Four and a half years of experience of a clinician born and raised in Fukushima: discrepancy found through dialogues and practices

1. LOOKING BACK ON PAST EXPERIENCES AROUND PRESENTATIONS AT THE ICRP DIALOGUE SEMINARS

The author was a professional diagnostic radiologist before the Great East Japan Earthquake and the accident at Fukushima Daiichi nuclear power plant (FDNPP) caused by the tsunami in the immediate aftermath of the earthquake. After assisting in radiation emergency medicine in response to the accident at FDNPP, the author began to engage actively in the multiple-site sharing of information regarding management of the accuracy of whole-body counters (WBCs), which began to be introduced into Fukushima Prefecture in large numbers in the latter half of 2011, and providing information to local governments that were contemplating introducing WBCs. In 2013, the author started to measure and explain individual external exposure doses to residents, particularly those living in areas adjoining the evacuation zones. This was made possible using new features of a new generation of electronic personal dosimeters developed after the Great East Japan Earthquake. One of the themes that emerged through these activities was the issue of how government authorities, which possess vast amounts of data on individual exposure doses, should use such data.

During this early stage, the author was given the opportunity to present at the first ICRP dialogue seminar, held in Fukushima on 26 and 27 November 2011 (although this presentation was not part of the initial agenda). The author reported on the efforts made by Fukushima Medical University in radiation emergency medicine as part of the early-stage response to the accident at FDNPP, and on how he began sharing knowledge about radiation and the state of contamination with the residents of Fukushima. The author’s conclusion at the time, less than 1 year after the accident at FDNPP, was that there was an urgent need to build a platform on which the residents and government could co-operate to devise appropriate measures, based on accurately measured and assessed data (i.e. set up a community-based infrastructure to share and use such data). In his presentation, the author also noted that merely communicating the accurately measured radiation doses (i.e. measurements) to residents is insufficient. As the concepts of exposure dose and radiation are unfamiliar to the general public, each community needed someone to explain what the measured doses, such as Bq body^-1, meant to residents. From the onset, it was clear that there was no process in place to properly interpret and communicate the results to individual residents to enable them to use the data in their lives. In other words, although there was a need for a process of ‘explaining/interpreting’ the data, such a process was missing. The serious lack of explainers and interpreters of measured radiation doses, particularly individual dose measurements, continues today.

At the third ICRP dialogue seminar, held in July 2012, the author gave a presentation entitled ‘Whole-body counting of Fukushima inhabitants’; this summarised the results of WBC screening tests that had been conducted for approximately 15 months after the accident at FDNPP (Miyazaki, 2012). The WBC screenings continue to be implemented in Fukushima to this day. However, Fukushima Prefecture has only published the number of recipients and their respective committed effective doses of radiocaesium by millisievert (mSv) bracket. Therefore, almost all subjects are classified as ‘<1 mSv’. It is known that approximately 30,000 Bq of radiocaesium has to be detected from a person’s body in WBC screening to assume that internal exposure of radiocaesium through chronic ingestion during the immediately preceding year exceeds a committed effective dose of 1 mSv (equivalent to annual ingestion exceeding 75,000 Bq). In Fukushima Prefecture, however, very few subjects exceeded the WBC’s lower detection limit (approximately 200–300 Bq body^-1), even at the time of the presentation, and for most of those who exceeded the detection limit, their levels of exposure were a few thousand Bq at most. Furthermore, their exposure levels decreased in accordance with the effective half-life of radiocaesium upon further testing. Given the state of radioactive contamination of food distributed in Fukushima at the time, and interviews on the dietary composition of those who exceeded the lower WBC detection limit, it is likely that many of those who exceeded the detection limit regularly consumed certain types of foods found in the wild that were not distributed in the market. Thus, the risk of internal exposure for the residents of Fukushima who consumed food purchased from regular distribution channels was considered to be extremely small. However, it was understood that the economic and cultural effect on farmers and residents who enjoyed wild produce as part of their traditional lifestyle was significant.

At the seventh ICRP dialogue seminar in November 2013, the author reported his experience acting as an interpreter of measured individual exposure doses from WBC screening tests, conducted at residents’ own initiative with the results shared within the community; an effort that remains rare in Fukushima today (Miyazaki, 2013b). This effort is still being conducted in Suetsugi district, Iwaki. This programme began when one resident voluntarily started measuring radiation levels of soil in the district without any support from the public sector. This led to measurement of radiation levels of foods, use of personal electronics, and sharing of results within the community (Ando, 2016). In this district, the author’s role was limited to that of an ‘explainer’. Through this involvement, he effectively resolved the lack of ‘explainer/interpreter’ of the results of individual measured doses that he highlighted in his presentation at the first ICRP dialogue seminar. Even before the author’s involvement, the people concerned about radiation in this district had ‘brought about a situation where data could be shared and used within the community’. Through participating in WBC screening and sharing the results within their community, the residents of this community succeeded in acquiring the means to understand the radioactive contamination in their district in realistic terms, and to make decisions about their future diets. As an explainer/interpreter, the author focused on how to explain the results of WBC screening – which only shows how many Bq body^-1, a value alien to the residents – in relevant and understandable ways so the residents could use the test results in their daily lives. It is important to understand that the objective of sharing the results of WBC screening within the community is not merely to dispel the residents’ health concerns nor to reduce internal exposure levels. What is crucial is to provide information so that each resident may make objective and informed decisions about whether they can resume their lifestyle (from before the accident at FDNPP) in the current environment, including eating home-grown vegetables and seasonal delicacies from the forest, etc. Experiences gained through involvement with this district were eye-opening and valuable for the author, as he witnessed how the whole community co-operated in considering their post-FDNPP accident lifestyles based on the WBC screening results.

The author’s presentations at the 11th and 12th ICRP dialogue seminars, held in May and September 2015, respectively, focused on how the results of individual dose measurements, which are only shown as numbers, may be explained in ways that could be used effectively by the residents in their daily lives (Miyazaki, 2015a,b). From the author’s viewpoint, the individual doses measured in WBC screening or using electronic personal dosimeters reflect the individual’s lifestyle. Behind the WBC screening test result is the story of ‘what he/she had been eating on preceding days’; behind the result from the personal electronic dosimeter is the story of ‘where he/she has spent time’. As such, it is extremely important to respect the privacy of the individual when handling such data. The author reported that his focus had been to think about each resident’s lifestyle and life setting when explaining the data, and to give concrete, easy-to-understand advice so that residents could make their own decisions about what to eat and where to spend time. The author also explained that, as the local government (municipal) staff met the residents on a daily basis, it was crucial that these people linked the residents and the interpreters for the municipal services to provide a new service to ‘explain radiation’, established after the unprecedented accident at FDNPP, in order to reach the outreach objective/target effectively (i.e. the residents of affected communities).

Needless to say, a system for linking the local government to interpreters or experts on radiation does not exist in times of normalcy. In the face of this reality, the situation after the accident at FDNPP called for someone who could fulfil a new role of an intermediary (a ‘liaising officer’) to link residents who needed information about radiation, the local government that had to provide municipal services to provide residents with such information, and experts who had the knowledge/capacity to provide such information. The author’s experience is proof that a local physician (such as himself) could fulfil both the ‘interpreter’ and ‘liaising officer’ roles. The lesson learned from this experience following the accident at FDNPP is that local physicians, nurses, and public health nurses involved in the health management of residents, as well as local professionals including school teachers, may act as ‘liaising officers’ when there is a need to quickly establish a new radiation-related service for residents of affected areas in the early stage after an accident. Additionally, there is a need to provide measures to prepare such professionals to fulfil said roles as part of emergency preparedness and response for radiation accidents.

2. THE GAP BETWEEN ICRP RECOMMENDATIONS AND THE REALITIES AFTER THE ACCIDENT AT FDNPP

The above summarises the author’s personal activities after the accident at FDNPP in chronological order, based on his presentations at ICRP dialogue seminars. Most of the presentations at these seminars were related to internal exposures, especially individual feedback of WBC screening results to individuals. In addition, the author also presented on activities (general health consultation services) carried out from the public health and preventive medicine perspectives to prevent the deterioration of health among evacuees at the sixth dialogue seminar (Miyazaki, 2013a). Outside the programme, the author gave updates on the progress of WBC screening to experts from both Japan and abroad. Details on and approaches to the measurement of individual external exposure doses using the electronic personal dosimeter, or D-shuttle, as well as explanation of D-shuttle results to individuals that were conducted in parallel with interpreting the results of WBC screening tests, were also shared through the ICRP dialogue seminars. In other words, the seminars provided valuable opportunities to communicate and share information with many experts as well as the residents who participated. The seminars also enabled real-time communication of the actual problems being faced by medical and health professionals in the field to experts from outside Fukushima. It was a valuable opportunity as the former tackled unforeseen situations after the nuclear accident. Conversely, dialogues with said experts clarified the deficiencies in existing manuals and/or recommendations on radiation accidents drafted prior to the accident at FDNPP.

There were no manuals available for the author’s activities. The author made use of his prior training and experience on radiation in his field in acting as an ‘explainer/interpreter’. In other words, ways to explain exposure doses to individual residents, and ways to analyse and share the measured exposure doses with related government departments were developed through trial and error. During this process, the author first learned of Publication 111 (ICRP, 2009) in September 2011. Publication 111 is based on the experiences of people living in long-term contaminated areas after the Chernobyl accident. Although Publication 111 is not a manual per se, it became the most reliable source of reference in the author’s subsequent activities. Especially in the early phase, there were many cases where Publication 111 provided suggestions to actual problems.

As the activities in Fukushima continued, the author identified gaps between Publication 111 (ICRP, 2009) and the actual situation on the ground. These can be summarised as follows:

Publication 111 does not refer to the role of the ‘interpreter’ or ‘liaising officer’.

The above shows that ‘integration of radiological protection into municipal systems’ is crucial to induce residents to participate in opportunities where the results of individual dose measurements are explained. It is also necessary for the authorities to use the statistically-processed results from large-scale measurement activities in the next policy step. Although the concept is not surprising, it was not included in Publication 111 (ICRP, 2009).

Another problem that emerged after the accident at FDNPP was severe restrictions imposed on the collection and use of information on individual exposure doses. This was because such data were considered as ‘personal information,’ subject to requirements of the Act on Protection of Personal Information. This response, however, may have been unique to Japan in the wake of a large-scale nuclear power plant accident, and may not apply to other countries.

Given the conditions after the accident at FDNPP, interpreters and liaising officers linked the policies of the authorities – especially those of the central government – with the understanding and needs of individuals and communities, thereby functioning as key instrumental players in integrating radiation protection measures in relevant municipal systems.

3. DUAL MEANING OF INDIVIDUAL EXPOSURE DOSE MEASUREMENTS

It may be difficult to visualise an administrative system that can measure individual exposure levels effectively and use the data for policy purpose. To illustrate this point, the author will depart from the context of radiation protection, and use the viewpoint of public health.

Let us envisiage Municipality A. Municipality A has many patients with hypertension, which has caused significantly higher health insurance costs (and resulting reimbursement) for hypertension compared with other municipalities. By carrying out a disease incidence rate survey, it became evident that the incidence of cerebral stroke in Municipality A was also clearly higher than the national average. Considering the gravity of the situation, Municipality A decided to add spot urine tests in the community’s health check-up programme to track the residents’ sodium intake. In addition, Municipality A implemented two measures, based on the high-risk approach and the population approach. Through Measure 1 (high-risk approach), the municipality’s public health nurses used the estimated level of sodium intake in individual counselling with those diagnosed as hypertensive, as such individuals tended to have higher levels of estimated sodium intake. The test was also used to continue following-up on the effectiveness of measures to reduce sodium intake. Through Measure 2 (population approach), Municipality A decided to make reduced sodium consumption one of the top priority health issues in the municipality, and invested in conducting health seminars to disseminate knowledge and campaigns aimed to encourage the residents to reduce the level of sodium in their diet. This was based on the finding that, looking at the distribution of sodium intake of the entire population of Municipality A, the average sodium intake in Municipality A was substantially higher than the level of sodium intake recommended by the national government.

The short-term goal of these efforts was to reduce the level of sodium intake, and the long-term goal was to reduce the number of patients with hypertension (and the associated health costs), and the number of patients with cerebral stroke (for which hypertension is a risk factor). As a result of these efforts, health insurance reimbursement for hypertension to Municipality A declined 10 years later, and the number of patients with onset of cerebral stroke decreased 15 years later.

The key ‘value’ for this fictitious Municipality A was ‘estimated sodium intake’. Although this is expressed as a simple value from a test result, it can be used for different purposes, in both the high-risk approach for specific individuals, and the population approach for the entire community. As an individual value, it is used to identify high-risk individuals from the group with high intake. Subsequently, it is used for ‘explanation’ by the public health nurses to explain the meaning/implication of said value and provide guidance on future diet through individual health consultation. Such individual consultations will not be conducted for the residents who did not belong to the high-sodium-intake group. However, based on the latter measure, the general implications of high sodium intake in Municipality A and a campaign to encourage a low-sodium diet will be promoted continuously through the municipality’s magazines and health seminars, etc.

To recap, the goal of the former approach is to reduce the level of risk for individuals who are at risk of suffering from hypertension or experience aggravation of hypertensive conditions. Similarly, the goal of the latter approach is to lower potential risk for the population, so as to reduce the number of cases of cerebral stroke among said population in the future (Law et al., 1991).

In Japan, local government authorities invariably have a section responsible for public health that is staffed with experts who understand the above-mentioned duality of these measurements. Most residents are familiar with this municipal system. Using this system, the municipality sets annual health check-ups, notifies the results to residents, provides health guidance, and draws up municipal health policies based on the analysis of the collective results. Many clerical and professional staff are involved in this process. When necessary, the municipality seeks advice from public health experts, and their advice is used in future health policies. Many residents are also aware of the meaning of test results, and the measures that need to be adopted based on the results. Such residents also help to disseminate the contents of campaign messages to other residents that the municipality may not be able to reach through official campaigns, etc. (e.g. if a member of a family attends any campaign activity, the information will be shared in the household). In daily health administration, the municipal system functions naturally and as a matter of course.

In stark contrast to the above, a municipal system to use the results of individual exposure dose measurements has not been established, even in the chronic phase after the accident at FDNPP. As explained above, one cause was the exceptionally limited number of interpreters. In addition, the authorities did not consider establishing a system to link the residents who received their test results with the interpreters. Further troubling is the fact that, even today, efforts to analyse vast amounts of data on individual measurements as tools for future policy making or to seek advice based on said analyses from experts remain inadequate.

Medical professionals are well aware that individual measurements in health check-ups, etc. are not only useful for individuals at high risk, but also for the population as a whole, through analyses of the measurement results of the entire population. This makes it all the more exasperating that individual exposure dose measurements obtained after the accident at FDNPP have not been adequately used for ‘optimisation’ measures for the entire population, which is conceptually parallel to the population approach in radiation protection.

4. CONCLUSION

This report looks back on the author’s four and a half years of activities in Fukushima, drawing on his presentations at ICRP dialogue seminars. As someone who has lived in Fukushima throughout his life, both as a student and a physician, the author could not pretend not to notice the impact of the accident at FDNPP on the region. Nor could he regard the activities as something temporary, as was the case among experts from outside the region who had the option to move away. In this context, the author had to question the roles to be fulfilled by local professionals in the wake of a nuclear accident.

Who has to respond to various problems that arise in the region on a continuous basis? The answer has to be those who are in immediate proximity to the residents. At the forefront are staff members of the municipalities and various local professionals. They enabled large-scale screening of individual exposure doses, agonised over the difficult task of radiation protection, and engaged in various tasks that did not exist before the accident. However, in most cases, they did not have experts by their side with whom they could consult on the basics of radiation or the most appropriate response to residents in a specific situation. As someone who grew up in Fukushima and as a professional committed to the region over the long term, the author was able to contribute to this region, although in a limited locale, by responding to their questions as quickly as possible and, where necessary, by linking them to high-level experts; in other words, he acted as a ‘liaising officer’ linking residents, the government, and experts.

In reality, there were few professionals who fulfilled such a role after the accident at FDNPP (obviously many of them were too busy performing their regular duties). These professionals, however, had received training that equipped them with the capacity to use measured data for both high-risk and population approaches. The author believes that their knowledge/capability could be used effectively in the chronic phase of a large-scale radiation accident such as the accident at FDNPP. Some radiation protection experts whom the author met firmly believed that individual dose measurements were personal information. The author experienced cases where such thinking prevented the use of vast amounts of data from measurements when drawing up measures for the entire population or large-scale policies. There is a need to balance the requirements of the Protection of Personal Information Act and the emergency circumstance following a nuclear accident, and this must be addressed as a policy issue.

The author proposes that training should be provided to physicians, public health nurses, and school teachers in regions where nuclear facilities are located, so that they can fulfil the role of liaising officer as part of preparedness for large-scale radiation accidents similar to the accident at FDNPP. By increasing the number of professionals who have advance knowledge/awareness of their responsibility to fulfil the role of liaising officer in times of emergencies, it is expected that gaps between residents and the authorities/experts would be closed more quickly, community-level understanding/approach would be promoted more widely, and a radiation protection culture would be enhanced. Although said professionals may not be directly involved in radiation in their regular line of duties, they are likely to understand the importance of acting as a ‘liaising officer’ in the early stage after an accident, through sharing the concept with other experts, including radiation expert professionals, in order to provide better service to the affected residents. In this context, the concept of ‘liaising officers’ is important in the aftermath of a nuclear accident. In giving a detailed description of his role as a ‘liaising officer’ for more than four and half years, the author hopes that his experience will be useful in the event of a future accident.