Beyond Becquerel and Sievert: Mental health and psychosocial support before, during and after radiation emergencies.

Introduction

Emergencies1, including radiation emergencies can seriously impact the “mental health and psychosocial well-being” of those affected (WHO 2020). Acute and long-term non-radiological health impacts of radiation emergencies and of the emergency response interventions are well documented and increasingly recognized. These include a range of various health conditions related to limited access to health care and health services, which could be especially critical for vulnerable populations (e.g. pregnant or lactating women, young children, elderly, ill persons and people with a disability) for whom emergency interventions such as sheltering, evacuation and resettlement may lead to drastic outcomes. The death toll of the evacuation of critically ill patients from health facilities in response to Fukushima nuclear accident is a tragic reminder of this (Tsubokura 2018).

For the purpose of this manuscript, only mental health and psychological impact of radiation emergencies and emergency interventions are meant by the term “non-radiological health consequences”. Long-lasting mental health and psychosocial consequences amongst individuals and societies were described after the Chernobyl and Fukushima nuclear accidents 1986 and 2011 respectively (WHO, 2006; Hasegawa et al 2015; Havenaar et al., 2016, UNSCEAR 2022). “Survivors of the Hiroshima and Nagasaki bombings were still having nightmares more than 50 years after the bombings, living in fear about the health consequences for the next generations” (Watts 2000).

The threat to health is a powerful stressor for populations affected by radiological or nuclear emergencies (Fukasawa 2017; Miura 2017). In addition, the protective actions aimed at safeguarding people's health, “such as iodine thyroid blocking, radiation monitoring, decontamination, sheltering and evacuation can also lead to fear, anxiety and anger amongst affected people” (BKK 2011, Hasegawa 2015, Nukui 2018, Carr 2018).

While international radiation safety standards make provisions for the inclusion of measures to address “mental health and psychosocial needs” in emergency response and recovery plans, they are limited in detail and practical guidance. The WHO “Framework for Mental Health and Psychosocial Support in Radiological and Nuclear Emergencies” (WHO 2020) was developed through interdisciplinary collaboration between radiation protection and “mental health and psychosocial support” (MHPSS) experts to fill this gap (OECD Nuclear Energy Agency). The aim of this publication is to highlight that MHPSS can and should be integrated into the full cycle of nuclear or radiological emergencies: preparedness, response, and recovery. The framework is applicable to a broad range of radiation emergency scenarios, from an isolated radiological accident to a full-scale emergency at a nuclear installation2.

This publication is based on and summarizes “A Framework for Mental Health and Psychosocial Support in Radiological and Nuclear Emergencies” (WHO 2020). It refers to existing literature, lessons learned from past radiological and nuclear and other public health emergencies, evidence and agreed best practices, and international standards and guidelines.

Rationale

Strengthening national capacities for preparedness, response and recovery after radiological and nuclear emergencies is an integral aspect of implementing the “International Health Regulations (IHR)” (2005).3 Monitoring of the “IHR” implementation through annual reporting and Joint External Evaluation (WHO 2018) missions indicate that half of WHO's Member States are still lacking essential elements of preparedness pertaining to radiation emergencies (WHO 2020). Likewise, only “28% of the WHO Member States report MHPSS preparedness programs” (WHO 2021a).

According to international guidance “Mental health and psychosocial support must be an integral part of emergency assessments, preparation, response and recovery plans” (IASC 2007). Governments around the world acknowledged this fact during the “Seventy-fourth World Health Assembly”, held in May 2021, where the Assembly urged countries “to develop and strengthen MHPSS services as part of strengthening preparedness, response and resilience to COVID-19 and future public health emergencies” (WHO 2021b).

“Mental health and psychosocial support aim to promote psychosocial well-being and/or prevent or treat mental disorder” (IASC 2007). It looks at the needs of individuals, families and communities. The WHO Framework makes use of this approach (WHO 2020). Traditionally, there is a more reactive approach to hazardous events, however, strong arguments exist for shifting MHPSS paradigms towards more proactive action that emphasizes preparedness, prevention and disaster risk reduction, while strengthening individual, community, societal and global resilience (Gray et al., 2020; IASC, 2021; WHO 2019), as recommended in the 2015 Sendai Framework for Disaster Risk Reduction” (UNDRR 2015). However, too often, “MHPSS activities and services are not following international guidance, are stand-alone initiatives and lack a coordinated approach” (NL Ministry of Foreign Affairs 2019).

It is recognized that the radiation protection system needs to take into consideration the psychological, social and economic consequences of radiation emergencies, as well as the impacts of emergency countermeasures on the exposed population (IAEA 2015; Carr et al 2016). Several cross-cutting issues should be addressed throughout the entire emergency cycle. Firstly, building common understanding among different actors with diverse views is key to effective coordination (IASC 2007). Secondly, “accurate information, provided early, often, and in languages and channels they understand, trust and use, enables people to make choices and take actions to protect themselves, their families and their communities” (WHO 2017). The COVID-19 pandemic has shown how people increasingly use social media to seek information. It also shows how correct and easy accessible information helps to prevent the spreading of misinformation and rumors (Tsoa et al 2021). At the same time, lack of, or incorrect or inconsistent information have been shown to increase public concerns (Gouweloos et al 2014) and may contribute to increased anxiety, distrust, and stigma. Thirdly, “emergency-affected people are first and foremost to be acknowledged as active participants in improving individual and collective well-being” (IASC 2007). Active involvement, gives people a sense of control, it promotes hope and coping and helps them to be “more active in rebuilding their own lives and communities” (IASC 2007; IASC 2019). Fourthly, in crisis and post-crisis settings the “mental health and psychosocial needs greatly exceed the response capacity of local communities and national and international responders” (Patel et al 2018). Investment in capacity building and a competent workforce is essential. Lastly, avoiding potential risks and keeping communities safe require core ethical values. These values are elaborated on in various guidelines (IASC 2007, IASC 2014, ICRP 2017).

WHO “Framework for mental health and psychosocial support in radiological and nuclear emergencies” (WHO 2020)

The WHO Framework addresses the abovementioned cross-cutting issues by identifying key elements in the integration of MHPSS for emergency preparedness, response and recovery planning (WHO 2020). The following section outlines main sections of the framework.

“Mental health and psychosocial consequences of radiological and nuclear emergencies” (WHO 2020)

Non-radiological impact of radiation emergencies, such as fear and uncertainty about radiation risks, are common and can be significant. “The number of people who are mentally affected can be considerably higher than the amount of injured persons” (BKK 2011). “Actions designed to protect human lives (such as iodine thyroid blocking, radiation monitoring and decontamination, sheltering, and evacuation) could impact on the mental health of affected people” (WHO 2020). Furthermore, because they are concerned about radiation exposure, people may overwhelm health services. (Hasegawa 2015, Carr 2018). In addition, there may be “social stigma towards affected people (including the workers of the affected nuclear facility)” (WHO 2020). For example, people, including children, that were evacuated after the Fukushima Nuclear accident 2011, experienced bullying (Sawano 2014). Fear for discrimination may lead to self-stigma (Watts 2000).

Identification of at-risk groups and people with specific requirements

“Almost all people affected by crisis will experience psychological distress. Many people show resilience and their distress usually improves over time” (IASC 2007). However, estimates indicating the rates of mental disorders in people affected by emergencies are high. For instance, a recent WHO study showed that “approximately one person in five living in conflict settings experiences a mental health condition in the 10 years following” (Charlson 2019). In the case of radiation emergencies, at-risk groups and people with specific requirements may include:

“People in close proximity to extremely stressful events, such as an explosion at an accident site “(IASC 2007);

“Parents and future parents concerned about the long-term effects of radiation and health of their children” (Bromet et al 2011; Maeda & Oe 2017; Miura et al 2017, Nukui et al 2018);

Children from affected areas who “may face discrimination, stigmatization and bullying at school” (Sawano et al 2018);

“People in residential facilities/institutions” (Nukui et al 2018);

“People with pre-existing mental health and psychosocial needs” (IASC 2007);

“Evacuees, as well as the members of hosting communities, whose lives were affected by the evacuation” (IASC 2007);

“First responders, health workers, clean-up workers, reporters and other responders working under hazardous or stressful conditions” (Rahu 2006, Matsuoka et al 2012; Nukui et al 2018);

“The workers (and their families) of the nuclear facility where the accident took place, who may be blamed for the accident” (WHO 2020).

People at-risk may have specific needs. They also have the capacities that enable them to contribute to and participate in humanitarian decisions that affect them. Care must be taken to avoid stigmatizing of at risk groups by targeting support only at them (IASC 2007).

Cross-cutting considerations for mental health and psychosocial support throughout the emergency cycle

Several cross-cutting issues need to be addressed throughout the entire emergency cycle. These issues are also known as ‘the 5 C's’: Coordination, Communication, Community Involvement, Capacity Building, and Core Ethics (Table 1).

Table 1

The five C's of the “Mental Health and Psychosocial Support (MHPSS) framework for radiological and nuclear emergencies” (WHO 2020)a

Cross-cutting mental health and psychosocial support (MHPSS) considerations for the entire radiation emergency cycle: preparedness, response and recovery
Coordination	• Coordination through inter-sectoral MHPSS working groups can guide action. • Coordination must involve functional lines of communication, clear operating procedures and agreed roles and responsibilities.
Communication	• Implementing emergency risk communication (ERC) strategies – developed during the preparedness stage and involving all stakeholders – increases the effectiveness of protective actions and can reduce fear. • ERC should include clear messaging about protective actions that is inclusive, adapted and disseminated by trained communicators who will listen to concerns.
Community involvement	• Affected people should be viewed as leaders in designing and implementing MHPSS activities that build upon existing community support networks. • Emergency response planners should identify trusted community leaders and involve them in decision-making throughout the emergency cycle.
Capacity Building	• Health-care workers, first responders and MHPSS providers should be trained in basic psychosocial support and in basic radiation protection. • Policies and procedures should be established to support the “mental health and well-being” of first responders, clean-up and plant workers and health-care staff.
Core ethical principlesb	• Care must be taken to ensure the primacy of community needs and protection from exploitation, abuse and discrimination. • Local culture and values should be respected and confidentiality maintained.

Used with permission of the World Health Organisation(ICRP 2018)

In addition to core ethical principles described elsewhere (ICRP 2018)

Key mental health and psychosocial support considerations for the different phases of the radiation emergency cycle

Different phases of the radiation emergency cycle include an emergency preparedness phase, an emergency response phase (combining both early and late response), and a recovery phase that includes a transition phase. Depending on the type and scale of emergency, these phases may overlap. Notably, there is generally an overlap in the “mental health and psychosocial needs” of populations across these emergency phases (WHO 2020).

Planning for emergency response

Planning for emergency response includes the development of an overall mental health policy, with provisions for specific emergency situations, such as contingency plans, operational procedures, identified priorities and criteria for resource allocation, as well as plans for their evaluation and revision. MHPSS planning should be informed by a risk, vulnerability, and a needs assessment. This includes the

“identification of the potential adverse impacts of radiation protection actions, of appropriate counter measures, of system's potential weaknesses, of priority needs and of capability or resource gaps. Furthermore, during this phase, mapping of the existing resources, including all available formal and informal MHPSS mechanisms should take place. Capacity building activities (training, exercises, drills etc.) should include MHPSS elements. Indicators for monitoring and evaluation the impact of MHPSS efforts during and after the emergency, should be identified at this stage” (WHO 2020).

A monitoring and evaluation strategy should include the impact of various MHPSS efforts at different levels, and address coordination, communication and capacity building, as well as MHPSS efforts at community- and individual levels. The “Inter-Agency Standing Committee (IASC), Common Monitoring and Evaluation Framework for Mental Health and Psychosocial Support in Emergency Settings” is a helpful instrument for this purpose (IASC 2021b).

Emergency response phase

“During a nuclear emergency, communities at risk of exposure may be asked to implement protective actions, such as iodine thyroid blocking (ITB), sheltering in place or evacuation. These measures, while necessary, can also result in fear, anxiety, confusion and anger.” They should be preceded and accompanied by an information campaign. Clear information should be given about the purpose and the process of these protective actions in order to promote awareness, to give some sense of control, and to reduce anxiety. Also, individual radiation monitoring and decontamination can be uncomfortable and provoke anxiety. The procedure should be arranged in a way that people are reasonably safe and comfortable, with appropriate religious and cultural considerations in mind. All actions should comply with radiation protection requirements and aim to promote healthy living” (WHO 2020).

Community and local leaders can play an important role in promoting the “mental health and psychosocial well-being” in their communities, and in ensuring compliance with the emergency protective actions. Therefore, collaboration with them is of importance.

Transition and recovery phase

Because the non-radiological impact of radiation emergencies is long-lasting, actions should be implemented with a focus on "community-based approaches to MHPSS” (IASC 2019). “Community-based approaches” tend to be more sustainable because they emphasize building on existing systems of support” (IASC 2007). “Coupled with communication campaigns tailored for specific situations and specific population groups, these efforts can be crucial for people's well-being and for the long-term resilience of the community” (WHO 2020).

Social stigma towards people affected by the emergency may be common and can prevent them from seeking help. “Dissemination of accessible, accurate and timely information can be effective in promoting social cohesion and reducing further risk of stigmatization” (WHO 2020). Also, “activities that are integrated into wider systems (e.g. existing community support mechanisms, formal/non-formal school systems, general health services, general mental health services, social services, etc.) tend to reach more people, are often more sustainable, and tend to carry less stigma” (IASC 2007).

Next steps

The WHO Framework discussed herein provides an initial step towards implementing practical actions to address the “non-radiological impact of radiation emergencies” (WHO 2020). However, this framework represents only the beginning. It is crucial that relevant international stakeholders and national authorities recognize and address the “non-radiological impact of radiation emergencies” and integrate MHPSS within their countries’ emergency preparedness plans. Adequate resources should be allocated to MHPSS and a monitoring and evaluation system for its implementation should be in place (WHO 2021c).

Since 2019, a dedicated “Expert Group on Non Radiological public health aspects (EGNR) of the Committee for Radiological protection and Public Health at the Nuclear Energy Agency” (NEA/OECD) with participation of WHO experts has been addressing the mental health and psychosocial and societal impact of protection actions. The EGNR is currently working towards developing mitigation measures for “mental health and psychosocial aspects” and operationalizing the WHO Framework through practical solutions, approaches and tools (OECD 2020). The operational guidance on non-radiological impact of radiation emergencies also has to be included into the existing system of international emergency preparedness and response norms and standards.

Conclusion

“Mental health and psychosocial consequences of radiation emergencies may outweigh the direct health impact of radiation exposure” (BKK 2011). These will in turn affect over-all health and well-being of people. Therefore, a public health approach that encompasses MHPSS is crucial and must include inter-disciplinary capacity building, community engagement, and targeted risk communication. At all times, core ethical principles must be respected while implementing MHPSS in radiation emergency preparedness, response and recovery.

The WHO “Framework for Mental Health and Psychosocial Support in Radiological and Nuclear Emergencies” (WHO 2020) was developed through the collaboration between radiation protection- and MHPSS experts. It represents an initial step towards integrating MHPSS within existing radiation emergency preparedness and response arrangements.

Practical tools need to be developed in order to promote the integration of MHPSS within existing radiation emergency preparedness plans and protection actions. Research is needed to further understand mental health vulnerability to radiation emergencies and strengthen the evidence base for appropriate actions.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.