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The skin of our teeth - How ISO 14001 helped save lives

The Pacific coastal regions of Eastern Japan were severely damaged by a tsunami triggered by the Great East Japan Earthquake that struck at 14:46 JST on 11 March 2011.

Though the tsunami washed away the Greenhills Dental Clinic in Minamisanriku, all the patients and staff members who were on the premises at the time escaped unharmed. How did they manage it?

This is a case which illustrates how certification to ISO 14001: 2004, Environmental management systems  ̶  Requirements with guidance for use,  can reap benefits even its authors did not directly intend. The primary focus of this International Standard is to protect the environment from human activity; in this particular case, it protected humans from their environment.

This standard, for which the clinic had received certification, not only describes structural concepts to improve methods for dealing with environmental issues in organizations, but it also requires organizations to prepare for emergency evacuations, even those involving the challenge of a 15-metre high tsunami wave. Subclause 4.4.7 Emergency preparedness and response gives only cursory guidance on how to deal with emergencies and their aftermath, but a diligent stakeholder used it to put together a faultless evacuation plan.

On 11 March 2011, the clinic's staff were advised by the emergency warning system that a tsunami had been generated and was advancing towards the coast. Greenhills' director, Dr. Nagayuki Sato, ordered all staff and patients on the premises to evacuate to a previously identified location. After checking that everyone had been evacuated, Dr. Sato then joined his staff and patients at the designated meeting point.

Despite all the panic and confusion arising from this catastrophe, everyone made it out safely.

ISO 14001 also recommends reviewing procedures with the experience gained in the aftermath of an emergency or disaster, and revising them where necessary. After the disaster, Dr. Sato discovered that examination data for patients had been lost when flood waters damaged electronic equipment. He is now considering using cloud storage to ensure that data can be extracted where and when necessary, protected from potentially destructive local conditions.

A very personal story follows. Dr. Sato kept a cool head in the midst of a tsunami, implementing elements of ISO 14001 to evacuate his clinic, saving the lives of his patients and colleagues. He also describes how, thanks to ISO's protocols, he began putting his professional life back together again in the aftermath of a cataclysm.

Out of harm's way

by Nagayuki Sato

The world's media covered the tragedy extensively. The toll was brutal: the dead and missing numbered 19 153 by February 2012. Before the disaster, the population of Minamisanriku, my hometown in Miyagi prefecture, was 17 382; the total of the dead and missing after the disaster was 1 206. Sixty-one percent of the buildings in the town had been damaged or entirely swept away by the rampaging flood waters. After the earthquake and tsunami, vital links of communication, electricity, water supply and transportation were cut off. Access to medical facilities was lost.

Essential infrastructure had been destroyed. It took ten days to restore mobile phone service. It took three months to restore electricity and four months to restore a clean water supply. Five months after the disaster struck, provisional housing in the town of Minamisanriku was completed and, only then, could temporary evacuation accommodations be returned to their former functions.

Living in an earthquake zone

I was the manager of a dental clinic in the town of Minamisanriku. When the disaster struck, there were 13 people in our clinic: five patients and eight members of clinical staff, including myself. Miyagi prefecture is a region which suffers major earthquake damage once every 30 years. Therefore, the clinic's procedural manuals clearly stipulated emergency measures to be taken in case of earthquake.

Every year, these measures were put into practice in regular emergency drills conducted with the help of the Minamisanriku fire department. As a result, even though the clinic itself and buildings within a 2-km radius were flooded, patients and staff were safely evacuated.

When the water receded

Two weeks after the earthquake and tsunami, I joined a mobile unit of dental professionals providing emergency care, working from a bus at the bay side arena evacuation centre in Minamisanriku and other clinics in my area. I subsequently moved to a temporary dental clinic set up at the evacuation centre in Shizugawa-shizen-no-ie, to carry out dental work on displaced persons.

In attempting to manage the aftermath of the crisis, the greatest concern became the loss of clinical records. All the clinical data had been stored, in chronological order, on ten external hard discs. The most recent back-up was kept in my home, located 1.2 km from the clinic. My home's location had no history of being hit by large tsunamis. However, due to the size of the tsunami this time, my own home was destroyed, washed away, and our back-up data were largely lost.

Some of the data were, fortunately, unaffected. Before the disaster struck, I had begun to experiment with data back-up on cloud storage. All the data that could be salvaged concerned risk assessment tools on tooth decay and gum disease in adult patients.

Disaster-related diseases

The number of earthquakes and tsunamis that have hit Japan over the years have, sadly, given us extensive experience dealing with the diseases whose onset can occur in the aftermath. In January 1995,

6 437 people died or went missing due to the Hanshin-Awaji Earthquake. Out of that toll, 922 people were confirmed dead due to earthquake-related diseases.

The most common cause of death was pneumonia. Moreover, it is reported that many cases of aspiration pneumonitis were diagnosed in the elderly. Poor hygiene conditions in shelters contributed to health issues many displaced persons experienced (particularly the elderly, many of whom had lost their dentures in the evacuation). The inability to maintain proper oral hygiene is a leading cause of aspiration pneumonitis.

Lessons learned

Nine years later, in October 2004, when the Niigata Chuetsu Earthquake occurred, dental emergency services were immediately set up. Though the seismic intensity of this earthquake was much lower than the Hanshin-Awaji with far fewer fatalities, only eight people were confirmed to have died from pneumonia with only one case confirmed to have been caused by aspiration pneumonitis, among 50 earthquake-related disease deaths.

Immediately after the Great East Japan Earthquake struck in 2011, the importance of oral hygiene and dental care was strongly emphasized.

Phoenix rising

Survival was the first hurdle, then came the difficult task of rebuilding. A decision was taken to move the clinic to a new location. By September 2011, though there was no name plate on the makeshift structure being used as the temporary office for the dental clinic, next door construction of a new clinic was already underway.

And then in December 2011, nine months after the earthquake and tsunami, I started work at a newly constructed clinic in Tome city in the Miyagi prefecture, which is about 20 km from Minamisanriku.

When operations began, one of the most valuable elements to ensure continuity and adequate dental care, was the surviving data to serve as the basis for resuming practice. The most valuable element was, of course, the reunion with all clinical staff and our regular patients.

And at this point, after the catastrophe, grants began to arrive from all over the world. To these generous benefactors, may I express the gratitude of my country and say:  DOMO ARIGATO!

About the Author

Nagayuki Sato, DDS, PhD had his dental practice at the Greenhills Dental Clinic, Tome City, Miyagi Prefecture. A graduate of the Iwate Medical University School of Dentistry, he also holds graduate degrees from Tohoku University. Dr. Sato is a member of the faculty of Tohoku University School of Dentistry and a fellow of the American Academy of Periodontology.