Chapter 35!

Improvement of Disaster Medicine
Field of expertise: International Cooperation for Disaster Medicine

Shinichi Egawa
SummaryThe disaster medical system in Japan began with the 1995 Great Hanshin Awaji Earthquake andevolved after the 2011 Great East Japan Earthquake. We must prepare for and know that every
disaster affects people's health differently. The Sendai Framework for Disaster Risk Reduction
described, for the first time, the concept of protecting physical and mental health and thepreparedness of disaster medicine. Health promotion in the ordinary time is actually the effort weput toward sound disaster risk reduction!
Keywords: disaster medical system, change of medical needs, information sharing, coordination,business continuity plan (BCP), Sendai Framework for Disaster Risk Reduction, life expectancydisaster risk correlation

Introduction
The national disaster medical system established after the 1995 Great Hanshin Awaji
Earthquake functioned well at the 2011 Great East Japan Earthquake and saved many lives. But,
unexpectedly, there were fewer injuries than expected. Chronic diseases, mental health care, andthe recovery and reconstruction of local healthcare became the most significant problems, and thedisaster medical system needed revision.

1: Problems Revealed by the Great East Japan Earthquake
What happened?
The 1995 Great Hanshin Awaji Earthquake killed 6,000 people and injured more than
40,000 people, mainly by the collapsed houses and buildings. At that moment, medical doctors
estimated many preventable disaster deaths and established a national disaster medical system toreduce such deaths. The Japanese government certified more than 700 disaster base hospitals
and more than 1,000 disaster medical assistance teams (DMATs) to arrive at the affected areawithin 24-48 hours after the onset. Because of the difficulty in providing satisfactory medicalservices in the affected areas, the national disaster medical system had the staging care unit for
wide-area transportation and the emergency medical information system for coordination (Figure35-1).
1

The reality of the damage
The tsunami resulted in 20,000 deaths and losses. Still, the number of direct injuries wasaround 6,000 because of the improved anti-seismic structures based on the experience in theGreat Hanshin Awaji Earthquake and in anticipation of Miyagi Earthquakes every 30-40 years. Onthe other hand, there were more than 400,000 displaced people, many of whom suffered fromhealth problems. The most frequent medical need in the evacuation centers and the residential
area was non-communicable disease (68%), such as chronic disease or pollinosis, followed by
infectious diseases (22%) because of the worsened sanitation and hygiene, mental healthproblems (6%), including sleep disturbance and anxiety, minor injuries (4%) caused by clearing
rubble. There were medical needs with pregnant mothers and infants (0.3%) (Figure 2) (Suda etal., 2019).

Figure 35-1. The national disaster medical system in Japan

Figure 35-2. The trend of medical needs in Minamisanriku Town, Miyagi Prefecture, after the Great
East Japan Earthquake (Suda et al., 2019)
Because of the aging society, the inactive lifestyle in the evacuation centers had asignificant impact. Due to the physical and mental expiration, the official disaster-related deaths,
including suicides, reached more than 3,000. The hospitals and the healthcare workers wereaffected. Especially in the coastal areas, the tsunami killed many patients and medical staff andforced hospital evacuations. Even though the healthcare workers themselves were affected, they
had to care for other affected people without rest.
2

2: Paradigms Destroyed by the Earthquake
Conventional wisdom and necessary responses
The national disaster medical system after the Great Hanshin Awaji Earthquake assumed
the multi-casualties after an earthquake and focused on the transportation of the severely injured
patients to the resource-rich area. The Disaster Base Hospitals had anti-seismic structures andemergency power supplies but did not expect and prepare for the loss of its functions. The nuclear
power plant accident created an unprecedented situation for the relief medical teams to protect thesafety and security of patients and healthcare workers in the affected area.
In the Great East Japan Earthquake, the primary purpose of the medical relief teams was tofill the gaps between the medical needs and supplies in the affected area. For example, thehemodialysis resource in the Kesennuma area became too short. The network of relief teams
conducted a mission to transport many patients to the Tohoku University Hospital to provide
transient hemodialysis and finally transported them to Hokkaido Island or the Tokyo Metropolitan
area. No patient died because of the unavailability of hemodialysis. Hospital evacuation with skilledcoordination by Japan DMAT considering the radioactivity and adjusting the upper limit of relief aidworkers, the relief mission from the radioactive area became successful. Substitution from Tohoku
University Hospital helped the affected local healthcare workers rest. Based on the long-term
mental health damage after the Great Hanshin Awaji Earthquake, many psychosocial assistanceteams came in immediately and provided long-term mental health support. To avoid an inactive
lifestyle that will lead to the disuse syndrome of older people, rehabilitation support teams provided
early intervention. The shortage of public health nurses meant that public health assistance fromthe supporting local governments was needed. With keeping the radiology safe, medical relief
teams offered support to protect affected people's health.

3: A New Approach
After the Great East Japan Earthquake, the change of health affects and medical needs
became apparent, and the national government revised the disaster medical system. Every
prefecture had appointed disaster medical coordinators to respond simultaneously to various
medical needs and to coordinate various stakeholders using the disaster medical system. The roleof DMAT became more focused on the support of affected hospitals. The emergency medical
information system was updated by integrating the geographical information system to indicate thelocation and situation of target hospitals, evacuation centers, and the DMATs for effective
information sharing. It became mandatory for disaster base hospitals to implement the business
continuity plan (BCP) for certification. Various expert teams now exist, including the disaster
psychiatry assistance team (DPAT), Japan Rehabilitation Assistance Team (JRAT), Disaster
Health Emergency Assistance Team (DHEAT) for public health assistance, liaison teams forpediatrics, and hemodialysis. There is a new system, called J-SPEED, for surveilling the healthsituation of evacuation centers. These teams join the operation of medical and public healthheadquarters in disaster drills assuming the South Trough Earthquake, or the Tokyo Metropolitan
Earthquake.

4: Achievements and the Future3

A new approach to disaster science
The Sendai Framework for Disaster Risk Reduction 2015-2030, for the first time, clearly
described that disaster affects the health of people. There is significantly increased usage of theword “health” (Egawa et al., 2018). Disaster risk is a function of hazard and exposure, vulnerability,and lack of coping capacity. I clarified the negative correlation between life expectancy and overall
disaster risk as shown in Figure 35-3. Japan has high hazard and exposure risks including
earthquakes, tsunamis, and typhoons. But Japan has very low vulnerability risks such as poverty,
under-five-malnutrition, under-five-mortality, and very low lack-of-coping capacity risks such as
medical doctors per capita, and the lack of access to healthcare. Consequently, the overall
INFORM risk index is very low and the life expectancy is very high in Japan. A healthy society isresilient against disasters.

Figure 35-3. Countries with high life expectancy have low disaster risk
The INFORM disaster risk index is squaring of hazard & exposure risk, vulnerability risk, and lackof coping capacity risk (Egawa et al., 2018)

Conclusion - from the author
Disaster comes back in a cycle longer than a human’s life. Disaster creates a panic but its
memory does not last generations. Forgetting is a necessary function for human beings to keep
living. The health needs in future disasters will be different from the health needs we experienced
in the Great East Japan Earthquake. Please take a moment to think about the bigger picture
regarding how we can build a healthy society that is resilient against disasters.

References
Egawa, S., Jibiki, Y., Sasaki, D., et al. (2018). The correlation between life expectancy and disasterrisk. Journal of Disaster Research, 13(6), 1049-1061. http://doi.org/10.20965/jdr.2018.p1049
Ministry of Health, Labor, and Welfare. (2011). Report on the National Disaster Medical System.
https://www.mhlw.go.jp/shingi/0106/s0629-3.html (In Japanese)
Suda, T., Murakami, A., Nakamura, Y., et al. (2019). Medical Needs in Minamisanriku Town after
the Great East Japan Earthquake. The Tohoku Journal of Experimental Medicine, 248(2), 73-86.
https://doi.org/10.1620/tjem.248.73.

4