title: Fukushima after the Great East Japan Earthquake: lessons for developing responsive and resilient health systems.
abstract: BACKGROUND
  On 11 March 2011, the Great East Japan Earthquake, followed by a tsunami and nuclear-reactor meltdowns, produced one of the most severe disasters in the history of Japan. The adverse impact of this 'triple disaster' on the health of local populations and the health system was substantial. In this study we examine population-level health indicator changes that accompanied the disaster, and discuss options for re-designing Fukushima's health system, and by extension that of Japan, to enhance its responsiveness and resilience to current and future shocks.
  
  
  METHODS
  We used country-level (Japan-average) or prefecture-level data (2005-2014) available from the portal site of Official Statistics of Japan for Fukushima, Miyagi, and Iwate, the prefectures that were most affected by the disaster, to compare trends before (2005-2010) and after (2011-2014) the 'disaster'. We made time-trend line plots to describe changes over time in age-adjusted cause-specific mortality rates in each prefecture.
  
  
  RESULTS
  All three prefectures, and in particular Fukushima, had lower socio-economic indicators, an older population, lower productivity and gross domestic product per capita, and less higher-level industry than the Japan average. All three prefectures were 'medically underserved', with fewer physicians, nurses, ambulance calls and clinics per 100 000 residents than the Japan average. Even before the disaster, age-adjusted all-cause mortality in Fukushima was in general higher than the national rates. After the triple disaster we found that the mortality rate due to myocardial infarction increased substantially in Fukushima while it decreased nationwide. Compared to Japan average, spikes in mortality due to lung disease (all three prefectures), stroke (Iwate and Miyagi), and all-cause mortality (Miyagi and Fukushima) were also observed post-disaster. The cause-specific mortality rate from cancer followed similar trends in all three prefectures to those in Japan as a whole. Although we found a sharp rise in ambulance calls in Iwate and Miyagi, we did not see such a rise in Fukushima: a finding which may indicate limited responsiveness to acute demand because of pre-existing restricted capacity in emergency ambulance services.
  
  
  CONCLUSIONS
  We analyze changes in indicators of health and health systems infrastructure in Fukushima before and five years following the disaster, and explored health systems' strengths and vulnerabilities. Spikes in mortality rates for selected non-infectious conditions common among older individuals were observed compared to the national trends. The results suggest that poorer reserves in the health care delivery system in Fukushima limited its capacity to effectively meet sudden unexpected increases in demand generated by the disaster.
authors.affiliation: Department of Healthcare Epidemiology, Kyoto University, Yoshidakonoe, Sakyo, Kyoto 606-8501, Japan.; Center for Innovative Research for Communities and Clinical Excellence (CIRC(2)LE), Fukushima Medical University, Fukushima, Japan.
authors.forename: Shingo
authors.initials: S
authors.lastname: Fukuma
authors.affiliation: Boston University School of Public Health, Department of Global Health, 801 Massachusetts Avenue, Boston, Massachusetts, USA.
authors.forename: Shahira
authors.initials: S
authors.lastname: Ahmed
authors.affiliation: Graduate School of Business Administration, Keio University, Yokohama, Japan.
authors.forename: Rei
authors.initials: R
authors.lastname: Goto
authors.affiliation: Center for Innovative Research for Communities and Clinical Excellence (CIRC(2)LE), Fukushima Medical University, Fukushima, Japan; Regenstrief Institute, Indiana University School of Medicine, Indianapolis, Indiana, USA.
authors.forename: Thomas S
authors.initials: TS
authors.lastname: Inui
authors.affiliation: Department of Healthcare Epidemiology, Kyoto University, Yoshidakonoe, Sakyo, Kyoto 606-8501, Japan.; Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA; Joint last authorship.
authors.forename: Rifat
authors.initials: R
authors.lastname: Atun
authors.affiliation: Department of Healthcare Epidemiology, Kyoto University, Yoshidakonoe, Sakyo, Kyoto 606-8501, Japan.; Center for Innovative Research for Communities and Clinical Excellence (CIRC(2)LE), Fukushima Medical University, Fukushima, Japan; Joint last authorship.
authors.forename: Shunichi
authors.initials: S
authors.lastname: Fukuhara
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003695:Delivery of Health Care / Q000639:trends; D004190:Disasters / Q000706:statistics & numerical data; D055866:Earthquakes / Q000706:statistics & numerical data; D004632:Emergency Medical Services / Q000458:organization & administration* / Q000600:supply & distribution; D062406:Fukushima Nuclear Accident; D006301:Health Services Needs and Demand / Q000458:organization & administration*; D006308:Health Systems Plans / Q000458:organization & administration*; D006801:Humans; D007564:Japan / Q000453:epidemiology; D008171:Lung Diseases / Q000453:epidemiology / Q000401:mortality; D008483:Medical Assistance / Q000592:standards*; D009026:Mortality / Q000639:trends; D009203:Myocardial Infarction / Q000453:epidemiology / Q000401:mortality; D010820:Physicians / Q000706:statistics & numerical data; D020521:Stroke / Q000453:epidemiology / Q000401:mortality; D057192:Tsunamis / Q000706:statistics & numerical data