In recent years, depopulation and aging have progressed rapidly in rural areas, posing serious challenges to the sustainability of local communities. When a disaster strikes, the shortage of human resources and the increase in those vulnerable to disasters become even more severe, making it difficult for local residents to cope with the situation on their own. Therefore, continuous collaboration with government, medical, nursing, and welfare institutions would be essential [1]. It is necessary to build a robust regional disaster prevention system that functions effectively in the event of a disaster. This continuity becomes the foundation for protecting the region. In this article, some examples of local initiatives are described that were initiated through the Regional Collaboration Association, Kizuna (RCA-Kizuna). Kizuna means bonds of the heart in Japanese [2].

Conventional Disaster Medical Care and DMAT

Disaster medicine has traditionally focused on life-saving efforts and hyperacute response at disaster sites such as earthquake [1]. Rapid relief is certainly important. However, when disasters affect a wide area and cause long-term damage, medical institutions alone cannot respond to a large number of evacuees. Evacuation shelter operations span a long period, from the time of disaster to recovery. Therefore, a support system in which diverse professions work together is essential. For example, maintaining a safe and healthy evacuation shelter environment and providing prompt medical care are required. This is because these factors directly affect the lives and health of disaster victims, and responsiveness to external conditions such as weather and temperature can affect survival rates.

The Disaster Medical Assistance Team (DMAT) was established in 2005 after the Great Hanshin-Awaji Earthquake [3]. Since the Great East Japan Earthquake, various disaster medical dispatch teams have been developed [4]. These medical teams have been active in various disasters and have gradually become more sophisticated. DMAT, in particular, functions nationwide as the core of rapid medical support during the hyperacute phase. Based on our extensive experience, we believe that a system for early hospitalization at disaster-reliant hospitals close to the affected area is essential. This means that the medical institution closest to the disaster area will be responsible for the initial response. In the cases of difficulty to treat, they will be required to direct and coordinate the rapid transport of patients to more advanced medical institutions outside the disaster area. This is a natural progression, but in the event of a disaster, many hurdles arise, such as maintaining hospital functions, securing personnel, and sharing information. It is only through training and cooperation during peacetime that this can be made more effective.

Supporting the "Disaster Vulnerable"

Evacuation centers will house many "disaster vulnerable" individuals, including the elderly, people with disabilities, and residents with multiple underlying conditions [5]. Supporting these individuals requires more than just hyperacute care, where continuous, highly specialized support is essential. The Noto Peninsula earthquake that occurred on January 1, 2024, highlighted this real-world challenge. The affected areas are experiencing a significant aging and declining population [6]. While residents previously required daily medical and nursing care services, local nursing facilities had lost coordination and were unable to provide support at evacuation centers, creating a dire situation. Specifically, nursing care staff were unable to provide services, and medical support teams such as DMAT and Japan Medical Association Team (JMAT) took on a wide range of tasks, including daily living and monitoring. The activities of nursing care staff are particularly important. Based on this experience, the national government urged each prefecture to form Disaster Waiver Teams (DWATs).

For DWATs dispatched from outside to function smoothly, the establishment of appropriate medical, nursing, and administrative systems in the receiving areas and daily coordination are essential. Community-based medical institutions and care providers have a deep understanding of people's daily lives and health conditions. If these institutions do not have a well-established information and support system, confusion will arise in information sharing and the division of roles during a disaster. Even if the organizations are different, building mutual relationships and sharing policies during normal times will directly lead to smooth cooperation during a disaster.

Bonds of Community Collaboration

The Great East Japan Earthquake occurred on March 11, 2011, which was a large disaster [7]. One month later, the chairman of the Social Medical Corporation Houetsu-kai (then known as Medical Corporation Houetsukai) visited Mangokuura, Ishinomaki City, Miyagi Prefecture [8]. It was as a member of the Tokushima Medical Association's medical relief team. He learned that in large-scale disasters, there is community cooperation, and it is the community strength that supports the community and makes cities, towns, prefectures, and countries function [2]. The Nankai Trough earthquake, which is sure to occur in the future, will be accompanied by large-scale disasters. With this in mind, we need an organization that can expand close cooperation between the various professions that support the community on a daily basis.

At the same time, the corporate staff wanted to establish an association where local medical, nursing, and welfare services could raise the level of each other, regardless of their size, and where private sectors could complement each other's differences in their services. Driven by the passion of those involved, the Community Collaboration Association "Kizuna?CCA-Kizuna?"?was established in September 2013. The Houetsukai provides administrative support to ensure that everyone, from government and private sectors, can participate, and has continued to hold regular meetings and study sessions 4-5 times a year. Until now, membership was primarily from Mima city and Tsurugi town, but by expanding collaboration with government agencies to increase contributions to the community, the association has gradually grown to include staffs from Mima city, Tsurugi town, and public health centers.

Collaboration with DMAT and AMDA

Houetsu Hospital, a member of the Houetsukai Social Medical Corporation, joined the DMAT in July 2014 and has actively provided support to disaster-stricken areas and participated in various drills. DMAT has continued various activities for years according to certain guidelines [9]. The 2023 large-scale earthquake medical activities, led by the Cabinet Office and DMAT, simulated damage to four Shikoku prefectures and two Kyushu prefectures. These drills are sponsored by the national and prefectural governments, and are not usually announced to municipalities.

We requested Mima city to conduct this drill, which was based on the same disaster situation and time scale as the one we conducted. The purpose was to foster collaboration between medical care, nursing care, and government administration. The Kizuna Chairman and other relevant parties participated, sharing information about local nursing care facilities and establishing support systems. Learning from these lessons, we have encouraged staffs from the city hall health and welfare department, long-term care insurance department, crisis management department, and public health center to participate in regular Kizuna meetings to further promote collaboration.

The Houetsu-kai is also a member of the AMDA Nankai trough disaster response platform collaboration conference, and AMDA regularly participates in these drills and meetings [10]. In the January 2024, Noto peninsula earthquake occurred. At once, Kizuna members, the Japan medical association disaster medical assistance team (JMAT), nursing care-related teams, DMAT secretariat staff, and AMDA all actively participated. They reported on their activities together and continue to exchange opinions. In August 2025, we conducted a Mima city disaster response headquarters operation training, during which we confirmed the effective interoperability of each organization (Figures 1 and 2).

Figure 1: Disaster Management Headquarters operation training.

Figure 2: The drill of inter-organizational mutual communication

Practical Training for Simultaneous Opening of Medical Aid Stations and Welfare Evacuation Shelters

On October 24, 2025, an important drill was conducted at Udatsu Arena in Mima city, in order to set up a wide-area evacuation shelter to accommodate victims from the southern part of the prefecture in the event of a Nankai Trough earthquake. It was a secondary venue for the Tokushima Prefecture Comprehensive Disaster Prevention Drill. The arena has been designated as a regional evacuation shelter, and a practical training exercise was conducted in which a medical aid station and a welfare evacuation room were opened within the same venue. The purpose of this drill was to establish a seamless collaboration between medical care and welfare by dispatching doctors from the medical aid station to the welfare evacuation room to provide medical care (Figure 3). In previous disaster prevention drills, medical care and welfare services have almost always been operated separately, and it is extremely rare for local nursing care facilities to collaborate and work with the government. This drill emphasized collaboration based on a realistic disaster scenario, specifically reviewing the division of roles, traffic flow, and information sharing methods.

For the management of Mima city, local government, medical care, and welfare departments are working together to improve disaster response capabilities. It was driven by a strong sense of responsibility to "protect our community ourselves." In many regions, there is insufficient coordination between medical care and nursing care. Consequently, very few institutions seem to establish a system of cooperation with the government's crisis management department. From mentioned above, Mima city's efforts for years are worth spreading nationwide as a "model case of regional disaster prevention" that can be put into practice even in regional cities experiencing depopulation.

Figure 3: A drill in role playing for medical staff and patient.

Concerning our disaster prevention drills, similar drills were performed and evaluated [11]. They surveyed the degree of knowledge and attitude before and after the drill. The results showed significant increase of both achievement. Consequently, such drills of DMAT would bring positive changes of knowledge and attitude the participants. Therefore, such training by DMAT is believed to bring about positive changes in the knowledge and attitudes of participants, and useful guidelines are gradually being developed [12].

As the population continues to decline, the ability to protect a community in the event of a disaster will be proportional to the depth of cooperation established during peacetime. The collaborative system between local government, medical care, nursing care, and welfare that Mima city has built up to date is likely to become increasingly important in the future. We hope that this initiative will not only serve as a model for improving community strength on a daily basis and protecting communities from disasters, but also revitalize communities across the country, connecting them and creating a brighter Japan.

Conflict of interest: The authors have read and approved the final version of the manuscript. The authors have no conflicts of interest to declare.

Funding: There was no funding received for this paper.

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