Minamata disease: catastrophic poisoning due to a failed public health response.

We present the history of Minamata disease in a chronological order from the public health point of view. Because the appropriate public health response - to investigate and control the outbreak - as set out in the Food Sanitation Act was not conducted, no one knew how many became ill following the outbreak. Exposure could not be stopped. In our discussion, we offer two reasons as to why the Japanese public health agencies did not apply the Act: social circumstances in the 1950s and 1960s that placed emphasis on industrial development, and the Japanese medical community's lack of knowledge about the Act. The history of Minamata disease shows us the consequences when public health responses are not implemented. Minamata disease should be an invaluable lesson for future public health responses.