What We Have Learned

Stress-related physical symptoms have been the first to appear soon after the earthquake. Hemorrhagic ulcer and hypertension increased soon after the disaster, peaked at 2-3 weeks, and gradually decreased by 6 months. They were rather short-lived. Among psychological symptoms, anxiety symptoms were prevalent from the beginning and decreased with time. Guilt feelings appeared together with anxiety and decreased by 6 months. However, depressive symptoms did not decrease with time: they increased up to 6 months. Also, depressive symptoms were frequent among those who lost their home and family. Social problems became dominant after one year. Alcohol problems and interpersonal difficulties increased gradually with time, and they continue to exist as major problems among victims [12].

Post-Traumatic Stress Disorder

The concepts of ASD and PTSD are not adequate to cover the full range of trauma-related psychological problems [13]. Studies at the Psychological Care Center of Hyogo Prefecture have demonstrated that, among 1,956 cases seen at the Center after the earthquake, those with the full PTSD syndrome according to DSM-IV were 2.5%. However, the prevalence was 4.5% among those who lost their homes, and 13.1% among those who lost their family members [14]. The prevalence of PTSD was clearly related to the severity of damage such as loss of home and loss of family. However, the complete picture of PTSD so far has been fairly rare among the victims in Kobe.

There may be many reasons and possible interpretations for the low rate of PTSD among the victims in Kobe. One explanation is the low reporting of PTSD symptoms: victims might have had some reservations in reporting such symptoms as dissociation to medical professionals due to the stigma attached to mental symptoms. A second explanation could be the low recognition of PTSD by medical professionals: there was no particular motivation among medical professionals to ask about the existence of PTSD among victims. On the other hand, the PTSD concept became so popular soon after the earthquake that its widespread use contributed to reduce even the stigma attached to psychological problems in general. The media reported almost every day about PTSD. Almost all Japanese psychiatrists became familiar with the DSM-IV and its criteria for PTSD. A third explanation could be that Asians, including Japanese, tend to somatize rather than to develop psychological symptoms such as dissociation under a stressful situation [15]. However, there are no data supporting this explanation, which would invite discussion on the relationship between PTSD and somatoform disorder, and on the clinical validity of the current concept of PTSD among Asian victims. A fourth explanation could be that many victims in Kobe did not feel abandoned or neglected after the earthquake. The community-oriented Japanese society might have contributed to lower the incidence of PTSD in Kobe. Also, no political and financial incentives have been involved, for patients or doctors, in the diagnosis of PTSD in the Kobe area.

These explanations seem plausible. However, no rigorous epidemiolo-gical study on PTSD among the victims of the Hanshin-Awaji earthquake has been completed up to now. PTSD might increase with time. We have to continue careful observation regarding the psychological status of the victims in the Kobe area.

Volunteers

Soon after the earthquake, psychiatrists and mental health workers from all over Japan came to the Kobe area to provide mental health care. Some groups set up psychiatric clinics for the shelter population. However, very few victims visited. The care most valued by victims living at shelters was the help of housewives who could advise them about how to get food and information. Young volunteers who carried water and food and listened to the experiences of the victims were much valued. A group of psychiatrists prepared a simple manual for volunteers on basic rules on how to listen to victims. These rules included such topics as the importance of sharing experience, the need for informed consent, and how to keep confidentiality. These contacts might have been like briefing and debriefing sessions for many victims. They could feel that they were not abandoned. Also, victims could receive psychological support for 24 hours from their neighbors and volunteers, which was much more important than professional support. In summary, there were positive and negative aspects to professional mental health care in the Hanshin-Awaji earthquake: traditional psychiatric care, such as setting up psychiatric mobile clinics, was not at all useful; however, basic information on mental health care, distributed to volunteers through the mass media, was useful to the victims.

The usefulness of foreign volunteers was difficult to evaluate. A number of international experts on disaster mental health came to Kobe. They put a heavy burden on the small number of local experts, as they needed translators and someone to arrange their visits to the shelters. Some experts in Kobe developed burnout symptoms after meeting with so many foreign disaster experts. However, foreign experts were the ones who enlightened the Japanese media and professionals on the needs for psychological support to the victims. No one in Japan was prepared to cope with the mental health needs of the victims of the disaster. International experts surely contributed to increase the awareness of the importance of mental health care for the victims in Kobe.

WHAT WE SEE NOW 10 YEARS LATER Social Issues Never End

For health professionals living in Kobe, the most important concern has been how to promote health among victims of the disaster and especially how to prevent so-called solitary death (unattended death) among victims. Immediately after the earthquake, there was a flood of volunteers to the Kobe area to take care of victims. Three years later, all volunteers had gone. Local governments mobilized public health nurses to visit temporary housing. However, the number of public health nurses was extremely limited. In each temporary housing community, autonomous committees have been set up to foster self-help among residents. These mechanisms have been working to prevent solitary death and long-term health problems.

It is very difficult for those who lost their homes, money, friends, and partners in old age to hold on to the meaning of life and hope. A minimum amount of compensation to rebuild homes and to start small-scale businesses will be indispensable for victims to find meaning in life.

We have to continue to promote public awareness of the long-term health consequences of the disaster and to find effective measures to reduce these problems.

From Victims to Supporters to Victims

In 1999, the Kobe University School of Medicine decided to organize an International Training Course on Comprehensive Health and Medical Care for Victims of Disasters, supported financially by the Japan International Cooperation Agency (JICA). Experts in disaster medicine from disaster-prone developing countries have the opportunity to study in Kobe for 8 weeks. The Kobe University School of Medicine felt that it was its duty and responsibility to share its experiences and to transfer the related technology to experts from developing countries. So far, we have had 30 doctors and nurses. They were from Turkey, Egypt, Bangladesh, Nepal, China, Thailand, Pakistan, India, Kenya, Peru and Nicaragua. The University dispatched emergency relief teams immediately after the earthquakes in Turkey and Taiwan.

Likewise, Hyogo Prefecture and Kobe City invited several United Nations agencies to set up research and training centers for disaster prevention in the Kobe area. It will be important for the victims of the Kobe earthquake to become supporters to victims of disasters. Through this process, Kobe City and its residents are trying to recover from their traumas.

From Kobe to Asia

Asian countries are constantly menaced by violent natural disasters. Up to now, little attention has been given to the impact of disasters on mental health. However, in the past decade, disaster mental health has gained an increased attention. In Japan, the Hanshin-Awaji earthquake marked the turning point in popularizing PTSD and the need for mental health care for survivors. This recognition has spread to mental health professionals in China and Taiwan after major disasters in their respective countries [16,17]. The Hanshin-Awaji earthquake was very tragic. However, the lessons learned in Kobe are being shared by mental health experts in Asia and in other developing countries.

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