integrating andleveraging many different kinds of knowledge.

Professor, Sciencee-mail: fortuk@rpi.edu

24

and

Technology

Studies,Rensselaer

Polytechnic

Institute104

Learning Objectives
After reading this chapter the reader will be able to:(1) Have enhanced understanding of recurrent issues faced by survivors and technicalprofessionals in different disaster contexts(2) Describe the structures and dynamics of disaster(3) Reason and develop a response to a specific disaster context(4) Generalize learning through the application of analysis and evaluation techniques to prepare acreative response to disaster
Keywords: Disaster recovery, knowledge politics, information deficits, public health programs,
thought styles

Introduction
How do different kinds of people – in different time and places – experience disaster? What problems
have emerged in different disaster recovery efforts? What challenges are faced by technicalprofessionals responsible for facilitating disaster recovery? What does it look like to rebuild the healthof individuals and communities after disaster?
These questions are at the heart of research in the emerging subfield of disaster Science andTechnology Studies (STS), which brings together work by anthropologists, sociologists, historians,
political scientists and others working to understand the human dimensions of disaster, with a special
focus on the roles that technical professionals of many kinds – engineers, scientists, and physicians,
for example – play in disaster preparedness and response. This extends a large body of work in thehumanities and social sciences focused on how individuals and communities are impacted by disaster,
on disaster communication and news coverage, and on the role of governments in disaster prevention
and response. The goal of disaster-STS is to develop comparative perspectives on disaster so thatpeople can better recognize recurrent structures and dynamics of disaster, while also becoming
attuned to the ways every disaster is unique and shaped by context.

7.1 Learning across DisasterA key focus of STS research is on the “thought styles” of differently positioned and educated people,
including scientists, physicians and engineers. A “thought style” is a habitual way of conceptualizing
problems, data, facts, what requires explanation, and what counts as a good explanation. Importantly,“thought styles” are collective; thought styles are produced by communities of practice as they work,
105

talk and exchange ideas. Often, the shared assumptions embodied in a thought style are tacit; they
aren’t talked about explicitly, despite shaping the way people prioritize concerns and organize theirwork.
The unstated aspects of thought styles intensify the challenge of working across thought styles – aswhen scientists from different disciplines try to work together, or when physicians try to work
collaboratively with their patients to understand the sources and experience of disease. In contexts ofdisaster, the interplay of different thought styles poses particular challenges – because of the urgency
of working collaboratively, because disaster so often generates problems that are different in kind andcomplexity than those dealt with previously, and because critical information for thinking about the
problems at hand is often missing, sometimes intentionally. Indeed, a useful definition of disaster isharmful phenomena that cannot be adequately addressed using established procedures, operationalor conceptual.
Disaster impacts conceptual as well as technical infrastructure in the environments in which theyoccur, and there are often conflicting interests behind competing perspectives on what is going on.
Governments and corporations with responsibilities in disaster contexts often constrain information
flows, for example, sometimes trying to prevent panic, sometimes trying to cover-up operational
failures. Information and knowledge politics are always part of the dynamics of disaster.
People responding to disaster thus need to draw on earlier experience, education and establishedprocedures – on cultivated “thought styles” -- while also acknowledging that disaster always requires
new ways of thinking and acting. As the quotes above suggest, thinking in disaster needs to be bothstrict and loose, styled and open. Thinking in disaster also needs to be attentive to different thoughtstyles, the various ways differently positioned people will see the problems at hand; this is the
explanatory pluralism identified by Keller (2002) as a critical advantage in apprehending complex
phenomena. Different kinds of understanding and explanation can be vital resources in disaster,offering the best chance of coming to terms with unfolding events, information deficits and what STS
researchers call “knowledge politics.”

Figure 7.1: Rabbit-duck Illusion, from theFliegende Blätter issue on October 23, 1892.
Translation of caption: “Which animals are most
like each other? Rabbit and duck.”106

Austrian-British philosopher Ludwig Josef Johann Wittgenstein used the image in Figure 7.1(published earlier in a German humor magazine) to illustrate how the same thing can be seendifferently, from different angles (1953). In disaster contexts, recognizing how different people see
unfolding events differently can be leveraged for better overall understanding, helping offset problems
associated with information deficits.

Figure 7.2: The Intelligent Eye(Gregory 1970), photo by Ronald
C JamesFigure 7.2 points to the challengeofseeingphenomena–

distinguishing figure from ground– without prior knowledge about what one is looking for. Once a viewer is told that they should see adog in this image, for example, the dog becomes much easier to see. This poses special challenges indisaster contexts given the ways disasters generate entangled problems, often without precedent. In
disasters, there are always things to see, understand and respond to, which are very difficult to see
through established analytic frameworks. For additional help seeing the dog here, see
http://www.michaelbach.de/ot/cog_dalmatian/.

7.2 Structures and Dynamics of Disaster
Disaster is often defined as a sudden event that disrupts normal functioning of a community orsociety; often, disasters are also cast as intricately unique, and bounded in time. Research acrossdisaster contexts, however, confirms that disasters are extremely enduring. They continue, often
without end. Often recovery efforts come to be talked about as “second disasters” (Fortun 2001).

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Research also confirms that there are recurrent dynamics and challenges across disaster contexts – inthe lead-up to disaster, in the instance and experience of disaster, and in disaster recovery initiatives(Fortun and Frickel 2012). Awareness of these dynamics and challenges, acquired by working throughdifferent disaster cases, provides a kind of disaster literacy that improves capacity to “read” newdisasters as they unfold.
One recurrent dynamic emerges from the fact that disasters, by definition, reveal that something hasgone wrong. Disasters are failures, usually of many kinds. This often provokes secrecy, about the
impacts of a disaster as it unfolds, about the causes of a disaster, and about continuing organizational
incapacity to deal with a disaster. Government agencies implicated in disaster often constrain
information flows, for example, striving to cover up their mistakes or to mitigate public anxiety, or
simply because they don’t have the capacity to process and communicate the data available to them.
Often, efforts to anticipate or prepare for disaster were misdirected; this implicates operational
efficacy (the availability of appropriate equipment and personnel for immediate response, forexample) and can exacerbate secrecy. Actors may be reticent to admit that they prepared for thewrong disaster; they also may not have infrastructure in place for collecting, analyzing and sharing
data on the disaster actually at hand.
Data is always a problem in disaster contexts, in multiple ways. How data is collected delimits what
problems are recognized. Often, data is released without means to interpret it. Different nations orunits of a government may collect data that is configured differently, making it difficult to discern
where there are contradictions and where there is complementarity. Increasingly, citizens’organizations are involved in data collection and circulation in disaster contexts, leveraging relatively
low cost monitoring technologies and social media. Citizen produced data is often more granular andreal-time than data produced or made available by government actors, making it particularly useful for
local level decision-making by individuals and families as well as local governments. This often
generates continuing and important debate about the quality and credibility of different sources andways of configuring data. Such debates are particularly intense when there is concern about
government information withholding, and subsequent failures of trust. Disasters thus produce
complex communication challenges, often involving a need for continually revised statements about
what is going on. Technical professionals are often challenged to explain changing data andconditions to diverse audiences, and can play critical roles as advocates for transparency.
Technical professionals in disaster contexts also face complex ethical challenges of many kinds.
Often, for example, technical professionals themselves and those that work alongside them faceconsiderable risk – from damage to buildings and roads, toxic contamination, social unrest, etc.
Technical professionals must make difficult assessments of the adequacy of their own working
conditions, and often are responsible for the safety of those working with them as either paid108

employees or volunteers. The urgency and tragedy of disaster makes these assessments especiallydifficult. New ways of thinking about risk and responsibility are often called for, though this caneasily legitimate unfair imposition of risk on workers with restricted social status (because of age,gender, ethnicity, etc.). The need for thinking that is simultaneously “styled” by established protocols
yet open and sensitive to its own limits and uncertainties becomes particularly acute.
Identification and categorization of victims is also a recurrent problem in disaster, exacerbated by
evacuations and dispersal of people during the disaster. This can slow access to much needed relief,and create new social divisions; those who aren’t categorized as victims can become a new underclass. Predictable, as well, is the way disaster exacerbates previously entrenched social inequalities;
people that were poor and politically marginalized before a disaster tend to be even more so after adisaster; gender, age and racial bias also tends to be exacerbated. Proving their status as victims, andnegotiating what counts as a disaster-related harm, can thus become a major stressor for people
impacted by disaster. Identification and categorization of victims also creates stress for doctors, who
know that any diagnosis they provide can implicate access to resources.
Another recurrent dynamic in disaster emerges from the development of public health programs toaddress the injuries and disease produced by disaster. Such programs are often desperately needed,
and must be put together with limited time and financial resources. Health professionals must
determine the types of care that will be available, methods for assessing a need for care, andsupporting documentation that will be required to secure access to care. These delimitations are anecessary part of the development of public health programs, but always marginalize some problems
and people. Doctors need to help their patients develop ways of describing their health care needs inways that fit with program requirements, but this comes at a cost. In learning to describe theirailments in terms that fit with public health programs, patients and their doctors can miss problems
that aren’t recognized by these programs. Patients’ rights can also be reduced to those conferred bypublic health programs, undercutting broader rights and political engagement.

7.3 Rebuilding HealthRebuilding health after disaster is complicated by many factors, including the thought styles of healthprofessionals. Modern health care and research aims to identify the cause and mechanism of disease,progressively ruling out what is not determinative. The logic is binary: Is it X, or not? If not X, is itthen Y, and not Z? Modern health care and research are also organized into disciplinary
specializations, allowing for impressive depth of knowledge and analysis, but making it difficult tosee “the whole (bodily, much less environmental) system.” And modern health care and researchprivilege “in-body” constructs of disease; environmental health stressors are often systematically109

discounted. Health professionals in disaster contexts thus need to see phenomena that establishedframeworks don’t make visible. This often calls for intensive collaboration with patients to understandtheir injuries and illness from their perspective, and with scientists from different disciplines. The
complex multidimensionality of injury associated with many disasters is difficult to deal withclinically and scientifically, and also culturally. Here, too, Bateson’s (1935/1972) challenging call forthinking that is both “formal” and “wild” is critical.
Health care in disaster is also complicated by what anthropologist Mary Jo Good (2007) has termed a“medical imaginary” that fosters belief that modern medicine can provide both explanation and cures
for any range of ills. Even in the most difficult cancer cases, Good argues, there is often great
expectation that biomedicine will come through – with clear explanations and solutions to the
problem of illness. This drives people in varied positions – patients, family members, doctors,
researchers, the media – to conceive, represent and deal with disease in a particular manner: one
which is straightforward and clearly actionable. People want to know what, exactly, to do whensomeone is sick, and they count on health professionals to tell them. Injury and disease in disaster
contexts are often much less straightforward.25
In disaster contexts, available information and procedures are always inadequate yet decisions must
be made, often very quickly. This poses deep challenges for people acting as individuals of
responsibility - as heads of families, as professionals, and as representatives of governments andcorporations. They must simultaneously draw on prior experience and established knowledge andrecognize that they are dealing with an unprecedented situation, with limited information. Often,
understanding and decision-making can be improved through collaboration that brings the expertise ofdifferent positioned people together, leveraging (rather than just trying to manage) differences inthought styles and ways of seeing things. Drawing people from different scientific disciplines,
government agencies and sectors (academia, business, government, NGOs) into collective
deliberation has critical value, as does inclusion of women, youth, and others often left out ofdecision-making arenas. Explanatory pluralism is especially valuable in disaster contexts.
Disaster recovery programs are themselves often disastrous, failing to rebuild health, economic
security, social support and political capacity. The research literature is replete with examples of this.
Recovery initiatives clearly improve when survivors are allowed to participate in the design ofrecovery programs, but participatory schemas themselves often create problems. Participatory
schemas often enroll people with the greatest cultural authority and sense of their own politicalagency, reproducing long-entrenched social hierarchies. Participatory schemas often also lack
The two paragraphs here about medical imaginaries and the binary logic of disease
determinations are drawn from a 2014 article entitled “Asthma, Culture, and Cultural Analysis,”which I co-authored with others in the Asthma Files Research Group. See under “Further
Reading” for a full citation.
25

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durability, failing to integrate the many types of expertise needed to conceptualize robust recovery, ora means to sustain diverse involvement across time and generation. Familiarity with failures ofdisaster recovery efforts is sobering, yet contributes to a disaster literacy from which better recovery
efforts could emerge. A key challenge is in enabling both strict, historically informed ways ofthinking, and loose, innovative ways of thinking, attentive to both recurrent dynamics across disasterand to the special needs and conditions that every particular disaster creates.
Physician-anthropologist Paul Farmer (1996) calls for a “critical epistemology of disease” throughwhich medical professionals continually question the adequacy of the conceptual and organizationalmodels relied on in efforts to build health. According to Farmer, medical professionals need tocontinually evaluate not only the efficacy of their models and associated programs, but also whatthese models and programs leave out. Farmer makes this argument as part of his long-running work tounderstand and improve health in the poorest regions of the world. His initial work was in Haiti; healso has worked extensively in Africa. In these contexts, poor health, according to Farmer, results not
only from infectious agents, environmental contamination and inadequate health services, but also
from a long history of colonial exploitation and continuing social inequality. Models of disease
emergence need to be continually updated to address these many variables, striving to be “global yet
alive to local variation,” always questioning what features of disease emergence are obscured indominant analytic frameworks. As a matter of routine, Farmer insists, medical professionals –collaborating with others – need to continually ask, “What is obscured in this way of conceptualizing
disease? What is brought into relief?”

7.4 Conclusion
Critical perspectives on the knowledge frameworks and thought styles used to understand disease areimportant in all disaster contexts, especially when dealing with radiation and chemical exposures that
could have cumulative effects that are difficult if not impossible to anticipate with available data,
methods and established environmental health knowledge. Medical professionals in disaster contexts
thus need to be attentive to the limits and politics of knowledge as they continue to use theirknowledge to care for patients and plan health care programs. This is a key challenge for medical
professionals, and one that they can prepare for psychologically and intellectually.
As noted earlier, research has made clear that disaster impacts conceptual as well as technicalinfrastructure in the environments in which they occur, and that there are often competing interests
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behind competing perspectives on what is going on. Simply knowing this about disaster can advancecapacity to deal with disaster. Learning about the ways different disasters have unfolded can provide
the intellectual and psychological grounds for making sense of a disaster context in which one works.
The challenge is multifold: one must anticipate the chaos, information deficits and knowledge politics
of disaster, knowing that this is part of disaster; the intellectual challenge harbors a paradox: one must
anticipate the impossibility of fully anticipating the conditions and demands of disaster. Disaster
literacy thus builds on a rich repertoire of examples to think through the dynamics, contradictions andobligations of disasters as they unfold, mindful of both recurrent patterns and of ways each disaster
poses fundamentally new challenges, demanding creative and innovative response.

Questions and Answers
What challenges do technical experts (including medical professionals) face in disaster contexts?
Technical experts face a number of challenges in disaster contexts. Six of these challenges stand out:
(1) Data about disaster and associated problems are often very volatile, requiring experts tocontinually analyze the source and validity of available data, while using the data to update
their understanding of the problems at hand. The design of data collection efforts forcefully
shapes what is known about problems, calling for inclusive and deliberative processes in allphases of effort to understand disaster.
(2) Disasters create complex and evolving problems, requiring experts to utilize the knowledge
and skill they have developed through years of training and experience while recognizing thelimits of previously codified knowledge and skill. Disasters pose fundamentally new
problems, which are difficult to apprehend with established ways of thinking. Expertise canproduce both insight and blindness, and this is amplified in disaster contexts.
(3) Disasters often exacerbate social problems that existed before disaster, such as income,gender and ethnic inequalities, and insensitivity to the needs of different groups. At every
stage of their work, technical experts need to question whether and how these groups andneeds can be addressed, recognizing the value of including people in decision making that areusually left out.
(4) Given the complexity and volatility of problems in disaster contexts, technical experts often
need to collaborate with others much more intensely than they are accustomed to. Complex
understanding of individuals and communities in disaster contexts necessarily includes
qualitative as well as quantitative dimensions, for example, and thus depends on collaboration
between researchers with different skills, including skills that elicit feedback and enable
learning from people directly impacted by disaster.
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(5) Disasters create an immediate need for experts to communicate to diverse audiences,including journalists, policy makers and people impacted by the disaster. Technical experts
thus need to be prepared for this communication challenge, mindful of the ways trust can beundermined by information withholding, and of the importance of trust in collective effort torespond to disaster.
(6) Technical experts and those that work with them in disaster contexts are themselves often
subject to considerable risk, requiring difficult assessments – both technical and ethical – ofworking conditions, and the possible need to evacuate. The instability of built structures, toxic
contamination and social unrest, for example, often threatens those responding to disaster,whether as paid employees or as volunteers. In trying to respond to the urgency and tragedy
of disaster, technical experts must ensure to adequately protect their own health and that of
co-workers. Special care must be taken not to impose risk on co-workers with restrictedsocial status because of age, gender, ethnicity, etc.

References
Bateson, Gregory. 1935. "Culture Contact and Schismogenesis." Man 35: 178-183. Republishedin 1972. Steps to an Ecology of Mind. 75. San Francisco: Chandler.
Farmer, Paul. 1996. “Social Inequalities and Emerging Infectious Diseases.” Emerging Infectious
Diseases 2 (4): 259-69. http://www.ncbi.nlm.nih.gov/pubmed/8969243
Fortun, Kim. 2001. Advocacy after Bhopal: Environmentalism, Disaster, New Global Orders.
Chicago: University of Chicago Press.
Fortun, Kim and Scott Frickel. 2012. “Making a Case for Disaster Science and Technology Studies.”
An STS Forum on Fukushima. http://fukushimaforum.wordpress.com/online-forum2/online-forum/making-a-case-for-disaster-science-and-technology-studies/
Good, Mary-Jo D. 2007. “The Medical Imaginary and the Biotechnical Embrace.” In Subjectivity:
Ethnographic Investigations, edited by Joao Biehl, Byron Good, and Arthur Kleinman.
Berkeley: University of California Press.
Gregory, Richard. 1970. The Intelligent Eye. New York: McGraw-Hill.
Keller, Evelyn F. 2002. Making Sense of Life: Explaining Biological Development with Models,Metaphors, and Machines. Cambridge, MA: Harvard University Press.
Wittgenstein, Ludwig (1953/2001). Philosophical Investigations. Blackwell Publishing.

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Further readingde Carmargo Jr., Kenneth Rochel. 2002. “The Thought Styles of Physicians: Strategies for
Keeping up with Medical Knowledge.” Social Studies of Science 32 (5-6): 827-855.
http://sss.sagepub.com/content/32/5-6/827.short.
Fleck, Ludwik. 1979 (1935). The Genesis and Development of a Scientific Fact. Edited by Thaddeus
J. Trenn and Robert K. Merton, Foreword by Thomas Kuhn. Chicago: University of Chicago
Press. (First English translation of Fleck’s 1935 book Entstehung und Entwicklung einer
wissenschaftlichen Tatsache. Einführung in die Lehre vom Denkstil und Denkkollektiv. Basel:
Schwabe und Co., Verlagsbuchhandlung.)
Fortun, Kim, Brandon Costelloe-Kuehn, Tahereh Saheb, Daniel Price, Alison Kenner, Jerome
Crowder, and Mike Fortun. 2014. “Asthma, Culture, and Cultural Analysis: Continuing
Challenges.” In Heterogeneity in Asthma, edited by Allan R. Brasier. Series: Advances inExperimental Medicine and Biology, Vol. 795. New York: Springer.

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Glossary
Adaptive expertise
Autonomy

Civil society

Communication

Community
Contested disease
Contributory expertise
Counter expertise
Cultural memory

Deficit model

DiseaseDisasterDisaster recovery
Discrimination
Distributive justiceSee under Expertise (i).
The independence or freedom of will of a rational
individual to make a decision that is informed and notcoerced.
The organized non-state, non-market sector that exists
above the family and individual; it is made of both formal
and informal organizations and groups and it is defined by
its relationship to the state.
The act or process of making opinions, feelings, orinformation known or understood by others, or of sharing
them with others.
A social group that shares common values and/or acommon significant event.
A condition with disagreements over definition, causes andtreatment of suffering or unpleasant states.
See under Expertise (ii).
See under Expertise (iii).
A shared vision of the past; it is a product of representations
that is mobilized through multiple media by a given
community in order to preserve or promote a common
cultural heritage or a national identity.
The model that there is plenty of knowledge for specialists,
whereas citizens are ignorant. This model hypothesizes thatthe public’s negative attitudes toward science andtechnology are caused by their lack of information andknowledge. In this formulation, it is the public who areassumed to be deficient, while science is deemed“sufficient”. In addition, this model also hypothesizes thatin lacking a proper understanding of the relevant facts,
people fall back on mystical beliefs and irrational fears of
the unknown.
Any impairment from the normal structure and function of
the body that is manifested by objective medical criteria of
characteristic signs and symptoms.
A sudden event that disrupts normal functioning of acommunity or society; often, disasters are also cast as
unique, and bounded in time. However, disasters areenormously durable: they often continue without end, where
recovery efforts come to be regarded as “second disasters”.
Such an event may also be considered as harmful
phenomena that cannot be adequately addressed using
established procedures, operational or intellectual.
The process, procedures and policies that enable recovery
from disaster.
The prejudice or treatment of an individual because of thegroup that they do or are perceived to belong to.
A socially just distribution that emphasizes that theoutcomes or benefits are fair for those who carry the115Ecological approach tohealthEmpowerment

EquityExperience

Expertisei. Adaptiveii.

Contributoryiii.

Counteriv.

Interactionalv.

RoutineExplanatory pluralism

Explicit knowledge
Fiduciary duties

HealthHolistic approachburden, costs or risks.
An ecological perspective on health that emphasises bothindividual and contextual, or environmental systems, andthe interdependent relations between the two; by contextual
systems one should understand political, social, economic,
and cultural contexts that are locally specific.
A social process by which individuals or groups gain
control over those issues (including health issues) that areof concern to them.
Where the decision taken is fair and impartial such that no
person is favoured over another. Can also refer to equity inopportunity, access to resources, or the achieved
distribution of societal resources.
Knowledge or skill which comes from practice in an
activity or doing something for a long time, rather thanfrom books or articles.
The development of a conceptual understanding that allows
the “expert” to invent new solutions and new procedures tosolve problems; the demonstration of flexible knowledge
handling; the understanding of learning trajectories for nonroutine expertise.
The ability to contribute to analysing and solving a specificproblem by drawing together different sets of informationfrom research as well as other information sources.
A construction by members of civil society to control
classical expertise as well as to allow for alternativeinterpretations of risk and of the information collected byclassical institutions.
Expertise that emerges through complete immersion in a
specific problem context; the learning of an expert
community to use the language of another expert
community; the capacity to actively engage with theknowledge and experience available in another community.
The mastering of well established procedures of finding
solutions in such a way as to become highly efficient andaccurate.
The diversity of explanatory styles being used in scientificpractice, which reflect the variety of knowledge-seeking
methods researchers bring to their work, as posited by
Evelyn Fox Keller in Making Sense of Life: Explaining
Biological Development With Models, Metaphors, andMachines (2002).
See under Knowledge (i).
The legal duty of medical professionals to care for theirpatients and ensure that their decisions and actions serve thewelfare of their patients, even at some costs to themselves.
A state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity.
A concept that the psychological, physical and social needs
116Illness
Interactional expertise
Justice

Knowledgei. Explicit

ii.

Local

iii.

Scientific

iv.

Tacit

Linear no-threshold model
Local knowledge
Medicalization
Medical ethics

Neutral data

Probability
Radiation protection models
i. Linear no-thresholdii.

ThresholdRationality
i. Scientificii. Social
Risk

Risk communicationof the person must be considered in health care.
The subjective experience of feeling unwell.
See under Expertise (iv).
Conformity to the principle of what is morally right, or tofair and transparent procedures for societal decision
making.
Knowledge that can be articulated verbally and in writing,is often codified, and circulated and stored often in form of
print media.
Knowledge that is shared locally and historically by theresidents.
Knowledge that is produced by a community of scientists
through their experimental and interpretative conventions
that have been agreed to within relevant communities ofscientists.
Knowledge that is difficult to transfer to another person in
written or verbal form. People are often not entirely awareof their possession of this kind of knowledge or how it
could be valuable and thus made available to others; it
becomes visible through practice in a particular situationand is transmitted through social networks.
See under Radiation protection models (i).
See under Knowledge (ii).
The extension of the medical sphere into areas which havebeen previously outside of its realm.
An applied sub-discipline of moral philosophy concernedwith the conduct of medical practitioners and theirrelationships with patients.
“Data” without effect of any background value judgments:for example, value judgment to avoid nuclear power or thatto promote nuclear power.
The estimation of how likely it is that a statement is true orthat an occurrence will happen
Risk of damage caused by ionizing radiation is directly
proportional to the dose
Risk of damage caused by ionizing radiation below thethreshold value is too small to be clinically important
Rationality that is ensured by the scientific community.
Rationality that is ensured by society.
Possibility that something harmful or undesirable may
happen to the individual. The concept of risk is always
related to a “possibility” or “likelihood” that something bad
may happen, to protect our environment or our health.
The act or process of sharing opinions, feelings, orinformation on risk with others. In this process, the media
plays an important role; for example, a rapid disseminationof information related to public health; public perception of117

risk issues; interactive communication with stakeholders;personalized health messages; promoting publicengagement and empowering them.
The evaluation and identification of priority risks that will
Risk management
have a coordinated application of resources in order to limit
and control the impact of an event.
The subjective judgement by an individual about the
Risk perception
severity and type of risk from the hazard or threat
See under Expertise (v).
Routine expertise
See under Knowledge (iii).
Scientific knowledge
See under Rationality (i).
Scientific rationality
A condition of being sick as conceived of by the society
Sickness
and/or its institutions
Two interdependent elements according to Pierre Bourdieu:Social capitalsocial relationships that allow individuals to claim access toresources possessed by their associates, and the amount andquality of these resources.
A phenomenon or category that exists only because it wasSocial construct
created and developed by society through social practiceSocial determinants of health Social, economic, cultural, and historical factors which arerecognized to be powerful determinants of health in modern(SDH)
societies.
Social justice in health focuses on health inequities andSocial justicepromotes the providing of structures and services whichmight ensure the general population has equal access tohealth care services regardless of income level, gender or
education. Integrating social justice to health inherently
reflects the SDH model (see social determinants ofhealth).
An organised investigation since the 19th century of how
Social medicine
multiple social and economic conditions impact health,disease, and the practice of medicine; it also fosters local
conditions in which this understanding can lead to healthiersocieties.
See under Rationality (ii).
Social rationality
The lack of ability of people in a particular group to tolerate
Social vulnerability
the adversity or stressors to which they are exposed.
A specific type of discrimination wherein individuals or
Stigmatisationgroups are treated as (or suffer the experience of) being in
disgrace or having a tarnished reputation.
See under Knowledge (iv).
Tacit knowledge
A specific deeply culturally entrenched way in which aTechno-political culture
society relates technological and social development.
A group of people who share a specific way of seeing theThought collective
world as they work, talk and exchange ideas. In science,
thought collectives are equivalent to scientific communities
A habitual way of conceptualizing problems, data, facts,
Thought stylewhat requires explanation, and what counts as a good
explanation. Produced by a community of practice (seethought collective). Microbiologist Ludwik Fleck, who
118Threshold model
Tolerance dose

Trading zone

Uncertainty
Virtue ethics

developed early frameworks for historical and sociologicalstudies of the sciences, defined the concept of “thoughtstyle” in the 1930s.
See under Radiation protection models (ii).
The amount of radiation that may be received by anindividual that would be unlikely to cause permanent
damageA metaphor to describe a problem space where different
experts have to work together to find a solution; a specificlanguage has to be developed which all kinds of involved
experts can understand and use.
Any situation of departure from the ideal of complete
determinism.
An approach of ethics which focuses not the agent’s actions
themselves but his/her values and characters that underlies
them. So the primary normative question is “what a good or
virtuous doctor would do in this situation?” rather than“what action would be right?”

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Contributors:
Rethy Chhem, formerly IAEA bengmealea@yahoo.com
Gregory Clancey, National University of Singapore hisgkc@nus.edu.sg
Penelope Engel-Hills, Cape Peninsula University of Technology
EngelhillsP@cput.ac.za
Heiner Fangerau, Ulm University heiner.fangerau@uni-ulm.de
Ulrike Felt, University of Vienna ulrike.felt@univie.ac.at
Kim Fortun, Rensselaer Polytechnic Institute fortuk@rpi.edu
Yuko Fujigaki, University of Tokyo fujigaki@idea.c.u-tokyo.ac.jp
Satoshi Kodama, Kyoto University kodama.satoshi.4v@kyoto-u.ac.jp
Tamra Lysaght, National University of Singapore tlysaght@nus.edu.sg
Laurence Monnais, University of Montreal laurence.monnais-rousselot@umontreal.ca
Kwan-Hoong Ng, University of Malaya ngkh@ummc.edu.my
Deborah Oughton, Norwegian University of Life Sciences deborah.oughton@nmbu.no
Azura Z. Aziz, formerly IAEA noor.azura.zuhairah@gmail.com

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