This section presents examples of climate adaptation in public health initiatives throughout the 16 U.S. states uncovered in this survey; eighteen initiatives are presented as full case studies. Readers should refer to the full-length case studies for more details.

The majority of initiatives at the state health departments we surveyed are focused on capacity building. Primary strategies include monitoring environmental and climatic conditions and impacts; assessing vulnerabilities and developing adaptation options; increasing public awareness through outreach and communication efforts related to climate change; creating resources and tools; and enhancing collaboration between state health departments and others. Additional strategies include tribal climate and health assessments and infrastructure retrofits.

Strategies

• Monitoring environmental and climatic conditions and impacts
• Assessing vulnerabilities and developing adaptation options
• Increasing awareness through education and outreach campaigns
• Enhancing resources and tools
• Enhancing collaboration between public health officials and other stakeholders
• Tribal climate and health assessments
• Infrastructure retrofits

Monitoring Environmental & Climatic Conditions & Impacts

Monitoring programs can track environmental and climatic changes and detect trends in human health. Many state health departments are integrating climate change into existing environmental health tracking tools, such as those associated with the National Environmental Public Health Tracking Program, and syndromic surveillance systems.

The National Environmental Public Health Tracking Program, funded by the CDC, is a network of state and local health departments collecting and sharing environmental and non-infectious disease data. Ten states and one city in our survey participate in the program, including Colorado, Florida, Iowa, Michigan, Missouri, New Jersey, New York, New York City, Oregon, Washington, and Wisconsin. For example, the Missouri Department of Health & Senior Services hosts the Environmental Public Health Tracking Data Portal, which collects and provides data to support decision-making to improve prevention and response measures.¹¹ The site is used to analyze trends over time through hazard and disease surveillance, identify effective interventions, and to support public health research. The portal provides observed weather and climate data (1990-2015) on factors such as temperatures, winds, and humidity, and links to resources on extreme heat and cold events, heavy precipitation and flooding, vector-borne diseases, and harmful algal blooms.

The Washington Tracking Network (WTN) includes data on air and water quality, drought, flooding, snowpack, heat events, weather extremes, wildfire, and disease.¹² WTN also includes an Environmental Health Disparities Map that provides a way to compare broader environmental health risks between communities depending on exposure and social determinants of health. For example, users can compare particulate matter concentrations, toxic releases from industrial facilities, percentage of disabled population, and cancer deaths between an urban area such as Seattle and Moclips on the remote outer coast.

Syndromic surveillance is a rapid monitoring system to detect symptoms, track outbreaks and emergent disease occurrence (e.g., tracking clinical and emergency room visits), and provide early alerts that signal a need for immediate public health response. Several health departments are engaged in syndromic surveillance programs, including New Jersey, Nevada, Washington, and Philadelphia. For example:

• The New Jersey Department of Health uses the Hippocrates online system to capture and share critical health information and support day-to-day operations and rapid response and recovery for emergency situations.¹³ The system integrates data from the state Medical Coordination Centers, local health departments, clinics, and other healthcare facilities, combining real-time feeds of weather events (e.g., fires, floods), incidents, and medical assets (e.g., hospitals, command centers, blood banks) with basic GIS map layers on a closed system only accessible by public health practitioners.
   
• The Nevada Health Alert Network (NVHAN) is a statewide alert system that supports rapid connection between healthcare facilities and providers, first responders, law enforcement, and critical services (e.g., communications, water, energy) during public health emergencies. HAvBED (Hospital Available Beds for Emergencies and Disasters) tracks bed availability and hospital capacity and its system features multiple backup servers containing critical health and emergency preparedness documents that are useful during crises (e.g., Nevada’s Public Information and Communications Plan).¹⁴
   
• The Washington Department of Health runs the Rapid Health Information NetwOrk (RHINO), which collects real-time data on symptoms, diagnoses, and demographic data from clinical and emergency room visits. Public health practitioners and officials have access to these records to compare trends across communities, regions, and the country.
   
• The Philadelphia Department of Public Health used 10+ years of syndromic surveillance data to identify trends in heat-related visits to emergency departments and compared the data with weather conditions during those times. Through this analysis, the department developed a health-focused system for issuing excessive heat declarations.

Assessing Vulnerabilities & Developing Adaptation Options

The CDC created the BRACE framework to guide public health officials through a structured climate-informed decision-making process. The steps include identifying impacts and assessing vulnerabilities, quantifying projected health outcomes, determining the most suitable interventions or adaptation options, developing and implementing an adaptation plan, and evaluating the impact of the implemented strategies.¹⁵ Seven states and one city in this study have been funded through the CDC’s Climate-Ready States and Cities Initiative to apply the BRACE framework, including Florida, Illinois, Michigan, New York, New York City, North Carolina, Oregon, and Wisconsin.

While the process used by these states was similar, some approaches were unique. For example, the North Carolina Department of Health and Human Services first identified a range of possible actions vetted in the scientific literature, which were then presented to and evaluated by stakeholders according to a variety of criteria, such as ease of implementation, cost, and timeliness. Stakeholders then ultimately selected health interventions based on a combination of evaluation scores and the needs of local communities. Other state and local health departments have used the BRACE framework to guide assessment and planning efforts, including health departments and organizations in New Jersey, Ohio, Virginia, and Philadelphia. For example, the New Jersey Climate Change Alliance (formerly the Climate Adaptation Alliance) used the initial steps of the BRACE framework to create a Climate and Health Profile Report.¹⁶

Increasing Awareness Through Education & Outreach Campaigns

Many of the states surveyed are working to increase awareness of climate-related health risks for the general public, health professionals, and emergency responders. Examples from our survey include:

• North Carolina’s heat health alert system in southeast North Carolina, which is tailored to residents most at risk for heat-related illness, including farm workers, older adults, low-income families, and youths. This pilot system will alert target populations when heat levels become dangerous, and provide residents with actions they can take to reduce their risk.
   
• New Jersey’s Clean Air NJ campaign to raise public awareness about the negative effects of ground-level ozone and measures that can reduce the likelihood of smog. Clean Air NJ provides details about the health and environmental effects of smog, access to daily air quality data via the Air Quality Index, and tips on how the public can reduce ozone formation and avoid exposure.
   
• The New York City Department of Health and Mental Hygiene’s “Be A Buddy” outreach campaign, which encourages healthcare providers and community members to check on at-risk individuals and neighbors, particularly during extreme weather events.
   
• The Washington Department of Health’s efforts to effectively communicate public health risks associated with wildfire smoke to local health departments and communities. Department epidemiologists have prioritized public messaging on wildfire smoke and preparedness as wildfires have increased in severity over the last few years, including online air quality advisories and recommendations for preventative measures (e.g., masks, air filters) in multiple languages.

Enhancing Resources & Tools

Many states have created various resources and tools to support climate-informed action in public health. For example:

• The Colorado Department of Public Health and Environment has created disaster recovery guides, which detail human health concerns that arise from emergencies and disasters such as issues related to sanitation, disease, pollution, and shelter availability.¹⁷
   
• The Illinois BRACE Program created an online heat toolkit for local health departments, including social vulnerability and heat health data for each county, and templates (e.g., press releases, social media) for community outreach during extreme heat events.¹⁸
   
• The Missouri Department of Health & Senior Services’ Disaster and Emergency Planning program created the online Ready in 3 toolkit to help residents prepare by (1) creating a plan for different situations (e.g., evacuation vs. staying home), (2) preparing an emergency kit, and (3) listening for information from city, county, and state officials. Other resources included in the toolkit are guidelines for schools, adult care facilities, healthcare facilities, and emotional preparedness.
   
• The New York State Department of Health partnered with the New York State Office for the Aging to develop materials for senior citizens, including adding a link to the Cooling Center Mapping Application¹⁹ on their Aging Services mobile app, which connects older adults with information on health, housing, and transportation options.

Enhancing Collaboration Between Public Health Officials & Other Stakeholders

Several of the state health departments support efforts at local health departments to address the climate-related impacts on public health. Examples include:

• The Florida BRACE program is collaborating with county health departments to implement and evaluate the effectiveness of extreme heat education campaigns and hurricane evacuation and shelter procedures.
   
• The Michigan Climate and Health Adaptation Program is working with Marquette County to integrate climate and health into existing plans. Activities have included one-on-one conversations with vulnerable populations (e.g., homeless, veterans, aging) and convening charrettes with the community to increase awareness about climate, health, and equity issues.
   
• The Oregon Health Authority collaborated with five local health departments—Benton, Crook, Jackson, and Multnomah Counties, and the North Central Public Health District—to develop local climate and health adaptation plans.

Within the study area, there are several key nongovernmental actors working to advance health-related climate adaptation action. Examples include:

• The Florida Institute for Health Innovation, which has evaluated the health-related effects of the climate change strategies recommended by the Southeast Florida Regional Climate Change Compact, and recently partnered with Florida Atlantic University and the South Florida Regional Planning Council to identify the effects of sea level rise on health and map the most at-risk communities in Palm Beach, Broward, Miami-Dade, and Monroe counties.
   
• The Iowa Public Health Association, which released a statement that the health-related effects of extreme events (e.g., extreme heat and precipitation) were the most obvious and immediate threats to the state, and called for the adoption of strong climate policies to ensure human health and well-being.²⁰
   
• The Southern Nevada Water Authority, which conducted a vulnerability assessment of its service area in Clark County to evaluate risks associated with extreme heat, drought, and harmful algal blooms.
   
• Clean Air Carolina’s Medical Advocates for Healthy Air program, which is a statewide network of over 400 medical and health professionals in North Carolina focused on improving air quality for all residents. Climate change is a priority issue for MAHA and action has focused primarily on education and outreach (e.g., climate training for pediatric residents at Levine Children’s Hospital) and advocacy efforts (e.g., testifying at air quality hearings, sign-on letters to reduce carbon emissions and invest in renewable energy sources, participating in the Southeast Climate and Energy Network).
   
• The Ohio Clinicians for Climate Action network, which is working to raise awareness of the links between climate and public health policies, and provides a space for health professionals to exchange knowledge on how to best address Ohio’s climate and health issues.

Tribal Climate & Health Assessments

Several tribes in the study area have prioritized planning for climate change impacts on public health. Examples include:

• The Inter-Tribal Member Council of Michigan led a process to assess climate change impacts, vulnerabilities, and adaptation options for nine federally-recognized Tribes in Michigan, including the Bay Mills Indian Community, Lac Vieux Desert Band of Lake Superior Chippewa, Grand Traverse Band of Ottawa and Chippewa Indians, Little River Band of Ottawa Indians, Little Traverse Bay Bands of Odawa Indians, Match-E-Be-Nash-She-Wish Band of Potawatomi (Gun Lake Tribe), Pokagon Band of Potawatomi, Saginaw Chippewa Indian Tribe, and Sault Ste. Marie Tribe of Chippewa Indians. Health-related mitigation and adaptation strategies recommended in the plan include reducing carbon pollution and implementing alternative energy sources; increasing green infrastructure; routine monitoring of infrastructure integrity; increasing community awareness through outreach and education; implementing an early warning system for extreme weather events and low air quality days; and creating environmentally-friendly pesticides to target specific species that may be vectors for disease.²¹
   
• The Gun Lake Tribe also created a standalone adaptation plan to address climate change impacts on human health, natural resources, food resources, and infrastructure.²² The main climate concerns outlined in the plan include heat waves, extreme weather events, and changes in precipitation regimes (e.g., more intense rain events). The plan also takes into consideration the impacts of contamination pathways, transmission dynamics, changes in agroecosystems, hydrology, and socioeconomic and demographic disruption on human health. Strategies recommended in the plan include increasing educational efforts to share climate change information with Tribal members; increasing energy efficiency of buildings, industries, and residences; and managing forested parcels for wildlife and air quality. Since the plan’s release in 2015, the Gun Lake Tribe has installed rain gardens to filter stormwater pollution and developed a Conservation Incentive Program to incentivize energy retrofits in homes.
   
• The Saint Regis Mohawk Reservation in upstate New York’s St. Lawrence River Valley is projected to experience rising temperatures, degraded air and water quality, flooding, threats to food production, extreme weather events, and drought. The Tribe’s Environment Division developed a climate change adaptation plan in 2013 to guide future activities.²³ The plan identifies current non-climate related health threats within the Tribe including high rates of respiratory and coronary problems, cancer, diabetes, thyroid disease, and obesity. Climate change will exacerbate these existing issues and may also result in restricted access to healthcare facilities, and reduced capacity to provide medical services during extreme weather events. Notable health adaptation activities underway include maintaining the Tribal Seniors’ Center as a heating and cooling shelter, reducing mosquito breeding sites, increasing outreach on community health services, and emergency planning for disease outbreaks and epidemics.
   
• The Puyallup Tribe of Indians prioritized heat waves, changes in air quality, and food-borne illnesses in its climate adaptation plan.²⁴ A core priority emerging from this planning effort was ensuring that services provided by critical medical and emergency facilities are consistently available to at-risk populations.

Infrastructure Retrofits

Incorporating climate change into the development or retrofitting of infrastructure may help limit the effects of climate change. Examples include:

• Brooklyn’s Seagate Rehabilitation and Nursing Center (formerly known as the Shorefront Rehabilitation Center) is elevated almost 30 feet above ground to accommodate flooding. In addition, the facility’s emergency power supply is capable of maintaining power to all systems and equipment during power outages. During Superstorm Sandy, the center was able to withstand the floodwaters, the emergency power supply supported services for four days during the local power outage, and staff and patients were able to safely shelter in place during the storm due to the center’s sufficient supply of food and medical supplies.²⁵
   
• The City of Anacortes water treatment plant was redesigned to incorporate climate change projections. The plant serves over 55,000 customers and is the largest single source of water for Skagit and Island counties. The Skagit Climate Science Consortium worked with the City Public Works Department to develop a plan focused on future issues such as flooding, sediment deposit, and saltwater intrusion, all of which can impact human health by threatening the quantity and quality of water available to customers. In the redesign and construction, staff sought to protect against higher risk of flooding by (1) minimizing floodwater penetration below current 100-year flood elevation; (2) raising critical electrical equipment out of the 100- year flood level; (3) utilizing water-proofing techniques below 40-foot elevation; and (4) designing ring dikes for flood protection. The plant was elevated and dikes and pumps were installed to reduce risk of flooding and saltwater intrusion.^26,27