[Special Feature: Disaster Prevention and Communication] Motoyasu Yamazaki: What is the Meaning of "Preventable Disaster Death"? — Through the Experience of Evacuation Coordination in the Noto Peninsula Earthquake

Are you familiar with the term "Preventable Disaster Death"? Understanding the meaning of this term, including its evolution over time, will surely help in understanding modern disaster medicine in Japan, so I would like to discuss its significance.

"Preventable Disaster Death" is defined as a "disaster death where there was a possibility of life-saving if peacetime emergency medical care had been provided." Following reports that approximately 500 (about 7.8%) of the 6,434 fatalities in the Great Hanshin-Awaji Earthquake were potentially "preventable disaster deaths" due to delays in initial emergency medical care, preventing these deaths has since become the primary goal of disaster medicine in Japan.

In the Great Hanshin-Awaji Earthquake, it was pointed out that while the functions of medical institutions within the disaster area significantly declined immediately after the event, there was a shortage of medical teams entering the area from outside to provide aid, a lack of means to transport severely injured patients out of the disaster area, and a lack of information-sharing infrastructure. Using these lessons, systems that form the backbone of current disaster medicine were established, such as disaster base hospitals, DMAT (Disaster Medical Assistance Team), wide-area medical transport, and EMIS (Emergency Medical Information System). It can truly be said that the history of modern disaster medicine in Japan began with the Great Hanshin-Awaji Earthquake.

The concept of the so-called "72-hour survival wall" also originated from the Great Hanshin-Awaji Earthquake. It was reported that the percentage of survivors among those rescued dropped rapidly from 74.9% (518/692) on the first day to 24.2% (195/806) on the second day, 15.1% (133/883) on the third day, and 5.4% (26/484) on the fourth day. Consequently, the importance of rapid rescue and emergency services to break through the "72-hour wall" became a shared understanding.

Furthermore, the fact that 77% of deaths were caused by suffocation or being crushed by collapsed houses and 9% were due to fire-related burns or thermal injuries—meaning trauma-related deaths, or so-called "direct disaster deaths," accounted for the majority—is likely one reason why the perception of "disaster medicine ≈ emergency medical care immediately after the disaster" spread. Incidentally, I graduated from the School of Medicine in 1995, the very year the Great Hanshin-Awaji Earthquake occurred, which was also the catalyst for me to pursue a career as an emergency physician.

In fact, the concept of "Preventable Disaster Death" has its roots in "Preventable Trauma Death" for severe trauma patients in peacetime. This refers to cases where it is believed the patient would not have died if they had received appropriate medical care or if standard procedures had been performed after the injury. Generally, the probability of survival (Ps) is calculated (TRISS method) using the patient's age, consciousness level at the first visit, blood pressure, pulse, and the degree of bodily injury obtained through diagnostic imaging or surgery. Cases where the patient died despite a Ps ≥ 0.5 are first classified as "Unexpected Death." Furthermore, after a peer review by multiple independent trauma specialists, it is determined whether it was a "Preventable Trauma Death." Various measures are then taken to prevent such deaths, helping to improve the quality of medical care.

This concept first became widespread in the United States, but it began to attract attention in Japan following a 2001 Health and Labour Sciences Research study. A questionnaire survey of emergency and critical care centers nationwide revealed that a staggering 38.6% of trauma deaths in one year (excluding those who were cardiopulmonary arrest on arrival) were judged to be "highly likely preventable trauma deaths." This situation was roughly equivalent to that of the United States 30 years prior, and significant regional and facility disparities within Japan were also pointed out. These results were shocking to Japanese emergency medical professionals, especially since the survey targeted only emergency and critical care centers (so-called tertiary emergency hospitals) that are supposed to provide the highest level of emergency medical care in Japan.

In response to these results, training systems for standard initial trauma care and aid, such as JATEC (Japan Advanced Trauma Evaluation and Care) and JPTEC (Japan Prehospital Trauma Evaluation and Care), as well as emergency transport means like the Doctor-Heli (medical helicopter) program, were established and spread nationwide. In particular, as of 2024, 57 Doctor-Helis are in operation across 47 prefectures, and they are being utilized as an important means of patient transport during disasters, including the Noto Peninsula Earthquake. Some regions have also implemented their own measures; for example, in 2014, Yokohama City designated two of its nine emergency and critical care centers (Saiseikai Yokohama-shi Tobu Hospital and Yokohama City University Medical Center) as "Yokohama City Major Trauma Centers," centralizing emergency transport and trauma physicians for severe trauma patients. A verification report in 2022 stated that this has had a certain effect on reducing "Preventable Trauma Deaths."

While I was working at Saiseikai Yokohama-shi Tobu Hospital, I also served as the director of the Yokohama City Major Trauma Center. As symbolized by the phrase "Trauma is the neglected disease of modern society," I felt firsthand the importance of not dismissing severe trauma as an "unfortunate accident" but recognizing it as a "disease that will inevitably occur with a certain probability in a region" and responding by building a system for the entire region. This way of thinking has a high affinity with preventing the aforementioned "Preventable Disaster Deaths"—that is, "saving trauma patients immediately after a disaster through emergency medical care"—and it can be said that the perception of "disaster medicine ≈ emergency medical care" exists as an underlying current among Japanese professionals.

However, on the other hand, saving lives during a disaster is no longer necessarily just a matter of emergency medical care in the early stages. In particular, the majority of deaths in the Great East Japan Earthquake were due to drowning from the tsunami, and many who escaped the tsunami were uninjured. Therefore, it was a disaster where the previous standard approach of "saving the injured immediately after the disaster through emergency medical care" did not apply. Furthermore, because it was a region with an aging population, it was characteristic that many victims developed illnesses such as pneumonia because it became difficult to maintain health during evacuation life.

Even in such a situation, "Preventable Disaster Deaths" still existed. According to a report from Iwate Medical University, which investigated the causes of death for 153 people who died in the 20 days following the disaster at 15 hospitals in the coastal areas of Iwate Prefecture, 63 people (41.2%) died from causes related to the disaster. Among them, 28 (18.3%) were considered to be "potential preventable disaster deaths," with causes analyzed as deterioration of the living environment, decline in hospital functions, breakdown of information-sharing functions, and delays in early medical intervention.

In other words, rather than acute emergency care or surgical treatment, chronic phase medical care and internal medicine treatments—dealing with the difficulty of continuing treatment for chronic diseases, drug shortages, and infectious diseases—came into focus. As a result, it was recognized that to prevent "Preventable Disaster Deaths," it is important to have a bird's-eye view of the entire region from immediately after the disaster through the chronic phase, and to develop human resources and networks that coordinate across various organizations and medical teams. Following the Great East Japan Earthquake, "disaster-related deaths" began to attract attention as a cause of "Preventable Disaster Deaths," in addition to "direct deaths" such as injuries from collapsing houses. In the subsequent Kumamoto Earthquake, while there were 50 direct deaths, there were over 200 related deaths. Consequently, "disaster-related deaths" are now receiving even more attention, and it is recognized that preventing them leads to preventing "Preventable Disaster Deaths."

Also, during the Great East Japan Earthquake, coastal hospitals suffered such immense damage that they could not continue medical operations, leading to frequent "hospital evacuations" where all inpatients were moved inland. In this context, I would like to mention Futaba Hospital, located about 4.5 km from the Fukushima Daiichi Nuclear Power Plant, which was forced to evacuate all its inpatients. Approximately 400 inpatients and residents, including those from related facilities, were evacuated by bus, but a very tragic situation occurred where about 50 people died during or immediately after the transport. Naturally, they did not die from radiation exposure. Deaths associated with such evacuation actions are "disaster-related deaths," and the thought that these might have been "Preventable Disaster Deaths" is shared by many disaster medical professionals.

Moving a large group of people who require continuous medical care or nursing over long distances in large buses inherently carries great risks, and the period immediately following an earthquake, tsunami, or nuclear accident is one of extreme chaos. Safely transporting a large number of patients over long distances without interrupting medical care or nursing in the midst of a disaster is an extremely difficult task. However, through this painful experience, the system for transporting many patients over long distances while maintaining medical care and nursing was strengthened, centered on DMAT and DPAT (Disaster Psychiatric Assistance Team). As a result, in the subsequent Kumamoto Earthquake (transporting 1,459 people from 11 hospitals) and the 2019 Boso Peninsula Typhoon (transporting 99 people from one hospital to 20 hospitals inside and outside the prefecture), no deaths occurred during transport.

These activities were also repeated during the COVID-19 pandemic. For example, in the response to the Diamond Princess cruise ship in 2020, where I served as a DMAT member for transport and other duties, 769 COVID-19 positive individuals were transported over long distances to 16 prefectures, from Miyagi in the north to Osaka in the west, and admitted to hospitals and other facilities. This was made possible precisely because the experience of disaster medicine centered on DMAT was utilized.

While patient transport outside the disaster area was initially conceived during the Great Hanshin-Awaji Earthquake with the emergency treatment of trauma patients (such as those with crush syndrome) in mind, it has now evolved to include a chronic-phase perspective aimed at continuing the medical care and nursing that was provided before the disaster.

In January 2024, as a DMAT member within the Health, Medical, and Welfare Coordination Headquarters of the Ishikawa Prefectural Government, I was in charge of the practical coordination for evacuating residents of elderly welfare facilities from the severely damaged Oku-Noto region to areas south of Kanazawa City, or outside the prefecture to Toyama, Fukui, Aichi, and other prefectures. I would like to reflect on the response to the Noto Peninsula Earthquake once again.

By January, when it became certain that water outages would be prolonged, the peak of winter had arrived, and securing medical and nursing care personnel was extremely difficult, many hospitals and social welfare facilities were forced to transport inpatients and residents to areas south of Kanazawa City or outside the prefecture. According to the Japanese Association for Disaster Medicine, this involved 915 inpatients and 701 facility residents; if cases where people moved on their own are included, the number is estimated to be around 2,000. Because so many evacuees were admitted simultaneously, hospitals and welfare facilities near Kanazawa City became full, and emergency medical care in Kanazawa City became strained. However, by utilizing cooperation with administrative agencies, DMAT, the Self-Defense Forces, Doctor-Helis, care managers, and others, the transport itself was generally carried out safely. In that sense, it can be said that "Preventable Disaster Deaths" were prevented and "disaster-related deaths" were reduced.

However, according to a report by the Japanese Association for Disaster Medicine, as of June 4, 2024, six months later, only 5 out of 68 people transported from social welfare facilities in the disaster area to Aichi Prefecture have been able to return to Ishikawa Prefecture. Fifty-one are still hospitalized or in facilities within Aichi Prefecture, 4 have transferred to facilities in other prefectures, and 8 have already passed away in Aichi Prefecture.

It was a situation where transport to distant locations was necessary to avoid "disaster-related deaths," and many of those transported were very elderly. However, taking these results seriously, I cannot help but deeply reconsider whether my coordination within the Ishikawa Prefectural Government truly contributed to the happiness of the victims, and what the correct answer was. Is it possible that we should have prioritized the option of remaining in the local disaster area, even while accepting the risks of "disaster-related death" or "Preventable Disaster Death"? In other words, the question of whether there was something more important than "preventing disaster death" weighs heavily on my heart as someone involved in coordinating the long-distance transport of many victims.

Currently, the Ministry of Health, Labour and Welfare has proposed the "Guidelines on the Process of Medical and Care Decision-Making at the End of Life." These guidelines recommend that medical care and nursing at the end of life should be based on the individual's decision-making, with families and medical/care teams discussing it with the individual repeatedly in advance. Such discussion forums and processes are called Advance Care Planning (ACP), and their adoption is being promoted. As a method for decision-making, Shared Decision Making (SDM) is recommended—a technique where everyone thinks and discusses together, rather than leaning unilaterally toward the thoughts of only the individual, only the family, or only the medical/care team.

In the past, such discussions tended to be limited to cancer patients and to the terminal stage where the time of death could be clearly identified. However, it is now believed that discussions should take place even for non-cancer patients and not just when a clear terminal stage is recognized, but also in daily life. Furthermore, since an individual's wishes can change, it is required to discuss and reconsider each time.

In fact, in 2014, the Japanese Association for Acute Medicine, the Japanese Society of Intensive Care Medicine, and the Japanese Circulation Society proposed the "Guidelines for End-of-Life Care in Emergency and Intensive Care — Recommendations from Three Societies." These target emergency patients and heart disease patients, and a revision to a joint guideline involving four societies, including the Japanese Society for Palliative Medicine, is planned for 2025. While there is a general idea that "emergency patients should first be saved with all effort," it might be said that even in the world of emergency medical care, there are things that should be prioritized over simply "saving a life."

In that sense, it is possible that similar values could arise in disaster medicine. Of course, "direct deaths" should be avoided as much as possible, and it remains important to prevent "Preventable Disaster Deaths," including "disaster-related deaths." However, whether "preventing disaster death" should be the top priority in all cases might be something that cannot be understood without being close to and unraveling the victim's own life.

To that end, what kind of life values does one usually hold? What does one want to prioritize at the final stage of life? Whether in daily life or when an emergency or disaster occurs, communication that seeks the individual's happiness through discussion at each turn will likely be required of people in all positions.