Healing Fukushima: Radiation hazards and disaster medicine in post-3.11 Japan

Introduction

On March 13, 2011, a few hours after the sudden explosion at reactor no.1 of the Fukushima Daiichi nuclear power station (Daiichi), Dr. Hasegawa Arifumi, ¹ head emergency physician at Fukushima Medical University (FMU), received a call asking him to prepare a base of emergency medical treatment for radiation casualties. Hasegawa and his team had never handled radiological emergencies before. Nonetheless, the daunting task of providing emergency care in response to the nuclear meltdowns at Daiichi fell to them. Seven years on, radiation emergency medicine (REM), or radiation disaster medicine, as it is alternately known, is an established specialty at FMU, which now provides a model for medical institutions worldwide.

This paper recounts the compelling stories of medical first responders during the Fukushima disasters, and highlights the emergence of expertise in REM in subsequent years. ² It illuminates the formation of new expertise amidst disaster, centering on the process of knowledge production in crisis. Our study of REM’s rise to prominence in Fukushima asks three questions: What happens when expertise must confront disasters of unprecedented scale? How is knowledge produced in critical moments when every action and decision involves life or death? And how do local agents mobilize social networks to cope with escalating crises?

Several years after northeastern Japan suffered 3.11, ³ a substantial number of studies on Fukushima have emerged across many disciplines. These studies typically examine the social, economic and/or environmental impacts of radiation contamination at Fukushima Daiichi, or Japanese nuclear energy policy. The former category includes analyses of the suffering of Fukushima residents forced into long-term evacuation at temporary shelters (e.g. Tanigawa et al., 2012), the setback of economic activities in Fukushima due to fears of its products being radiation-tainted (Yamaguchi, 2014), and the public health concerns of people in Fukushima and surrounding prefectures over elevated levels of environmental radiation (Kimura, 2016; Yasunari et al., 2011). In the latter category, scholars have examined dramatic changes in Japan’s nuclear energy industry (Ahn et al., 2015), transformations of nuclear regulatory bodies (Vivoda, 2012), and how the nuclear energy issue has shifted national politics (Samuels, 2013). Other works highlight lessons learned from unprecedented disaster (Fujigaki, 2015; Fujigaki and Tsukahara, 2011). While this array of social-scientific studies critically analyzes Fukushima’s impact on Japan and the world, it largely neglects how medical care functioned in relation to radiation hazards. As we show in this paper, the nature of medical response is a critical factor in disaster resilience. By focusing on REM, our work contributes a perspective from science and technology studies (STS) that elaborates some of 3.11’s implications for scholarship on knowledge production and disasters.

STS has made knowledge production in modern medicine a central subject since the field’s early years (Fleck, 1979). Our article illustrates the flexible nature of medical expertise when it deals with uncertainties and untoward circumstances in the aftermath of large-scale disasters that profoundly disrupt its social and institutional structures. It further highlights how the resilience of medical first responders in Fukushima emerged through a reconfiguration of existing knowledge and practices that compelled the evolution of REM as a new area of medical expertise. We characterize the expertise of our subjects as serviceable, drawing inspiration from Jasanoff’s (1990, 2015) theorization of scientific knowledge as ‘serviceable truth’ in relation to legal practice and public policy. Serviceable truth, for Jasanoff (1990), is ‘a state of knowledge that satisfies tests of scientific acceptability and supports reasoned decision making, but also assures those exposed to risk that their interests have not been sacrificed on the altar of an impossible scientific certainty’ (p. 250). Disaster expertise, in our reading, presents a useful analogue to this concept. Emergency plans and guidelines often fall short, or are overwhelmed by the scale and vicissitudes of catastrophe, necessitating a transformation of expertise’s epistemological contents. As our study of REM in post-3.11 Japan shows, disaster expertise draws on extant knowledge combined with real-time contingencies in a process that constantly compelled our interview subjects, as medical first responders, to work with insufficient knowledge and preparation in the countermeasures they undertook, and to produce serviceable expertise out of limited resources.

Throughout this paper, we show how Japanese medical professionals responded to 3.11 by articulating the challenges they faced in providing medical treatment at the height of the disaster, and their reflections on these experiences. Drawing on eight interviews with practitioners from two municipal hospitals and FMU (see Appendix 1), Fukushima’s flagship institute of medical education, as well as background documents and secondary sources, we explore their understanding of the medical and health issues produced by 3.11. In addition, we examine the complexities involved in creating and conducting post-disaster medical care, identifying the three themes of responses, contingencies and practices in our characterization of institutional and individual responses to the crisis.

The Great East Japan earthquake of 2011

March 11, 2011 began as a clear winter day in Japan. But around 2:46 p.m., an undersea quake of magnitude 9.0, running 24 kilometers deep, struck around 70 kilometers off the northeast coast (hereafter Tōhoku). Japan’s largest ever observed quake and the world’s fourth largest generated a massive tsunami – a record 16.7 meters at peak height – and run-up waves that reached 40.1 meters. The natural disasters severely damaged reactors at the Fukushima Daiichi plant, causing meltdowns and explosions in three units over the next few days (see Figure 1). This produced uncontrolled releases of radioactive materials over Tōhoku and most of the Kantō plain, creating a chronic risk of environmental contamination (Amir and Juraku, 2014).

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Figure 1.

Chronology of major events the first few days of 3.11 (Reproduced with permission from Tanigawa and Hasegawa, 2014: 47).

The events shattered the lives of Tōhoku denizens, causing over 22,000 dead and missing casualties (Fire and Disaster Management Agency Japan (FDMA), 2016). The death toll is only one aspect of the costs Tōhoku continues to pay. The containment and cleanup process at Fukushima Daiichi needs decades to accomplish, while decontamination efforts have no permanent solution for disposing of radioactive debris (Jiji Press, 2016). Deep distrust about countermeasures taken by the government and Daiichi’s operator, the Tokyo Electric Power Company (TEPCO), have led some residents to permanently evacuate. Irreconcilable priorities over post-disaster life have caused social rifts in families, including the ‘nuclear power plant divorce’ (Haworth, 2013).

As a country prone to earthquake and tsunami, Japan was familiar with those disasters. But 3.11 was unprecedented because it entailed massive efforts not only to evacuate affected communities but also to mitigate high levels of radiation hazard. It is in this context that Fukushima Medical University (FMU) Hospital emerged as the institution that played a central role in responding to the unforeseen crisis. Hasegawa Arifumi, an emergency medicine specialist, was in charge of FMU Hospital’s emergency room during the first two days after the earthquake and tsunami. On March 13, he received a call from an unknown organization asking him to prepare his facilities to receive casualties from the nuclear power plants if the need arose (Fukushima Medical University Team, 2013: 22). Hasegawa hastily assembled a team of staff from the emergency medicine and radiology units; his senior colleagues were tasked with reporting to prefectural and national disaster assistance teams, leaving Hasegawa in charge of REM treatment for newly-arrived patients. Hasegawa and his team, including fellow emergency physician Ōkubo Reiko, set up a contamination control area with plastic sheets and bags, suited up in protective gear, opened their REM manuals and got to work. Along with basic emergency response procedures to diagnose external injuries, they had to assess patients’ contamination states, remove their clothes and wipe them to prevent the spread of radioactive material within the hospital.

From March 11-14, FMU had become the headquarters for 180 personnel from 35 groups of Disaster Management Assistance Teams (DMAT), dispatched from the Ministry of Health, Labour and Welfare, who aided the hospital’s efforts (Kondo et al., 2009). However, on March 15, the DMAT were decommissioned from FMU, leaving Hasegawa and his team without their support. In their place, another team called the REMAT (Radiation Emergency Medical Assistance Team) arrived the same day, comprising REM experts from Hiroshima and Nagasaki dispatched to FMU as support staff; Kumagai Atsushi and Yoshida Kōji came with this group (Fukushima Medical University Team, 2013: 12–32). The REMAT’s presence brought temporary relief, and a fresh infusion of expert manpower. This aid provided initial relief, but Hasegawa soon realized that external helpers could only mitigate the crisis; their presence did not constitute a solution to the disaster. As the situation at Daiichi threatened to grow increasingly severe, he and his staff had to discuss whether or not to stay – a decision eventually left to individual judgment.

By the last week of March, FMU had an established process for treating casualties sent in from the nuclear power plant, in cooperation with personnel from the JSDF, the Japan Atomic Energy Agency (JAEA), and the National Institute of Radiological Sciences (NIRS). This process combined routine emergency care procedures with radiation evaluation, protection and decontamination work. The REM team cobbled together during the disaster, including staff from the REMAT dispatch team, was officially integrated into the university hospital as the Radiation Disaster Medical Center from June 2012 onwards (Fukushima Medical University Team, 2013: 32–33, 48, 57).

During the first week of 3.11, Hasegawa and his team labored to treat patients, while enduring intense anxiety over the situation unfolding at Fukushima Daiichi. On March 12, a hydrogen explosion occurred at reactor no. 1, injuring five workers. On March 14, an explosion occurred at reactor no. 3, injuring eleven more personnel from TEPCO staff, TEPCO’s partner companies, and the Japan Self-Defense Force. They had to be ferried into the FMU hospital by land or air routes as the local hospitals had lost operational capacity. On March 15, three more patients injured inside the plant were admitted for REM care. Later that same day, as the timeline in Figure 1 shows, further damage occurred inside reactors no. 2 and no. 4, leading to fears of further environmental release of radioactive substances (Fukushima Medical University Team, 2013: 20). Yoshida Kōji, one of the nurses in the REMAT group, talks frankly about his anxieties before flying in to Daiichi to do on-site care on March 16, and how he managed them through a sense of professional duty:

[W]hile I was making preparations, I realized the levels at [FMU] were already quite high. Wouldn't they be even higher when we went closer to the nuclear power plant? … And if we flew in to the plant by helicopter, would we really be OK? I’d studied hard and taken courses on radiation for one year [in a radiation nursing program]. So I did at least have some basic knowledge about radiation, but that was precisely why I felt really scared not having information about conditions here at the [radiation disaster] site. I understood radiation, understood the conditions for safety, and here I wanted to know more. Was it really all right for me to be here? I was extremely – how should I put it – I had intense anxiety. Yes. But, although I felt anxious, this anxiety was something I later realised I had felt then. At the time, more than anxiety, I felt a stronger sense of mission - that if there were casualties, medical professionals had to go to them.

Hasegawa and his team had a steep learning curve for about two weeks until the situation stabilized. Like many other first responders to disasters, they operated on minimal sleep and performed their duties with straitened resources, lacking necessities such as water for routine cleaning and hygiene, as well as gasoline for vehicular transport. ‘I had absolutely no knowledge at about emergency radiation [at the time]’, he recalls.

I had these files from a research workshop that I attended before and I pulled them out of my shelves, and opened them [to read] before the patients arrived. I also called in another person … a radiation technologist, who had far more knowledge than I did, to come and be with me like a buddy. I could do medical treatment, but with regards to radiation and risk assessment … I didn't have the ability or the knowledge[.] So if I happened to be in a dangerous situation, I requested that he alert me to it, and in this way I tended to patients [with the radiation technologist]. … That’s why I slept as little as possible and studied as much as I could.

The radiation crisis caused by the meltdowns at Daiichi disrupted the established medical expertise that Hasegawa and his FMU colleagues possessed. At this point, medical expertise faced pressure to transform its practices and assumptions. Tensions between the existing epistemology of emergency physicians and the urgent need to handle the threat of radiation hazard catalyzed an epistemological shift at FMU. This entailed a messy and challenging process, largely because disaster medicine is based on contingent needs rather than narrowly defined specializations. Disasters render the usual structures and divisions of specialty-based medicine irrelevant, as the nature and scope of each disaster creates specific needs in affected localities that often create a shortage of medical resources (Tanigawa and Hasegawa, 2014: 55–57). In order to practice REM, Hasegawa and his team needed to adapt to a landscape of unknown and rapidly shifting risks, and to adopt skills beyond the remit of their extant expertise in emergency medicine.

FMU pre- and post-3.11

Hasegawa and his colleagues worked within an institutional context that enabled them to mobilize medical resources in responding to the crisis at Daiichi. Understanding the network amongst these Fukushima-based medical experts requires examining FMU’s history and connections with other local medical institutions. FMU, established in 1947, is Fukushima Prefecture’s flagship public institute of medical education. Many of its graduates practice in Fukushima and the broader Tōhoku region, and its hospital is a key provider of medical services in the locality. In 2011, it had 1,527 employees, soaring to 2,313 by 2016. The significant increase was due to financial support from Tokyo as FMU had become a national center of radiation medicine (FMU, 2011, 2016). Our interviewees all have a professional connection, former or current, with FMU. Hasegawa Arifumi served as a node in this network, introducing us to Oikawa Tomoyoshi and Shigetomi Shūichi, his former teachers, and the FMU colleagues he worked with during 3.11.

Local healthcare providers occupy a unique niche in the social landscape of post-disaster medicine. As experts whose lives are bound up with the affected communities, their experiences provide unique insights into the realities of public health post-3.11. They live, work and raise families alongside their patients; they are not outsiders making judgments from afar. Like all care-givers, they must guard their own well-being against burnout and fatigue. At the same time, their lives are simultaneously bound up with their affected communities’ experiences. Their situations thus provide unique insights into the realities of public health post-3.11. They are healthcare professionals who also live, work and raise families alongside their patients; they are not outsiders making judgements from afar. In the words of Gotō Aya, a health literacy specialist who works closely with public health nurses in Fukushima, ‘In the midst of environmental contamination by radiation, people here [in Fukushima] bear various kinds of fears and anxieties, but they try to balance that with going about everyday life.’ Gotō, at a public symposium commemorating the disaster, presented an astonishing photo of a sakura tree that appeared to have been split in half, the remaining side laden with pink blossoms. It stood next to the swimming pool at her son’s elementary school. Using this visual aid, she shared a story about how the school, in consultation with parents, removed only the branches on the side of the tree that faced the pool. This was a compromise that reduced the risk of radiation-contaminated arboreal matter dropping into the pool, and, instead of cutting it down completely, preserved part of the beautiful tree for the community’s enjoyment (Healing Fukushima, 2016, min.50:12–51:13). As Gotō’s story about her son’s school illustrates, the disaster’s impact on medical practitioners’ own lives means that, like other casualties of 3.11, they understand questions of radiation risk not as abstract scientific debates, but rather as issues of lived experience that potentially impinge on their personal and familial well-being.

At the same time, our interviewees’ professional identities lead them to emphasize the primacy of responses rooted in scientific empiricism, and to adopt approaches that emphasize the agency of individuals to self-educate and self-evaluate on issues of radiation risk. Shigetomi Shūichi is the former director of Futaba Kōsei Hospital, now permanently closed due to its location in the mandatory evacuation zone. Despite being doubly displaced through losing his home and workplace, Shigetomi advocates a rational approach to understanding radiation risk in order for regional recovery to proceed. In similar terms, Ōkubo Reiko, pregnant at the time we interviewed her, points to the availability of information about radiation contamination in Japan today as a factor influencing her decision to stay. ‘After studying the issue and concluding that the risk of raising a child here is now [in 2016] about the same as elsewhere, I would like to have my child and raise it in the Fukushima I am living in.’ Shigetomi and Ōkubo’s stances touch on issues of risk awareness and personal responsibility in responses to 3.11, which we discuss in the conclusion.

Personal and professional identities are thus tied to the evolution of serviceable expertise, as shown in our interviewees’ decisions to stay and to adjust to a Fukushima transformed by 3.11. Kumagai Atsushi’s mother and grandmother survived Hiroshima, while Yoshida learned about the atomic bombings as a schoolboy in Nagasaki. Both identify their personal connections to Hiroshima and Nagasaki as their motivation to become radiation medicine professionals, reminding us that expertise requires contextualization not only of its institutional forms, but also its practitioners. Gotō Aya’s and Ōkubo Reiko’s accounts further highlight how identities transform the contours of expertise, where an individual practitioner’s personal sense of belonging to a locality mingles with professional responsibilities in their everyday life.

Medical approaches highlight the complicated processes of recovery during the acute and the chronic phases of disaster. Acute care and chronic care, says Ohtsuru Akira, the current head of FMU’s Radiation Disaster Medical Center, is integral to every accident involving nuclear power. During 3.11, the acute-stage work of saving lives was provided through a REM framework. As the situation stabilized, medical priorities shifted to monitoring and managing local communities’ anxieties about the health risks of continued radiation exposure. Fukushima prefectural officials developed the Fukushima Residents’ Health Management Survey (FHMS) for this purpose. The FHMS is a voluntary series of five screenings that collect information and track the health of the population in Fukushima (about 2,020,000 in 2011). It comprises a basic survey and a follow-up set of four surveys to compile participants’ medical records, including an ultrasound check of the thyroid gland that has proved highly controversial (Fukushima Medical University Team, 2013: 166–174). The thyroid ultrasound examination targets Tōhoku’s roughly 360,000 residents under 18 years of age (Ito et al., 2013; Kahoku Shinpō, 2016). By August 2015, the Fukushima government had identified 104 cases of thyroid cancer in the prefecture, although experts disagree on whether or not they were caused by radiation exposure (Kyodo News, 2015). The controversy over thyroid cancers found after 3.11 highlights the larger issue of radiation risk and how it is understood by medical practitioners.

REM and disaster contingencies

Fukushima’s REM system was originally created as part of a national network radiation emergency medical system. The prefecture designated six hospitals located in the vicinity of nuclear sites as REM primary facilities, and one more as a secondary facility (see Figure 2).

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Figure 2.

REM system in Fukushima prior to March 11, 2011 (Reproduced with permission from Tanigawa and Hasegawa, 2014: 47).

When the earthquake and tsunami hit Fukushima Daiichi, there were roughly 76,000 people within a 20-kilometer radius of the plant. By March 15, when the plant released its largest radioactive plume, almost all of these residents had followed government orders to evacuate (Hayano and Adachi, 2013: 196–199). Unfortunately, confusion and contradiction marred the evacuation process. As the Daiichi reactors became progressively unstable, the government expanded evacuation zones around the plant from a three-kilometer radius to ten and then twenty kilometers in the course of a single day. The lack of a concrete evacuation strategy and an expanding evacuation zone forced many evacuees to constantly relocate (National Diet of Japan, 2012: 38). Residents in the affected areas had no information about crucial issues including atmospheric radiation levels, evacuation duration, or radiation protection measures. A shortage of transportation vehicles, damaged roads, and utilities cutoffs exacerbated the situation. Disruptions to telecommunications and radiation-monitoring systems further hampered efforts to organize the evacuation process (Hasegawa et al., 2016: 238). First responders also saw their work confounded by the forced closure of the prefectural headquarters coordinating the relief efforts on March 15 due to power and water outages (Kamiya, 2011).

Japan designed its national system of REM to handle occupational accidents within a nuclear facility and its immediate environs. The broad-based, compound disaster at Fukushima Daiichi overwhelmed it. First responders scrambled to deal with a disaster that far exceeded the assumptions and provisions of the original system. Fukushima Prefecture’s six designated primary facilities lost operational capacity. Three of them lay within the twenty-kilometre zone of mandatory evacuation, forcing their medical staff to evacuate with existing patients. Futaba Kōsei Hospital was one such facility. Shigetomi, speaking on behalf of his former staff, explains how evacuation negated all their previous training in REM, describing a calamity where those trained to provide support for evacuees became evacuees themselves. They faced the same issues of food shortages and power outages as their fellow survivors, made especially challenging due to the burden of caring for their existing inpatients in the evacuation process. Two institutions located about 44 kilometers away in Iwaki City also lost capacity (Tanigawa and Hasegawa, 2014: 46). Minamisoma City General Hospital, another primary care facility, fell in a zone where people were ordered to shelter indoors. According to Oikawa Tomoyoshi, the hospital’s assistant director, about 90% of locals temporarily evacuated. Hospital staff received official permission to do the same on March 14, leading to an exodus of two-thirds their personnel. ‘[People] had to choose whether to stay as a medical professional, or evacuate for their family’, Oikawa observes, acknowledging the ethical conundrums faced by many of his staff. Personal fears and anxieties compounded the situation, as Shigetomi witnessed amongst his own team:

The first time I actually felt radiation exposure was when we had been evacuated by helicopter and first arrived at a shelter. [There] we were screened, and it was clear that we had received some degree of external exposure. It was then that I first became aware we had been exposed to radiation. However, my staff and I are doctors who had some knowledge of radiation – we figured that the level of exposure we had received was probably not going to affect the human body. But there were other staff who did not have this knowledge, who might have experienced psychological shock just by hearing the fact of their exposure.

FMU’s affiliated hospital, originally designated as a secondary institution of REM, is situated roughly 80 kilometers away. However, in the chaos of the unfolding disaster, it had to function as a primary institution. This sorely taxed the hospital’s existing capacities, as it had no official department for REM until slightly over a year after 3.11. In 2001, the hospital had designated a ‘decontamination wing’ to handle radiological emergencies; the following year, it created a staff manual on REM procedures. However, Hasegawa reflects that no one had ever imagined they would actually need to use those things. As a result, many staff members had neither been to the decontamination wing nor had practical experience in applying REM procedures (Fukushima Medical University Team, 2013: 20). Hasegawa frankly admits that

We were facing the dispersal of radioactive substances, along with radiation exposure and radiation contamination. Thus, we could not accurately perform a risk assessment of the extent to which our patients and indeed ourselves were being exposed. Even if we had been given complicated numbers and units, at the time we didn't have the knowledge to evaluate them – we didn't know anything at all.

Oikawa confirms that a major source of chaos was the shutdown of the communications network, where fixed-line telephones and the internet had ceased to function. Kumagai adds, on the difficulty of deciding how to change their medical response strategy in the event of a new crisis at Daiichi:

We weren’t getting official information on our end [at FMU]. So the only way was for people to call my cellphone. And when I wanted to ask questions, the other side would have no proper phone, either. So I had to call the cellphone of a professor from Hiroshima University [at Fukushima Daiichi]. Radiation emergency medicine could only proceed via the networks between individuals.

Furthermore, those attending to the disaster unfolding in real time at the Daiichi plant further had to manage the unpredictability of the scale of casualties that might result, as Kumagai explains:

[E]xplosions were still continuing to happen at the nuclear plant, and we had no idea when they would occur, while radioactive substances were being continuously spewed out into the atmosphere. We were working within the 20 km zone – depending on the situation, we might have to pull out, or just run away, we would have to stop our work at certain times. But there was no easy standard for deciding on those times. And in the first place, we didn’t even know what doses of radiation the people doing screenings were getting.

Kumagai further details how even a radiation physics specialist from the National Institute of Radiological Sciences could not confirm whether or not reactor no. 4, supposedly shut down for maintenance, had entered a state of recriticality, with the potential to cause another explosion. Absent certainty of the reactor’s situation, the relief team’s targets of care had to shift. Instead of precautionary screenings of the local residents, they had to prepare for a worst-case scenario where the roughly 300 workers who remained inside the Daiichi plant faced life-threatening casualties in the event of another explosion.

The above accounts from Hasegawa, Oikawa and Kumagai illustrate how the concept of serviceable expertise can describe medical practitioners’ evolving epistemologies in a disaster context. The formation and reconfiguration of connections between individual practitioners gave them access to knowledge located in pre-existing networks of expertise on radiation disaster. During the failures of existing systems, the medical practitioners on the ground at Fukushima had to function via networks of colleagues. While having institutional dimensions, these networks were built and maintained through personal ties by practitioners who shared a common profession and, in some cases, an identity as Fukushima residents. This network reinforced the commitment of these medical practitioners to helping the communities in Fukushima to cope with unforeseen radiation hazards scattered around the prefecture. Thus, when this network drew on externally situated knowledge resources, it prompted Hasegawa and his colleagues in Fukushima to modify and transform their expertise in response to the developing crisis.

REM and new practices for radiation disasters

As the narrative above illustrates, REM is a specialty of medical first responders who focus on managing the crisis period of a radiological disaster. It combines emergency care with radiation exposure countermeasures for patients and medical personnel. The second half of the twentieth century saw the expansion of nuclear energy generation in Japan and the increasing risk of accidents caused by growing use of radiological systems worldwide. This created the need for emergency care systems capable of handling radiation exposure. Disaster medicine’s most urgent priorities are to transport victims away from the disaster area and to treat victims with serious injuries. REM, in addition to standard emergency medical procedures, must ascertain other radiological questions, including the following: What kind of radiation exposure has occurred, and to what degree? Are there radioactive substances inside or outside the body? These tasks usually require an attending team of emergency doctors collaborating with technical experts in radiation measurement and radiation nuclide analysis. This latter group assists in diagnoses by supplying data from blood tests and specialized measuring equipment. Where contamination is present, the team may also call on the expertise of specialists in radiation decontamination and radiation protection.

In Japan, a national system of REM emerged following a severe criticality accident in 1999 which occurred in Tōkaimura, Ibaraki Prefecture, at a processing facility which enriched uranium for use as reactor fuel. Illegally simplified work procedures at the facility created an uncontrollable fission chain reaction which delivered fatal doses of radiation to three workers and further irradiated other staff in the facility, as well as residents in its environs (Bevelacqua, 2009: 134–143). Japan subsequently developed a basic REM framework to treat workers at nuclear facilities and residents living near nuclear power plants when accidents occurred. Medical institutions held primary, secondary or tertiary status in a hierarchy of care that triaged their responsibilities. As Figure 3 shows, primary institutions, located closest to nuclear facilities, would provide initial treatment and decontamination procedures; secondary institutions, located at a further distance, would perform advanced treatment for radiation injuries; tertiary institutions, located in different prefectures, would conduct any further necessary care with specialized equipment unavailable in secondary and primary facilities (Fukushima Medical University Team, 2013: 20). In the case of Minamisoma General Hospital, a secondary institution located 23 kilometers from the Daiichi plant, this system assisted in its response to 3.11, as Oikawa explains, the hospital held annual exercises in radiation disaster response, and had stocked up on survey meters to measure external radiation dose and Geiger counters to measure external contamination. This level of preparedness allowed Oikawa to swiftly create a disaster countermeasures bureau in the hospital that took charge of measuring the radiation air dose, screening outpatients, and extending health support services to the evacuation shelters in Minamisoma City from March to September 2011.

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Figure 3.

Hierarchy of REM hospitals (Reproduced with permission from Tominaga et al., 2014: 94).

From 2001 onwards, a newly structured program in radiological emergency response trained first responders, including medical personnel and local officials. This system assumed a worst-case scenario along the lines of the 1977 Three Mile Island accident in Pennsylvania (Walker, 2004). Another major assumption was that the actual emergency would be confined to nuclear facilities. The scale of the actual meltdowns at Daiichi was, in the words of TEPCO and then-Prime Minister Kan Naoto, ‘unforeseeable’ (sōteigai). Assuming that the physical scope of the disaster could be contained led to the further assumption that only first responders required knowledge of radiological emergency countermeasures. On this issue, Yoshida observes that medical practitioners’ knowledge of radiation, where applicable, is usually limited to medical practice and does not extend to accidents or disaster situations. Hasegawa’s recollections of how he knew nothing about radiation emergencies illustrates this point. Reflecting on the chaotic situation in medical responses 3.11, Yoshida says that:

[The nurses] in particular really didn’t understand [radiation emergencies.] …. [W]hen they're students, radiation is entirely missing from their medical school education. What we call public health [nurses] responsible for the health of a specific locale … receive the same kind of curricular training for nursing school, and in that curriculum radiation isn’t taught. So they don’t know about radiation, and so [although] these public health nurses need to deal with the local residents, just lacking knowledge about radiation delayed their handling of the situation.

Ohtsuru echoes Yoshida's observation, testifying to the inadequacy, up to the shock of 3.11, of medical education about radiation disasters in Japan. ‘The issue of what kind of medical education to enact is being worked out in collaboration with international organizations’, he says, ‘and we're striving to implement these measures in medical education across all of Japan as well’. In FMU’s case, Hasegawa now teaches a course on radiation for undergraduate medical students that introduces them to the principles of radiation physics and engages them as first-hand witnesses to the realities of radiation exposure in their immediate environment. In one exercise, Hasegawa asks a male student if he will put a paper-wrapped tuft of mildly radioactive grass from a section of the university grounds into his pocket; when the student agrees, Hasegawa praises him for understanding that the amount of radioactive substance is too small to have any significant effect on his health. ‘Five years on people have acquired some knowledge’, Hasegawa tells his class, ‘but initially, if I’d asked someone to put [this grass] into their pocket they’d have refused, … thinking that if they put this grass in their pocket when they took it out the area around their pocket would be in tatters.’ (Healing Fukushima, 2016, min.39:16–39:51)

Managing the chronic

FMU’s response to its disaster experiences has been to develop into a new center of radiation medicine that conducts activities at local, national and global scales. As in Lindee’s study of the Hiroshima-based Radiation Effects Research Foundation (RERF), FMU now constitutes a node in the global network of scientific institutions involved in adjudicating radiation risk (Lindee, 2016: 184). In June 2012, FMU Hospital established a new Radiation Disaster Medical Center (RDMC) to coordinate REM measures, emergency preparedness, and human resource development. The center is expected to play a role in responding to accidents that occur in the process of reactor decommissioning, and any other radiological emergencies in Fukushima Prefecture. Kenneth Nollet, an American physician at FMU, observes that the school has positioned itself, post-3.11, as a node within institutional networks of radiation disaster medicine that have national and international reach:

Fukushima Medical University is cooperating with institutions, global institutions that concern themselves with nuclear energy and radiation. … [W]e also have formed alliances that I might not have expected. For example, we receive students from Mount Sinai Medical School in New York, and other institutions around the world, but it started with Mount Sinai. What do we have in common? Well, Mount Sinai and the people of New York City experienced 9/11. We experienced 3/11. But by exchanging ideas, we can discover the common themes, the common issues of humanity that need to be addressed in any kind of disaster, and share that experience with the wider world … centers of expertise have been established at Hiroshima and Nagasaki, for obvious and tragic historical reasons; Fukushima is now the third such center.

Nollet’s comments speak to how disasters can resonate across space and time, creating new networks of expertise. While the worst impacts of disasters are localized, expertise is created across national boundaries, leading to new collaborations amongst institutions and individuals that extend the scope of serviceability. The emergence of new medical expertise in a disaster context includes the creation of new networks and institutional forms that draw on accumulated reserves of knowledge from different sites of disaster. Since the establishment of the Atomic Bomb Casualty Committee in the 1940s (Lindee, 1994), the predecessor institution to RERF, Japan has amassed a unique reserve of human and medical resources on the health effects of acute radiation exposure. These have been deployed in Chernobyl and Fukushima (Lindee, 2016: 193, 198–199), and the circulation of expertise is not unilinear: Japanese REM in 3.11 drew on multiple historical experiences of medical responses to other nuclear disasters: the 1986 explosion at the Chernobyl power plant in Ukraine, and the 1987 Goiânia accident in Brazil (International Atomic Energy Agency, 1988, 2014). Medical responses featured in large-scale radiation protection measures aimed to address public health and environmental safety, including sheltering, evacuation, and administering stable iodides to guard against internal exposure (Tanigawa and Hasegawa, 2014: 29–78). Medical conclusions drawn from longitudinal research on the hibakusha survivors of Hiroshima and Nagasaki also provide context for evaluations of the radiation exposure effects on Fukushima residents (Yasumura, 2014: 18–24).

In a world prone to ‘unforeseeable’ disasters, disaster medicine now encompasses a wider spectrum of human health needs beyond emergency care. During 3.11, large numbers of residents were evacuated by fiat from restricted zones with higher recorded levels of radiation contamination. However, this measure, intended to protect their lives, harmed their well-being in other ways. Evacuees have been forced to reside in cramped, inconvenient temporary shelters for an extended length of time. Staying positive in these reduced circumstances is a huge challenge for many. Fukushima Prefecture alone recorded 86,308 evacuees in March 2011, and this number kept growing, peaking at 99,205 in June of the same year. Over the following year, a further 62,831 prefectural residents voluntarily evacuated. In total, 3.11 displaced over 460,000 people to around 2,400 shelters all over Japan. According to a 2012 report by the Reconstruction Agency of Japan, 1,632 recorded deaths in temporary housing and other shelters had occurred, with the numbers rising each successive year (Reconstruction Agency of Japan, 2017). These casualties are called ‘earthquake-related deaths’, arising from the poor quality of post-disaster life. Most occurred in people over 66 years of age within a month after 3.11, with the highest rate occurring in Fukushima (Tanigawa and Hasegawa, 2014: 44–45).

FMU’s medical practitioners and their local colleagues agree that the biggest current risks facing Tōhoku evacuees and residents are lifestyle-related. Oikawa notes the increased incidence of ‘lifestyle diseases’ such as strokes and diabetes, as well as a potential increase in mental health conditions. Recent medical studies conclude that the everyday conditions of affected people pose a far greater health risk in the short and medium term compared to radiation exposure. For instance, poor diet and lack of exercise increases the risk of obesity, high blood pressure, and strokes. Many evacuees and residents develop symptoms of post-traumatic stress disorder from multiple stressors, including forced relocations, the loss of loved ones, or intra-familial conflicts over changes in living conditions. Stress and depression breed isolation, alcoholism, and erode social networks and healthy interaction with others, particularly in mothers of young children (Goto et al., 2015; Maeda and Oe, 2014: 79–88).

Reflecting on the disaster’s acute phase, the FMU doctors concluded that radiation posed a far lower risk to public health compared to numerous other hazards. Outside of deaths caused by the earthquake and tsunami, many other lives were lost during the chaotic evacuation process and the inability of medical, physical and administrative infrastructures to safely relocate patients. Patients who required medical support were especially prone to suffering hypothermia, dehydration, and scarce resources for treating pre-existing medical conditions (Hasegawa et al., 2015: 484–486). The elderly constitute another vulnerable group heavily dependent on access to caregiving and medical treatment. The general shortage of doctors and medical supplies in Tōhoku forced their relocation, sometimes permanently. This consequent deterioration in their living environments increased their mortality rate to a larger extent relative to younger, healthier population groups (Yasumura et al., 2013: 186–188).

Disaster medicine further possesses a longitudinal component. DMAT in Japan developed from the recognition that saving lives from trauma and other severe illnesses or injuries takes first priority during a disaster’s acute phase (Kondo et al., 2009: 556–564). Moving into the chronic phase of disaster, especially for displaced victims, general medical needs acquire prominence: medicines for common illnesses, as well as routine procedures like dental care and vaccinations. These general needs require a wide variety of specialists and are usually served by physicians from governmental and non-governmental institutions, including national hospitals and Red Cross hospitals (Ishii et al., 2011: 131–140; Tanigawa and Hasegawa, 2014: 56). Commenting on the thyroid gland survey, Yoshida Kōji emphasizes the need to pursue long-term studies of 3.11’s health effects before drawing conclusions:

Although current examinations postulate it is unlikely there are radiation effects, that’s still ultimately an issue of probability, and it will be decades, any number of years from now before FMU can discover whether or not there are any radiation effects, which is why we will continue our investigations to demonstrate the true situation one way or another.

Public anxieties persist amongst residents of Fukushima and Tōhoku who willingly remained (or who could not afford to evacuate). In response, FMU and medical associations in Fukushima Prefecture, in conjunction with counterpart organizations in Japan, have begun providing kokoro no kea, literally ‘care of the heart’. Kokoro no kea provides pharmacological and psychiatric treatment, along with counseling services, to Tōhoku evacuees (Yasumura, 2014: 40–41). Yasumura Seiichi, the associate head of this center, notes that the natural disasters alone were fearsome ordeals which inflicted trauma on survivors through the loss of homes, family members and livelihood. He draws parallels with survivors of Chernobyl, stressing long-term shifts in emotional and physical well-being as the most prominent health impact in that disaster (Fukushima Medical University Team, 2013: 178–179).

Another major issue in REM practices, and for disaster response practices in general, is how to preserve the mental health of first responders, encapsulated in Hasegawa’s emphatic statement of medical professionals as human beings. He likens the emotional evolution of first responders to an unprecedented and unpredictable disaster to that of a cancer patient dealing with the news of their illness: from denial to pain (and its physical symptoms) to adjustment. One way in which the FMU community managed their emotional health through these stages was by group sharing sessions. In the first couple of weeks, when the acute phase of the disaster unfolded, FMU staff came together at night to vent their stress and fear to one another, everyone breaking down in tears during their turn to speak (Fukushima Medical University Team, 2013: 38–39). Medical responses to 3.11 show how the humanity and subjectivity of those in positions of assumed expertise are intertwined with their work. It is significant that the RDMC provides extended physical and psychological care for radiation workers, including first responders such as firemen and policemen (RDMC, 2013).

The chronic dimensions of disasters impinge on the well-being of local communities, including medical practitioners. This is exemplified in the persistence of psychological distress for first responders, as well as the long timespan of scientific research on its health effects. These observations underscore that serviceable expertise describes an ongoing process rather than a stable result. The process of creating emergent institutions and practices hinges on the evolution of new social networks amongst practitioners, as well as shifts in individuals’ epistemologies that are, as earlier discussed, contingent on their personal and professional identities.

Coda: Service and serviceability

3.11 remains a phenomenon in the present progressive tense. Many former or current Tōhoku residents continue to struggle with chronic problems of livelihood that resist straightforward solutions. So, too, do former residents-turned-evacuees, who face difficult choices about whether to return or to leave permanently. TEPCO and the national government face lawsuits from plaintiffs bereft of homes, livelihoods and hope (Field and Mizenko, 2015).

A salient question raised by the experiences of our interviewees is how individuals manage risk in everyday life. Kumagai Atsushi frames this issue in contrast to the services that publics expect experts to render as their social responsibility. Expressing surprise at the extent to which residents of Fukushima were unaware of nuclear power’s risks, he cites how some medical students at FMU told him that, until 3.11, they had no idea the prefecture housed nuclear power plants. Kumagai believes that everyone is responsible for learning about the risks they face in their everyday lives. While experts have a role in determining the calculus of risk, he ultimately thinks that individuals must decide what they can and cannot live with, instead of relying on professionals to decide for them. Hasegawa echoes Kumagai’s stance, frankly admitting how little he knew about radiation and its health risks prior to 3.11, and emphasizing how he and his team were forced to take agency in responding to the disaster instead of passively waiting for external assistance (Fukushima Medical University Team, 2013: 59).

Kumagai and Hasegawa’s positions as medical professionals dispose them to value and evaluate science on epistemic terms, in ways that may be inaccessible to ordinary people, and which also potentially conflict with normative framings of risk. Their statements shade into what Kimura (2016) has criticized as Japanese state and society’s neoliberal slant to policing citizen concerns about radiation after 3.11. Nonetheless, their foregrounding of individual agency in performing risk assessments is a crucial consideration for Fukushima residents, experts trying to communicate with laypeople, and every denizen of locales that house nuclear facilities. 3.11 has not deterred the Japanese government from restarting the country’s nuclear reactors, temporarily stopped in the wake of disaster, signaling that REM is a specialty with continued relevance for the foreseeable future.

To conclude this article, we return to the notion of serviceable expertise. The experiences of Hasegawa and his colleagues suggest that expertise during disasters is a malleable and subjective phenomenon. Any established field of scientific expertise is invariably represented as robust but also rigid, along the lines of Kuhn’s (1996 [1962]) ‘normal science’. This relates to the question of boundaries, which are built around the field to protect the domain of knowledge over which a community of experts lays claims to authority. Medicine is no exception to the boundary phenomenon, where its practitioners are separated by specialization and compartmentalization into sub-areas rigorously institutionalized into training and practices (Cartwright, 1999). The unfolding of 3.11 in Fukushima, however, showed that the boundaries of specialization are less durable than their institutional forms. The totality of radiation hazards which enveloped the disaster area forced medical experts to adopt a flexible, piecemeal stance to the ways they defined the boundaries of their expertise, an approach which STS scholarship has abundantly unpacked (e.g. Gieryn, 1999; Gupta and Ferguson, 1997). Serviceability in expertise is both conditional and situational. In the stories of our interviewees, it is embodied in the transformation of specialization by Hasegawa and his team at FMU from emergency physician to radiation emergency medicine specialist. FMU is not the first institution to develop radiation emergency medicine. As discussed above, radiation medicine specialists from Hiroshima and Nagasaki helped FMU build local capacity for this specialization. Yet, it should be noted that radiation at Fukushima Daiichi is of a different nature from that caused by the 1945 atomic bombs. Accordingly, FMU had to develop a new sort of radiation emergency medicine to specifically address the hazardous situation at Fukushima Daiichi, thereby institutionalizing a new instantiation of knowledge and expertise formation.

Another key aspect of serviceable expertise lies in the drawing together of a particular network of social relations during disaster. STS scholars have emphasized that expert knowledge is deeply embedded in social relations. It implies that the construction of expertise is underpinned by how individuals and institutions are structured around particular arrangements (Fischer, 2007; Latour, 2005). In the context of 3.11, applying this notion leads us to examine two layers of social relations that intersected in the construction of radiation emergency medicine in Fukushima. One layer is external, i.e. the entry of individuals and institutions outside Fukushima into Fukushima in the context of disaster countermeasures and aid. The other layer is local, i.e. the personal ties between Hasegawa and his former teachers (sensei), which constituted a crucial network of expert knowledge mobilized for community survival. The amalgamation of these two layers of social relations eventually paved the path to a formation of new expertise in radiation emergency medicine. This especially characterizes the expertise of first responders – those charged with quelling the acute phase of a disaster’s eruption. Sudden, seismic shifts in conditions can force non-specialists into the roles of first responders, requiring them to assume the mantle of authority with no prior experience. This is daunting, since even experts with prior training have limited functional capacity if a disaster situation limits their access to resources and information. High-risk elements beyond physical perception, like ionizing radiation, compound the difficulty of their work. The concept of serviceable expertise, in the form of first responder experiences, rethinks traditional assumptions about the fixed character of expert knowledge, and clarifies the relationship between lived experience and theoretical expertise.

In closing, we are aware that our theorization of serviceable expertise remains incomplete, and admit that our characterization of this term is largely based on observations of one social network of experts in Fukushima. There are other networks of medical expertise in the area, which may have followed different patterns of expertise formation. However, since FMU is currently the leading medical institution in Japan that deals with radiation emergency medicine post-3.11, it is safe to assume that our analysis concerns a major strand of knowledge production in the aftermath of Fukushima nuclear meltdown. Finally, serviceable expertise is not a new category of expertise, but an alternate way to understand knowledge production and the challenges of forging expertise in the ever-evolving context of a disaster. In her original context, Jasanoff (2015) deploys the notion of serviceable truth to argue that the law should not strive to accommodate an idealized science, but instead ask how science can facilitate the law’s purposes (p. 1730). In similar vein, we argue that medical expertise should not aim to solve disasters whose contours are imagined in static fashion, but rather focus on how disasters in their contingencies shape medical expertise.