- Hideto Hirotsune, MD
- Osaka City General Hospital, Department of Child and Adolescent Psychiatry
Yasufumi Asai, MD, Yasushi Ito, MD, Masamitsu Kaneko, MD, Satoshi Nara, MD, Kazuhisa Mori, MD, Shoji Sakano, MD, Masashi Yoshida, MD, Hitoshi Imaizumi, MD, Kenji Kobayashi MD, and Tetsuro Shoji, MD
Department of
Traumatology and Critical Care Medicine, Sapporo Medical
University School of Medicine, Sapporo, Japan
The nations worst multiple chain-reaction traffic accident, which involved 186 vehicles, occurred on the freeway between Sapporo and Chitose International Airport. Two patients died in this accident. Traumatologists from Sapporo Medical University were dispatched to the scene by a helicopter. This was the first landing of a helicopter on a freeway in Japan, where emergency medical activity was performed.
Among the traffic accident victims 76 were slightly injured, 30 were moderately injured and two were dead. The first fatal case was a car driver who was crushed between a large bus and a truck and died on the spot from injuries to the cervical spinal cord.
The other patient who was transported to Sapporo Medical University by the helicopter, was a 38 year old male who was crushed beneath a vehicle. At the time the rescue team arrived, the patient was conscious. The rescue team started oxygen inhalation and requested dispatch of a medical team at 10:13 a.m. Doctors arrived at 10:30 a.m. and intravenous infusion was started. A so-called “medical helicopter” left the rooftop of Sapporo Medical University Hospital at 10:42 a.m. and arrived at the scene ten minutes later. Just as the helicopter arrived, the patient was rescued from the vehicle. Cardiopulmonary resuscitation including endotracheal intubation was performed for about 17 minutes and then he was taken on board the helicopter. Cardiac massage was continued in the helicopter, but cardiopulmonary arrest was confirmed 12 minutes after the arrival at Sapporo Medical University Hospital. Resuscitation efforts including open-cardiac-massage were continued. However, the heart beat did not return and the patient was pronounced dead 40 minutes later.
The problems of this accident in regard to the emergency medical care can be stated as follows:
1) notification of the accident to the medical institutions took more than one hour.
2) although this was a major accident with about 100 casualties, physicians did not carry out triage at the scene.
3) necessity of emergency medical care on site such as doctor attended ambulance and/or helicopter was not thoroughly recognized.
4) communication among hospitals was inadequate.
The following countermeasures are suggested:
1) to prepare an emergency manual for major accidents with close cooperation of physicians.
2) to get doctors on board ambulances and helicopters who can provide emergency treatment at the accident site.
3) to conduct frequent disaster drills on the freeways.
Key Words: Multiple chain-reaction
traffic accident, Transportation by helicopter
Masato Kon, MD, Tadashi Suzuki, MD, and Masatake Ishikawa, MD
Tokyo Women Medical
College, Department of Emergency Medicine
Sarin is a highly toxic, odorless, organophosphate nerve gas which is used as a chemical weapon. On March 20, 1995, terrorist attacks employing sarin gas occurred on the Tokyo Eidan subway lines. The present report deals with the problems in the management of sarin poisoning in relation to a patient of ours who died.
The patient was a 54-year-old man who suffered a cardiac arrest after exposure to sarin on the Marunouchi subway line. Two ambulance officers began cardiopulmonary resuscitation(CPR), but were unable to continue treatment due to their own exposure to sarin. Therefore, the patient was brought to our hospital about 30 minutes later without any vital signs. CPR was performed and the heart beat was restored. About one hour after transfer to the Intensive Care Unit, information about the sarin gas attack was obtained. Although spontaneous respiration resumed and brain activity was detected on EEG waves for a time, it became difficult to maintain blood pressure and the patient died about 20 hours after admission.
Secondary injury to ambulance crew and hospital staff occurred during transportation and after arrival at the hospital due to confusion and lack of information. Our main source of information was the local news media rather than the National Police Agency, the Fire Defense Agency, or the Self Defense Forces. For the future handling of large-scale disasters, an organization should be developed that is capable of nationwide information gathering, analysis, and transmission. Use of a media such as Internet could allow simultaneous reception of data by multiple medical institutions.
Key Words : Sarin, CPAOA, Poisoning
Masaki Kaneda, MD
Toyoko Hospital ,
St. Marianna University School of Medicine
In the event of an earthquake disaster, we can assume that many injured will rush to hospital. In order to be well prepared for this king of disaster, it is important to have a comprehensive medical plan and advanced training. Each hospital must set up emergency plans in order to transport hospital workers to perform triage by medical teams, and to set up emergency treatment centers.
Furthermore, medical personnel should be well aware of their own individual responsibilities during this type of disaster by repeated drills with simulated patients.
St. Marianna Tokyo Hospital is executing annual disaster drills involving all levels of hospital personnel in the assumption of various degrees of hospital damage.
Key Words: Urban earthquake disaster, Triage, Disaster medical planning, Training
Keishi Shiono
Department of Civil
Engineering, Nagaoka College of Technology
On the basis of disaster data collected from past earthquakes in Japan, the author derived relationships between ground shaking severity and injury rate. He also discussed the effect of local characteristics of affected areas on the occurrence of injuries.
First, he collected data from earthquakes that occurred in a period from 1964 to 1984 to examine the relationship between seismic intensity and injury rate. Among the earthquakes investigated were the 1964 Niigata, the 1968 Tokachi-oki, the 1978 Miyagiken-oki, and the 1983 Nihonkai-chubu earthquake. Injuries were defined as patients with no distinction of injury seriousness. A probable upper bound of injury rate was found over a range between 0.1% and 1% for a level of 5 on the Japanese scale of seismic intensity and over a range of 1% and over for a seismic intensity level of 6.
Data of the 1995 Hyogoken-nanbu earthquake were also collected and compared with the relationship mentioned above. As the result, those data essentially coincided with the tendency derived based on the data collected from the past earthquakes.
Second, the author discussed the scattering among the data from the past earthquakes from the view point of the effects of built and social environment of affected areas. Distribution of the injured in Noshiro attributed to the 1983 Nihonkai-chubu earthquake were compared with those of zone units where seismic intensity, collapse rate of buildings, building density, and rate of aged inhabitants (over 65) were relatively high. It was found that the areas in which injuries occurred were, in general, the zone units in which building density was high and aged inhabitant rate was high. This tendency suggests that the people who stay in a small space or are physically inferior are apt to be injured and is consistent with the results from some of the recent studies in which the detail of victimsﾕ surroundings and responses were directly investigated.
Third, the author collected data from the 1978 Miyagiken-oki earthquake to derive two empirical equations applicable to the estimation of occurrence rate of injuries that do and do not require hospitalization, respectively. The load per patient to medical facilities is significantly different between cases with and without hospitalization, it is desirable that the number, or occurrence rate, of hospitalized patients are estimated in addition to the entire number of injuries without distinction of hospitalization. Injury rates were given as functions of damage rate of buildings, which could be correlated with an indicator of ground shaking severity, such as seismic intensity.
Key Words; Earthquake
disaster, Mass casualty, Injury, Injury rate, Damage
estimation
Kiyoshi Tatemichi, MD
Director of
Emergency Department, Kobe City General Hospital
Weakness of hospitals was reviewed on the experiences from the great Hanshin-Awaji Earthquake. Weakness can be summarized into three categories; poor strength of building, functional disability and fragility of equipments.
The Nishishimin Hospital, one of the two municipal hospitals in Kobe, had 7 stories, 5 stories of which were constructed 25 years ago and two stories at the top were added 7 years later. The 5th floor was crashed remaining inside 44 patients and 3 nurses. One patients could not be helped.
The Kobe City General Hospital, the other municipal hospital with 1,000 beds, had buildings tough enough to stand the earthquake but the damages in its utilities (water and gas) and fragilities of equipments deprived of its proper functions as central hospital and emergency center in the disaster. Main causes of hospital dysfunction were destruction of water reservoir at the top of the building and insufficient fixation of equipments.
It will take about 5 years for The Nishishimin Hospital to be rebuilt and start functioning. Renewal of medical equipments need time of 2 to 5 months and water supply started on the 23rd day after the earthquake.
Key Words; Weakness of hospitals, Damage to utilities(Lifeline), Destruction of equipments, Fixation of apparatus
Masanori Matsusaka, MD, Tatsuro Kai, MD, and Muneo Ohta, MD
Osaka Prefectural
Senri Critical Care Medical Center
On January 17, 1995, the Great Hanshin-Awaji earthquake occurred in the Kobe area and the number of deaths amounted to 6,000. The authors present a case of disaster death following injury in this earthquake, and discuss the risk factors of delayed death after the earthquake.
The case was a 20 year old female who was crushed under a collapsed apartment house, and rescued by neighbors about 6 hours after the quake, carried to a first aid station, and then transferred to a city hospital in the disaster area. Three days after the disaster she was transferred from the city hospital to Senri Critical Care Medical Center (SCCMC) to receive tertiary care. Although the necessity of leg amputation and introduction of hemopurification was explained to her family, they could not accept the patient's miserable destiny and refused the operation and the more aggressive treatment. Their minds were much damaged by the disaster experience. The patient died the day after her transport to SCCMC.
Through this delayed-death case after the disaster, several problems in emergency care could be pointed out. In search and rescue, manpower was absolutely insufficient especially in the very early phase after the disaster. Search and rescue teams from outside should come into the disaster area as early as possible. Rescue efforts of civil volunteers in the community should be systematized, as this type of rescue is the most basic, popular and effective method of search and rescue at the time of extensive disaster.
Most of the shelters or first aid stations were not manned by triage experts. It is obviously important that the triage officers should be in any shelters and first aid stations. A system of assigning triage staff in the disaster area should be established.
Every hospital in the disaster area could not get means of transportation in the early phase of the disaster. We have to build up the system of helicopter transportation in the early phase of a disaster, to connect the disaster area and the non-affected area efficiently to carry rescue teams, patients, and relief goods including medical materials.
Deterioration of medical services in the disaster affected hospitals should always be kept in mind. Hospitals should prepare for big scale disasters like earthquake, not only in their structure but also in the system of gathering personnel, communication and logistics.
In the case reported in this paper, the patient's family, who lost everything by the quake, was so severely damaged mentally that they had lost its own will to survive and could not accept further treatment for their daughter. Mental support of the casualties of disasters should be given even from the very early phase of the disaster.
Key Words ; Great Hanshin-Awaji Earthquake, Disaster, Delayed death, Risk factor
Shuhei Tsuboi, MD, Fumio Meguro, MD
Bureau of Public
Health, Kobe City Government, Kobe, Japan
Over 6,000 people died and more than 20,000 residential and commercial buildings were destroyed by the Great Hanshin-Awaji earthquake. Kobe City Government, Bureau of Public Health, dispatched health care personnel to many places 1) to help to provide medical supplies and food for damaged medical facilities, 2) to help evacuees secure places to live and food, 3) to coordinate volunteer activities, 4) to obtain and distribute information on the status of medical facilities, 5) to act as liaison between the government agencies and the medical, dental and pharmacist associations.
From our own experience, we would like to suggest the following plans;
1) to recruit and train health care volunteers
2) to request wholesale dealers of medical supplies to stock emergency medical supplies. At least three days' medical supplies should be kept at each medical facility.
3) to prepare not only medical but also psychiatric and dental relief teams. In case of a large disaster, it is vital to set up a standard for medical records to facilitate medical treatment.
4) to establish an information network connecting city office, each ward office, fire station and medical facilities, by using CATV, wireless and computer network.
5) to consider as priority the prevention of food poisoning and infectious diseases, and on the supply of drinking water by water wagons.
6) to transfer to medical facilities senior citizens living alone, bedridden patients and patients receiving home treatment; alternatively, these patients should be visited frequently by public health nurses.
Key Words: (National Library of Medicine, Medical Subject Headings) The Great Hanshin-Awaji Earthquake, Volunteer workers, Disaster relief work
Hiroko Kuroda
Former Assistant
Head-nurse,Takarazuka City Hospital
The author reported the activity of a nurse who worked in a hospital and a shelter in the midst of the disaster at the time of the Great Hanshin-Awaji Earthquake. In the early stage after the quake, she could only respond to each problem that sprang out one after another, and systematized well-planned relief activity was impossible in the chaos. However, she, as a professional nurse, tried to utilze every available items as nursing devices, to arrange personal medical records,to take care for foods, prevent infection, to assange human relations and security among casualties, and to assist casualties in mental health care, etc.
This report deals with the relief activities of a nurse after the disaster and some proposals derived from her own experience.
Key Words; Shelter, Role of nurses, Mental health care
Mototsugu Kohno, MD, Noriyoshi Ohashi, MD
Department of Emergency, Critical Care Medicine and Traumatology
Tsukuba Medical Center Hospital,
Ibaraki, Japan
The author describes his observations and experiences of the relief activities at the Great Hanshin-Awaji Earthquake of 1995. Tsukuba Medical Center dispatched a relief team fourteen days after the initial tremor and maintained it for three weeks under the supervision of Suma district health agency of Kobe City. Prefectural health organizations from all over Japan dispatched relief teams and Tsukuba Medical Center made all necessary arrangement for its relief team.
The relief mission of the Tsukuba team started when the number of relief activities were at their peak in Kobe City, and ended when other teams began leaving the city. The need for surgical assistance was almost satisfied, but there was still room to discuss the need of external assistance for ongoing health issues. Clinical services and schools were reopening, and previously interrupted railroad schedules were gradually returning to normal. Evacuees began to resume their daily routines, and clinics in the community were reopening for practice. Society was returning to normal.
It was found that the progression of post-disaster events was similar to the progression of a disease, exhibiting acute, sub-acute and chronic phases. Based on his observations and experiences, the author concludes that official agencies should control and coordinate medical relief efforts in the sub-acute phase of post disaster progression.
Key Words; Disaster relief, Sub-acute phase, Relief team, Aid spot
Akira Okita, MD
Director, Osaka
Medical Association
The author describes the experiences of relief operations of the Osaka Medical Association (OMA) after the Great Hanshin-Awaji earthquake, and discuss the newly developed disaster preparedness plan reflecting on these experiences.
In the first two days (acute phase), it was quite difficult to collect information on the availability of medical facilities in the disaster area due to telecommunication cut-off. Relief requests were not received from the disaster area. The extremely congested road traffic isolated the disaster area even from the next-door prefecture. Thus, two days were wasted before the start of relief activities from the OMA. However, during those days, some casualties were self-evacuated from the disaster area and visited hospitals in Osaka for consultation.
On the third day, communication with the disaster area was restored. The OMA made contact with the Hyogo Medical Association and the Hyogo Prefecture government. From then on, official relief operations from the OMA were started. To accept casualties, 4,500 beds were prepared in Osaka in the next few days. 523 renal failure patients (including crush syndrome and chronic renal failure) and 628 newborn babies and pregnant women were transferred from the disaster area. 92 patients were carried by helicopters and some were transferred by ships. In the first three weeks, 3,818 patients were admitted to the hospitals in Osaka, and 7,634 outpatients visited medical facilities for consultation.
Drugs, medical materials and sanitary goods were sent on 6 trucks. Volunteer doctors, nurses, pharmacists and clerks were dispatched to the hospitals in Kobe so that they could help local medical personnel who had been exhausted by the hard and continuous work after the quake. From January 26, two first aid clinics were established by the OMA in Higashinada ward of Kobe. In total, 946 volunteer medical personnel were sent and 11,748 patients were taken care of in these clinics in 160 days.
From the lessons learned in the Great Hanshin-Awaji earthquake, the OMA developed several plans as follows to reinforce emergency medical services in a disaster setting:
1) Plural information networks should be established among local government offices, the OMA and hospitals.
2) Existing Emergency Medical Information Center of Osaka Prefecture should be used more effectively in case of disaster.
3) Osaka Prefecture could be devided into 8 subareas. Each subarea should have at least one core hospital for disaster emergency care. This hospital would be able to decide to dispatch medical teams into the disaster area without any request and should be able to receive casualties without any notice from the disaster area. The OMA should give its full support to these core hospitals.
Key Words; Medical disaster response , Sub-acute phase, Medical response of Osaka Medical Association
Hideto Hirotsune, MD
Osaka City General
Hospital, Department of Child and Adolescent Psychiatry
The psychological consequences of disasters have been the subject of growing attention in the past decade. Disasters may cause not only each individual but also communities severe psychosocial trauma. Thus, in the past twenty years, many countries have made efforts to organize mental health services in preparation for disasters.
At 5:46 a.m. on January 17, 1995, a devastating earthquake named Hanshin-Awaji Earthquake struck the Hanshin Area in Japan. The earthquake killed 6,308 people, destroyed approximately 200,000 houses, and forced more than 300,000 people to become refugees. Many medical rescue and support teams from the whole of Japan hastened to be in the Hanshin area. Mental health specialists,-psychiatrists, psychologists, psychiatric social workers and so on- also gathered there and participated in psychological support activities for the victims, in cooperation with regional mental health personnel. The Hanshin-Awaji Earthquake was an epoch-making disaster in some sense for Japanese mental health specialists, because there had never been such a disaster taxing mental health activities in Japan.
This catastrophic earthquake gave many lessons to the Japanese mental health specialists, such as that, 1)there had been too little preparations in Japan for psychosocial responses to disasters that included organizations of mental health service systems which had been supported socially and politically, as well as medically, and techniques of crisis interventions for psychologically traumatized people, 2)mental health activities should have been much more interested with sections of disaster management, especially disaster medicine, and so on. During and after the disaster, predominant mental health approaches were traditional clinical ones based on so-called medical models that emphasized the diagnosis and cure of disorders. However, the community-oriented, psychosocial model should have been much more stressed in the mental health sector. To make matters worse, further planning and organizing of mental health services were begun only after the earthquake had occurred. It can be said that prevention, preparedness, and mitigation are essentially the key activities for coping with disasters, not only in general but also from the psychosocial point of view.
In order to contribute to an urgent realization of mental health services which would respond to an unexpected disaster in Japan, this paper has reviewed the literatures which had investigated mental health responses to respective disaster cases, and has made some proposals for the future as follows; i)to prevent or treat psychosocial stress-related disorders including post traumatic stress disorder, intervention programs should be carried out as soon as possible. Thus, mental health teams should be sent immediately after an impact and organized systematically. ii)Registration system on a large scale, national level must be established for effective and rapid response.
It is impossible that mental health services during and after disasters can exsist and function alone. All persons who are engaged in disaster management should be trained for basic knowledge of disaster behavior and psychological reactions to disaster, stress-related disorders, and how to deal with the main psychosocial needs of affected people. It is also desirable that the knowledge should become known among citizens. For the most effective crisis intervention, mental health activities should cooperate with the disaster organizations specially involved in emergency work.
Key Words; Disaster, Disaster management, Disaster medicine, Mental health services, Posttraumatic stress disorder
Hisashi Kobayashi,
MD
Ryokufukai Hospital, Osaka Japan
More than 5,500 people were killed
and over 34,900 were injured in the Great Hanshin-Awaji
earthquake of January 17, 1995. The earthquake caused
deterioration of treatment in the hospitals and the
disturbance of transfer of patients.
In the medical reconstruction committee of the Hyogo
prefecture government, problems were discussed to
establish an emergency
disaster medical response plan and preparedness in
earthquakes.
The new Hyogo prefecture emergency disaster medical
system was based on seven precepts:
1) establishment of a channel of emergency medical
information and command system.
2) establishment of a disaster medical center.
3) reinforcement of the regional emergency network
system.
4) establishment of an emergency transportation system.
5) establishment of a system to stockpile medicine and
other necessities.
6) establishment of a municipal disaster medical system.
7) establishment of research and training in disaster
medicine.
Key Words; Great Hanshin-Awaji
Earthquake, Problems of emergency medical system, Hyogo
Prefecture revised emergency disaster medical plan
Masataka Kono
International Relief
Center, Japan Red Cross Society, Tokyo, Japan
1. Japanese Red Cross Society (JRCS) framework
JRCS is a member of the International Red Cross Movement and the head office coordinates all Red Cross operations at chapter offices set up in every prefecture throughout Japan. Ninety-one regional Red Cross hospitals offer ordinary medical services.
2. Legal authority for JRCS relief operations
In accordance with the Disaster Relief Act, the JRCS has been authorized as one of the nationﾕs designated organizations to cooperate with disaster support projects at the time of a disaster. About 3,000 trained medical staff comprising 458 rescue teams at JRCS hospitals are constantly on the alert to respond to any state of emergency.
3. Disaster relief activities
Disaster relief must be further developed in terms of community support and medical relief that cope with the situation which changes from minute-to-minute.
JRCS is making an effort to shorten Phase 0 as much as possible, and is ready to support evacuees by distributing relief items and coordinating volunteers.
4. Review of relief efforts for the Great Hanshin-Awaji earthquake
a. Plans must be formulated to help disaster-stricken JRCS chapters restore coordination functions in the shortest time.
b. We must determine how to rebuild medical care facilities of regional JRC hospitals that are stricken in disasters.
c. It is vitally important to secure promptly the means to transport victims to referral hospitals and to train staffs of referral hospitals who treat large numbers of victims.
Key Words; Japanese Red Cross Society (JRCS), Disaster relief operations, Relief operations following the Hanshin-Awaji Earthquake
Takashi Komura, MA
Research Associate,
National Institute for Defense Studies, Japan Defense
Agency
The Great Hanshin-Awaji Earthquake of January 17,1995 was the turning point of the Self Defense Forces(SDF) disaster relief activities. In this catastrophic disaster, the SDF dispatched a total of about 2,280,000 personnel, 350,000 vehicles, 680 vessels, 13,000 airplanes including helicopters from the first day of the earthquake to April 27 when SDF relief activities ended (101 days). This was the largest relief operation since the SDF was inaugurated. Records of SDF activities were as follows: rescued 165 lives, recovered 1,238 bodies, carried 7,110,000 rations and 230,000 blankets, served 580,000 hot meals and 54,000 metric tons of drinking water, opened 19 first-aid stations and offered 22,000 medical cares, opened 21 outdoor bath stations and offered 515,000 bath-takings(which won high praise from the suffering citizens), cleared various parts of the road amounting to 35 km, cleaned up 2,600 destroyed houses, etc.
The experience of the Great Hanshin-Awaji Earthquake raised not-well-considered and unsolved questions of Japanese disaster management; how should we utilize military resources of the SDF.
The principle of disaster management is "Self-help, Mutual-help, then Public-help, civil sector first, military sector last." In this respect, we should first vitalize ordinary peoplesﾕ counter disaster capabilities. On the other hand, military resources are highly suitable for disaster relief activities. Unfortunately, in Japan, mainly from political debate surrounding the SDF, their capabilities were not well-utilized, but ignored or rejected to play any active role.
The Great Hanshin-Awaji Earthquake drastically changed this atmosphere. People began to acknowledge SDFﾕs capabilities for disaster management and to consider how to utilize them. In this meaning, we should also build a new bridge between SDF and other disaster-related organizations and personnel. Therefore, we must understand more about systems and characteristics of SDF disaster relief activities. In fact, SDF disaster relief activities were not at all well known.
Disaster relief activities of the SDF are one category of national aid for suffering. Local government, which holds primary responsibility for disaster relief, and are to be carried out basic requests of the civil sectors. Prefectural Governors and other designated officers are entitled under article 83 of the SDF law to request the dispatch of SDF units and personnel. Commanding officers of garrisons and other senior commanding officers can send SDF units for relief activities. If the situation is urgent, they can dispatch the SDF without waiting for a request. Although details of relief activities are decided on a case-by-case basis, they are basically classified into 12 categories including search and rescue, medical, health and sanitary control, etc. Costs for these activities are paid by the national budget except for some extra portions(e.g., some special equipment).
The disaster management system, Japan is just like an "orchestra without a conductor." Mutual cooperation is the most important element for successful disaster relief activities but vertically divided administrative culture and lack of knowledge of other disaster-related organizations disturb these efforts. We should share organizationsﾕ characteristics of officers and should develop "the sense of concert master".
Self-sufficient capability, mobility (especially air-mobility) and manpower are the top three main advantages of the SDF that make it quite suitable for disaster relief. In addition, the SDF has much experiences of operations mobilizing many people toward common goals as well as trainings on know-how to do so.
Unfortunately, these hardware and software capabilities of the SDF were not fully acknowledged or utilized in this catastrophe. We must share these capabilities with disaster related organizations and personnel. Above all, training know-how by Commanding Post Exercise (CPX) is one of the skills most necessary for disaster management of such catastrophic disasters.
After the Great Hanshin-Awaji Earthquake, several revisions of the Japanese disaster management system and SDF disaster relief activities have been made. The most important change in the SDF disaster-related system is the revision of the National Defense Program Outline of November, 1995. In this revision, disaster relief activities were situated among the triad of missions of the SDF in the post cold war era. Our present tasks is to put this basic policy into a concrete system in a mutually beneficial manner with other organizations and personnel.
Key Words; Disaster relief activities of the SDF, Medical service Corps, Disaster management system, Rivision of the national defense program