Keywords

1 Post-disaster Team

In both of the projects in Miyako and Koriyama, we will discuss the leaders which were the local pediatricians, Dr. Shintaro Kikuchi and Dr. Kimiko Toyoshima. They were supported by the pediatrician Dr. Natsuko Tokita, the child psychologist Mrs. Michiko Sakai, and the child psychiatrists Dr. Hiroko Suzuki and Dr. Hisako Watanabe. Dr. Watanabe is the director of the Child Mental Health Division and assistant professor of Pediatrics at the Keio University School of Medicine, Tokyo. Together, these clinicians formed a professional team to support post-disaster child mental healthcare.

2 Introduction: Colleagues Respond to a Triple Disaster

On March 11, 2011, at 2:46 pm, the ground in Tokyo began to shake in an unusually powerful and long-lasting fashion. All public transportation came to a halt, and internet and telephone lines stopped working. That evening, the streets were filled with men and women walking silently for hours as they attempted to return to their homes. Gradually, the news reached Watanabe, Sakai, and Tokita at Keio University Hospital in Tokyo that a magnitude 9.0 earthquake and an ensuing gigantic tsunami had destroyed the 500-km-long combined coastlines of Iwate, Miyagi, and Fukushima Prefectures. This was an unprecedented, calamitous natural disaster, expected to occur only once in a millennium in Japan.

The man-made disaster. On March 12, at 2:00 pm, the No. 1 nuclear reactor of the Fukushima Daiichi Nuclear Power Plant (FDNPP), which had been disabled by both the earthquake and the subsequent tsunami, exploded, sending radioactive materials into the air. Northwesterly winds carried these radioactive materials to Tohoku, Kanto, and beyond. Panic spread nationwide. On March 14, the No. 3 reactor exploded, and then on March 15, the No. 2 reactor followed, emitting further radioactive materials. A 20-km evacuation zone was established, and a frantic exodus of people ensued. Residents within a band of 20–30 km of the nuclear reactor sites were ordered to stay indoors. Scientists abroad rated the severity of the disaster as seven out of a possible seven on the International Nuclear and Radiological Event Scale (INES), equivalent to that of Chernobyl, in which only one reactor was affected.

The government’s response was slow. Officials initially concealed the data from the System for Prediction of Environmental Emergency Dose Information (SPEEDI) that showed the pathway of radioactive clouds. Because of this, people fled to the north, taking the same course as the northwesterly winds, naively believing that it was safe when in fact it was not. Fear of radiation gripped the nation. Electricity, public transportation, water, and gas services were disabled for a long period, and people had to join long queues for petrol. Information was not forthcoming. In fact, nobody in the immediate disaster areas seemed to know what was actually happening. Foreigners in Japan were better informed by their countries and quickly left Japan, while the people of Japan were left in ignorance of the true extent of the danger (Fig. 9.1).

Fig. 9.1
figure 1

Japan’s Great Tohoku Earthquake and Fukushima Daiichi Nuclear Power Plant. Map Created by George J. Musa, PhD, Global Psychiatric Epidemiology Group (GPEG), Columbia University—NYSPI, on August 8, 2018. Sources: USGS Earthquake Epicenter Coordinates; ESRI Data & Maps for ArcGIS 2016. Projection: Asia North, Lambert Conformal Conic

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In the immediate aftermath of the GEJET, every hospital in Tokyo implemented emergency measures to respond to the disaster. All hospital staff were placed on call and were ordered to cancel any travel for conferences in the coming months. Most businesses ran as usual during the day, but a curfew was enforced during the night. Shops in Tokyo first ran out of bottled water and then ran out of food.

Only weeks later did the government and TEPCO (the company that owned the Fukushima Daiichi Nuclear Power Plant) inform the Japanese public that the three nuclear reactors in the FDNPP had melted down. The government assured the public that the accident was not at all comparable to Chernobyl and rated it as 5 on the INES; only much later did Japanese authorities change it to the more accurate rating of 7. This was the first of what became a pattern of information mismanagement by the government.

On a personal scale, the authors, based in Tokyo, had great concern for their colleagues in the Fukushima Prefecture. Phone calls conveyed a sense of imminent danger in the disaster-stricken areas and raised the level of concern even further (Papoušek and Papoušek 1987). Kimiko Toyoshima, who was one of only two pediatricians in Miyako City, had lost numerous acquaintances in the community, and soon after, Watanabe and Suzuki went to the cities of Koriyama and Miyako. This marked the start of their long-term commitment to the children of the Tohoku region of Japan, a commitment that also developed into a naturalistic longitudinal research project on the aftermath of GEJET (Anthony 1975).

2.1 Koriyama on March 21, 2011

March 21, 2011, was a national holiday and the tenth day of the disaster aftermath. The streets in Koriyama were vacant, while radioactive rain fell silently. The city issued a warning for the citizens to refrain from opening windows or hanging clothes to dry outside.

With a population of around 300,000, the city of Koriyama, a southern gateway to Tohoku, was the second largest commercial city in the region, after Sendai in the Miyagi Prefecture, and was positioned 50 km to the east of FDNPP. Its schools were famous for winning prizes in national music contests, especially through the excellence of their choirs. The city had actively planned for prevention and response to disasters. For example, an evacuation center was built in the bullpen of Kaisei Baseball Stadium in response to prior events, such as the SARS epidemic.

Physician members of the Koriyama Medical Association (KMA) and city administrators acted swiftly to protect the lives of victims and citizens; KMA rescued all bedridden senior patients from coastal regions (Kikuchi and Kikuchi 2012) and tended to more than 2000 evacuees fleeing from the coastal areas near the FDNPP. However, Koriyama itself was contaminated by northwesterly winds carrying radioactive material. Koriyama City Hall had partially collapsed, and local administrative services had to be moved to the baseball stadium.

Creation of a safe haven. In Koriyama, despite limited damage by the earthquake and no damage by the tsunami, aftershocks were felt repeatedly in March of 2011. When radioactive plumes assaulted the city, there was a sudden emergence of radiation stigma—people became fearful of contamination by their fellow citizens. This negative response came as a shock to many people. For example, vehicles with Fukushima license plates were denied entrance to other cities for fear of radioactive contagion. Such blatant victim blaming and harsh ostracism were events that Koriyama citizens had never previously experienced. Some previously lively children who had fled to other regions to stay with relatives became quiet and withdrawn. These incidents alerted our team members that effective measures were needed immediately to prevent children from developing post-traumatic stress disorder (PTSD) and other emotional problems. The team resolved to create a safe haven for children, where they would feel at home and could play freely with peers.

2.2 Koriyama: Basic Principles in the Immediate Aftermath

Watanabe and Kikuchi visited three different evacuation centers in Koriyama, one in a baseball stadium, another in a convention hall, and one on the upper floors of Koriyama Children’s Care Center. There, they saw and witnessed many people frantically searching for their family members and relatives, while others sat or lay on mattresses on the floor.

In the case of this disaster, disabled or ill children and infants were the most vulnerable; some were even abandoned by their parents. To establish a safe and secure environment, all the public facilities for children in Koriyama were soon reopened. After prolonged confinement at home, the children were reunited with their peers, and the sound of their playing and laughter offered a sense of relief to everyone. The local administrators acknowledged the power of children in reviving vitality, positive affect, and hope in the community.

On March 15, 2011, a newspaper article appeared in The Asahi Shimbun (a leading newspaper in Japan) by Hisao Nakai, a psychiatrist in Kobe who survived the Hanshin-Awaji Earthquake of 1995. Dr. Nakai recounted his survival experience and encouraged his readers to see the world through the eyes of the victims of mass disaster. His message, which, for Watanabe and her team, became a reference point for basic principles of disaster care, can be summarized as follows:

Hold the plight of the victims in your mind; to be forgotten is the worst blow to the victims.

Listen quietly to their breathing and the sighs that convey their unspoken internal truths. Don’t intrude with questions and jargon, which are what the victims dislike the most; convey utmost respect and trust that they will eventually recover. Warm meals and comfortable places to sleep are crucial. Respond swiftly to the survivors within fifty days (Nakai 2011).

The nature and the scale of the combined GEJET and FDNPP disaster defied an easy solution or manualized approach to recovery efforts. A plan was needed to help retrieve people’s sense of agency and morale. The importance of Primum non nocere (first do no harm) and of conveying utmost respect to the survivors echoed through Hisao Nakai’s message and provided a base for offering a supportive presence. The team explored effective approaches and engaged the survivors to determine what intervention would help create relationships that felt safe, validating, and emotionally accessible in the local community.

In Fukushima, the chaos was further aggravated by incessant aftershocks and fears of radiation contamination. Despite being disaster victims themselves, local pediatricians and child mental health professionals worked day and night to restore life to a community that could not even meet its own basic needs. One primary role of outside supporters like Watanabe and her colleagues was to help meet the interventionists’ basic needs so that they could continue to care for others.

To revive and enhance the morale and sense of agency in people affected by the disaster, the authors drew on the principles of infant mental health, which often deal with containing primitive anxieties. Neuroscience and gene-environment research have shown that the brains of fetuses and infants are vulnerable to maltreatment and malfunctioning environments that fail to respond to their needs (Lyons-Ruth et al. 2017). Using photos and diagrams, the authors drew upon the metaphor of the womb as a nurturing environment in order to illustrate the importance of basic trust in any relationship, regardless of age. The people in Tohoku, who were in the throes of primitive anxieties, proved receptive to this metaphor of interpersonal trust. A universal image for reciprocal interaction and empathic support yielded a sense of unity and structure, and promoted positive self-identity (Stern 1985; Emde 1992).

2.3 Ban on Outdoor Activities

Koriyama was devastated by the unexpected radiation and the associated stigma of contamination. During the first year of the aftermath, a ubiquitous fear of outdoor play prevailed in the community, making the streets of Koriyama empty of children. During the spring of 2011, outdoor activities were strictly forbidden in schools, kindergartens, and day nurseries. In the summer, the rules were relaxed, and school children were allowed 3 h of outdoor activity each day. This continued until the beginning of 2012. However, young children under 5 were allowed only 15–30 min of outdoor play each day for the following 2 years. In addition, adults were tense, and aftershocks were frequent, adding to the children’s anxiety. The residents of Koriyama were imprisoned by invisible and odorless radiation.

2.4 The Koriyama City Post-disaster Childcare Project (KCPCP)

On March 29, 2011, Kikuchi asked leaders in the field of childcare to set up a project that would create a “new normal” for the children of Koriyama (Watanabe 2011, 2012; Kikuchi 2012). Twenty-five leaders, including local administrators, public health officials, pediatricians, clinical psychologists, nurses, daycare teachers, librarians, physiotherapists, speech therapists, and others, participated. Kikuchi envisioned the three principles of the project to be unity, structure, and continuity.

The concept of unity stressed the need for the project members to create harmonious relationships with mutual respect and reciprocity. Kikuchi previously encountered pervasive and unspoken sectionalism, which prevented the efficient communication needed to help the children. For example, when he inquired about the number of children evacuated in the prefectural building of a convention center, he was met with bureaucratic barriers. One local staff member refused to give any information about the affected children in the area because the researchers were members of the medical association of the city, and not the prefecture at large.

Undeterred, Kikuchi went into the evacuation center himself and counted the children one by one. Watanabe also encountered a similar absurdity when a director of the Ministry of Labor, Health, and Welfare warned her that the government, not pediatricians in Koriyama, would decide on plans for Tohoku. Such rigid and pointless bureaucratic limitations posed an unnecessary hurdle in the post-disaster environment.

The second principle of structure emphasized the need for discipline and coordination in order to ensure that the contributions of each team member would create a multidisciplinary project to support the children. Thus, KCPCP was to function as an orchestra with Kikuchi as the conductor. The project team members shared the same ethos: the children cannot wait and the community must protect them. Third, the principle of continuity focused on long-term support and engagement with the community and was built into the planning from the beginning of the KCPCP. Ultimately, a mega-disaster of this magnitude requires years of recovery efforts. In the facilitation of healing in the surviving community, the KCPCP team developed a shared understanding of the importance of ongoing individual and group sacrifice to sustain outreach and recovery efforts.

2.5 KCPCP Activities: Story Time for Mothers and Infants

Watanabe focused on activities that Koriyama traditionally excelled in, especially pastimes that people had long enjoyed with their children. Koriyama had a long tradition of picture book reading, similar to story time at the library. The community had an excellent children’s library with hundreds of volunteers already trained in picture book reading. Kikuchi and Watanabe worked with the city office to organize the project. The KCPCP team started out with a scheduled story time in several places across the city. A total of 150 sessions reaching 3900 parents and children were conducted in the first year. During each session, a trained story time volunteer read picture books, while a public nurse carefully observed whether some mothers and children might need special attention and care.

KCPCP made it a rule to put the infant-mother relationship at the center of its efforts and to reinforce mothers for moments of positive experience within the dyad (Watanabe 1987, 1992). KCPCP produced 50,000 fliers for the local city government to distribute, specifically aimed at mothers with infants and young children. The two-page flyers contained the following messages with colorful pictures:

  • Mother is the one who can best soothe her child.

  • Contain your child’s worries by trying the following:

    • Embrace and hug your child.

    • Listen to your child.

    • Tell your child, “It is not your fault.”

    • Tell your child, “It is OK to be scared. I will find a way to make you feel safe.”

    • Tell your child “It is OK to be baby-like. Come and cuddle with me.”

    • Tell your child “If you have tummy ache or headache, I will hold you till they go away.”

The flyers were meant to convey hope to anxious mothers, who were confined indoors and were dealing with aftershocks, that their distressed children could be supported and soothed by simply embracing and responding to them. Parents came to understand how to hold their children when they were in acute stress, and this empowered them to feel in control even when their children were distressed. The campaign enhanced attachment relationships and gave parents a renewed sense of agency and confidence.

Pregnant mothers were the most vulnerable and required consistent care and assurance. Tatsuo Kikuchi, with public health nurses and midwives in the Children’s Care Center of Koriyama, reduced their fear and anxiety by inviting them to weekly pregnant mothers’ classes, where they could freely ask questions and confide in one another. Additional individual counseling sessions were provided, if needed. For particularly anxious mothers, the nurses would ask Tatsuo Kikuchi to respond to their questions. A total of 550 pregnant women were cared for in the first year. It is possible that this intensive, individualized care, with an emphasis on trust between the mothers and staff, contributed to the fact that there was no significant increase in abortions in Koriyama in the year following the GEJET.

In addition, Shintaro and Tatsuo lectured vigorously and extensively to reduce the fear and shame concerning radiation in the citizens of Koriyama. Within a year, they gave 20 lectures to a total of 1500 people, and clinical psychologists held 8 mental health workshops for teachers, midwives, and health nurses.

When KCPCP was formed in March 2011, its members resolved to commit themselves for the minimum of a decade, defining the first half of the decade as the first stage and the latter half and beyond as the second stage of the aftermath. The KCPCP succeeded in identifying at-risk children early and prevented several severe cases of post-traumatic stress disorder and other emotional disorders. Its programs became models for other disaster regions in Japan and were presented globally through congresses of the FOUR WINDS (Forum of Universal Research on the Workings of Infants and Neonatal Developmental Support) and WAIMH (World Association for Infant Mental Health). Kikuchi was appointed as a professional member of the Ministry of Disaster Restoration, and Narui was appointed as a member of the Committee of the Fukushima Prefectural Health Management Survey. Now into the second stage of the aftermath, challenges in Fukushima have become even more diverse and complex.

As part of the recovery support for the community, miscellaneous music, art, and creative workshops were conducted by volunteer artists from around Japan. As mentioned above, Koriyama had been a renowned musical community with choir groups and brass instrument bands that frequently won national contests. On Children’s Day, May 5, 2011, Kikuchi organized a Kid’s Festival which hosted 1500 children. On August 26, 27, and 28, he again hosted a summer festival with the help of the members of the FOUR WINDS and a toy company named Bornelund. The event was attended by 3500 children. This led to a sizeable donation from a local entrepreneur and the construction of a permanent public indoor playground, which marked a rare collaboration between the private sector and the city. The indoor playground, known as PEP Kids Koriyama, was opened on December 23, 2011.

3 PEP Kids Koriyama

PEP Kids Koriyama was the largest indoor playground in Tohoku, with a building of 2400 m2 on grounds of 7000 m2 with 120 parking spaces. It accepted children up to the age of 12 accompanied by an adult, and admission was free. During its operating hours from 10:00 to 18:00, each child could have a 90-min play session per day. Two dozen trained staff members supervised the play zones and assisted the children, thus enhancing their play and developmental skills. The indoor playground was open throughout the year, except on New Year’s Day. It was composed of four zones: the activity zone, the seminar zone, the food and cooking zone, and the resting zone. In the activity zone, there were areas for dynamic, gross motor and sensory play, including a bouncing track, running track, and a sand and water play area. A gymnastics expert and professor of Human Science at Yamanashi University by the name of Kazuo Nakamura supervised children’s motor skill development and trained the play leaders employed by the city. In the seminar zone, parents could request free counseling in one of the private counselling rooms. In the food and cooking zone, children enjoyed group cooking lessons by expert nutritionists. In the resting zone, an area was available for quiet rest. At the end of the first year of the GEJET aftermath, no significant PTSD was reported in Koriyama. By March of 2017, 6 years after the GEJET, the total number of PEP Kids visitors reached 1.9 million, providing clear evidence of its popularity. PEP Kids Koriyama became the symbol of the child-centered recovery effort of the city. Many other cities emulated the idea and built similar playgrounds nationwide.

3.1 NPO Koriyama PEP Childcare Network (KPEPCN)

In 2012, Kikuchi established a nonprofit organization called Koriyama PEP Childcare Network (KPEPCN) to create a structure for the support and training of professionals who worked with the children of Koriyama. The network was comprised of four sections: motor and physical development, community childrearing, mental healthcare, and radiation education. Watanabe and Tokita took on the mental health section with the help of the largest infant mental health community in Japan, FOUR WINDS and the World Association for Infant Mental Health.

4 Koriyama Cohort Study on Children’s Motor Skills

In the second year after GEJET, from April 2012, KPEPCN launched a 10-year cohort study of Koriyama school children focused on motor strength and skill development. The concern was that living in an environment of low-level radiation would impact not only physio-motor but also the cognitive-behavioral and socio-emotional development of the children, resulting in extensive psycho-physio-social problems in the future. A year of confinement indoors for healthy children was likely to have been too long and stressful, potentially causing deterioration in motor development and skills and possibly paving the way for a sedentary lifestyle, obesity, and general passivity. Kikuchi and colleagues, therefore, formulated the following research questions: (1) How did the first year of indoor confinement impact the children of Koriyama? (2) What should be done to mitigate these adverse effects?

In June and July of 2012, a total of 27,704 school children in Koriyama were studied, ranging in age from 6 to 15 years old. There were 17,975 school children (9246 boys and 8729 girls) from 59 primary schools and 9729 adolescents (4936 boys and 4793 girls) from 29 junior high schools. A questionnaire was also sent to parents, and another battery (developed by the Ministry of Education, Science, and Sports) on physical strength and skills measurement was also used. The items collected were height, weight, and obesity index calculated according to the Standardized Diagnostic Manual for Japanese School Children. Also included was the New Motor Strength Test, which included 50-m running time, jumping length, repetitive side stepping, throwing a soft ball, grip strength, and torso raising.

The results were as follows: the children in Koriyama showed obesity in all of the nine grades across primary and junior high schools, except for the boys in the first grade of primary school. The children also scored low in basic motor skills such as running, jumping, and throwing. They also showed less strength as well as lower skill level in motor activities by age. This trend had first appeared in the 1980 national survey but had worsened markedly after GEJET.

5 Post-disaster Care in Evacuation Centers of Fukushima

Soon after the GEJET, Kanae Narui, a local psychologist and head of Fukushima Society of Clinical Psychologists and a member of the KCPCP, started an early intervention program for infants under the age of 3 to prevent emotional problems in the low-grade radiation contamination areas of Fukushima. With funding from Japan UNICEF, she formed the nonprofit organization Heartful Family Care Society, which created support programs to enhance a sense of agency in parents and children living as evacuees. There was evidence of delayed speech, apathy, purposeless movements, irritability, clinginess, tantrums, and other problems in these young children. Moreover, they were often misdiagnosed as having a Pervasive Developmental Disorder, when in fact they were manifesting symptoms of PTSD or reactive attachment disorders, due to the insecurity of being dislocated and living with harsh stigma.

Narui’s Child-Parent Play and Parent Meetings (CPPPM) started in June 2011 and were composed of public health nurses, clinical psychologists, and day nursery teachers. The team visited villages in 1-month rotations. They conducted a 2-h intervention program in local halls where toddlers and preschoolers could play and run around freely. Six to seven pairs of mothers and children attended at a time. Holding reflective staff meetings before and after each session, CPPPM had the following schedule: nursery teachers greeted the children on their mother’s laps (Part 1: Introduction). Then they facilitated parent-child interactive play. The mothers were encouraged to demonstrate focused affectionate attention, which promoted secured attachment (Part 2: Development). Nursery teachers then widened the children’s horizon by guiding them to run toward their mothers from a distance. Repetition of this separation and reunion allowed the children to gradually play with the staff and the toys spread around them, away from their mothers. This set the stage for the peer meeting of the mothers, who would sit in a circle and talk freely for an hour (Part 3: Climax). The mother and child would then reunite, and the staff would provide a brief review of the day’s play (Part 4: Resolution). The team reviewed the sessions afterward. If the team identified a mother and child that needed further support, a public health nurse would offer a home visit. In the peer meeting, which was facilitated by a psychotherapist, mothers would often start to open up and share their experiences.

The outcome of the first 5 years of CPPPM is summarized as follows: from June 1, 2011, to December 31, 2014, CPPPM was conducted 547 times in 46 venues covering 26 villages, towns, and cities in Fukushima Prefecture. Over 5000 mother-child dyads and a total of 14,110 families participated, of which 6312 were infants and children and 7798 were adults. The age of the children ranged from 0 to 6 years. The total number of supporting staff was 3559 (1164 clinical psychologists, 1395 nursery teachers, and approximately 1000 public health nurses).

The overall ratings of CPPPM in mothers’ feedback sheets were highly positive. The mothers felt supported and revived after CPPPM, and children with emotional and behavioral problems improved.

6 Moonmin Valley Study Group

In 2015, in response to requests from local day nursery head teachers, Narui and Watanabe started a monthly evening case conference at Kikuchi Clinic, which came to be known as the Moonmin Valley Study Group. Participants were encouraged to bring to the group any problems they faced in their work, which were discussed in strict confidentiality. By word of mouth, Moonmin Valley Study Group became well-known to local providers, and complex cases were brought in for consultation. The variety of cases informed Narui and Watanabe about the complexity of family conflicts in the aftermath of GEJET. Participating teachers shared how young children 5 years and under were showing general restlessness. The citizens of Fukushima had been so traumatized by the stigma related to the FDNPP nuclear accidents that it had been taboo for residents to mention GEJET to each other. The Moonmin Valley Study Group helped to overcome this conspiracy of silence. Initially, the participants were anxious, passive, and compliant. Narui and Watanabe gently encouraged the members to voice their opinions and feelings. The facilitators modeled sharing about their mistakes and encouraged the group to reflect and learn from their own errors rather than feel shame. Thus, the case conference became a safe space for processing difficult experiences. Gradually, the group developed into a lively gathering. With five to six core members and a few newcomers each time, it became a secure base for the day nursery teachers to have reflective consultation (Weatherston and Osofsky 2016).

In the following 12 months, the Moonmin Valley Study Group dealt with more than 50 cases presented by 160 nursery teachers from 20 different nurseries. As the teachers learned to reflect on their concerns in relation to the GEJET and PDNPP disasters, the directors and administrators of daycare centers voiced their feelings on the trauma of the GEJET and began to see the children’s problems in the context of the breakdown of ordinary, age-appropriate experiences. The participants eventually felt safe enough to reflect on their feelings related to the multiple and complicated traumas of GEJET, which had not been previously discussed. In response to requests from core members, Watanabe added a training component focused on the theory of early development. This included Margaret Mahler’s video of the separation-individuation process and drew from the text of The Psychological Birth of an Infant (Mahler et al. 1975).

A joint case supervision by Koriyama PEP Childcare Network and Moonmin Valley Study Group started in July 2017 as an offshoot of the KCPCP. Teachers and caregivers at schools and daycare nurseries reported an increasing number of problematic cases of restlessness, irritability, and insecurity, and these professionals sought to learn the basics of therapeutic interventions for the children they worked with. More than 100 elementary and nursery teachers, pediatricians, psychologists, psychiatrists, and administrators attended, and these cases were discussed with enthusiasm and a shared commitment to deepen their understanding of the problems and better support the children.

7 Plight of the Children of Iitate Village

In March 2015, Watanabe came across the unusual plight of children and parents in a village in Fukushima, when two executives of the World Association for Infant Mental Health (WAIMH), Miri Keren, the president, and Palvi Kaukonen, the general secretary, visited Iitate Village. There, Watanabe met families who had been exposed to high-level radiation for months, largely because prominent radiology experts, Noboru Takamura and Shunichi Yamashita, had come to Iitate-Mura previously and persuaded residents to remain in the area, claiming it was completely safe. Radioactive materials were invisible and odor-free, and locals were inclined to believe the experts. Young children continued drinking the water and milk from the cows and eating vegetables and fruits from the area until April 22, 2011, when the government ordered the whole village to evacuate. The residents were shocked and ultimately sued the government and TEPCO (the corporation that owned the Fukushima Daiichi Nuclear Power Plant) for misleading the villagers when they had originally prepared to flee (Keren 2015).

8 Post-disaster Care in Miyako, Iwate Prefecture on March 11, 2011

Miyako is a fishing town situated on the coast of Iwate, the largest prefecture in mainland Japan, to the north of Fukushima and Miyagi Prefectures. With three sides surrounded by mountains and dense forests, this isolated town of 60,000 residents prospered as one of the leading fishing ports in Tohoku. It had weathered many natural disasters in the past and had previously developed disaster-resistant systems in the community. For example, concrete X-shaped double banks, 10 m high and 2.4 km long, were constructed along the Bay of Taro in the northern part of Miyako. The Prefectural Hospital of Miyako stood on top of a steep rock and employed obstetricians who practiced disaster perinatal medicine (Nishigori et al. 2015). In 1999, the third Annual Congress of the FOUR WINDS was held in Iwate Prefecture, which created momentum for the establishment of an active, multidisciplinary infant mental health team in Miyako. Children in Miyako experienced regular drills in tsunami survival.

On March 11, 2011, a 19m-high tsunami occurred 30 min after the huge earthquake, destroying the X-shaped banks of Taro Bay. Miyako lost more than 1000 people. The city office and nearly 5000 homes were destroyed. Kimiko Toyoshima was the local pediatrician who led the local child healthcare team. Toyoshima partnered with Hiroko Suzuki, who practiced child psychiatry in Morioka, an inland capital of Iwate, and together they started a monthly consultation with the people of Miyako (Suzuki 2012).

8.1 A 5-Month-Old Boy Who Survived the Gigantic Tsunami

As Suzuki and Toyoshima worked together in the post-disaster care of Miyako, they came across young children with noteworthy development and symptoms. One case involved a toddler who had been miraculously revived after drowning, at the age of 5 months. On March 11, he was swallowed by the tsunami while tied with a sling to his mother’s chest. Miraculously, the boy and his mother survived. At the hospital, 2 weeks hence, a litany of medical examinations revealed no significant areas of concern. He was heralded as the “miracle baby,” and a mob of journalists awaited his discharge from the hospital.

Back in Miyako, which was reduced to rubble, the boy’s maternal grandfather had been swept away. The boy’s grandmother and mother now lived together in a small temporary shelter. The grandmother took over care of the boy, and the mother became depressed. The boy’s father was forced to work far away in order to support the family.

At the age of 1 year and 9 months, the boy manifested avoidant gaze and overall delay in speech and other areas of psychosocial development. Suzuki called Hisako Watanabe to consult on the case. When Watanabe met him for the first time in June 2012, the little boy showed quasi-autistic features and a clear delay in speech and social interaction. Watanabe carried out a crisis intervention in infant-parent psychotherapy (Fraiberg 1987). Initially he was avoidant and unresponsive. Slowly but steadily, he responded to Watanabe’s attempts to engage with increasing affect; his eyes opened wider and his gaze showed interest (Stern 1985). He began to utter sounds, which became louder, more frequent, and expressive. Eventually, he smiled at Watanabe and showed her a toy. The boy showed small but tangible signs of development. When this intervention ended, the boy’s mother was relieved. Watanabe explained that the boy was likely to be suffering from post-traumatic stress disorder in infancy, due to cumulative trauma from the earthquake, tsunami, hospitalization, and being forced to live in temporary housing with an emotionally distant mother (Papoušek and Papoušek 1987).

Following this breakthrough, Suzuki continued with family therapy and empowered the mother to retrieve her sense of agency. As her husband came home and her mother moved out to live with her sister, she recovered from depression. The team regularly followed up with the family. The boy began to attend a day nursery, where he started to speak and socialize with peers, albeit awkwardly. At a steady pace, he grew out of the initial symptoms. In July 2017, when team members last saw him, the boy had completely recovered. He presented as a physically and emotionally healthy, adaptive school-aged boy.

For the local team led by Toyoshima, the collaboration with outside experts provided a firsthand experience of efficacious treatment. They acquired observational skills in parent-child interaction and a psychodynamic understanding of family and community relationships. The team also learned to differentiate a pervasive developmental disorder from reactive attachment disorder combined with PTSD in infancy (Rutter et al. 1999).

8.2 Community-Oriented Training and Support

Beginning in 2014, representatives of Miyako requested biannual visits from the post-disaster team. By the summer of 2017, Hisako Watanabe and Michiko Sakai had made nine joint visits to offer didactic training and case consultation, as well as informal discussions and emotional support. The content of the consultations and other professional support was tailored to the needs of the community. Visiting team members jointly assessed and reflected upon the community’s traditional ways of being, relation to their environment, cultural values, community priorities, and responses to the trauma and adversity experienced by the community members. Year by year, the level of consultation shifted from an introductory to an advanced level and from simpler cases to those with more complexity.

Watanabe and Sakai trained the local team of healthcare professionals regarding observation and assessment of the child-parent relationship. For this training and consultation in particular, Watanabe developed ways to elicit the child’s maximum response, and she would translate their intentions, feelings, and thoughts aloud. The local healthcare workers also learned to empower mothers with the confidence needed to respond to their children. After the sessions, Watanabe and Sakai would jointly explain particular interactive sequences for the workers to focus on. Explanations were given in plain everyday language without psychological jargon. The interventions were video recorded with families’ permission for training purposes. These were disseminated around the community and provided local workers with an invaluable resource for case consultation. From 2015 onward, basic theories of child development, such as the separation-individuation process of M. Mahler (Mahler et al. 1975) were added to the training content as the team advanced to a higher level. Adolescent development, pervasive developmental disorders, sexual abuse, and parent training were further added to the list. In 2016, in response to rising needs, Watanabe and Sakai provided specific case consultation and lectures to groups of special education teachers, health visitors, and day nursery teachers.

The multidisciplinary team of local professionals learned together how to assess vulnerabilities and strengths in each case and to decipher meaning from ambiguous symptoms and problematic behavior. The consultations also helped child professionals to monitor their own affect and reflect on their reaction to the child, thus introducing the community to reflective practice and exploring possible parallel processes in their work (Weatherston and Osofsky 2009). Raw emotions evoked at gut level and uncontrollable surges of anger and irritability experienced in the professionals were explored in terms of “countertransference.” The participants became interested in innovative, professional use of negative feelings, as they began exploring their own visceral responses in the context of the emotionally safe consultation group.

8.3 Outcome of the Miyako Project

The project in Miyako promoted the morale and skill of the child-focused community workers. Individual child professionals and many other members of the community acquired a newfound competency in coping with diverse problems of children and families. The future of the community became brighter as youngsters who survived the disaster showed their hard-fought resilience in surprising ways. A 10-year-old boy, Asato Sasaki of Taro in Miyako, won a national essay prize. He wrote:

I will become a Hanmoudo (Miyako dialect for “fisherman”) and go down to the sea where my Dad and Grandad lay. The tsunami took them away from me but they still live in my heart. I hear my Dad’s voice calling me, ‘Asato, you are still alive. How wonderful it is to be alive!’ My Mom works hard in a fish factory; she works so fast. With the blink of an eye she packs different fish into different packages. One day I will buy a ship. I will paint my Grandad and Dad’s names on it as my Dad had done, and I will add my name as well.

9 Reciprocal Encounters for Sustainable Post-disaster Care

Thus far, this chapter has described the recovery efforts during the first 6 years following the GEJET and the ensuing FDNPP accident. The authors acted swiftly to organize multidisciplinary post-disaster childcare projects in Koriyama and Miyako. These efforts developed into new, sustainable, child-centered mental healthcare centers for those communities.

Initially, the idea of having a post-disaster child mental healthcare center in the region of Tohoku was considered to be very difficult. This hardship is attributed to the fact that Tohoku is a remote, closed region with mountains, rocky coasts, harsh snowy winters, declining economics, an aging and diminishing population, and a lifestyle that still revolves around traditional filial piety and community ties (Terada 2011). However, Tohoku was also home to poets and writers who represented the soul of Japan. The people of Tohoku were in touch with the impermanence of life, and they cherished the continuity that children represented.

By virtue of the trust that local people and government officials had in the local mental healthcare providers, experts from other parts of Japan were more easily integrated into the community. Even visits by foreign infant mental health experts were accepted and proved to be invaluable. Joy Osofsky, a psychologist and childhood trauma expert from the United States, advised team members on how to prepare for the difficult task of recovery from a man-made disaster. Kaija Puura, a representative from WAIMH, encouraged the post-disaster team at the FOUR WINDS congress and emphasized the global commitment to victims in Japan. Miri Keren, then president of WAIMH, and Palvi Kaukonen, another representative from WAIMH, listened to the deserted villagers of Iitate, which paved the way for Watanabe to follow. The genuine concern of the visiting experts touched the hearts of the devastated locals. The basic tenets of infant mental health, which include building a relationship through reciprocal interaction, compassion, and meaningful encounters, were all echoed as universal principles in the support of those surviving the disaster.

However, as years passed, awareness of the plight of the 2011 disaster victims began to fade across Japan, which was a second blow to the people of Fukushima. In September 2013, prime minister Abe declared the problems of radiation in Fukushima to be resolved, and the nation turned its eyes toward the future as Tokyo was announced as the site of the 2020 Olympic Games. The costs of building soared, and builders left the post-disaster recovery efforts in Tohoku region for more lucrative work in Tokyo. This hampered the restoration of Tohoku; many individuals had to give up rebuilding their houses, and many local administrations reconsidered rebuilding plans altogether. Restoration of Tohoku was no longer a priority, despite the many thousands of people still living in temporary housing, and the victims felt abandoned. This massive denial and neglect of Tohoku and its people by the government trickled down to Japanese society which led to a social trend of victim criticism and bullying and further alienated the victims, especially of Fukushima.

This national denial prevailed, not only in the general public but also in medical and other academic fields. In universities and colleges, any mention of concerns over nuclear power in Japan was discouraged. Kanae Narui, the third author of this chapter, sat on the Committee of the Fukushima Prefectural Health Management Survey and heard committee members discuss the discontinuation of thyroid screening on the grounds that there could not be a significant increase in thyroid abnormalities because the radiation dosage was small. Kikuchi and the project team fiercely fought against this national denial and compiled records of the first 2 years of recovery efforts of Koriyama into a book entitled, The Tale of Koriyama (Kikuchi et al. 2014).

Victimized communities began to realize that Prime Minister Abe was no longer interested in the plight of the victims in Fukushima, as he never mentioned it on ensuing commemoration days. When the Abe administration pushed forward plans to send people back to their contaminated and still dangerous land, evacuees in Yokohama filed a law suit against the government and TEPCO in November 2013.

10 The Toll

Tohoku suffered 15,896 deaths and 2537 missing persons as a result of the 2011 GEJET (The National Police Agency of Japan 2018). One week after the disaster, the official number of evacuated and stranded people was placed at 402,069 (WHO 2012). Dislocation bred conflict and rifts in families and communities, including suicide, poverty, separation, divorce, domestic violence, alcoholism, and depression. In school, children suffered from bullying and maladaptation. Evacuees had to weather a variety of other stressors as well, including uncertainty over receiving monthly compensation that was arbitrarily based on whether they were forced to flee or fled on their own. Disaster-related deaths continued to rise, mainly in Fukushima due to suicide, chronic illness made worse by stress, and the isolated lifestyle of temporary housing.

11 Earthquake, Tsunami, Nuclear Accident, and Stigma

The post-disaster team shared the view that in Fukushima, the earthquake, tsunami, and nuclear accident were actually a quadruple disaster when stigma was taken into account. The FDNPP accidents displaced large populations, tore apart community relationships, and left survivors stressed by their chronic exposure to radiation. The stigma of radiation evoked unspoken dread and rage, which the stigmatized individuals tended to keep to themselves. Misinformation and the lack of transparency by government officials, business leaders, and certain members of the scientific community perpetuated this uncertainty and allowed the insidious stigma to grow. It would later become clear that the stigmatization experienced by citizens of Fukushima was actually indicative of a wider problem in Japanese society.

11.1 Japanese Society and Its Structural Problems

When the GEJET hit the FDNPP and caused its meltdown, the nuclear disaster revealed not only the technological vulnerabilities of the nuclear plant but also the structural flaws of Japanese society. The confusion and chaos were compounded by inconsistent or nonexistent information and orders from the government, TEPCO, and radiation experts. As a result, victims of Fukushima were left in limbo without a map for the future. The agonizing question of whether to flee or to stay continues to this day.

The plight of the Iitate Village is one example that highlights this point. Just as the village leaders were preparing to evacuate the children, radiation experts sent from Fukushima Prefecture came to the village, imploring them to stay because it was, according to these experts, safe to eat the food and drink water as usual. The citizens believed the experts’ advice and acted as if things were normal. Then, a month later, the order for the whole village to evacuate came. Shocked and confused, the villagers felt deceived by the government and the experts. One civic servant disclosed that the mayor ordered him to hide measurements of high radiation from other villagers (Hasegawa 2013, 2015).

Later, in the Fukushima Prefectural Health Management Survey (FPHMS), about 150 children of Iitate Village were found to have been exposed to very high radiation (Tadano 2014; Ishii et al. 2016). The incensed villagers waited for feedback, an apology, or an offer of care, which never came.

Another controversy affected the FPHMS, the only official survey to monitor the effect of the nuclear accident on the health of the residents of Fukushima. From its start in November 2011, the response rate had been very low, less than 25%, in spite of vigorous promotion. This reflected the lack of trust that the population had. Another criticism was that participation was restricted to residents of Fukushima Prefecture.

Radioactive plumes have no border, and post-disaster team members believe that the government should have studied the at-risk population in its entirety. Also, the survey was restricted to external exposure, leaving out more relevant data on internal exposure. After the lessons of Chernobyl pertinent to cancer and other diseases in low-dosage radiation zones, even areas of exposure below 100 mSv/year should have been included. Instead, the Japanese radiation experts maintained that exposure under 100 mSv/year was completely safe. Another incident added to the loss of public trust. In the spring of 2017, a 4-year-old girl who had been screened and operated on at the Fukushima Medical College presented with a diagnosis of thyroid cancer, yet her case was omitted from the data of FPHMS.

In June 2012, the Act for Protection and Support for the Children and other Victims of TEPCO Disaster (APSCVTD) was established to provide a framework for support and care to those who were affected by the nuclear accident. This could have opened the door to at-risk children in the surrounding Ibaragi, Tochigi, Gunma, Saitama, and Chiba Prefectures. Unfortunately, this failed to be implemented, and no at-risk children were officially registered in Japan.

In 2012, a UN commissioner conducted an investigation in Fukushima and pointed out the negligence of the Japanese government regarding the basic provision of preventive iodine and of crucial information on the flow of the radiation plume from SPEEDI. He urged the government to improve the care of the victims and to set up evacuation zones according to the dose map of radiation contamination, and not based on geographical distance from the accident (Grover 2014).

This also highlighted a larger point that, had the national energy policy been openly discussed with the citizens and with a wider field of scientists, the nuclear plant disaster might never have happened in the first place. Repeated warnings of impending danger of FDNPP from seismology experts, nuclear chemists, and engineers of the Onagawa Nuclear Power Plant went largely unheeded (Hongo 2011; Takagi 1995, 2012; Katsuhiko 2007; Taki 2016).

11.2 The Decommission Process Revealed

Fukushima could not recover without a clear plan to decommission the FDNPP. However, that plan came out for the first time in early 2017, when TEPCO publicized the following:

Three remote controlled innovative robots probed the inside of the containers: Quince, the first robot failed to probe the No.1 nuclear reactor. Scorpion, the second one, detected a lethal level of radioactivity of 530 Sv/h outside the No.2 reactor, and Sunfish, the third one, dived into the bottom of the No.3 reactor and found debris. It became clear that the meltdown was unassailable (Kyodo 2017).

The government announced that the decommission would take another 40 more years and 21.5 trillion more yen. Kikuchi, Narui, and Watanabe attended a full tour inside the FDNPP in March 2017 and witnessed the decommission process of the crippled FDNPP, filled with radioactive waste which has nowhere to go. The surrounding land, equal to the size of Tokyo, is lost to radiation contamination forever.

11.3 The Vertical Social Structure of Japan

Increasingly, the FDNPP accident revealed structural flaws of the Japanese society. As Chie Nakane, a sociologist, had surmised, Japan remained a vertical organization, putting profit above the value of people’s lives (Nakane 1970). Right after the FDNPP disaster, the Japanese government minimized the harm and declared a continued pursuit of nuclear energy.

Japan had been a male-dominant hierarchical society, with leaders embracing both fear of nuclear weapons and obsession for obtaining nuclear power. Leading nuclear scientists and medical professionals were closely linked to political and economic powers. They created an invincible conglomerate dubbed “Atomic Village” (AV) (Nakane 2017). It filled the Japanese public with optimism about the safety of radiation exposure up to 100 mSv/year, while Jinzaburo Takagi, Tetsuji Imanaka, Hiroaki Koide, and many other scientists thought otherwise.

11.4 “Japan Disease” and the “Zero Process”

Over the past 6 years, Kikuchi has closely observed the extent of the damage done to the lives of children in Koriyama. In his presentation at the WAIMH Congress in Prague (Keren 2015), he explained how the plight of the children in Fukushima reflected a wider deprivation of children in the rapidly industrialized society of Japan. He raised awareness of the adverse effect of the “Japan Disease” as a most difficult factor hindering recovery efforts. The term “Japan Disease” denoted a lack of accountability and credibility of the Japanese leadership in disciplines across the nation, including the government, economy, industry, education, commerce, and labor. The combination of technological vulnerability and structural irresponsibility to the society yielded the tragedy that had ensued for the children of Fukushima (Yanagida 2013).

As more candid disclosures emerged, they alerted people to the “zero process” and psychic numbing caused by massive disasters, which had been previously pointed out by a Hiroshima researcher and a Canadian psychoanalyst in (Lifton 1968, 1976; Fernando 2012). The “zero process” is a frozen state of psychic numbing caused by massive disasters. While the victims could all be suffering from the “zero process,” the government, as a collective system, could also be suffering from “zero process,” insisting on the continuation of nuclear energy policy without reflection on the risks of having 54 nuclear plants along the coasts of Japan. Thus, the “zero process” and psychic numbing could be important concepts for the Japanese people to study in the coming years.

Fukushima is now increasingly discussed in the context of other unresolved problems of industrial and military disasters including the wartime trauma of Hiroshima, Nagasaki, and Okinawa, wartime atrocities in Asia, and the postwar industrial pollution in places like Minamata. All of which have been treated as hushed taboos in Japan. The victims of Minamata, whose bodies were polluted by industrial waste of methylated mercury, a symbol of the dark side of Japan’s miraculous economic rise, persevered to bring about the Minamata Treaty in the summer of 2017, which banned the use of mercury, not just in Japan but around the world.

12 Emergent Voices and Movements

Citizens have felt increasingly responsible for protecting their children and themselves in the face of the past inaction of the government, and they have formed numerous citizen’s groups. One such group is Mothers’ Radiation Lab Fukushima (MRLF), a nonprofit organization for measuring radiation levels. Mothers living in Iwaki, a fishing town situated to the south of FDNPP, opened this laboratory in November 2011 with the following functions: (1) measurement of radiation including gamma ray (Cesium 137) and beta ray (Strontium 90), (2) thyroid screening, (3) research on the effects of radiation on the ecosystem (Akimoto et al. 2017; Sawano 2017), (4) rehabilitation programs including children’s camps on the southern island, and (5) Tarachine (Mothers’) Clinic to provide physical and mental healthcare. MRLF carried out extensive monitoring of the effect of the FDNPS meltdown on the ecosystem and publicized monthly data on its website (NPO Iwaki Radioactive Citizen Measurement Office). While MRLF has tried to create a comprehensive care system, the government denies any need for a national registration system for the children who had been badly exposed to initial radiation.

In the Japanese scientific field, pediatricians, general practitioners, and epidemiologists are independently investigating the increase of thyroid cancer and other health problems in the at-risk regions. Hayashi and Scherb published their findings of an increase in perinatal death in Medicine (Scherb et al. 2016; Scherb 2017). Two rounds of thyroid screening for children under 18, carried out in 2011 and in 2014, revealed increasing prevalence of thyroid cancer. While the Committee of the FPHMS strongly dismissed the increase in thyroid tumors as due to screening effect, Tsuda argued that an increase of thyroid cancer within 4 years of the FDNPP accident was unlikely to be explained by a screening surge (Tsuda et al. 2016). Going forward, medical doctors should be alert to the emergence of leukemia and other diseases, which might be due to radiation pollution (Aoki 2016).

As the truth emerged over the years, and massive evidence of the negligence in implementing safety measures accumulated, a criminal trial of TEPCO started in June 2017. In August, more than 12,000 victims had filed suit in 20 or more district courts in Japan. The first victory against TEPCO and the government was won in Gunma Prefecture in spring 2017. In March 2017, 48% of the general public in Japan answered “no” to a newspaper survey on restarting atomic plants (Suzuki 2017). The rift between the villagers and the local and central administration was deep. The village leader warned:

Nuclear power fragments everything, family relationships, friendship, and community ties. It fragments human trust and humanity to pieces. It fragments ecological systems into pieces. To prevent being annihilated into oblivion, we stand up to speak out for the sake of our grandchildren (Hasegawa 2013, 2015).

12.1 “Vox Populi Vox Dei”: The Voices of the People Are the Voices of God

The right of children to develop in a healthy environment was at stake in Fukushima and the surrounding regions. People’s voices need to be heard for our nation to become a more accountable and credible society. A 17-year-old victim, who was 11 at the time of the FDNPP disaster, spoke out in an opinion column of The Asahi Shimbun. With the title “Let the sufferings be limited to the people of Fukushima” she wrote:

The name ‘Fukushima’ today is synonymous with Hiroshima, a place where a mistake took place, which should never be repeated. Fukushima should be known to the world to warn of the tragedy inflicted on innocent people. This should never ever happen again to others. People wonder where the massive nuclear wastes and contaminated soil from the Fukushima disaster would go. I insist they be kept inside Fukushima, because we know what it is to be contaminated by radiation: some killed themselves when forced to evacuate, while others were bullied in their new schools. If the nuclear wastes go elsewhere, then the people there would suffer. Oh, no! I refuse to let such a thing to happen to anyone else. Because I know what it is like, I do not want others to suffer this agony. What a long time it takes to overcome the stigma! Having said this, I am steadily recovering and no longer depressed. We encounter conflicts yet we face forward. Whatever the stigma, we will strive to be the people of ‘the fortune island’ which is what Fukushima means (Suzuki 2017).

13 Conclusion

The Great East Japan Earthquake and Tsunami (GEJET), with the ensuing explosions of the Fukushima Daiichi Nuclear Power Plant (FDNPP), have devastated Japan over the past 7 years. However, it has brought us, the authors, back to the basics of life: survival, adaptation, and evolution in our mutual and empathetic support for one another. We feel that the time has come for radiology scholars, pediatricians, child psychiatrists and psychologists, epidemiologists, administrators, and citizens to come together to reach a universally acceptable consensus on the levels of radiation exposure to ensure a safe environment for children and their families. To this end, the authors will strive in the coming years to cultivate a viable platform where the voices of the children of Tohoku can be heard and reflected in a way that promotes a life-centered environment for the next generation.