Health in Disasters A Science and Technology Studies Practicum for Medical Students and Healthcare Professionals Editors: Rethy Kieth Chhem Gregory Clancey Formerly Division of Human Health STS Cluster, Asia Research Institute International Atomic Energy Agency National University of Singapore Vienna, Austria Singapore Editorial team: Pisith Phlong, IAEA Azura Z. Aziz, formerly IAEA Ryan Crowder, IAEA Penelope Engel-Hills, CPUT Agustina Grossi, IAEA Joanne Heng, IAEA Disclaimer: The views and opinions expressed in this handbook belong solely to the authors and are not representative of the views and opinions of the International Atomic Energy Agency, National University of Singapore or any other institution involved. This book is intended for educational and informational purposes only and does not constitute legal, technical, medical or fiscal advice. Information in this book should not be used as a substitute for professional expert advice given individually regarding a specific situation. We decline all responsibility for any decisions taken by readers based on the topics covered in this book. ACKNOWLEDGEMENT This STS handbook has been produced as the result of several technical meetings at IAEA in Vienna, Austria, that gathered international experts and Japanese medical doctors who have been involved at the frontline of the Fukushima nuclear power plant accident to respond to medical emergencies. Through a series of intense discussions with these concerned Japanese physicians and scientists, and in consultation with a panel of experts in social sciences, the participants of the meeting reached the conclusion that only a multidisciplinary STS approach could help in addressing a complex situation such as the Fukushima Daiichi accident. The preparation of this STS handbook is in line with the educational needs of Fukushima Medical University and other Japanese institutions and has been possible through the contributions and expertise of many experts, especially Japanese medical doctors from Fukushima Medical University, Hiroshima University, Nagasaki University and National Institute of Radiological Sciences (NIRS). Special thanks go to Dr Shunichi Yamashita, Dr Tetsuji Okamoto, Dr Kenji Kamiya, Dr Akira Ohtsuru, Dr Koichi Tanigawa, Dr Arifumi Hasegawa, Dr Atsushi Kumagai, Dr Hirooki Yabe, Dr Kenneth Nollet, Dr Noboru Takamura, Dr Tomoyoshi Oikawa, Dr Makato Akashi, Dr Hideo Tatsuzaki, Professor Hideyuki Matsui and Dr Jun Shigemura. We would also like to thank Dr May Abdel-Wahab and Dr Ahmed Megzifene for their inputs and editing of this handbook. PREFACE Historically, the main concern of medical professionals was the symptom. The patient was a carrier of symptoms to which observation, medical reasoning, and techniques were applied. Therefore, the medical concern did not extend much farther than the biological body. Even when operating in a public health capacity, it was not seen as the responsibility of medical professionals to understand socio-cultural factors, even when they had an obvious influence on outcomes. The Fukushima nuclear power plant accident of March 11, 2011 has challenged these assumptions. Through technical support by the International Atomic Energy Agency (IAEA), a number of meetings between international and Japanese experts were organized by the Department of Nuclear Sciences and Applications, the Division of Human Health (NAHU) with the collaboration of the Fukushima Medical University in 2013-2014. The international experts were impressed and moved by the attempts of Japanese health professionals to mitigate the damage caused by the compound disaster – the earthquake, tsunami, and nuclear power plant accident. However, many responders would be the first to admit that they were greatly disadvantaged by their limited training in the social dimensions of disaster. Thus, items not covered in the education and training of these professionals impinged on the efficacy of the Japanese medical response to the Fukushima Daiichi accident, and by extension, on the general health of the Japanese population. There is a persistent need for medical professionals, educators, and aspiring medical students to acquire a broader understanding of the tightly bound relationship between patient and society. This requirement becomes only greater when facing disaster, as knowledge of the social is increasingly important in establishing and maintaining a relationship between professionals and citizens during catastrophic events. This handbook has emerged from this need to better understand the social dimensions of disaster. International and Japanese experts in Science and Technology Studies (STS) and medical education gathered in a meeting in October 2013 to discuss the most relevant needs of the medical curriculum as expressed by faculty members of Fukushima Medical University, Hiroshima University, Nagasaki University and the National Institute of Radiological Sciences. The expert knowledge presented within the following pages urges i professionals and students alike to assume responsibility beyond that of the traditional care of patients, and to acknowledge the complexities of culture which persist beyond the examination room. Of course, writing is a form of understanding. This handbook attempts to create and cultivate a relationship between the reader and the academics represented within their field of expertise. These chapters seek to illustrate the many areas of importance associated with disaster often neglected in the education of medical professionals. Each chapter will include important case studies to aid the medical students and health professionals in exploring and applying relevant STS concepts throughout the handbook. We begin with an overview of general radiation history and the historical shaping of cultural experience surrounding disasters in the Japanese context. Following this we address the crisis in expertise often inherent to the onset of disasters and the nature of contested diseases, especially with regard to psychosomatic afflictions. Next, the topics of coping with disasters, risk communication, and social determinants of health address the issues of risk perception and communication within society, and between medical professionals and their patients. Finally, we discuss the interrelated topics of professionalism, law and ethics with regard to conceptions of value-based practice, and conclude with a general discourse upon disaster studies as a topic of analysis. Although the primary context of this handbook is the Japanese experience, all medical professionals, students, and educators working within the medical sector would benefit greatly from the breadth and acuity of expertise presented within these pages. Disaster is a contextual matter, but its effects are universal, and arming medical professionals with the knowledge presented herein will provide strong aid to communities plighted by disaster. Rethy K. Chhem Gregory K. Clancey formerly IAEA, Vienna, Austria Singapore, Singapore ii Contents Guide to the Handbook: Promoting Learning through Curriculum Penelope Engel-Hills ............................................................................................................................ 1 Introduction Gregory Clancey and Rethy Chhem ..................................................................................................... 8 1 Techno-natural Disaster and the Role of Expertise Ulrike Felt and Rethy Chhem ...................................................................................................... 13 2 Disease, Illness, and Sickness: A contested boundary Heiner Fangerau, Azura Z. Aziz and Rethy Chhem .................................................................... 25 3 Perception of Radiation Risk: The Ethical Dimensions of Coping with Disaster Deborah Oughton and Penelope Engel-Hills .............................................................................. 40 4 Risk Communication Yuko Fujigaki and Kwan-Hoong Ng .......................................................................................... 62 5 Social Determinants of Health Laurence Monnais ....................................................................................................................... 77 6 Professionalism, Law & Ethics Tamra Lysaght and Satoshi Kodama .......................................................................................... 91 7 Learning across Disaster: Rebuilding Health Kim Fortun ................................................................................................................................ 102 Glossary ................................................................................................................. 113 iii GUIDE TO THE HANDBOOK: PROMOTING LEARNING THROUGH CURRICULUM Penelope Engel-Hills1 Introduction The compound disaster in Fukushima alerted the medical community to the need for all healthcare practitioners and educators to engage with the complexities and dynamics of patients as integral to society. The need for awareness and understanding of the social aspects of health, disease and healthcare, in disaster, has been exposed. This handbook is one response to this acknowledged need and is prepared for medical students and all healthcare practitioners. Each of the chapters of the handbook draws on the valuable lessons learnt from the Fukushima Daiichi nuclear accident and incorporates applied case studies of this and other disasters. However the goal of the handbook is to provide a platform to stimulate discussion and