MILITARY PERSONNEL & READINESS
Not Healthy and Not Optimized
Bottom Line Up Front
The COVID-19 pandemic has not only impacted all aspects of the military but also exposed a fault line that has been growing within the Department of Defense (DoD). DoD has a personnel and readiness problem far beyond the damage done by this global disease — it can’t get enough troops, breaks the ones it has, doesn’t fix them, and doesn’t optimize their potential — an unsustainable path that threatens the nation’s power.
- Costly Injuries: Servicemembers get injured throughout their military journey — as new recruits, active troops, and service veterans. Pervasive injuries are costly to readiness, both financially and in availability, yet prevention and recovery efforts lag, and commanders lack insight into the health of their forces.
- Eligibility: While recruiting has essentially stopped during the pandemic, the services have struggled to fill key jobs and find the right people for years, with a nationwide obesity problem impacting DoD as well.
- Suicides: Servicemember and Veteran populations both suffer tragically high rates of suicide with wider impacts on the community and must be slowed.
- Not Optimized: Past performance programs tackled individual issues while ignoring ancillary problems or causes. And each service has forged its own path in addressing human performance and readiness, with little commonality DoD wide.
- Solutions: End-to-end solutions — from recruit to Vet — are becoming available, but adoption is slow, and the health and readiness of the force continues to suffer.
Discussion
DoD’s competitive advantage is its people with leaders continually emphasizing this fact. “People are our most valuable resource,” states the President’s Budget request for FY2021. The “World’s Greatest Air Force” is “Powered by Airmen,’’ according to the latest vision from the Air Force. The 38th Commandant of the Marine Corps, General Berger, states, “The most important thing we do is make Marines.” The Army and Navy make similar assurances about the criticality of their personnel, and U.S. Special Operation Command’s first SOF truth is, “Humans are more important than hardware.” And yet with over 1.32 million active military personnel in service currently, DoD has yet to develop DoD-wide programs that optimize this precious resource.
Ignoring personnel issues is a threat to U.S. security as DoD shifts resources, training, and capabilities to face competitors Russia and China while technology proliferates. Near peer competitors will soon be peers, and reliance on technology will not win future conflicts. The U.S. finds its advantage in the people that make up the Total Force and the human systems — the social connections, the emotional, spiritual, behavioral, physical and mental support systems and networks — in place to develop the human capital.
Despite investment, this capital is currently sub-optimized as the effects of almost 20 years of combat impact everyone from “boots” to retirees. New recruits, comprising almost 13% of the force annually, enter a military at constant war, with many active duty troops diminished from repeated overseas deployments into combat zones. Taking care of this resource is certainly a priority for DoD, yet programs are underutilized and ineffective as they struggle to provide meaningful impacts on health or performance, and few provide true insight to commanders about readiness. Further, with few programs looking at human capital holistically across the services, DoD’s efforts to improve and optimize human performance are inefficient and do not address current issues facing the military.
As a result, pervasive injuries and ineffective recovery lead to lost work and disabilities after service, suicides continue to exceed combat deaths, and the personnel so vital to the function of DoD continue to operate in a sub-optimal environment, creating a fissure in the readiness of DoD, a fragility exacerbated by COVID-19.
READINESS
Ultimately, DoD is judged by its capacity to protect the nation and fight its enemies. This ability is measured by “readiness,” a broad term that has many meanings. DoD’s Joint Publication 1 defines readiness as, “The ability of military forces to fight and meet the demands of assigned missions.” In total, readiness incorporates individual and unit training, physical preparedness, personnel and equipment availability, and capability. Improving readiness is the first priority of the 2018 National Defense Strategy (NDS). Personnel readiness — the ability of enough Soldiers, Sailors, Airmen, or Marines to be ready and able to fight when needed — is a condition of heightened importance today. In addition, this personnel readiness directly translates to the health, wellness, and societal contributions of Veterans after their service.
Regrettably, readiness is currently a subjective condition, with commanders receiving very little quantitative data about their personnel’s health and performance. Leaders know if tanks are running and planes are flying, but have little data to measure the “readiness” of their “most valuable resource.” While physically unable to perform servicemembers are obvious, the underlying health conditions and injuries that build over time are a readiness threat that commanders are not seeing but that can be measured and monitored.
COSTLY INJURIES
As recruits enter service, a career of training and operations follows. Military training is challenging and risky. Operations are often dangerous, but to succeed, training needs to be realistic and usually follows the mantra of General Norman Schwarzkopf, “The more you sweat in peace, the less you bleed in war.”
Unfortunately, ‘sweat’ under the current training construct has led to a lifetime of injuries for too many. Recruits get injured, then join the force and get re-injured (see box). Veterans leave the service injured. Training is lost, unit capabilities are impacted, and personnel performance is compromised, with injuries and disabilities following servicemembers into civilian life — a high cost for all.
In the Army’s 2018 Health of the Force, the Army reported 56% of Soldiers had a new injury, with 71% of all injuries stemming from musculoskeletal overuse. Worse, 66% of women had an injury, meaning two-thirds were hurt at some point during that year. And this is just the Army. DoD-wide, injury rates for cumulative traumatic injury (musculoskeletal injury resulting from repeated micro-trauma) were 988 per 1,000 people per year in the active component. While this is a slight decrease of 3.9% from 2016 data, when combined with acute injury rates of 305 per 1,000 servicemembers, the joint force suffered more injuries than servicemembers in 2018 — data that does not support the “ability… to fight and meet the demands of assigned missions.”
The cumulative effect of these injuries is significant on the readiness of the entire force. Noncombat MSIs led to 25 million days of limited duty and over two million clinic visits per year at a cost of $3.7 billion. After service, the results get worse. In a Veteran population of over 19 million, almost 25% receive disability compensation — 4.7 million Vets. And more recent Veterans (post- 9/11) suffer at a higher rate, with 41% leaving service with a disability. Further signals of crisis: osteoarthritis develops in a third of servicemembers and Veterans (while only occurring in about one-fifth of the population) and 44% of Veterans suffer from joint pain. In total, a force composed of a majority of personnel with such injury history is compromised before conflict has begun. And after service, civilian productivity is impaired as Veterans with a service-connected disability have higher unemployment rates.
“The primary health threat to troops for more than two decades has been common muscle, joint, tendon/ligament and bone injuries like knee or back pain that are caused by running, sports and exercise…” Veronique Hauschild, MPH, of the Injury Prevention Program, Army Public Health Center, Aberdeen Proving Ground, MD
DoD continues to secure the country’s freedom, yet at what cost and is this sustainable? The answer is not to train less to reduce injuries, which would reduce preparedness as the country faces a multitude of threats from Russia, China, North Korea, Iran, and terrorist organizations, but to train and recover smarter — flight simulators were once scoffed at, now represent a significant part of flight training. Over 40% of recent Vets should not be leaving service disabled. We can do better for our men and women in uniform.
ELIGIBILITY FOR SERVICE
Readiness depends on having troops available, yet even before COVID-19, the Army and Marine Corps struggled to recruit enough talented people to join and the Navy and Air Force were short required personnel. In addition, too many servicemembers also suffer from the national epidemic of obesity, placing their physical readiness at risk.
With the pandemic shutting down basic training and limiting recruiters, the problem has amplified. The Navy only has about 60% of the enlisted leaders needed to mentor and train junior Sailors on its current inventory of ships, and it doesn’t have enough ships (see Navy Force Assessment). On the air side, the Navy reported a shortfall of 1,242 aviators and a separation rate 31% above average in 2019.
The Air Force is expected to grow by 3,700 active airmen in 2020, partly as a result of the new Space Force. However, it is also facing a shortage of 2,000 pilots, particularly fighter pilots. In fact, the Air Force has not met its pilot retention goals since 2013. Where are the available troops? Why are they not joining?
In this all-volunteer force, entrance into the military follows stringent physical and mental standards, an increasing challenge as the pool of eligible citizens is shrinking. DoD may not have enough young people qualified to enter military service in the future. Over two-thirds of the population between 18 and 23 do not meet DoD standards. Of the many ways to be disqualified from joining, obesity or “Failure to meet weight standards” leads the way. And it is only getting worse.
According to the National Institutes of Health (NIH) and Center for Disease Control and Prevention (CDC), over 42% of adults and 19% of children in the U.S. are classified as obese. In the usual ages fit for military service, the nation sees a 40% prevalence of obesity in ages 20–39 and 21% among 12–19 year-olds. In 10 years, over half the nation will be obese, with one in four Americans “severely obese” (Body Mass Index >35). Few young adults will qualify for military service, notwithstanding having a desire for it.
DoD cannot simply recruit its way out of this threat. In a sad paradox, obesity is highest in states where military recruiters are the most successful — the South. For the last several decades, 13 southern states contributed a greater share of their young adult population, approximately 20% more recruits than might be expected for ages 18 to 24, and a total of 41% of new enlistees in 2017. Unfortunately, recruits from this region pose a readiness risk to the military, as one Army study found that “incidence of injuries increased by 22% and 28% in male and female recruits from the ‘least fit states,’ respectively.….the states identified here pose a greater threat to military readiness than do other states.” As shown above, injuries in initial training lead to more injuries during service.
And obesity problems do not end with recruiting the few people who meet standards. While below national averages, DoD still has high numbers of obese personnel. The recent DoD Health of the Force (2018) showed an increasing percentage of obese servicemembers, with 15.8% obese in 2014, increasing to 17.4% in 2018. Obesity was highest in the Navy with almost one fourth of sailors (22.0%) obese, while lowest in the Marine Corps (8.3%). Unsurprisingly, obese servicemembers are at a greater risk of injury and other health issues— together a readiness double whammy. With fewer people able to serve, and those that do serve at increasing risk, the readiness issues of today will continue to worsen.
SUICIDES
Another indicator of the health of the force are the grim statistics around suicides, further reminders that human capital is not being optimized.
According to the Department of Defense 2018 Annual Suicide Report, active component suicide rates have increased 34% over the past 5 years. This increase is attributed to small increases across all the services, a pervasive issue. The suicide rates over the same 5 years for the Reserve and the Guard have remained relatively unchanged. After adjusting for age and gender, the military suicide rate in 2018 is roughly equivalent to that of the U.S. population for both the Active and Reserve components. The Guard, however, has a suicide rate that is higher than average (with the Army National Guard at an alarming 35.5 suicides per 100,000 people).
In the latest report, the 2019 National Veteran Suicide Prevention Annual Report estimates an average of 16.8 Veteran suicides each day in 2017, resulting in 6,132 Veteran suicides that year. This represents a 129 person increase from 2016 — the first increase since 2014.
Additionally, the suicide rate for Veterans ages 18–34 increased by 76% from 2005 to 2017. Therefore, after adjusting for age and gender, the Veteran suicide rate was 1.5 times the national average suicide rate. Separating these suicides by gender reveals that the male Veteran suicide rate was 1.3 times higher than that of non-Veteran males, and the female Veteran suicide rate was 2.2 times higher than their non-Veteran counterparts. These numbers, of and in themselves, represent a disproportionate negative trend that must be reversed for the optimization of our Veterans.
However, there is hope. Veterans with recent Veteran Health Administration (VHA) use have shown a slower increase in suicide rates than Veterans without such involvement. The 2019 report showed that of the roughly 17 Veteran suicides a day, 11 were committed by Veterans who had not received care or assistance from the VHA. While this points to a positive impact from programs and interventions, only approximately 45% of the Veteran population uses the VHA.
Indeed, much like injuries and obesity, programs and resources that address the wellness and health of servicemembers and Vets would also help reduce suicides while increasing personnel readiness as a whole. These programs must work together to focus on early intervention and comprehensive engagement while reaching those who are not currently seeking help or affiliated with a program. And in these times of required isolation, the risk to personnel and Veterans is increasing.
NOT OPTIMIZED
In 2009, then Chairman of the Joint Chiefs, Admiral Mike Mullen, recognized the stress the force was under and wanted to make DoD more resilient. Through research, consultations with health and military professionals, the Total Force Fitness (TFF) concept arose. According to Admiral Mullen, “A total force that has achieved total fitness is healthy, ready, and resilient; capable of meeting challenges and surviving threats.” With its eight domains, including medical, nutritional, environmental, physical, social, spiritual, behavioral, and psychological, TFF was the beginning of DoD’s efforts to look at personnel in a broad manner. Unfortunately, TFF was mainly an educational concept run by the Defense Health Agency (DHA), and little has come of it, as funding and programs have not followed the grand idea of Admiral Mullen. Each service and specialized units have sought their own solutions, with little unifying themes or programs throughout DoD.
U.S. Special Operations Command (SOCOM) has led efforts looking at personnel in an integrated and comprehensive way. In 2010, Admiral Eric Olson, then Commander of SOCOM, set up a task force that studied Special Operations Forces (SOF) warriors and their families and documented a force “fraying” from a decade of combat. The subsequent commander, Admiral William McRaven began the Preservation of the Force and Family (POTFF) Initiative in response to that growing concern. POTFF created human performance programs, psychological performance programs, family support programs, and operational psychologists — the first major service program to attempt to look at a servicemember’s health and performance holistically.
POTFF paved the way for future programs by introducing professional strength and conditioning regimes, personalized training, physical therapists, and improved facilities. Physical readiness tests started to align with functional operational requirements, emphasis was placed on recovery and rehabilitation, and the benefits of proper nutrition, sleep, and movement were introduced to operators.
SOCOM’s efforts have begun to trickle through the services as they play catch-up. The Air Force has devoted a wing to studying personnel performance — the 711th Human Performance Wing — and begun embedding strength coaches, physical therapists, and trainers in fighter wings in a program called Optimizing the Human Weapon System. The Air Force hopes healthier pilots will remain flying. Unfortunately, the program deals mainly with injuries rather than taking a more holistic approach, and funding is only requested at $16 million for FY21, a drop compared to the $194 million requested for Aviation bonuses in FY21. The Air Force is relying on cash to sway pilots to remain flying rather than improved health.
The Army has seen wholesale changes in the way well-being and health is promoted and practiced. Based on the Human Dimension Concept it started in 2014, the Army has evolved to Holistic Health and Fitness (H2F). The Army has revamped physical fitness tests, unit conditioning, nutrition, and a host of other human performance areas — changing doctrine, employing health and fitness professionals down to the Brigade level, and attempting to quantify and analyze data around fitness and health. The lead command is the U.S. Army Center for Initial Military Training, where many of the changes are taking place. Spending is projected at over $1B for the next 8 years, although cuts are already seen in the proposed FY21 budget, while additional money will be used to upgrade facilities on bases throughout the world. Like SOCOM, the Army is building Soldier Performance Readiness Centers (SPRC) aimed at providing professional services to Soldiers while they workout. The focus of physical readiness is slowly shifting from individual interests to professional training to improve operational functions.
Yet, despite these efforts and hundreds of millions of dollars, injuries continue on a massive scale, both in SOF and the services. Treatment and recovery efforts often lag what high school athletes receive, much less the human performance science applied in professional sports. Soldiers are failing the latest army functional fitness test. Commanders still do not have the necessary insight on their personnel as data collection is sporadic and technology has not been leveraged to its potential. And while each of the services is taking much needed steps to help personnel function and perform at a higher level, holistic approaches from the beginning of service to the end of service do not yet exist. Personnel and Veterans continue to suffer from a host of fixable and preventable wellness issues.
The below scorecard is an attempt to identify issues facing the personnel readiness of the force. By identifying problems and applying holistic solutions, DoD can begin to reverse the negative trends impacting readiness and harming its personnel.
PERSONNEL READINESS SCORECARD
HOLISTIC SOLUTIONS
DoD has siloed many of the personnel and readiness problems, impeding progress and solutions to this crisis.
One group has cut across boundaries and proved effective. The Close Combat Lethality Task Force (CCLTF) recognized early on the necessity of addressing this problem. An outcome of former Secretary Mattis’s desire to improve the effectiveness of combat formations, CCLTF identified the importance of manpower policy and human performance optimization, studying the problem intensely before being moved administratively from under the Office of the Secretary of Defense to the Army last month, where priorities may shift.
The Joint Artificial Intelligence Center (JAIC) is another unit faced with many problems seemingly unrelated to human performance. However, with its mission to “use AI to solve large and complex problem sets that span multiple services; then, ensure the Services and Components have real-time access to ever-improving libraries of data sets and tools,” JAIC plans to tackle human capital management. The Warfighter Health Mission is another related area where JAIC’s AI-enabled capabilities will transform military medicine. AI is also being used to help study injuries, with both the Army’s IA Task Force and the Office of Naval Research (ONR) making progress on prevention.
The National Guard is using machine learning to help reduce suicides with SPRING (Suicide Prevention and Readiness Initiative for the National Guard). This dashboard uses data to provide risk factors and potential interventions. Housed in the Warrior Resilience and Fitness (WRF) Division, SPRING is a positive step to combat the rising tide of suicides. In addition, the WRF Division is also sponsoring 36 pilot programs across states in 2020. While no solutions are finalized and the programs are in the early stages, the National Guard is sharing information among state guards and making evidence-based decisions. Resources are limited with constrained budgets taxed even more by the current pandemic response.
In private industry, innumerable tools utilize technology to improve performance — apps and wearables that measure sleep, heart rate, breathing, muscle activity, distance moved, and more, while also providing feedback and suggestions on activities. While the military has adopted or studied some of these tools, migration into the .mil domain can prove to be problematic. Just recall the huge headache the commercial Strava app caused two years ago by revealing the location of military personnel around the globe using the product while running. Currently, commercial technology products and military use do not mix well, but integration is needed.
Crossing the .com to .mil chasm requires public private partnerships and sharing data. A few programs are tackling this issue, including SPEAR (Soldier Performance Enhancement and Readiness) and SPRINGboard. Collecting usable data is an important step to allow future analysis and provide commanders the insight they require to make better decisions and better investments in their personnel, so the human capital can truly be optimized. Additional successes have come in the formation of new support networks, often in the form of digital communities. Lastly, DoD’s COVID-19 response has spurred JAIC to reach out to private companies for datasets, particularly those companies in healthcare and consumer products, in order to perform data aggregation and predictive analytics. Cooperation between the public and private sector could lead to promising innovations and solutions.
Yet, despite these singular efforts, DoD programs continue to fall short in stemming the rash of injuries, suicides, obesity, behavioral health disorders, and other factors indicating a lack of human optimization and decreased readiness. While missions are accomplished, the cost is high and unsustainable. Something must change.
CONCLUSION
The personnel entering, serving, and departing the military are the most important aspect of DoD. Their wellbeing, functionality, and performance are critical to readiness. Current programs have been reacting to problems in the force and addressing them piecemeal. A new approach is required for DoD to solve this crisis. Holistic efforts that get ahead of problems need to be implemented. Preventative solutions must be incentivized for maximum adherence and early engagement — before, during, and after service. DoD must support investment in programs that consider the entire ecosystem of a servicemember’s wellness.
Leveraging technology is critical today in providing personalized solutions at scale, not only to combat arms but also to support personnel often forgotten in performance discussions. AI can catalyze improved performance, while data sets can move readiness from a subjective term to a quantitative one, providing commanders uncommon insights into the true performance of formations.
In this current crisis, the U.S. military is again at the forefront, with the National Guard performing humanitarian relief, Navy hospital ships called to help major cities, Army engineers building field hospitals, and airmen transporting critical supplies around the country, to name a few. With so much at stake resting on the readiness of the force, DoD must first invest in the health of the force.
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