Large-scale disasters such as the Nankai Trough megathrust earthquake are evaluated as national crisis [1]. The priority must be saving human lives when a disaster occurs. The government established the Disaster Medical Assistance Team (DMAT) in 2005 and has conducted extensive disaster response and training [2]. While DMATs are responsible for supporting base hospitals and transporting critically ill patients across a wide area, evacuation center operations are the responsibility of municipalities. However, the coordination training between the national and prefectural governments and municipalities has been insufficient. As a result, prompt medical care provision to those in need at evacuation centers has been difficult in some cases.

The 2024 Noto Peninsula earthquake highlighted the inadequate support for the elderly and disabled [3]. Among the disaster, the fragility of support systems were found, particularly in depopulated areas. Since care facilities and support workers themselves are affected by the disaster, there are several limits to the continuation of community welfare. Therefore, the government has developed research of earthquake, Disaster Welfare Assistance Team (DWAT) and encouraging each prefecture to implement its activities [4]. However, even during disasters, collaboration have with those involved in caregiving and welfare in the community on a daily basis is essential. There is a need to build a system that can utilize the cooperation between municipal governments and local medical care in the case of disaster.

During the rescue period of Great East Japan Earthquake, the first author was dispatched to Ishinomaki City, Miyagi prefecture as a member of the Tokushima Prefectural Medical Association [5] (Figure 1).

Figure 1: Actual rescue activity in Ishinomaki in 2011.

a. The registration at the task force.

b. The examination room in the school.

c. Bed for drip infusion in music room.

d. Author is attending in music room.

I have keenly felt the importance of collaboration between medical care, nursing care, and government. Taking the most of this opportunity, I have launched the "Community Collaboration Association - Kizuna" in Tokushima in 2012. It was a forum for deepening collaboration between local medical care and welfare, and has continued to hold regular meetings and study sessions four times a year. Some topics have included urinary disorders, dementia, and eating disorders. In recent years, however, the focus has been on disaster response, where our medical staff should always keep them in our mind.

Disaster Medical Assistance Team (DMAT) was recognized from Tokushima prefecture in July, 2012. DMAT consisted of 5 members in Houetsu hospital, and it was approved to operate as a disaster medical team [6] (Figure 2a). Just two months after the DMAT was established, a DMAT wide-area medical evacuation training exercise was held in September 2012. Sponsored by the Cabinet Office, this exercise also served as a comprehensive disaster prevention exercise for Tokushima Prefecture. Two hospitals in the prefecture, Naruto Hospital and Houetsu Hospital, served as bases for the exercise. Three controllers from the DMAT management organization participated in the training. When the training began, the instructors were surprised to see that all staff had participated and already demonstrated high levels of skill (Figure 2b). This situation was presented at the Japanese Society of Disaster Medicine.

Figure 2: DMAT in Houetsu Hospital, Tokushima.

a. Approved DMAT by Governor of Tokushima Prefecture.

b. DMAT training with all hospital staffs.

Japan is a country prone to earthquakes. This is due to the overlap of four tectonic plates. Numerous studies have suggested that a major Nankai Trough earthquake will occur in the near future—perhaps tomorrow [7]. Its scale could be the largest in the 100 years since modern Japan began its development, suggesting unprecedented.

Figure 3 shows the seismic intensity of various parts of Japan and the areas where a Nankai Trough earthquake is likely to occur. Tokushima Prefecture is close to the epicenter, and the seismic intensity is expected to reach 6-7 (Figure 4). This scale is from Japan Meteorological Agency Seismic Intensity Scale. Furthermore, a large tsunami could arrive in a short period of time, potentially destroying the coastal urban areas east of Tokushima Prefecture. Patients would need to be transported inland to Houetsu Hospital (Figure 5).

Figure 3: Seismic Intensity in each area in West Japan.

Figure 4: Seismic Intensity in each area in Tokushima Prefecture.

Figure 5: Tsunami comes just after Earthquake to Tokushima.

It is important for everyone to prepare for a tsunami at any time. Unless we change the way we live, our government, and our major industries, we risk a situation that could threaten the very existence of our nation. This should be the national policy priority above all else. If an earthquake and tsunami occurs, there will be a considerable number of casualties. In that case, we hope that as many people as possible will survive and be able to work on Japan's reconstruction.

Houetsu Hospital has been a designated DMAT hospital. In 2023, Mima City and "Kizuna" also conducted disaster response training, that was in parallel with the large-scale earthquake drills held in the Shikoku and Kyushu areas. A logistics manager from Houetsu Hospital was dispatched to Mima City's Disaster Response Headquarters as a liaison person, and a representative from "Kizuna" also participated in the headquarters. Furthermore, AMDA participated the training, where we have a disaster support agreement and then the training was practical and satisfactory [6]. AMDA stands for the Association of Medical Doctors of Asia: a global health NGO.

Tokushima Prefecture has been divided into three regions, which are eastern, southern, and western. In the fiscal 2025, the western region had the role of responsible for disaster prevention drills simulating a Nankai Trough earthquake. Mima City plans to operate a large-scale evacuation shelter together with Miyoshi City, and the Medical Association, Kizuna, and AMDA will also participate in cooperation. Prior to the drill, a tabletop exercise was also conducted with local nursing care facilities and related organizations. It was satisfactory performed for confirming the emergence of a local DWAT and the establishment of a new collaborative system.

On October 24, 2025, an important drill was conducted at Udatsu Arena in Mima City [6]. Its purpose was 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.?On the same day, a helicopter rescue drill was also conducted. It involved moving disaster victims from southern Tokushima Prefecture (on the Pacific coast, where there is a high probability of disaster) to a large-scale evacuation center (Udatsu Arena) in Mima City in western Tokushima Prefecture (mountainous area). A helicopter (Japan Maritime Self-Defense Force 24th Squadron) was used to airlift patients to the Houetsu Hospital Heliport. Figure 6 shows the helicopter just before landing. By accumulating the above-mentioned training, we will be able to prepare for future disasters and be able to respond appropriately [8].

Figure 6: A Helicopter Rescue Drill in Comprehensive Disaster Prevention.

Japan has a history of frequent disasters and has responded in various ways. Authors have listed some useful suggestions that will be necessary in the future. Our medical staff are required to be as prepared as possible on a daily basis. Certain kind of community solidarity and everyday collaborative system will become the key to responding not only to large-scale disasters, but also to the ongoing depopulation of our society.

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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