Kizuna refers to the strength of Japanese society. It signifies the ties that bind people together and thus Japan’s intangible social resources.

Journalists and academics have honed in on how kizuna affects the recovery process in the aftermath of disasters, highlighting the critical role of social networks and personal contacts in forming the core engine of recovery. Undeniably, kizuna served as the foundation of resilience and the recovery in Fukushima. But it is an unfortunate reality that in 2011 Japan had to resort to kizuna, even during the initial phase of crisis management, due to inadequate centralised management.

The Rebuild Japan Initiative Foundation studied the responses of four hospitals located within a 20 to 30 kilometre radius of the Fukushima Daiichi Plant immediately after the 11 March disaster. This area was designated as a sheltering zone, within which people were allowed to stay, but were required to remain indoors whenever a radioactive plume was expected to pass by. A number of commercial companies — including couriers, medical suppliers and agencies that supply support staff to hospitals — opted to cease providing services and withdrew their staff as early as the evening of the disaster.

Within two days, hospital staff had fell by two-thirds on average and stockpiles of medicine and other essentials had begun to run out. With supply channels skewed and minimal personnel, four hospitals were left to their own devices. All became seriously under-resourced and resorted to frantically calling any of their available contacts for help.

The study revealed the challenges each hospital faced; both in the logistics required to maintain medical functions and in making the necessary preparations for voluntary evacuation. Under the current disaster management system, Fukushima prefecture’s disaster control headquarters was supposed to gather all relevant information from the representatives of each division responsible for a specific issue, such as provision and transportation of necessities. But, with a shortage of staff and insufficient information, the malfunctioning of the headquarters was inevitable.

Rarely was a hospital able to reach the headquarters due to substandard telecommunications, and even when this was possible hospitals found the headquarters overstretched and overwhelmed. This prevented the efficient matching of available resources to needs, and inhibited authorities from facilitating the delivery of much-needed medical goods, food, water, gasoline and other forms of help to hospitals for a week, before an official supply route was set up.

Instead, what filled this gap in centralised management in the first week after the disaster was spontaneous operational coordination arranged through personal connections. Some of the four hospitals managed to continue providing community healthcare and medical treatment to critical patients until they finally transferred them outside the sheltering zone. This was made possible by the voluntary support of a few companies that decided to continue deliveries to the area, namely Kowa Yakuhin, a major Fukushima-based pharmaceutical supplier, and Koike Medical, a provider  of medical gases, and the efforts of the Japan Self-Defense Forces (SDF).

Moving supplies to, and evacuating patients from, these stranded hospitals relied entirely on the SDF, since virtually no one else dared to enter the sheltering zone until the beginning of April. The SDF took over transportation during the last 10 kilometre leg, which was not in their original mandate. Hospitals and the SDF orchestrated their operations through the personal connections doctors formed through various channels such as their university alumni community, through individual politicians at both the local and national level, and through the national academic network that extends beyond Fukushima.

Despite their brave efforts, there is a major drawback to this type of bottom-up, network-based crisis response: it puts too much reliance on the capabilities, attributes and connections of each individual. The director of one hospital — who had social resources outside of the local health authority’s official jurisdiction — managed to ensure relatively smooth coordination between large hospitals in other prefectures, the SDF, local police and municipalities. Not all hospitals were that fortunate. Those with lesser social resources could not hold out longer than few days and therefore decided to temporarily suspend operations, moving out of the area. After only 10 days, with all four hospitals voluntary evacuated, healthcare in the sheltering zone ceased.

It was only possible to continue healthcare services during those 10 days through the herculean efforts made by the volunteers who remained. A crisis response framework based on such self-sacrifice is fragile and cannot be applied elsewhere. Japan urgently needs to examine the logistical and evacuation problems that undermined its disaster management system. But five years on, little progress has been made.

Instead of one-off and ad-hoc support arrangements, Japan should install systematic public–private coordination schemes that clarify the systems for medical collaboration and compensation scheme for the collaborators not only in a crisis, but also during ordinary activity. Japan must now look beyond kizuna and build a crisis response apparatus that doesn’t overly rely on the goodwill of the Japanese people.

Kay Kitazawa is Research Director at the Rebuild Japan Initiative Foundation.