Case Study: Kobe Earthquake
On January 17, 1995, a 6.8 Richter earthquake struck Kobe, Japan, killing 6,434 and causing US$102.5 billion in damages. Ten spans of the Hanshin Expressway Route 43 in three locations in Kobe and Nishinomiya were knocked over, blocking a link that carried forty percent of Osaka-Kobe road traffic. Most railways in the region were also damaged. Only 30% of the Osaka-Kobe railway tracks were operational.
In the Nagata section of the city, where small wooden houses were built in tight, compact clusters, fires started and quickly outstripped the city’s fire-fighting ability. The quake ha also damaged water lines, leaving many fire-fighters with no water at all. Several major landslides buried people. Meanwhile, the man-made islands in Osaka bay liquefied and were cut off from the rest of Japan when connecting bridges were destroyed. Severe infrastructure damage made it difficult to bring in relief supplies.
In the aftermath, both citizens and specialists lost faith in the technology of their early warning systems and earthquake construction techniques. The national government of Japan was criticized for not acting quickly enough to save many people, for poorly managing Japanese volunteers, and for initially refusing help from foreign nations, including the United States, South Korea, Mongolia, and the United Kingdom. The language barriers and the obvious lack of Japanese medical licensing by foreign volunteers were cited as justification.
Local hospitals struggled to keep up with demand for medical treatment, largely due to collapsed or obstructed “lifelines” (roads) that kept supplies and personnel from reaching the affected areas. People were forced to wait in corridors due to the overcrowding and lack of space. Some people had to be operated on in waiting rooms and corridors.
Approximately 1.2 million volunteers were involved in relief efforts during the first three months following the earthquake. Retailers such as Daiei and 7-Eleven used their existing supply networks to provide necessities in affected areas, while NTT and Motorola provided free telephone service for victims. Even the Yamaguchi-gumi yakuza syndicate was involved in distributing food and supplies to needy victims.
Mental Health Response
Kobe has the highest psychiatric clinic to local population ratio in Japan. These one-person clinics are organized by a ikyoku system where local university departments serve as the professional organization that manages the patient care of psychiatrists in the local area. It is this highly centralized network that allowed for the biggest psychological response to a natural disaster in Japanese history. Information needs in each area were gathered through clinics and public health centers and psychiatrists were sent to areas such as schools, which had become shelters for earthquake victims.
The first priority for the psychiatric response was to establish and maintain contact with known patients who were living on their own or with their families. The earthquake undermined the treatment of these patients who lost their medications or had to adjust to living in overcrowded shelters. Given the stigma of mental illness in Japan, doctors were surprised to find patients come with medication requests on their own accord. Other common symptoms included psychomotor excitement, including newly diagnosed cases of mania. To accommodate new patients in overcrowded local hospitals, stabilized patients were transferred to hospitals in nearby cities.
Surprisingly after the quake, the news media focused on the psychological effect of the earthquake on ordinary people. Graduate psychology students visited primary schools, where they asked children to draw pictures. This was seen as a therapeutic intervention, offering students a way to express their thoughts and feelings about the disaster. The term attributed to this field of intervention came to be known as kokoro no kea or, roughly translated, “care for the heart.” In the first weeks after the quake, virtually all major newspapers ran editorials emphasizing the long-term need for kokoro no kea. Before the earthquake, dissociative disorders and alcohol dependence had been the flagship diagnoses after a disaster. The concept of kokoro no kea suggested that mental illness is a possibility for anyone involved in a traumatic event, opening up the discussion for PTSD, a previously unacknowledged diagnosis in the Japanese system.
Mental Health Methodology
There are four psychological stages of a disaster. The Heroic Stage occurs immediately after the disaster and lasts up to one week. During this stage, emotions are intense and people respond altruistically, using resources on hand to help people in dire need. In the second stage, known as the Honeymoon, feelings of camaraderie are strong, as assistance is promised from the outside and hopes for recovery are at their highest. This phase lasts up to six months after the disaster. The third stage, Disillusionment, follows; people feel disappointed and angry about their situation, as promises of aid are unmet and hopes for recovery remain unfulfilled. The spirit of camaraderie fades and people become concerned with their own problems. In the final stage, Reconstruction, new movements for rebuilding based on resources within the community arise. This may last for several years following the disaster.
Physical Symptoms: increased heart rate, high blood pressure, problems with visual focus, weakness, difficulty breathing, numbness, tingling, lumps in throat, nausea, upset stomach, diarrhea, sweating and chills, hot/cold spells, clammy skin, tremors, muscle soreness, lower back pain, muffled hearing, faintness, startled response, headaches
Cognitive Responses: memory problems, difficulty naming objects, disorientation, slowness of thinking, difficulty comprehending, mental confusion, difficulty calculating, poor logic, trouble making decisions, inability to prioritize tasks
Emotional Responses: anxiety, irritability, depression, moodiness, blaming, apathy, isolation, guilt, denial, suppression, flashbacks, sleep disturbances
The Critical Incident Stress Debriefing method is used in group settings and contains six phases. In the Fact Phase, each person talks for a few minutes about what happened, leaving judgments and emotional reactions aside. In the Thought Phase, people reported their first thoughts on what happened. In the Reaction Phase, the debriefer asks the group, “What about this incident got under your skin? What was your gut reaction?” The Symptom Phase asks participants to talk about the lingering effects of the incident. In the Teaching Phase, the debriefer teaches about the syndromes associated with traumatic stress, tailoring the details to the particular event. Finally, in the Re-entry Phase, participants are encouraged to ask questions about the process. The main goal of debriefing is overcoming guilt by focusing on intentions rather than actions to convince the person that they did their best to help under the circumstances.
Not all countries accept the same DSM IV standards for diagnosis. Responding within the cultural context requires sensitivity to differences in diagnostic methods, categories, and level of social stigma associated with mental illness. By increasing the social acceptance of PTSD, those who need aid will be more likely to seek aid. Japan’s centralized ikyoku system facilitated the matching of psychiatric resources with those in need of aid. In a less centralized country, how can psychiatrists and qualified volunteers quickly mobilize? Through the disaster stages, how can proper expectations be set early to extend camaraderie through reconstruction? What objects might facilitate community-organized debriefings? Can design allay the physical, cognitive and emotional symptoms of a disaster?
Breslau, Joshua. “Globalizing Disaster Trauma: Psychiatry, Science, and Culture after the Kobe Earthquake.” Ethos 28.2 (2000): 174-97. Print.
23, By May. “Great Hanshin Earthquake.” Wikipedia. Web. 06 Nov. 2010. <http://en.wikipedia.org/wiki/Great_Hanshin_earthquake>.