Doctors in Long Aftermaths of Disaster: Fukushima Out of Focus
For IAEA meeting, “Science, Technology and Society (STS) Perspectives on Nuclear Science, Radiation
and Human Health: The View from Asia”
-- draft lecture, 9 November 2015 --
Kim Fortun, Department of Science and Technology Studies
Rensselaer Polytechnic Institute, USA
Abstract
Disasters never really end, imprinting landscapes and imaginations forever, living on in bodies considered
healthy in clinical terms. The long aftermaths of disaster thus pose considerable cultural as well as
scientific, technical and operational challenges. In this presentation, I will describe challenges that
emerge as disasters extend over time, becoming increasingly “out of focus,” casting all social actors,
including health professionals, in new roles. As disasters extend in time, they become increasingly “out of
focus” in a number of ways. Over time, disasters fall out of media attention, calling for active and creative
memorialization to keep both disaster survivors and future disaster risks in mind. This, in turn, calls for
action at different scales – with local survivor communities, regionally, nationally and internationally, with
each scale requiring different ways of focusing and representing disaster. And work at all these scales is
complicated – and often enriched -- by competing ways of thinking about a disaster, and both enduring
and emerging effects. Over time, new research from different disciplines becomes available, people and
established solutions age (and sometimes ossify), and contextual conditions shift (often transforming who
counts as trustworthy, who has resources, and who doesn't, etc.) Robust recovery efforts thus call for
methodological humility, knowledge pluralism, deep collaboration, and innovation of many kinds.
Illustrative examples will be drawn from research at an array of disaster sites, including Bhopal,
Chernobyl, New Orleans, New York City, and Nepal, drawing out how doctors have worked in the long
aftermath of disaster. The presentation will conclude with a call to discuss conditions and dynamics that
will shape the long aftermath of disaster in Fukushima, and roles that can and need to be played by
health professionals, in particular.
Biographical sketch
Kim Fortun is a cultural anthropologist and Professor of Science & Technology Studies at Rensselaer
Polytechnic Institute. Her research and teaching focus on environmental risk and disaster, and on
experimental ethnographic methods and research design. Her research has examined how people in
different geographic and organizational contexts understand environmental problems, uneven
distributions of environmental health risks, developments in the environmental health sciences, and
factors that contribute to disaster vulnerability. Fortun’s book Advocacy After Bhopal Environmentalism,
Disaster, New World Orders was awarded the 2003 Sharon Stephens Prize by the American Ethnological
Society. From 2005-2010, Fortun co-edited the Journal of Cultural Anthropology. Currently, Fortun is
working on a book titled Late Industrialism: Making Environmental Sense, on The Asthma Files, a
collaborative project to understand how air pollution and environmental public health are dealt with in
different contexts, and on design of the Platform for Experimental and Collaborative Ethnography (PECE),
an open source/access digital platform for anthropological and historical research. Fortun also runs the
EcoEd Research Group, which turns ethnographic findings about environmental problems into curriculum
delivered to young students (kindergarten-grade 12), and is helping organize both the Disaster-STS
Research Network, and the Research Data Alliance’s Digital Practices in History and Ethnography
Interest Group.
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Lecture text (20 minutes, 3000 words)
Good morning. I’m honored to be part of this continuing effort to keep the Fukushima disaster in mind,
drawing perspectives from the interdisciplinary field of Science, Technology and Society into thinking
about both local recovery in Fukushima prefecture, and a global need for continuous attention to the
human health implications of radiation, both positive and negative.
I am a cultural anthropologist and STS researcher from the United States, and have spent my career
studying industrial and environmental disasters in different settings. My presentation today will focus on
challenges that emerge as disasters extend over time, becoming increasingly “out of focus,” casting all
social actors, including health professionals, in new roles.
Disasters demand attention, particularly at the outset. All eyes are on diagrams, maps, and other
visualizations that promise to explain why the disaster occurred, and what injuries resulted, both to people
and infrastructure. Such focus is called for. But it has limits — of many kinds. Here, I’ll draw out the many
limits of such sharp focus on disasters, encouraging the development of comparative perspective and
what I have come to think of as “disaster literacy.” The challenge is to see disaster “out of focus,” seeing
both patterns across various disasters, as well as the many ways in which each disaster is indeed in a
class of its own, beyond comparison.
Disaster is often defined as a sudden event that disrupts normal functioning of a community or society;
often, disasters are also cast as intricately unique, and bounded in time. Research across disaster
contexts, however, confirms that disasters are extremely enduring. They continue, often without end.
Often recovery efforts come to be talked about as “second disasters” (Fortun 2001). Research also
confirms that there are recurrent dynamics and challenges across disaster contexts – in the lead-up to
disaster, in the instance and experience of disaster, and in disaster recovery initiatives (Fortun & Frickel,
2012). Awareness of these dynamics and challenges, acquired by working through different disaster
cases, provides a kind of disaster literacy that improves capacity to “read” new disasters as they unfold.
The great Brazilian educator Paulo Friere, author of the book Pedagogy of the Oppressed, used the verb
“read” in this way, encouraging the development of capacity to “read” the historical conditions in which
one lives, noting how structural conditions produce injury, often with social pattern – pointing to
possibilities for redressive collective action. It is this kind of reading of disaster that I am after here.
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Disasters in Data, News and Research
First, it must be noted that disasters, by definition, reveal that something has gone wrong. Disasters are
failures, usually of many kinds. This often provokes secrecy, about the impacts of a disaster as it unfolds,
about the causes of a disaster, and about continuing organizational incapacity to deal with a disaster.
Government agencies implicated in disaster often constrain information flows, for example, striving to
cover up their mistakes or to mitigate public anxiety, or simply because they don’t have the capacity to
process and communicate the data available to them. Often, efforts to anticipate or prepare for disaster
were misdirected; this implicates operational efficacy (the availability of appropriate equipment and
personnel for immediate response, for example) and can exacerbate secrecy. Actors may be reticent to
admit that they prepared for the wrong disaster; they also may not have infrastructure in place for
collecting, analyzing and sharing data on the disaster actually at hand.
Data is always a problem in disaster contexts, in multiple ways, and often becomes an ever more
complex problem over time. How data is collected delimits what problems are recognized. Often, data is
released without means to interpret it. Different nations or units of a government may collect data that is
configured differently, making it difficult to discern where there are contradictions and where there is
complementarity. Increasingly, citizens’ organizations are involved in data collection and circulation in
disaster contexts, leveraging relatively low cost monitoring technologies and social media. This happened
with notable reach in Japan after Fukushima.
Citizen produced data is often more granular and real-time than data produced or made available by
government actors, making it particularly useful for local level decision-making by individuals and families
as well as local governments. This often generates continuing and important debate about the quality and
credibility of different sources and ways of configuring data. Such debates are particularly intense when
there is concern about government information withholding, and subsequent failures of trust. Disasters
thus produce complex communication challenges, often involving a need for continually revised
statements about what is going on. Technical professionals – including health professionals -- are often
challenged to explain changing data and conditions to diverse audiences, and can play critical roles as
advocates for transparency.
[Often, the media doesn’t help. Almost inevitably, there is disaster fatigue —the way media and media
consumers often tire of a topic over time—requiring active, creative memorialization to keep a disaster in
view. Such fatigue is exacerbated by the monotony of many recovery initiatives. Such initiatives often
take a very long time to build and involve bureaucracy, squabbles over money, and tired, sometimes noncompliant “victims.” Scenes of recovery are often neither pretty nor dramatic — boring even, without the
“hook” needed to capture media attention. The period months and years into a disaster thus pose
considerable representational and political challenges. Descriptions of “what happened” often become
canned, even while different versions remain at odds — often lending a shrill tenor to all discussion about
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the disaster. Thirty years after the 1984 Union Carbide chemical plant disaster in Bhopal, India, for
example, several politically charged versions of “what happened” continue to circulate; the debate has
become tiresome to the point of absurdity, and diverts attention from on-going efforts to rebuild the lives
and communities of people impacted by the gas leak. In Chernobyl, the inverse seems to have happened
– in an almost singular focus on plant operator error as “the cause” of the Chernobyl disaster. Again and
again, this narrative has been repeated in the popular press, often with at least some show of contempt
for all things Soviet, suggesting that “it can’t happen here.” Historian Sonja Schmid has shown with
careful detail that the Chernobyl story is far from this simple. Schmid’s book, Producing Power: The PreChernobyl History of the Soviet Nuclear Industry (MIT Press, 2014) provides a detailed and invaluable
description of nuclear power development in the Soviet Union, drawing out a remarkable story of the
development of multiple reactor designs—shaped by strong personalities and intellects, the desire for
international recognition, bureaucratic jockeying, and political culture—and how this came to matter in the
Chernobyl disaster. Her account of the Chernobyl disaster—how it unfolded and was evaluated, how
plant operators were put on trial, how “human error” solidified as the cause—is powerfully instructive,
emphasizing structural conditions and design decisions behind individual decisions leading to
catastrophic technological failure. Clearly, how we narrate our disaster stories matter; how we set up the
characters in these stories has truly fateful effects.] (381 para)
Disasters in Medicine and Public Health Programming
So let us now turn to disaster victims, and how they are staged, particularly as disasters extend over time.
Identification and categorization of victims is always a problem in disaster, exacerbated by evacuations
and relocations. This can slow access to much needed relief, and create new social divisions; those who
aren’t categorized as victims can become a new under-class. Predictable, as well, is the way disaster
exacerbates previously entrenched social inequalities; people that were poor and politically marginalized
before a disaster tend to be even more so after a disaster; gender, age and racial bias also tends to be
exacerbated. Proving their status as victims, and negotiating what counts as a disaster-related harm, can
thus become a major stressor for people impacted by disaster. Identification and categorization of victims
also creates stress for doctors, who know that any diagnosis they provide can implicate access to
resources. And doctors often must help their patients learn to tell the stories that will grant them access
to resources. Anthropologist Vin Kim Nugeyn powerfully writes about this in his book The Republic of
Therapy: Triage and Sovereignty in West Africa’s Time of AIDS. Nugyen describes how stories of
illness and suffering provide access to resources, and how these stories can become overly codified,
bringing some problems to the fore while pushing others to the margins. Patients’ rights can also be
reduced to those conferred by public health programs, undercutting broader rights and political
engagement.
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Then there are the inevitable problems with public health programs to address the injuries and disease
produced by disaster. Such programs are often desperately needed, and must be put together with
limited time and financial resources. Health professionals must determine the types of care that will be
available, methods for assessing a need for care, and supporting documentation that will be required to
secure access to care. Standardized programs of care, with delimitations, are necessary in the aftermath
of disaster (as well as in routine circumstances) but also pose inevitable problems. Particularly since the
nature of injury and disease after disaster so often has environmental dimensions, with contested
impacts.
Diagnosis after disaster is rarely straightforward, requiring linkage between clinical and epidemiological
perspective, ever a troubled relation (as Michael Fischer just emphasized in the talk before mine). The
epidemiology of disaster is complicated, usually calling for inventive study designs and proxies. A 2012
article in the International Journal of Environmental Research for Public Health of is illustrative, including
a chart that lays out inventive epidemiology after disaster in Bhopal, Chernobyl, in New York City in
20012, and resulting from a chlorine gas leak from a train in the US State of North Carolina.
Epidemiologic Methods Lessons Learned from Environmental Public Health Disasters: Chernobyl, the
World Trade Center, Bhopal, and Graniteville, South Carolina
Erik R. Svendsen, Jennifer R. Runkle, Venkata Ramana Dhara, Shao Lin, Marina Naboka, Timothy A.
Mousseau, Charles Bennett. Int J Environ Res Public Health. 2012 August; 9(8): 2894–2909. Published
online 2012 August 16. doi: 10.3390/ijerph9082894
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Ecologist Tim Mousseau, one of the authors of the study, has also done research in the forests of
Fukushima – telling me that “there is a lot that is dead.” Mousseau’s ecological research points to yet
another challenge in the long aftermath of disaster.
New research, from different positions and
perspectives, becomes available, and there is – almost always – different evaluations of what remains
wrong, what is emerging, what can and needs to be done, and on what timetable. Contestation over facts
is just a fact of disaster. The challenge is to recognize divergent knowledge as a structural condition of
disaster, potentially becoming a critical resource.
The logic of medicine, however, often just complicates things, because it habitually resists complication.
Modern health care and research aims to identify the cause and mechanism of disease, progressively
ruling out what is not determinative. The logic is binary: Is it X, or not? If not X, is it then Y, and not Z?
Modern health care and research are also organized into disciplinary specializations, allowing for
impressive depth of knowledge and analysis, but making it difficult to see “the whole (bodily, much less
environmental) system.” And modern health care and research privilege “in-body” constructs of disease;
environmental health stressors are often systematically discounted.
Health professionals in disaster
contexts thus need to see phenomena that established frameworks don’t make visible. This often calls for
intensive collaboration with patients to understand their injuries and illness from their perspective, and
with scientists from different disciplines. The complex multidimensionality of injury associated with many
disasters is thus difficult to deal with clinically and scientifically, and also culturally.
Health care in disaster is also complicated by what anthropologist Mary Jo Good (2007) has termed a
“medical imaginary” that fosters belief that modern medicine can provide both explanation and cures for
any range of ills. Even in the most difficult cancer cases, Good argues, there is often great expectation
that biomedicine will come through – with clear explanations and solutions to the problem of illness. This
drives people in varied positions – patients, family members, doctors, researchers, the media – to
conceive, represent and deal with disease in a particular manner: one which is straightforward and clearly
actionable. People want to know what, exactly, to do when someone is sick, and they count on health
professionals to tell them. Injury and disease in disaster contexts are often much less straightforward.
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Disaster in Social Roles, Ties, and Education
Injury and diesease in disaster are not straightforward because the eitiology and dyanimics of disease is
complicated. Injury and diease in disaster is also complicated because they are not just a matter of
health or economics, the primary means of assessing and responding to disaster. Social, cultural and
educational dyanimis are also crucially important – with enduring effects, not only for disaster survivors
but also for whole socieities.
Anthropologist Adriana Petryna has provided illustrative accounts of life in the years after the 1986
Chernobyl disaster, drawing out how disaster recovery always interlaces with other political
developments. The Chernobyl disaster unfolded as the Soviet Union was breaking up. The new Ukrainian
government, striving to demonstrate that it was more responsive to victims than the Soviets had been,
dramatically lowered what was considered acceptable levels of radiation exposure. This made thousands
more Ukrainians eligible for compensation and set in motion a mass of people looking to be labeled
terminally ill, which had a macabre appeal in a context with few other economic opportunities. Petryna
observes that recovery schemes produce much more than health and wealth; they also produce ways of
being and relating — to governments, to family and friends, to the future. In Petryna’s account, the
expansiveness and design of Ukraine’s recovery scheme created “biological citizens” who were
dependent not only on state welfare, but also on narratives that literally made them sick; sustaining these
narratives was the only way to secure access to much needed economic support, with far reaching
personal ramifications (Petryna 2004, 2002). The lesson is sobering, with clear implications for other
disaster contexts. Recovery schemes in Fukushima need to be built with Petryna’s “biological citizens” in
mind, aware of the hazards of recovery schemes that encourage "non-recovery," producing citizens who
must be sick to be eligible for state support. The lesson is sobering, with clear implications for other
disaster contexts. Recovery schemes in Fukushima need to be built with Petryna’s “biological citizens” in
mind, aware of the hazards of recovery schemes that encourage nonrecovery, producing citizens who
must be sick to be eligible for state support.
It also needs to be acknowledged that, like in Chernobyl,
recovery in Fukushima is playing out in precarious times. As anthropologist of Japan Anne Allison has
poingnatly described, Fukushima has unfolded in a time already “precarious” for many, a time of
economic insecurity, impossible-to-realize aspirations, and disconnection (2013). Recovery schemes for
survivors of the Fukushima disaster need to be designed with this context in mind, striving to cultivate
new forms of social connection, security and collective action
And all should remain alert to implications for the future. U.S. legal scholar Michele Landis Dauber
award-winning recent book The Sympathetic State: Disaster Relief and the Origins of the American
Welfare State provides an important caution. Dauber writes about how the Roosevelt administration made
the Great Depression of the 1930s in the United States into a disaster, justifying an expansive role for
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national government but with a restricted rationale for relief that continues to undermine social welfare
initiatives in the United States today. In Dauber’s account, state recognition of and assumption of
responsibility for injury resulting from the Great Depression depended on the construction of “blameless”
victims, stricken by circumstances beyond their control. It was on these grounds that the Depression was
a “disaster,” and the logic retains currency in the United States today, undergirding paradoxically
unforgiving welfare programming. Disaster recovery is thus significant in many ways often underacknowledged. It sets up the routines, resources, narratives and political positionting of disaster
survivors. Disaster recovery also lays ground for the way whole societies will develop, direct their
resources, legiatimate these resources, and consider themselve on good terms.
Doctors in Disaster
Doctors and other health professionals have important roles to play in all of this,
One clear challenge is the need to work across scale. As I detailed at an earlier conference in this series,
most health professionals are trained to focus on the micro scale, the scale of technical practice and
proficiency: caring for patients in one-on-one encounters. But disaster inevitably draws them into work at
other scales, which challenge their operational and conceptual capabilities.
The micro level is where doctors are conventionally educated to work and focus on. It is the level of
clinical practice, patient-physician engagement, and encounters with patients’ cultural frames. This is a
critically important scale of work, but not the only needing one demanding attention in disaster. The
ecological level is inevitialbiy important, for example; with health professionals engaged in analysis and
debate about contaminatin of soil, water, food and air. At the macro level are policies, laws, and financial
drivers that shape health outcomes.
At the meso level – the level of social organization – are challenges in coordination among healthcare
providers, between government agencies and hospitals, of recovery programs over extended periods of
time.
At the meta level are popular discourses that circulate in media, within families and etc. --
shaping how people think about health and risk. Too often, what happens at the meta level is
perjorativley dismissed as rumor.
What I call the nano level is particularly important, and so often under-attended to. The nano level is
where health professionals make sense of things for themselves, develop world views and thought styles,
and struggle to make sense of the credibility and utility of data inputs from different sources.
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Doctors and other health professionals also need to think historically and structrually.
Physician-
anthropologist Paul Farmer (1996) calls for a “critical epistemology of disease” through which medical
professionals continually question the adequacy of the conceptual and organizational models relied on in
efforts to build health. According to Farmer, medical professionals need to continually evaluate not only
the efficacy of their models and associated programs, but also what these models and programs leave
out. Farmer makes this argument as part of his long-running work to understand and improve health in
the poorest regions of the world. His initial work was in Haiti; he also has worked extensively in Africa. In
these contexts, poor health, according to Farmer, results not only from infectious agents, environmental
contamination and inadequate health services, but also from a long history of colonial exploitation and
continuing social inequality. Models of disease emergence need to be continually updated to address
these many variables, striving to be “global yet alive to local variation,” always questioning what features
of disease emergence are obscured in dominant analytic frameworks. As a matter of routine, Farmer
insists, medical professionals – collaborating with others – need to continually ask, “What is obscured in
this way of conceptualizing disease? What is brought into relief?”
Finally, a last concept that is very important – the concept of a “moral pioneer,” describing how people
sometimes – particularly in disaster contexts -- must invent new modes of judgment to deal with the
information and problems before them. Anthropologist Rayna Rapp used this term to describe the
women she studied dealing with the results of amniocenteses – most of whom did not have a cultural
frame to guide their decision about whether to continue their pregnancy, or not; encountering
amniocentesis information was beyond the reach of established cultural frames. They had to invent ways
to deal with it. Doctors in disaster often also encounter these kinds of situations, needing to invent
relevant modes of judgment, selectively (often under intense time pressure) which information and
examples to use as the basis and justification for decisions. This is never a perfect process, and
requiring a mix of conceptual skill and character. But this is what we need to build to support doctors in
disaster.
Conclusion
Diverse accounts of Fukushima need to be cultivated, curated over time, and built into educational
programs for all ages — in Japan and beyond. And accounts of Fukushima should be engaged alongside
accounts of other disasters — counting on the ricochets set in motion, moving in and out of focus on
Fukushima itself.
The challenge is to see disaster “out of focus,” seeing both patterns across various disasters, as well as
the many ways in which each disaster is indeed in a class of its own, beyond comparison. Following
Paulo Friere, let us build critical pedagogies for disaster.
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DISASTER STS
SHAPING RECOVERY
How has disaster recovery been conceputualized and planned? What roles have different groups of
people played in recovery planning?
What experiences and ideas shape the way people think about, plan and experience disaster recovery
programs?
What resources have been invested in disaster recovery programs and how have they been distributed?
Who can make claims on recovery resources, and through what processes? Is access to recovery
resources perceived as fair and efficient? Who feels left out?
What groups of people will find it most difficult to recover?
What factors will shape recovery in the next ten years, and in the next twenty years? How, in particular,
has the future been imagined by differently positioned groups?
How are recovery programs likely to shape the way people think about themselves, and their roles in their
families, communities and societies?
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