Fukushima is known for its akabeko (red Aizu cow), fruits (peaches and cherries are in season in June), soma nomaoi (wild horse festival), and as the birthplace of the late bacteriologist, Hideo Noguchi. Fukushima City, where I spent the majority of my time during the Nishimiya Fellows Program, is especially known for its enban gyoza, which I had the wonderful opportunity to try with other Fukushima Medical University students, and its three great hot springs. For many who have never set foot in Fukushima, the place may bring to mind a different image instead- namely that of the Great East Japan Disaster. However, this disaster also brought Fukushima citizens’ stoicism to light, and I was personally struck by the patience and kindness that the Fukushima people bestowed to me. During my fellowship at FMU, I was honored to be under the tutelage of so many experts who gave us lectures in great detail, engaged us in simulations with patience, and welcomed us warmly as their students. Along with the extensive knowledge I have gained in regards to Fukushima’s current situation, radiation biology, emergency medicine, among others (all detailed in my powerpoint presentation), I was also given the opportunity to examine and reflect on issues that could be traced to two key concepts: risk and being a professional.
As Dr. Aya Goto, an OB/GYN and public health doctor, mentioned, “risk” is an extremely difficult term to understand. Each individual defines risk differently, based on his or her own criteria. There is no right or wrong- and that is okay. In fact, during an emergency medicine simulation of treating a radioactive patient, the ER doctor, Dr. Arifumi Hasegawa asked each member what our acceptable radiation dose was before we started- a practice that he continues today with each team that he works with. Our answers ranged from 10uSv – 100mSv (I answered 1mSv). Dr. Hasegawa simply nodded after each response, and asked us to respect each other’s limit- each other’s definition of risk.
Not only is there no universal threshold to determine risk, but there is also variability in how we respond to one. During Dr. Akira Ohtsuru’s bioethics discussion, we examined genetic counseling and how its surrounding issues could be mirrored in that of radiation exposure. Although reaction to stress cannot be simplified to a dichotomy, “monitors,” for example, seek information and focus on health threats while “blunters” avoid information. Similarly, medical professionals faced difficulties reaching out to people in Fukushima, as some were overloading themselves with plethora of (often contradictory) information, while others were fearful or had simply given up and did not actively seek information. Genetic counseling is also complex as it incorporates risk estimates on not only themselves, but also on other family members- whether they wish to see it or not. As seen in Fukushima, there were disagreements in defining risk even among family members (such as if a child could play outside or not), which sometimes led to rifts between them. Even medical professionals respond differently to risk; Dr. Hasegawa would sometimes have to debate with other specialists whom he needed to forward potentially radioactively contaminated patients to if the doctors were hesitant to accept them. I was surprised to hear that this kind of debate occurred even in the medical setting, but I may also be hesitant if I did not have knowledge in radiation biology or if I felt that I, or my ward, was not well equipped to treat the patient.
So, even if you are scared, how do you still ensure that you offer the best care? And do you prioritize the patient’s decontamination or his or her life? These were two difficult questions that were proposed to us during the simulation- the first arguably more so than the second. In response to the first, we collectively came up with measures such as preparing proper equipment and facility, sharing knowledge amongst all team members, using disposable equipment, and checking the patient’s dosage constantly before touching any part of his or her body. We were also advised to practice flexible thinking: if we want to measure the patient’s internal contamination but are too afraid to measure the radioactivity inside a deep cut, we can measure the surface contamination of the gauze in the immediate proximity of the deep cut. Dr. Hasegawa shared his experience as the first doctor to treat a potentially radioactive patient at FMU; he was extremely scared and wore a personal dosimeter, which suddenly beeped when he took the CT scan. Previously he had always performed CT scans without wearing a dosimeter because it was the last thing on his mind, but he is now more careful of medical exposure during procedures. I was surprised by his story because it takes a lot of courage to admit fear, especially in front of one’s own pupils, and pleasantly so, because he was a living example of how a good outcome could unexpectedly arise from the bad.
As Dr. Hasegawa asked for both our personal acceptable dosage and mutual respect during our simulation exercise, we must first build trust and a supportive atmosphere to work as a team and as a professional. Dr. Goto’s lecture reinforced this thought. She asked us how we would have responded to public health nurses who did not know how to help mothers worried about radiation. Both Ns. Koji Yoshida and Dr. Atsushi Kumagai replied that they would have first thanked the nurses for their efforts and shown their support: a vital step that I completely omitted from my plan of action, and an answer that held all the more weight coming from two professionals who have continuously advised other professionals. However, trust also comes with responsibility. As a medical professional, your actions are continuously being watched by the community and are regarded as a standard to follow. Specific to Fukushima during the disaster, neighbors may observe your backyard to determine when it is safe to do their laundry outside. Thus, a professional needs to establish a trusting relationship, and then constantly be aware of its implications as they maintain that trust.
A professional should also be able to listen and give his or her own opinion. During our health consulting simulation, my ‘patient’ disclosed his concern for his son’s recent A2 thyroid cancer diagnosis; however, I struggled to find words to explain the actual risks of his situation. I needed more knowledge to respond confidently, and provide informed advice. Also, I needed heightened listening skills. My ‘patient’ kept listing a list of concerns: his child’s A2 thyroid cancer diagnosis, school lunches containing Fukushima vegetables, and his new neighbors who moved in from the NPP evacuation zones. While I was focused on responding to his concerns one by one, I had failed to see the big picture—that his primary concern was regarding radiation exposure. Thus, for a professional to effectively communicate knowledge, he or she must first obtain it, listen to identify what knowledge is being sought, and then advise a plan of action or, as in this case, assuage their main fear. As Dr. Goto claimed, health literacy is the ability to not simply read and understand knowledge, but also to convey information in a way that is easily understood. By disseminating knowledge, professionals simultaneously increase awareness, and empower and give responsibility to patients to make their own decision. That is how Dr. Goto started her cycle of empowerment in Fukushima- she trained public health nurses to formulate advising, which enabled residents to make their own informed decisions.
Lastly, a professional should be aware of fields outside their specialty, and be in tune with the current issues of his or her community. Some doctors were discouraged by their lack of expertise in emergency medicine and radiology during the Great East Japan Disaster, instead of using it as an opportunity to learn about these fields. On the other hand, some doctors and even non-medically inclined citizens made it their mission to gain ownership of current information and devised their own plan of action.
So what does this all mean for an aspiring medical professional and global citizen? To venture outside my comfort zone and experience various new things; to strive to be a trusted, wary member of my community, an understanding friend and good listener, and an articulate communicator. Just like Dr. Kumagai who grew up listening to his mother’s experience as an atomic bomb survivor, became a surgeon to examine the whole body, researched thyroid cancer -which is unraveling as an ongoing issue in Fukushima-, interned at the WHO through an interest in public health, was recruited from Nagasaki as part of a radiation medicine team, and is a local adviser and educator who engages any medical student or advisee mother just the same– with an affirmative voice, and a smile.
Summary of Nishimiya Fellows Program Itinerary:
- Arrived in Fukushima
- Checked into hotel near Fukushima station, alongside many other decontamination workers who were hired and staying in Fukushima temporarily
- Workshop with Ns. Yoshida to map the many inter-related problems surrounding the Great East Japan Disaster:
- Most of our answers were focused on health-related effects and the nuclear disaster, as opposed to the FMU students who were directly affected and thus wrote more concrete issues that arose during their evacuation
- Lecture with Dr. Kumagai on the disaster in Fukushima + basic knowledge of the evacuation timeline
- Lunch in Hospital Cafeteria
- Exercise with Dr. Kumagai & Ns. Yoshida on how to measure radiation (specifically, air dose rate and surface contamination)
- Courtesy Call with Dr. Yaginuma and Dr. Sekine
- Lecture with Dr. Kumagai on Radiation health risk in Fukushima
- Data obtained through US + Japan cohort studies (by ABCC and RERF) to compare radiated and irradiated atomic bomb survivors is being used as a reference.
- Continuation of lecture by Dr. Kumagai on radiation health risk in Fukushima
- There is a strong correlation between the distance you evacuate and how worried you are. This is especially a problem, because people in Fukushima still get constant updates on TV and newspapers but those currently in Tokyo or even Kyushu do not have access to this information.
- Lecture by Dr. Aya Goto on a public health approach, and maternal and child health
- Importance of building trust and support first, starting a cycle of empowerment via public health nurses, and considering “the demands made by the health materials themselves, the communication skills of those in the health field” as part of the definition of health literacy as well.
- Lecture from Dr. Ryo Motoya on mental health problems among the evacuees
- Lecture from Ns. Yasui on daily life of evacuees and the problems that they face
- When planning an evacuation shelter, we found it difficult to decide who needed extra care and attention and ended up choosing a lot of people.
- Dinner with Dr. Kumagai, Ns. Yoshida, Ns. Yasui, Dr. Ohtsuru
- Lecture from Ns. Yoshida on the history of radiation-related accidents
- Included a side-by-side comparison of Fukushima Daiichi to Chernobyl, further detailed in my powerpoint
- Lecture by/simulation exercise with Dr. Kumagai and Dr. Hasegawa + FMU Students on emergency radiation medicine and protection tools for contaminated patients
- Asked several difficult, personal questions: What is your acceptable dosage? Even if you are scared, how do you offer the best care? Do you prioritize decontamination or the patient’s life? It takes a lot of courage to admit fear
- Table-top exercise with Dr. Kumagai + FMU students on emergency radiation dose assessment
- Importance of preparation and flexible thinking to prevent further contamination, constant measurement of surface contamination throughout treatment, and explaining the radiation dose and your decision to patient (i.e. sewing a cut together will cause the patient to be irradiated by 110uSv, but there will be a gradual exposure throughout the body of a dosage lower than an actual CT scan = 15mSv)
- Discussion-based bioethics lecture by Dr. Akira Ohtsuru with FMU students
- Two case studies:
- Comparing the increased Cs-137 limit in lichen-reindeer meat in Norway after Chernobyl, as opposed to the decreased limit in Fukushima. Norway prioritized the preservation of culture and examined the overall low impact on the population- not every case is dealt similarly.
- Evaluating the different reactions people have to genetic counseling, and finding similarities to the radiation accident in Fukushima.
- Simulation of health consulting for evacuees from Ns. Yasui in preparation for Yorozu Health Consultation visit
- Citizens became reluctant to attend public seminars on radiation after activists kept interrupting them for 2-3 years. The need arose for a platform to seek individual help, such as health consulting, but it is still difficult for doctors because consultees don’t necessarily articulate their primary concern and also look for a change in expression as one indicator of consultation effectiveness.
- Two case studies:
- Started the day, each wearing a personal dosimeter
- Visited Yorozu Health Consulting in Kawamata city
- Talked to citizens who were waiting for their health check-up about their experience during and immediately after March 11th, and the doctors who were in charge of consultation that day.
- Traveled from Kawamata city to Minamisoma, and passed Okuma (which co-hosts the Daiichi NPP with Futaba), the coastline where the ruins of houses still remained, and the borderline of the ‘difficult-to-return’ and ‘restricted habitation’ zones.
- Meanwhile, passed many buses filled with exhausted, sleeping workers contracted to work at the NPP or on decontamination.
- At the end of the day, still only measured 1uSv
- Dinner with Fukushima WILL medical students, during which we discussed the US and Japanese medical system, why we became interested in medicine, and etc all over enban gyoza- a local delicacy. The students were all in the group out of a desire to increase awareness and help prepare other areas of Japan for future disasters.
- Visited Mt. Azuma, an active volcano in Fukushima, to examine another type of potential natural disaster risk.
- Discussion with Dr. Kumagai on risk communication and a physician’s role
- Important to increase your humanity by having various life experiences, not strictly medical, and to understand that being an expert in one area does not mean you only need to know your specialty. I, for one, felt that Dr. Kumagai is a living example of what a professional is and can be.