Lessons learned from the experience of the Great East Japan Earthquake and Disaster

Meigen Liu, MD, PhD

Professor and ChairDepartment of Rehabilitation Medicine

Keio University School of Medicine

Former PresidentJapanese Association of Rehabilitation Medicine

Where is rehabilitation disaster relief now?ISPRM2013, Beijing, June 19, 2013

Great East Japan Earthquake and Disaster on March 11, 2011

At an evacuation shelter in Miyagi Prefecture

Today’s topics

1. Characteristics of the Disaster2. Actions by rehab professionals in Japan3. Lessons learned from the experience of

the disaster4. Actions for the future

1) Rehab disaster relief manual2) Training of coordinators

Characteristics of the Disaster

1. Extremely strong earthquake (4th in the history).2. Geographically extensive (18 of 47 prefectures affected)3. Caused over 15,000 deaths, and more than 2,600 persons

are still missing.4. 92% of the deaths were caused by tsunami.5. Far less traumatic injuries (injury/death=0.372, serious

injury/slight injury=0.01 ） .6. Mortality higher among persons with disabilities (2.5% vs.1%).7. The tsunami wiped out basis of life.8. Affected areas of fishery, agriculture and high technology

parts factories, where medical and care resources had been scanty.

9. Complicated by nuclear power plant damage in Fukushima.

2011 2012

Miyagi

Fukushima

Iwate

Index of restoration of base for living after 2 years from the disaster (pre-disaster=100)

From National Institute for Research Advancement (NIRA) Report, March 2013

Miyagi 89.3Iwate 86.2Fukushima 81.1

FactorsNo. of evacuees

in shelters inside/outside the prefecture

Occupancy rate of temporary housingRestoration rate of

primary/secondary schools electricity gas railroads roads hospitals clinics

Rubbledebris Removal rate Processing rate

Support from other municipalitiesPayment rate of relief donationsPayment rate of insuranceLoaned moneyNo. of convenience stores

Actions by Rehabilitation Professionals in Japan

Establishment of the 10 Rehabilitation-Related Organizations of Rehabilitation Support Service

(10-Rehab Organizations)

The 2011 Disaster was unprecedented, being geographically widespread and multifaceted.

This made it impossible simply to apply previous experience, and forced rehab professionals to act together, in particular to prevent immobilization syndromes and progressive functional deterioration among frail elderly survivors and persons with pre-existing disabilities who were forced to stay in shelters not designed to encourage physical activity.

This prompted us to establish the “10 Rehabilitation-Related Organizations of the Great East Japan Earthquake Rehabilitation Support Service” (10-Rehab Organizations) 1 month after the disaster in order to try to cope with this unprecedented national crisis.

Relief activities by the10-Rehab Organizations

formulates grand plans makes decisions

analyzes and judges information and situations

makes proposals for decision making

gathers and classifies information performs daily management ensure coordination among

organizations and the activity bases in the affected areas.

10-Rehab Organiza-

tions

Strategic council

Think-tank

Joint Secretariat

The member organizations; • JARM, PT, OT, ST Associations, Rehab Hospitals and Institutions Group, Adult

Daycare Liaison Council, Visiting Rehab Association, Community-based Rehab Support Group and Care Manager Association.

Support activities by 10-Rehab Organizations

Since the disaster, each organization has been actively involved in various relief activities on its own initiative, and mutual exchange of information was actively practiced at strategic council meetings to facilitate coordination and collaboration.

Major support activities implemented by 10-Rehab Organizations included the following 3 activities. Support for the management of a welfare shelter in Ishinomaki Rehab support at a secondary shelter in Kesennuma Support activities for relocated victims in Inawashiro

Local health care professionals Tatami mattress corner

Beds provided by Paramount Cardboard partition

Upon request by Ishinomaki City in Miyagi, 10-Rehab Organizations supported a welfare shelter set up in a gym for persons with disabilities and their families (50 in total).

We sent a rehab team (1 physiatrist, 1 PT, 1 OT and 2 rehab nurses) on a weekly rotation basis to arrange living environment, prevent inactivity and improve functioning in collaboration with local rehab and care resources.

We continued the dispatch till September, when temporary housing became available.

Japanese style toilet for males Bathing available in nearby self-defense force camp

Support activities by 10-Rehab Organizations

Ishinomaki Kesennuma Inawashiro Total

Support started 3 May 2011 13 June 2011 15 June 2011Support terminated 26 Sept 2011 30 Sept 2011 30 Sept 2011Total days of dispatch 146 109 107Evacuees served, cumulative 3,300 1,200 2,800 7,300Evacuees served per day, mean 16.3 7.6 20.7Rehab professionals dispatched Physiatrists 34 0 26 60 Nurses 100 0 0 100 Care workers 36 0 0 36 Physical therapists 184 209 153 546 Occupational therapists 184 162 114 460 Cumulative number dispatched 538 371 293 1,202 Dispatched per day mean 2.7 2.4 2.2

Disaster preparedness of the 10 participating organizations Liu M et al. J Rehabil Med 2012

Questions Yes No1 Did a specific organizational disaster countermeasure system

exist?3 7

2 Were disaster countermeasures listed in the policy agenda? 1 9

3 Was a budget for disaster countermeasures individually appropriated?

0 10

4 Did a disaster countermeasure manual exist? 3 7

5 Had disaster drills and/or simulation trainings been performed? 2 8

6 Had disaster-related information been collected? 3 7

7 Had disaster-related information been utilized? 2 8

8 Were the organization’s disaster countermeasures publicized to its members?

2 8

9 Did the organization collaborate with related organizations concerning disaster countermeasures?

1 9

10 Did the organization collaborate with administrative offices concerning disaster countermeasures?

1 9

Assessment of the support activities implemented by 10-Rehab Organizations (1)

Items Very poor Poor Mode-

rate Good Very good

Timing of inaugurating 10-RRO 0 25.0 25.0 47.2 2.8

of starting relief activities 0 19.4 13.9 61.1 5.6

of terminating relief activities 0 19.4 13.9 58.3 8.3

Role of the strategic council 0 0 25.0 61.1 13.9

of the think-tank 0 0 19.4 55.6 25.0

of the joint secretariat 0 5.6 25.0 55.6 13.9

Collaboration among the organizations 0 5.6 44.4 41.7 8.3

Split of expenses for managing joint secretariat 0 11.1 38.9 44.4 5.6

of expenses for dispatch 0 22.2 61.1 11.1 0

Method of recruiting volunteers 0 0 44.4 52.8 2.8

Matching the volunteers and the needs 0 0 41.7 47.2 11.1

Selection of dispatch sites 0 0 25.0 52.8 22.2

Profession of dispatched volunteers 0 1.0 30.0 56.0 13.0

Number of dispatched volunteers 0 0 34.3 61.8 3.9

Support activities 0 0 20.8 63.4 15.8

*Response rate (%) by the executives of the participating organizations of the 10-Rehab Organizations

Assessment of the support activities implemented by 10-Rehab Organizations (2)

Items Very poor Poor Mode-

rate Good Very good

Collaboration with local government 0 2.0 21.6 57.8 18.6 with local healthcare professionals 0 0 29.7 63.4 7.9 with central government 0 14.7 64.7 17.6 2.9 with other organizations 0 8.8 61.8 23.5 5.9Achievement of the aim of dispatch 0 1.0 18.6 62.7 17.6Data collection 5 26.7 46.5 20.8 1.0Publicity to each organization’s members 0 11.1 52.8 30.6 5.6 to the society 0 50.0 41.7 8.3 0 to the administrative offices 0 11.1 50.0 22.2 16.7Scientific output 0 50.0 38.9 2.8 8.3Extraction of problems for future activities 0 13.9 50.0 33.3 2.8

Liu M et al. J Rehabil Med 2012Free comments: the needs for • a joint rehab disaster relief manual• advocating the importance of rehab in disaster relief

Lessons we have learned

1. Disaster preparedness2. Establishing crisis management system in each organization3. Appropriating specific budget for disaster countermeasures4. Disaster countermeasure manual5. Pre-disaster training6. Manpower training7. Disaster information management8. Collaboration with other organizations9. Collaboration with administrative offices10. Matching needs and volunteers11. Joint secretariat12. Advocating the crucial role of PM&R in disaster relief

Our first collaborative disaster relief endeavour by rehab-related organizations and professionals and interorganizational collaborative activities highlighted the importance and necessity of;

Tsuami Hazard MapProbability

The probability of experiencing an earthquake greater than M6 in 30 years

To-Nankai trough

Japan is a country where major earthquakes are unavoidable.

Actions for the future

1) Rehab disaster relief manual2) Training of rehab disaster relief

coordinators

• The necessity of formulating a basis for preparing appropriately in times of peace and conducting timely multidisciplinary collaborative relief activities at times of disasters.

• For this purpose, the “Rehab Disaster Relief Manual was planned after 5 mo. from the disaster, and was published in May 2012.

I. The aim and scope of the manualII. The definition of large-scale disastersIII. The application of the manualIV. Relief activities as the 10-Rehab OrganizationsV. Phases of rehabilitation disaster reliefVI. Organizing disaster relief systemsVII. Pre-disaster measuresVIII. Basic principles of rehab disaster reliefIX. Relief activities in the acute phaseX. Relief activities in the reconstructive phaseXI. Psychological issuesXII. International collaborationXIII. Information managementXIV. Assessment of disaster relief activitiesXV. Collaboration with related organizations and

administrative officesXVI. Ethical issues related with disaster reliefXVII. Reference materials

Rehabilitation Disaster Relief Manual

• Used at training workshops for coordinators and rehab disaster relief teams.

• To be regularly revised based on feedback and changes of social conditions.

Phase 1 Phase 2 Phase 3 Phase 4

Restoration ReconstructionConfusion Emergency restoration

Initial measure

Life saving/rescue

Emergency measure

Relief activities Restoration of community health care

Temporary/traveling clinic

Restarting life Community life support

Disaster phases and support

Life saving/rescue

Relief (trauma care/chronic diseases)

Immobilization syndromesRehabilitation

support

Deterioration of life function among the aged and persons with disability

Impact

Disaster medicine

DisasterRehab.

TowardReconst-ruction

Bottom-up approach

Self-reliance support

Continuity

Limited time

Workshop for training rehab disaster relief coordinators

To prepare for future disasters likely to occur in Japan;

To set up multidisciplinary, trans-organizational rehab disaster relief structures;

To develop multidisciplinary rehab disaster relief coordinators in each prefecture nationwide.

Objectives of the Workshop

Workshop for training rehab disaster relief coordinators

A two-day program; first WS on Feb 16, 17, 2013. Uses “Rehab Disaster Relief Manual” as a text. Lectures to teach basic knowledge about disaster relief Practice sessions

– Team building– Coordination in the disaster areas– Coordination in each community

Assessment– Assessment of the understanding level before and after the workshop– Assessment of the workshop program– Follow-up questionnaires after the workshop

Get together party

Outline of the Workshop

Rehabilitation Disaster Relief Coordinator Workshop

Characteristics of the participants 62 participants from 11 prefectures, 42 males (68%) and 20 females (32%) Age: 43.6±9.1 (26 〜 71, median 43) Years of experience as professionals: 18.1±8.9 (3 〜 41, median 17) Experience of disaster workshop participation: Yes 24 (39 ％ ), No 36 (5

8 ％ ), unknown 2 (3%) Experience of disaster relief: Yes 23 (37%), No 32(52%), unknown 7 (11%)

Type of profession No. % Male ％ Female ％

Physicians 11 17.7% 11 100% 0 0%

Care managers 8 12.9% 8 100% 0 0%

Nurses 11 17.7% 1 9% 10 91%

Speech therapists 10 16.1% 4 40% 6 60%

Occupational therapists 11 17.7% 8 73% 3 27%

Physical therapists 11 17.7% 10 91% 1 9%

Total 62 100.0% 42 68% 20 32%

Changes of scores of the understanding level of the participants

25-item questionnaire taken from the rehab disaster relief manual Full score 100 Pre-workshop: median 24.0 (0 〜 66), mean 21.2 Post-workshop: median 51.8 (0 〜 98), mean 51.8

(P=0.000 、 Wilcoxon’s singed rank test)

Pre-workshop Post-workshop

Total score Total score

No. No.

Assessment of the Workshop by the participants (N=62)

Items Very good Good Mode-

rate Poor Very poor

Program of the WS 34 55 11 0 0

Location of the WS 27 54 16 3 0

Timing of the WS 6 58 31 5

Recommend the WS to others 55 43 2 0 0

（ % ）

Assessment of the program by the participants （ N=62 ）

Title Very useful Useful Not

usefulThe role of DMAT and expectation for rehabilitation disaster relief teams 66 31 0

Outline of rehab disaster relief 66 32 2

Ethical issues related with disaster relief 71 29 0

Phases of disaster and rehab interventions 71 26 3

Legal and policy issues related with disaster 63 35 2

Triage and basic emergency skills 55 40 5

Organizations of rehab disaster relief 66 31 0

(Practice) Team building 73 26 2

(Practice) Logistic coordinators 79 18 3

(Practice) Coordination at the disaster site 79 19 2

(Practice) Coordination in the community 81 16 3

（ % ）

Follow-up at 2 months after the workshop （ N=62 ）

Items Very much Much Moderate Little None

Changes of attitudes toward disaster relief 32 63 3 0 2

Realization of the importance of collaboration

66 34 0 0 0

Realization of the importance of preparedness

56 42 2 0 0

（ % ）

Item Very useful Useful Moderate Not so

useful Useless

The workshop 18 66 16 0 0

The rehab disaster relief manual 24 58 18 2 0

Follow-up at 2 months after the workshop （ N=62 ）

Items Already done Planned Not yet

plannedCoordinator team activities

　 Team meeting 9 0 2

　 Contacting local government officials 9 0 2

　 Others 2* 2** 7

Individual activities

　 Feedback to the affiliated organizations 9 1 1

(no. of prefectures/11)

* Osaka started a mailing list; Shizuoka is planning a local workshop.** Chiba is planning a survey on disasters using the prefecture’s area rebirth grant. Kochi is planning workshops and simulation trainings in collaboration with the municipal government.

These results indicate that after the workshop, the participants are now actively involved in enhancing preparedness and coordination in their own communities.

Conclusions

1. Our first collaborative disaster relief endeavor by rehab-related organizations and professionals has proved successful.

2. In a country like Japan where major earthquakes are unavoidable 、 rehab professionals must always be well prepared for future disasters.

3. To enhance our preparedness and response capability, we formulated a rehab disaster relief manual, and started a workshop to train rehab disaster relief coordinators nationwide.

4. Their preliminary effectiveness has been demonstrated.