Adapting to Health Impacts of Climate Change in the Department of Defense

Abstract

The Department of Defense (DoD) recognizes climate change as a threat to its mission and recently issued policy to implement climate change adaptation measures. However, the DoD has not conducted a comprehensive assessment of health-related climate change effects. To catalyze the needed assessment—a first step toward a comprehensive DoD climate change adaptation plan for health—this article discusses the DoD relevance of 3 selected climate change impacts: heat injuries, vector-borne diseases, and extreme weather that could lead to natural disasters. The author uses these examples to propose a comprehensive approach to planning for health-related climate change impacts in the DoD.

The Department of Defense recognizes climate change as a threat to its mission and recently issued policy to implement climate change adaptation measures. But it has not conducted a comprehensive assessment of health-related climate change effects. This article discusses the DoD relevance of 3 selected climate change impacts: heat injuries, vector-borne diseases, and extreme weather that could lead to natural disasters.

The most recent Intergovernmental Panel on Climate Change (IPCC) report and US National Climate Assessment (NCA) found that climate change threatens human health through various pathways, including temperature and precipitation extremes, infectious diseases transmitted by arthropod vectors and in food and water, wildfires, decreased air quality, and threats to mental health.^1,2 The Department of Defense (DoD) has not assessed comprehensively how these health threats could affect its personnel and operations. As a first step, this article discusses selected health-related impacts that appear especially significant for the DoD and defines a path toward a comprehensive assessment and the climate change adaptation planning it should inform.

DoD Perspectives on Climate Change

Strategic planning for climate change adaptation in the DoD began most visibly in 2010 with the Quadrennial Defense Review (QDR),³ a congressionally mandated assessment of current and future security threats. The 2010 QDR identified 2 general ways that climate change affects the DoD: climate change could accelerate instability or conflict, and military installations and forces must adapt to a changing climate. This perspective continues to guide DoD planning for climate change

The DoD developed its adaptation strategy further in a 2012 Climate Change Adaptation Roadmap, the 2014 QDR,⁴ and a 2014 update to the Climate Change Adaptation Roadmap.⁵ The 2014 Roadmap, responding to a 2013 Executive Order requiring federal agencies to integrate climate change considerations into their operations,⁶ defined climate change adaptation needs in 4 areas: plans and operations, training and testing, built and natural infrastructure, and acquisition and supply chain management.

The Roadmap identified health-related climate impacts in several areas, calling for assessment of health and safety risks to DoD personnel, possible increased need for health surveillance and health services, changing distributions of infectious disease vectors, and demand for DoD emergency response assistance in the United States and abroad.

After extensive consultations across the department, DoD issued policy implementing the 2014 Roadmap in January 2016. DoD Directive 4715.21, Climate Change Adaptation and Resilience,⁷ requires that mission planning and execution for all DoD operations must include identification and assessment of the effects of climate change, consideration of those effects when developing plans and implementing procedures, and anticipation and management of risks that result from climate change. (The directive defines “adaptation” as “adjustment in natural or human systems in anticipation of or response to a changing environment in a way that effectively uses beneficial opportunities or reduces negative efforts.” It defines “resilience” as the “ability to anticipate, prepare for, and adapt to changing conditions and withstand, respond to, and recover rapidly from disruptions.”)

The directive identifies the Assistant Secretary of Defense for Energy, Installations, and Environment (who reports to the Under Secretary of Defense for Acquisition, Technology, and Logistics) as the DoD's primary climate change adaptation official. Senior officials across the DoD take on new responsibilities to address climate change impacts, including health threats (see sidebar).

Health-Related Tasks in DoD Directive 4715.21, Climate Change Adaptation and Resilience (2016) ⁷

Assistant Secretary of Defense for Special Operations and Low-Intensity Conflict. Under the authority, direction, and control of the Under Secretary of Defense for Policy:

• Monitors and directs appropriate planning for anticipated humanitarian assistance and disaster relief requests for DoD assistance.

• Provides guidance and oversight to the Combatant Commanders on ongoing humanitarian assistance programs and resources to encourage partner nations' efforts for:

o Disaster risk reduction, mitigation, preparedness, and resiliency.

o Building capacity for humanitarian assistance, global health engagement, and disaster prevention in light of changing climate risks.

Under Secretary of Defense for Personnel and Readiness. In coordination with the Under Secretary of Defense for Acquisition, Technology, and Logistics:

• Considers and plans for impacts of climate change on the safety, health, and well-being of the DoD military and civilian workforce.

DoD Component Heads ^a

• Update health surveillance programs to address effects on personnel, including changes in extreme temperatures, precipitation patterns, and disease vector distribution.

^a“DoD Components,” in this issuance, comprises the Office of the Secretary of Defense, the Military Departments, the Office of the Chairman of the Joint Chiefs of Staff and the Joint Staff, the Combatant Commands, the Office of the Inspector General of the DoD, the Defense Agencies, the DoD Field Activities, and all other organizational entities within the DoD.

Examples of DoD Adaptation Needs

DoD Directive 4715.21 does not provide detailed guidance on how to implement the requirements for climate change adaptation. To comply with the directive, responsible officials across the department will need to initiate planning efforts. To catalyze adaptation efforts for health-related impacts, we discuss the DoD relevance of 3 selected health-related impacts: heat injuries, vector-borne infectious diseases, and extreme weather that could lead to natural disasters.

These topics likely do not represent the full range of health-related impacts relevant to the DoD. But they are examples of focus areas for a comprehensive assessment: These health risks already are DoD priorities, considered apart from climate change, and climate change could elevate further their importance for the DoD (Table 1).

Table 1.

Selected IPCC and NCA Findings for Health-Related Impacts of Climate Change Relevant to the DoD

Climate Change Impact	IPCC^1,8	NCA²
Heat injury	Greater risk of injury, disease, and death due to more intense heat waves	Extreme summer heat is increasing in the United States; extreme heat events will be more frequent and intense.
Vector-borne diseases	Increased risk of some vector-borne diseases	Climate variability can alter the incidence of diseases carried by arthropod vectors (eg, mosquitoes, fleas, ticks) through effects on vector geographic distribution and vector and pathogen biology.
Extreme weather that may lead to natural disasters	Likely increased frequency of heavy precipitation events, likely increased tropical cyclone wind speeds in some ocean basins; very likely increase in coastal high-water extremes in areas currently experiencing inundation and erosion	The frequency of heavy precipitation events has increased for the United States as a whole and is projected to increase in all US regions; increases in extreme and total precipitation have contributed to increases in severe flooding in some regions.

Note. IPCC = Intergovernmental Panel on Climate Change; NCA = US National Climate Assessment.

The next sections discuss why climate change effects in these areas are important for the DoD and suggest next steps in planning for these and other health-related impacts.

Heat Injuries in Training and Operational Settings

Active duty military populations, though generally younger and healthier than the US population at large, are at risk for exertional heat illness (EHI) when engaged in training or operations in warm environments. Exertional heat illness includes heat cramps, heat exhaustion, and heat stroke, the most serious form of EHI, characterized by central nervous system dysfunction and possibly damage to other organs.

During 2010 to 2014, the Armed Forces Health Surveillance Branch (AFHSB) of the Defense Health Agency reported 12,719 cases of heat injury (heat stroke or other heat injury) in active duty personnel, with an incidence of 0.25 and 1.22 per 1,000 person-years for heat stroke and other heat injury, respectively.⁹ Heat stroke rates were highest in service members younger than 20 years of age, combat occupational specialties, and recruits. Heat injuries occurred at more than 100 military installations worldwide, but 7, all in the southeastern United States, accounted for nearly half.

Exertional heat illness risk among military personnel will increase in a warming climate without additional adaptation measures, especially at installations in the southern United States that already experience warm conditions during much of the year and a high burden of exertional heat illness. But the risk is not limited to this region: The DoD reported that around 150,000 military personnel were serving outside of the United States in 2015,¹⁰ some of whom could face dangerous heat extremes in strategically important areas.

For example, a recent study suggests that parts of southwest Asia may be uninhabitable without further adaptation, with an increase in daily maximum wet-bulb temperature (which combines temperature and humidity to provide a more direct indication of heat stress) of about 3°C across the region during 2071 to 2100 without reduced greenhouse gas emissions.¹¹ Most coastal regions adjacent to the Persian Gulf, the Red Sea, and the Arabian Sea will exceed a daily maximum of 31°C, a value rarely reached anywhere in the world under the current climate. Several areas reach 35°C, considered intolerable for more than a few hours. Even under a standard greenhouse gas reduction scenario, many areas will exceed a daily maximum of 31°C (though none reach 35°C).

Vector-Borne Disease Risk

Military personnel are at higher risk for some vector-borne diseases when stationed or deployed in endemic areas, or when performing training or missions that bring them into contact with vectors (eg, in areas of dense brush that harbor arthropod vectors). For several vector-borne diseases of high DoD importance, modeling studies suggest increased transmission risk in some areas as a result of climate change (Table 2).

Table 2.

DoD Burden and Potential Climate Change Effects for Selected Vector-Borne Diseases

Disease	Recent DoD Impact or Risk	Potential Climate Change Effects
Malaria	Declining incidence overall with 44 cases reported in 2014;¹² outbreaks in West Africa¹³ and Afghanistan;¹⁴ resurgence in Korea¹⁵	Changes in mosquito biting frequency, pathogen development, presence at given altitudes; expansion of population at risk^16,17
Dengue	Seroprevalence in Special Forces was 11% in 2006-2008;¹⁸ likely substantial under-reporting because of nonspecific symptoms. Ongoing outbreak in Hawaii is the 3rd since World War II;^19,20 the state hosts ∼46,000 active duty military and ∼82,000 dependents and DoD civilians.¹⁰	Geographic expansion of Aedes mosquito vectors, shorter time to mosquito infectiousness^16,21
Chikungunya	157 infections in DoD populations acquired in the Caribbean during January 2014-February 2015; Armed Forces Health Surveillance Branch determined the epidemic posed a potentially significant risk to DoD personnel, operations, and healthcare.²²	Geographic expansion of Aedes mosquito vectors; shorter time to mosquito infectiousness^16,21
Leishmaniasis	1,287 cases among personnel serving in Iraq and Afghanistan, 2001-2006²³	Geographic expansion of risk areas in endemic countries¹⁶
Lyme disease	Most commonly diagnosed vector-borne disease in US military;²⁴ incidence 2- to more-than-10-fold higher than national average (northeast United States²⁵).	Geographic expansion of tick vectors and pathogen in North America²⁶
Zika	Emergence and rapid expansion in Western Hemisphere in 2015; association with microcephaly cases and neurological disorders in Brazil prompted World Health Organization declaration of Public Health Emergency of International Concern. The DoD offered voluntary relocation to dependents and DoD civilians in risk areas.²⁷	Geographic expansion of Aedes mosquito vectors; shorter time to mosquito infectiousness^16,21

In particular, the recent expansion in the Americas of viruses transmitted by Aedes species mosquitoes—dengue, chikungunya, and Zika viruses—has led DoD and civilian authorities to initiate major response efforts. Aedes aegypti is widely distributed across Central and South America and is also present in parts of the southeastern and southern United States. The distribution of Aedes albopictus in the United States is broader, extending to most of the eastern half of the country. The ranges of both are predicted to expand with climate change, in the United States and across the Americas.²¹

Both species are vectors of dengue and chikungunya virus. Aedes albopictus has not yet been implicated in the Zika epidemic, but scientists at the National Institutes of Health warn that the possibility of Zika virus adaptation to Aedes albopictus is cause for concern.²⁸

Military Assistance in Disaster Relief

The DoD responds to domestic “complex catastrophes,” including public emergencies, in support of the Federal Emergency Management Agency (FEMA) or other lead federal agencies (Defense Support of Civilian Agencies, DSCA)^29,30 and to foreign disasters in support of the US Agency for International Development.³¹ The DoD brings unique assets to disaster response operations, such as air- and sealift, logistical expertise, engineering and communication capabilities, and emergency medical support.³²

For instance, the DoD supported the federal response to Hurricane Sandy (2012) in New York and New Jersey, one of its longest and most extensive DSCA missions. The DoD response, including more than 7,000 National Guard personnel, restored power and communication systems, delivered food and water to victims, constructed shelters, drained flooded areas, and provided health-related support that included home welfare checks, search-and-rescue operations, transportation of medical personnel, and medical logistics.³³

Abroad, the DoD diverted a major military exercise to support the US response when Cyclone Nargis struck Burma in 2008 and left almost 140,000 dead.³² The DoD committed at least 13,000 service members to assist the 2013 US response to Typhoon Haiyan, which displaced millions of people across the Philippines and resulted in several thousand deaths.³⁴

As climate change influences global patterns of extreme weather, the DoD will continue to receive more, or more substantial, requests for assistance in supporting US disaster response missions. Since the DoD is sometimes called on to provide healthcare and public health services when responding to disasters, planning for the increased demand with climate change should include a reassessment of medical relief capabilities and needs.

The DoD also must ensure its capacity to protect the health of DoD personnel participating in relief operations. Like other emergency responders, they are at risk for various health problems. For example, epidemiologic studies of nonmilitary responders to natural, accidental, or deliberate disasters have suggested associations with injuries,³⁵ infections,³⁶ behavioral health problems,³⁷ and chronic conditions³⁸ (little research is available specifically for military responders).

While prevention, surveillance, and care for health threats in operational settings are high priorities for the DoD, longer-term follow-up after service members leave active duty status is challenging. The importance of this limitation would grow with increasing demand for DoD relief support, since activated National Guard and Reserve personnel, who play a key role in DoD disaster assistance operations, usually separate from active duty status soon after their participation.

Adaptation Opportunities

We recommend the DoD establish a focal point to plan for the full range of health-related climate change impacts, including the examples described above. This would not require significant reorganization, since the focal point could be placed in existing bodies that coordinate DoD climate change adaptation, but which lack a dedicated and enduring health thrust.

The most important of these are the Senior Sustainability Council (SSC) and the Climate Change Adaptation Working Group (CCAWG), the DoD's primary entity for coordinating climate change adaptation, which advises and takes direction from the SSC.⁵ Drawing on their broad representation from across the DoD, these 2 groups likely would find immediate opportunities for integrating health-related climate change adaptation into existing DoD programs and capabilities. Some of these opportunities are in existing DoD public health and medical programs. For example, considering the 3 health impacts discussed above:

• Heat injury: The DoD has long recognized exertional heat illness as an important health risk to its personnel, especially uniformed service members in training and operational settings. Epidemiologic studies in recruits have examined exertional heat illness associations with individual risk factors^39-44 or environmental conditions, such as wet bulb temperature.^45,46 Integrated assessments of both individual and environmental risk factors could improve population- and individual-based prevention programs.

• Vector-borne diseases: The AFHSB held a workshop in July 2014 to assess DoD surveillance for chikungunya and dengue. Participants from the DoD medical, public health, and entomological communities noted key limitations, including varied Aedes mosquito surveillance practices across military services and installations, limited or no Aedes surveillance at many locations, lack of a comprehensive repository of DoD entomological surveillance data, and inconsistent use of personal protective measures.

• Disaster relief: Analysis of short-term health outcomes in responders is feasible using existing DoD protocols for deployment health surveillance. Longer-term follow-up is more difficult because many responders are reservists or National Guard members; DoD health surveillance programs do not routinely track them after they complete active duty service. Researchers could invite these responders to participate in longer-term observational studies, using the DoD's extensive healthcare and health information technology infrastructure to reduce data collection burden.

A comprehensive assessment likely would identify opportunities beyond these examples and beyond the DoD health sector. For example, the DoD could direct its considerable capacities in technology acquisition and development to the 3 example health impacts: fielding better environmental heat stress measurement devices to prevent heat injury; developing drugs, vaccines, and personal protective equipment to reduce vector-borne disease risk; and developing systems to share electronic medical data with federal disaster response partners and the Department of Veterans Affairs. Some of these efforts are under way in the DoD; climate change adaptation calls for even stronger emphasis.

Toward a Comprehensive Approach

A framework developed by the Centers for Disease Control and Prevention could guide a comprehensive DoD assessment of climate change health impacts and adaptation needs. The Building Resilience Against Climate Effects (BRACE) approach allows health officials to develop strategies and programs to help communities prepare for the health effects of climate change.⁴⁷ It includes 5 sequential steps: anticipate climate impacts and assess vulnerabilities, project disease burden, assess public health interventions, develop and implement a climate and health adaptation plan, and evaluate impact and improve quality of activities.

In adapting the BRACE framework, the DoD could divide the first step (anticipate climate impacts and assess vulnerabilities) into the following tasks:

1. Review the general biomedical literature for climate sensitivity of specific health outcomes relevant to the DoD (eg, ones that constitute a substantial burden of disease in DoD populations^48,49 or are known to compromise military operations or training).

2. Review any available literature for climate sensitivity of specific health outcomes in military personnel (eg, the exertional heat illness studies cited earlier).

3. Identify and assess existing surveillance data for specific health outcomes in military personnel to prioritize health outcomes, geographic areas, and vulnerable subpopulations (eg, certain demographic and occupational groups).

4. Analyze future climate drivers for specific health outcomes in areas of DoD importance (eg, military installations and strategically important regions worldwide).

5. Prioritize health issues, locations, and subpopulations for health-related climate change impacts.

6. Identify key information gaps and develop strategies to fill them (eg, through health surveillance programs and epidemiologic studies).

Along with this preliminary assessment, the DoD should begin preparing current and future leaders to confront climate change impacts. The most feasible way to begin is to integrate climate change adaptation into existing education and training programs. Ideally, health-related adaptation would constitute part of a broader training and education initiative across the DoD, with more specific focus on health in health-related programs, and a broader range of climate change impacts covered in more general command and leadership programs.

Conclusion

Health impacts of climate change threaten military personnel and operations. The DoD needs a comprehensive plan for lessening harmful impacts and could draw on existing coordination mechanisms, programs within and beyond the DoD health sector, and adaptation frameworks to accomplish this. The DoD recognizes climate change implications for national security strategy, infrastructure, and other core DoD interests; it must now extend its adaptation efforts to the US military's “decisive advantage”⁵⁰—its people.

Footnotes

Acknowledgment

The author thanks Koya Allen for substantive contributions to this article; Rohit A. Chitale for supporting this effort; and Jose Sanchez, Paul Lewis, Sean Friendly, and anonymous peer reviewers for constructive comments. No specific funding was used for this work. The views expressed are those of the author and do not necessarily represent the views of any part of the Department of Defense.

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