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Twelve years have passed since the Great Hanshin Awaji Earthquake. More than 6400 people died and over half were elderly, aged over 60 years. The elderly who survived also had a hard time. They lost their houses and had to be evacuated.

The 6434 victims of the 1995 Great Hanshin earthquake were mourned at ceremonies and events marking its 12th anniversary on 17 January 2007. Participants prayed for the souls of deceased loved ones, and vowed to pass on the lessons learned in the quake to future generations. One of the ceremonies was held in Kobe. About 4000 people prayed silently beginning at 0549 hours, the exact time the quake occurred.

The earthquake was centred below the major cities of Hanshin district, which include Kobe city of approximately 1.5 million populations. The Japanese scale for damage was 7 and the quake was measured at 7.2 on the Richter scale. If it had happened in the middle of the night while many residents were asleep, rescue work by neighbors might have been impossible. If the earthquake occurred one or two hours later, the transportation systems would have been busy, which might surely have caused the deaths of many more people due to traffic accidents. The number of people affected by the earthquake was estimated as 2.4 million. Over 320 000 people who lost their homes had to stay in emergency shelters. The number of dead was reported to be over 6000. Three-quarters of immediate fatalities were due to asphyxia by house furniture and roof materials. Other major causes were burns, multiple fractures, including of the cervical area, and traumatic shock.

The epicenter of the earthquake is near Kobe. Nobody expected an earthquake in the Kobe area. Kobe University was at the center of the worst hit area. Many victims in Kobe area were able to understand the magnitude of the earthquake only after watching the burning scene on television. It is important to understand that the population affected by a disaster is sometimes the least informed regarding the magnitude and nature of the disaster.

Soon after the earthquake, most of the victims experienced emotional numbness. One victim who lost his parents reported that he felt out of touch with the reality. He said that he could not feel sadness. The sensation of shaking continued due to frequent after-shocks. The writer experienced a kind of depersonalization. Depersonalization could be a psychological protection from the disaster.

Two or three days after the earthquake, the majority of the victims became talkative and joyful. Some people even became hypomanic and showed signs of psychomotor excitement. These symptoms might be caused by the joy of survival.

Major psychiatric problems during the early stage were recurrence of mental disease and epileptic seizures due to the suspension of habitual medication. Loss of memory and disorientation were reported, particularly among the elderly.

For the first week, everybody was anxious to secure food, water and information. Kind of a battlefield camaraderie existed for a certain period. This resulted in sustenance of mental excitement and friendship among victims. However, fear of aftershocks and general anxiety were experienced at the same time. Survivors' guilt was strong for those who lost family members.

After one week, the focus of health care was shifted from emergency medical care to mental health care. Treatment of chronic patients, including those suffering from hypertension, diabetes mellitus and mental diseases was resumed. Care for the senile demented and mentally handicapped was provided in shelters. Insomnia was common in the crowded shelters. Acute stress responses such as nightmares were reported. Psychiatric emergency care was provided at some shelters.

Volunteers, including medical professionals such as psychologists and psychiatrists flooded Kobe and damaged areas. It is reported that almost 1.5 million volunteers from all over Japan, and some from abroad, came to the Hanshin area offering assistance after the earthquake.

Two weeks later, life in shelters became very stressful for many victims. Increases in acute stress responses, including serious stress ulcers, was reported. The Department of Internal Medicine of Kobe University Medical School was busy with the treatment of many cases of extremely serious stress ulcers. Anxiety reactions and sleep disorders were common. An increase in the incidence of pneumonia and bronchitis was reported among the elderly. The earthquake took place in January, which is winter time in Japan.

After two weeks, victims start facing the reality of their loss, including family members, housing and jobs. Depression became manifest among victims. Acute symptoms of post traumatic symptoms (PTSD), such as flashbacks, continued among victims.

After one month, a considerable number of aged people became unable to cope with the continued stressful events of their lives. Among elderly victims, dementia, disorientation and incontinence were often reported. The consumption of alcohol increased among victims, which led to an epidemic of alcohol-related problems in some shelters. Alcohol related violence was sometimes reported. Children showed regression. Burnout syndrome become common among volunteers.

After two months, most of victims were transferred from shelters to temporary housing by lot. Later, this arrangement was criticized. In shelters, neighborhoods stayed together.

At one time, more than 320 000 people were staying in shelters, such as schools and other public buildings. The government started building temporary housing, which was similar to military barracks. For victims allocated to temporary housing by lot, neighbors were foreigners. Any sense of community was destroyed. Many victims faced the degradation of social status and economic difficulty, which in turn caused depression. Such psychological consequences are similar to the experiences of victims of other disasters.

Many problems remain to be solved. Among the major problems affecting victims are psychological difficulties resulting from the socially isolated life in temporary housing. This isolation and loss of community has led to tragedies such as suicides and so-called ‘solitary death’. A lack of local health professionals is cited as one of the major contributing factors to this tragedy. In the Nishi (west) District of Kobe city where more than 7000 people stay at temporary housing, there were less than 20 victims. The most disadvantaged victims included: the elderly who lost kin, a family of mother and children, physically and mentally disadvantaged and foreigners from developing countries.

Many victims lost their jobs and are facing economic difficulties. Unlucky victims still have to pay off loans for houses destroyed by the earthquake. Government and insurance companies have refused to provide personal compensation for the damage caused by the earthquake, including the loss of housing. Burnout, apathy, passivity and loss of hope are common among victims. Alcohol problems are reported to be on the increase among those living in temporary housing.

There are several unknown health and mental health problems among victims. Long-term physical and mental consequences of life in shelters and temporary housing should be studied further. These long-term effects will include the following areas: psychological effects, stress-related physical symptoms such as hypertension, reduced immunity and its effect, allergy, cancer, effects of nutritional unbalance and long-term effects on children.

Many reports have found a relatively low frequency of PTSD among victims compared with the data from disasters in other countries. However, scientific and large-scale epidemiologic studies have yet to be completed for the victims of the great Hanshin Awaji earthquake.

The large number of victims and the limited number of local specialists have been major constraints on the provision of mental health care for the victims of the disaster. Also, the stigma attached to psychiatric care has been noticed. Several psychiatric teams opened psychiatric consultation stations at shelters. However, they were very seldom visited by victims. Conventional psychiatric care showed some limitations in mental health care for the victims of the disaster. The psychological needs of the victims were different from the needs of mentally disturbed patients. The majority of the victims were in need of simple help such as cleaning, carrying water etc. During their stay at shelters, assistance with paperwork, such as requests for temporary housing, was valued by victims. Social work and consideration was what the victims valued the most during their stay at the shelters.

We must continue to promote awareness of psychological problems resulting from the disaster and effective measures to reduce these problems. Services for the victims should be continued. These services are particularly needed for elderly victims living in temporary housing. These services should be supported by the training of specialists, general practitioners and volunteers. However, it should be noted that the problems of victims cannot be solved by the health and social sectors alone. Health professionals should be active in promoting comprehensive and long-term programs for the victims.