After the Tsunami, Physician Volunteers Find Obstacles Both Obvious and Unexpected

May 17, 2011
Enoch Choi, MD

MD Magazine®, Volume 2 Issue 1, Volume 2, Issue 1

Enoch Choi, MD, writes about his experiences leading a disaster relief team in Japan.

The peak of the Sakura season of cherry blossoms blooming this week provide hope that “This, too, shall pass.” The Japanese people have suffered a triple threat, the worst within recent history: the strongest earthquake, the tallest tsunami, the worst nuclear disaster. It has been a perfect storm.

Japan—the country most prepared for natural disaster— initially fell flat in responding to each of the three crises. But the resilience of the Japanese people, and their civility, has shone a light through the rubble to the hope reflected by the yearly return of these softly falling cherry petals. We can learn much from not only their charitable character, but also about how their culture has limited the help that has been offered to them.

It reminds me of Haiti, where last year 300,000 died in a moment, and 2 million remain displaced. I am the medical director of Jordan International Aid, a 501c3 organization that sent nine teams of more than 200 physicians, nurses, and supporters to help in Haiti last year. We found Haitians who had never seen a physician in their lives, and we had the privilege of caring for them. Although the Japanese disaster led to fewer casualties, the destruction is even more vast.

The Japanese have devoted 100,000 troops to helping in the recovery, but they found that to be but a drop in the bucket. About 2 million citizens were stripped of water, electricity, and utilities—twice as many as in Katrina, and as many as in Haiti. The supply chain disintegrated, leaving those in shelters and those sheltering in their homes to depend on the sparse resources deployed by the military. Many are homeless due to the six-story wall of water that washed away their homes with a 150 mph tsunami. Complicating aid efforts are the fears about radiation release from the Fukushima nuclear reactors and the lack of fuel since the refineries along the coast were damaged. Sadly, due to the radiation fears, most medical relief groups, even the US government’s Disaster Medical Assistance Team have not deployed to help. I say “fears” because the dosimeters my team wore show no significant radiation exposure. My hopes are that those interested in going to help may be encouraged by our experience.

We arrived one week after the disaster on an otherwise empty flight. Narita International Airport, though, was jammed with expatriates fleeing the country, many of whom were worried about the nuclear reactors melting down. The roads were limited to emergency transport vehicles, and our bus cost $1,200 per person to get to Ishinomaki.

Although a lot of aid had reached Sendai, we brought the first physicians, hot food, baby formula, and energy bars to Ishinomaki. It was still very cold, and many illnesses we saw were due to crowding in the shelters as folks tried to sleep close together, conserving heat because kerosene was in short supply. The famously civil Japanese kept the peace in shelters, but survivors privately shared their frustration that blankets were inequitably distributed, leaving many shivering.

Due to the crowding, we were surprised to see that pneumonia and gastroenteritis also predominated in Ishinomaki, just as was common in Haiti. There wasn’t cholera in Japan, but many symptoms reminded us of Haiti and Hurricane Katrina, such as conjunctivitis, pharyngitis, and bronchitis due to irritation from the dust from rubble and silt left by receding floodwaters. The close quarters in shelters provided the opportunity for respiratory particles to get past face masks that were soaked with moisture from breathing. Only dry masks filter out infective organisms; when masks are wet, air seeps in around the edge of the mask. The typical fastidious cleanliness of the Japanese people was limited by the lack of running water. Diarrhea was spreading. Our teams were surprised by the odor of urine in shelters. Then we realized that the elderly, toddlers, and infants hadn’t bathed in a week and didn’t have a change of clothes. Some were incontinent of urine (which fortunately is sterile), but also with stool. Alcohol hand rub was in high demand, but no water was available to rinse the residue that accumulates after 20 applications.

Helping out in Japan is much easier in some ways than it was for past disasters, and in other ways it is more difficult in others. The Japanese are rightfully very proud of their excellent preparations for disasters, and the relative low death rate given the magnitude of the earthquake and the resulting tsunami speaks to the success of executing on those plans. It was heartening to hear stories from many survivors who shared how they followed their disaster plan and made it to higher land. It has compelled me to make a plan with my own family. It was heartbreaking to hear how many who followed the plan still died. That waters were so high that many who evacuated to elevated tsunami shelters still drowned.

As we cared for patients, we could ask for transport for sicker patients to get to the just-set-up Red Cross Ishinomaki Hospital. It’s great that the hospital is coordinating volunteer physicians and nurses to care for shelter residents. What is difficult is that, unlike in Haiti, where we were welcomed, shelter after shelter in Japan was unwilling to let us care for survivors. This was true despite the fact that we carried with us a letter from an Ishinomaki city council member asking the shelters to allow us to help. It wasn’t due to regulatory issues of credentialing; our physician was given permission to treat, just as was the case during Katrina. It wasn’t that patients didn’t need care—many were suffering from respiratory illnesses and exposure. It was more about the cultural reticence of seeing a foreign physician using a translator. We will soon return with Japanese-speaking physicians, but it speaks to the difficulty of the Japanese people to accept help, even when in great need.

Another difficulty is trying to get resources shipped to the disaster. We have been working to get two shipping containers full of medical supplies, new Gymboree children’s clothes, and EO Products hand sanitizer to Ishinomaki. We mobilized the shipment but it will take three weeks to get there. The shelter manager called and they recently got a big shipment and don’t have room for more. As I write, I’m scrambling to find another shelter to accept the shipment. This is the reality of relief work halfway around the world. Things change fast, and it makes it difficult to help. The delay in shipping was due to getting the customs clearance to import it duty-free, with the proper documentation from politicians we met while we were there in Ishinomaki. Needless to say, the donor is frustrated about the destination being up in the air, and I’m working my contacts with missionaries that have been distributing goods in nearby Sendai.

One commonality to these disasters was that we arrived a week after the disaster and although the cellular voice networks were often overwhelmed, we could text and access the internet on mobile phones. With the rapid changes from day to day in the disaster, it was helpful to review websites that listed the latest news. In disaster response parlance, it’s called “situational awareness.” It helped us email to coordinate with those at the shelters in terms of what the biggest needs were and where we could help. In Japan, XCom Global donated MiFi devices that gave up to five users the ability to share a Wi-Fi connection. It was a way we could upload photos and videos live to our Facebook and Twitter feeds to let our supporters know what we were up to. Taking this lesson home, I’ve suggested that my employer, a large clinic of a thousand physicians, create a disaster situation website and add mobile phone numbers to my clinic’s disaster preparation plans. That way, we can give updates via a website and do SMS blasts to give updates to all employees. Alternatively, we can text to ask for particular specialists to come help. Right after a disaster, the voice cellular networks are overwhelmed, but texts can get through.

One frustrating thing in a disaster is that survivors often tell you, for example, that they take the red pill for hypertension and a rainbow of other colored pills for a plethora of illnesses. At Palo Alto Medical Foundation (PAMF), I work in a multi-specialty environment where I can refer to the past medical history in an EpiCare electronic medical record (EMR). During Hurricane Katrina and in Haiti, we could also use mobile internet to access and store electronic medical records. During Katrina, the U.S. government aggregated electronic pharmacy records and allowed credentialed disaster relief physicians like my father and I to look up recent prescriptions of survivors online. In Haiti, we received a generous grant from Epocrates in order to do so with their iChart EMR on iPhones.

We helped Harvard develop new disaster relief EMR standards for the WHO last year. One difficulty in the Japanese medical system is that most health care professionals operate in small clinics with systems that are not integrated into larger data networks. There is no way to find out what medications Japanese survivors are taking. Here in the US, our government has incentivized physicians to adopt EMR via $64,000 in HITECH incentive payments over the next four years. In year four, there is a requirement for the EMR to be tied to Health Information Exchanges that create a repository of your health information across multiple providers of care. Four years from now, patients’ health information will be much safer in a disaster or even in less severe trips to the emergency room since physicians will be able to look up patients’ records online. In year two, giving patients access to these records via a Personal Health Record is incentivized. At PAMF, we have done that for a decade via our My- Health online portal. Just last month, we were the first in California to launch access via an iPhone app. My personal experience is that it’s a much more usable way to have electronic visits with my doctor wherever I am using my cell phone and review my records without being tied down to my desktop computer.

You may wonder how we operated these devices while in disasters where the electrical grids are down. We had solar power thanks to donations from We CareSolar, which builds battery-filled suitcases powered by donated Everbright Solar panels, a local manufacturer. This helps charge our headlamps so we can look down throats and see in the dark, and it allows us to recharge our cell phones and laptops. Portable solar lights donated by OneMillionLights were distributed in Haiti last year, and now to Japan. These lights miraculously provide eight hours of light so we can see at night. There is still sun in places where nuclear reactors melt down and leave millions without power.

I'm excited to go to Japan and organize more trips of friends willing to help survivors. If you’re interested in following our progress, you can “like” us on Facebook and read about how our first trip went. You can donate to our efforts using paypal or by mailing your tax deductible donation to “Jordan International Aid” at 12860 Llagas Ave, San Martin, CA 95046.

E-mail me if you’re interested in going to Japan or Haiti: enochchoi@gmail.com. Come join us in helping a country even more prepared that us recover from their “perfect storm.” Help them more fully celebrate their season of Sakura.

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