    [House Hearing, 110 Congress]
    [From the U.S. Government Publishing Office]

    9/11 HEALTH EFFECTS: FEDERAL MONITORING AND TREATMENT OF RESIDENTS AND
                                   RESPONDERS
    =======================================================================

                                    HEARING

                                   before the

                     SUBCOMMITTEE ON GOVERNMENT MANAGEMENT,
                         ORGANIZATION, AND PROCUREMENT

                                     of the

                             COMMITTEE ON OVERSIGHT
                             AND GOVERNMENT REFORM

                            HOUSE OF REPRESENTATIVES

                           ONE HUNDRED TENTH CONGRESS

                                 FIRST SESSION

                                   __________

                               FEBRUARY 28, 2007

                                   __________

                                Serial No. 110-2

                                   __________

    Printed for the use of the Committee on Oversight and Government Reform

      Available via the World Wide Web: http://www.gpoaccess.gov/congress/
                                   index.html
                         http://www.oversight.house.gov

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                  COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM

                     HENRY A. WAXMAN, California, Chairman
    TOM LANTOS, California               TOM DAVIS, Virginia
    EDOLPHUS TOWNS, New York             DAN BURTON, Indiana
    PAUL E. KANJORSKI, Pennsylvania      CHRISTOPHER SHAYS, Connecticut
    CAROLYN B. MALONEY, New York         JOHN M. McHUGH, New York
    ELIJAH E. CUMMINGS, Maryland         JOHN L. MICA, Florida
    DENNIS J. KUCINICH, Ohio             MARK E. SOUDER, Indiana
    DANNY K. DAVIS, Illinois             TODD RUSSELL PLATTS, Pennsylvania
    JOHN F. TIERNEY, Massachusetts       CHRIS CANNON, Utah
    WM. LACY CLAY, Missouri              JOHN J. DUNCAN, Jr., Tennessee
    DIANE E. WATSON, California          MICHAEL R. TURNER, Ohio
    STEPHEN F. LYNCH, Massachusetts      DARRELL E. ISSA, California
    BRIAN HIGGINS, New York              KENNY MARCHANT, Texas
    JOHN A. YARMUTH, Kentucky            LYNN A. WESTMORELAND, Georgia
    BRUCE L. BRALEY, Iowa                PATRICK T. McHENRY, North Carolina
    ELEANOR HOLMES NORTON, District of   VIRGINIA FOXX, North Carolina
        Columbia                         BRIAN P. BILBRAY, California
    BETTY McCOLLUM, Minnesota            BILL SALI, Idaho
    JIM COOPER, Tennessee                ------ ------
    CHRIS VAN HOLLEN, Maryland
    PAUL W. HODES, New Hampshire
    CHRISTOPHER S. MURPHY, Connecticut
    JOHN P. SARBANES, Maryland
    PETER WELCH, Vermont

                         Phil Schiliro, Chief of Staff
                          Phil Barnett, Staff Director
                           Earley Green, Chief Clerk
                      David Marin, Minority Staff Director

      Subcommittee on Government Management, Organization, and Procurement

                       EDOLPHUS TOWNS, New York, Chairman
    PAUL E. KANJORSKI, Pennsylvania      BRIAN P. BILBRAY, California
    CHRISTOPHER S. MURPHY, Connecticut   TODD RUSSELL PLATTS, Pennsylvania,
    PETER WELCH, Vermont                 JOHN J. DUNCAN, Jr., Tennessee
    CAROLYN B. MALONEY, New York
                        Michael McCarthy, Staff Director

                                C O N T E N T S

                                  ----------
                                                                       Page
    Hearing held on February 28, 2007................................     1
    Statement of:
        Agwunobi, Admiral John O., M.D., MBA, MPH, Assistant
          Secretary for Health, Department of Health and Human
          Services; and John Howard, M.D., MPH, J.D., Director,
          National Institute for Occupational Health, Centers for
          Disease Control and Prevention, Department of Health and
          Human Services.............................................    19
            Agwunobi, John O.........................................    19
        Gibbs, Linda I., co-Chair of Mayor Bloomberg's World Trade
          Center Health Panel and New York City deputy mayor for
          health and human services; Edward Skyler, co-Chair of Mayor
          Bloomberg's World Trade Center Health Panel and New York
          City deputy mayor for administration, accompanied by Joan
          Reibman, M.D., associate professor of medicine and
          environmental medicine, director NYU/Bellevue Asthma
          Center, director of Bellevue WTC Environmental Health
          Center; David Prezant, M.D., chief medical officer, Office
          of Medical Affairs, co-director, WTC Medical Monitoring and
          Treatment Programs, New York City Fire Department; Eli J.
          Kleinman, M.D., supervising chief surgeon, New York Police
          Department; Robin Herbert, J.D., director, World Trade
          Center Medical Monitoring Program Data and Coordination
          Center, associate professor, Department of Community and
          Preventive Medicine, Mount Sinai School of Medicine;
          Jonathan Sferazo, disabled union iron worker; and Marvin
          Bethea, paramedic..........................................    43
            Bethea, Marvin...........................................    88
            Gibbs, Linda I...........................................    43
            Herbert, Robin...........................................    77
            Sferazo, Jonathan........................................    92
            Skyler, Edward...........................................    52
    Letters, statements, etc., submitted for the record by:
        Agwunobi, Admiral John O., M.D., MBA, MPH, Assistant
          Secretary for Health, Department of Health and Human
          Services, prepared statement of............................    21
        Bethea, Marvin, paramedic, prepared statement of.............    90
        Fossella, Hon. Vito, a Representative in Congress from the
          State of New York, prepared statement of...................    10
        Gibbs, Linda I., co-Chair of Mayor Bloomberg's World Trade
          Center Health Panel and New York City deputy mayor for
          health and human services, prepared statement of...........    46
        Herbert, Robin, J.D., director, World Trade Center Medical
          Monitoring Program Data and Coordination Center, associate
          professor, Department of Community and Preventive Medicine,
          Mount Sinai School of Medicine, prepared statement of......    80
        Kleinman, Eli J., M.D., supervising chief surgeon, New York
          Police Department, prepared statement of...................    74
        Maloney, Hon. Carolyn B., a Representative in Congress from
          the State of New York, prepared statement of...............    99
        Nadler, Hon. Jerrold, a Representative in Congress from the
          State of New York, prepared statement of...................     5
        Prezant, David, M.D., chief medical officer, Office of
          Medical Affairs, co-director, WTC Medical Monitoring and
          Treatment Programs, New York City Fire Department, prepared
          statement of...............................................    67
        Reibman, Joan, M.D., associate professor of medicine and
          environmental medicine, director NYU/Bellevue Asthma
          Center, director of Bellevue WTC Environmental Health
          Center, prepared statement of..............................    60
        Sferazo, Jonathan, disabled union iron worker, prepared
          statement of...............................................    94
        Shays, Hon. Christopher, a Representative in Congress from
          the State of Connecticut, prepared statement of............   111
        Skyler, Edward, co-Chair of Mayor Bloomberg's World Trade
          Center Health Panel and New York City deputy mayor for
          administration, prepared statement of......................    55
        Towns, Hon. Edolphus, a Representative in Congress from the
          State of New York, prepared statement of...................    16

    9/11 HEALTH EFFECTS: FEDERAL MONITORING AND TREATMENT OF RESIDENTS AND
                                   RESPONDERS

                                  ----------

                          WEDNESDAY, FEBRUARY 28, 2007

                      House of Representatives,
                Subcommittee on Government Management,
                         Organization, and Procurement,
                  Committee on Oversight and Government Reform,
                                                        Washington, DC.
        The subcommittee met, pursuant to notice, at 12 p.m., in
    room 2247, Rayburn House Office Building, Hon. Edolphus Towns
    (chairman of the subcommittee) presiding.
        Present: Representatives Towns, Murphy, Welch, Maloney,
    Nadler, Bilbray, Duncan, Platts, and Fossella.
        Staff present: Michael McCarthy, staff director; Rick
    Blake, professional staff member; Velvet Johnson, counsel;
    Cecelia Morton, clerk; Lakeshia Myers, editor and staff
    assistant; Susie Schulte and Christopher Bright, minority
    professional staff members; and Benjamin Chance, minority
    clerk.
        Mr. Towns. The subcommittee will come to order. Welcome to
    today's hearing to help the thousands of New York City
    residents who were exposed to dangerous toxins after the
    terrorist attacks on the World Trade Center. This is the first
    hearing of the Government Management Subcommittee in this
    Congress. We are taking on the issue of 9/11 health effects for
    two reasons: First, it is a sign of how important this issue is
    for the House Oversight Committee. Second, we want to continue
    the bipartisan work that was done on this issue in the previous
    Congress and set the tone for continued cooperation in this
    subcommittee to make sure our 9/11 responders and affected
    residents get the health care they need. We also want to work
    toward our larger goal of making sure Government is working
    effectively and efficiently for all Americans.
        I have invited several members of the New York City
    delegation, and Mr. Shays, to be here today, and I would ask
    unanimous consent that they be able to participate in this
    hearing. It is our practice to recognize members of the
    committee first, then after that, we can go to other Members
    who are present. We also have with us Congressman Nadler, who
    is from New York, and of course, from within the district in
    which the incident occurred. We are delighted to have him with
    us and we will extend the same courtesy to him. Hearing no
    objection, that's an affirmative.
        We also have here my colleague from New York, Mr. Fossella.
    I would also like to thank my colleague, Mrs. Carolyn Maloney,
    who I understand is on her way. She has also played a great
    role in planning today's hearing and I want to thank her for
    that. Mrs. Maloney has been called to the House floor.
        Due to time constraints, the Chair and ranking member will
    each have 5 minutes to make opening statements. I don't like to
    do that, but on this particular day we will have no choice. So
    at this time, I would like to yield to the ranking member.
        Mr. Bilbray. Thank you, Mr. Chairman. Mr. Chairman, I
    appreciate the fact that the bipartisan team from the region
    that was attacked so terribly so many years ago, and that is
    living with the problems and the repercussions of that attack
    by Al Qaeda every day, I think that bipartisan approach is what
    American people not only want but expect from us, and I
    appreciate the fact that on this issue we have given, I think,
    the American people the kind of leadership that they have been
    desiring.
        Mr. Chairman, I think that we need to remember that this
    wasn't just an incident, it was an attack by a foreign body
    against the people of the United States, not just an incident
    in New York. The terrorist attack was unprecedented. The
    response was appropriate in the matter of the American people
    call to arms and to protect our neighbors. The impact of the
    response, and let me just say this, those of us that are
    involved in emergency response understand it. Those of you that
    have never been in an emergency team may not. But to ask a
    firefighter, a paramedic, a lifeguard, a police officer not to
    respond to this kind of incident is asking for the world not to
    spin for 24 hours, asking to fight the laws of nature. Those of
    us who are involved in emergency response, a response is
    natural and immediate, and is not voluntary. You go in because
    that is what you do.
        I think that kind of response is what we desperately need
    in this country. We have to understand the repercussions of
    that kind of response is something we need to address.
        It is not an issue that just affects New York and
    Connecticut and the surrounding areas. We had responders from
    San Diego getting out and going into the area as quickly as
    possible. This is a national issue. It was an attack by foreign
    powers on U.S. soil, but it was a response by all of America.
        I think the brave individuals who exposed themselves to the
    toxics, to all of the environmental threats here, need to be
    addressed here. We need to remind ourselves that the problems
    have not gone away. They are with us today. I think the
    President including $25 million in the budget for the coming
    year as placing a placeholder is a step in the right direction.
    But I think that we need to make sure that what resources we
    put to addressing the problems are as effective and
    comprehensive as possible.
        Finally, let me say, there is no disagreement with the fact
    that things could have been done better. All I have to say is
    that anyone who has ever managed an emergency response effort
    will always know that after the response, there is a process
    that we call debriefing, where everyone understands there are
    things that could have been done better. There were breakdowns
    in systems, that emergency response, much like war, is
    organized chaos. And you just hope to minimize that level of
    chaos and inefficiency.
        So hopefully, we will be able to build from and learn from
    that, move forward from here. Again, Mr. Chairman, I appreciate
    the chance to have this hearing. I hope we all remember that
    this was not a natural disaster. This wasn't something that
    happened to one State or one community. This was an attack by a
    foreign power directed at the American people. And the target
    here happened to be New York and Washington, DC.
        But it just happened to hit those two cities because the
    people wanted to strike at the American people, not New Yorkers
    or Washingtonians. I think that is one of the things that all
    of us need to remember. Again, this was an attack by a foreign
    power, this was caused by an attack by a foreign power and we
    have to remind ourselves again and again that the enemy is
    still out there. The enemy created this situation and we need
    to make sure we address it appropriately.
        At this time, I will yield back, Mr. Chairman.
        Mr. Towns. Thank you very much. We will give each Member 2
    minutes for an opening statement. We have time restrictions,
    let me go to Mr. Nadler from New York.
        Mr. Nadler. Thank you, Mr. Chairman. Let me say at the
    beginning I appreciate the consideration shown to me to enable
    me to sit in on this hearing, though I am not a member of this
    committee. I have an opening statement which I would ask be put
    into the record. It is considerably longer than 2 minutes, I
    won't read it now.
        Mr. Towns. Without objection, so ordered.
        Mr. Nadler. Thank you. Let me just say that I hope that
    this is the first of a series of hearings, both in this
    committee and other committees in the House, and I know Senator
    Clinton is going to hold a hearing in the Senate, that will
    begin to deal with these problems.
        I have had to spend the better part of my last 5 years in
    public life cajoling the Federal Government to tell the truth
    to its citizens about 9/11 air quality, insisting that there
    must be a full and proper cleanup of the 9/11 environmental
    toxins that to this day are still poisoning New Yorkers,
    because they were never properly cleaned up, and for those
    already sick, demanding that the Government provide long-term
    comprehensive health care. I hope that today's hearing will be
    the beginning of a process under which we can achieve what I
    believe are the four things that we must achieve.
        First, to increase and expand the Federal funds that are
    beginning to be made available to provide for long-term
    monitoring and treatment of all the victims of 9/11. Second, to
    bring into this process and to be clear that we are covering
    and giving the same help to residents and workers, not just to
    first responders, because it is clear that residents and
    workers in lower Manhattan and Brooklyn, maybe in Queens, we
    are not even sure where, were also affected by this.
        Third, to get the Federal Government to do the proper
    inspection and environmental cleanup of New York and possibly
    New Jersey that was recommended by the EPA Inspector General 3
    years ago, without which we will continue to poison people for
    decades to come, unknowingly, from toxins that are still
    present inside buildings, city government buildings, State
    government buildings, and regular non-government buildings all
    over perhaps Manhattan, Brooklyn, Queens, northern New Jersey,
    for all we know.
        And finally, that there should be a comprehensive medical
    screening and long-term care system put into place for all
    these people that is not dependent on annual appropriations in
    the future from Congresses and Presidents who may be more or
    less sympathetic or ignorant than this Congress is in the
    future. Because this problem is going to be with us for the
    next 30 or 40 or 50 years.
        So I hope this is the beginning of this process, and I
    thank you, Mr. Chairman.
        [The prepared statement of Hon. Jerrold Nadler follows:]
        [GRAPHIC] [TIFF OMITTED] 34912.001

        [GRAPHIC] [TIFF OMITTED] 34912.002

        [GRAPHIC] [TIFF OMITTED] 34912.003

        [GRAPHIC] [TIFF OMITTED] 34912.004

        Mr. Towns. You can be assured that we will be holding
    additional hearings because this is a very important issue.
        Now let me recognize the person who was the Chair of this
    subcommittee in the last Congress, who did a magnificent job,
    while setting a model in terms of how important it is to work
    together in a bipartisan fashion. I want to say to you, Mr.
    Platts, that I plan to continue in that same spirit.
        Mr. Platts. Thank you, Mr. Chairman. I don't have a formal
    opening statement either, but I do commend you for holding this
    hearing today. I especially want to congratulate you, Mr.
    Chair. It was an honor to serve as Chair of this subcommittee
    and it is indeed an honor to serve with you. Thank you, Mr.
    Chairman.
        Mr. Towns. Thank you very much.
        Now Congressman Murphy.
        Mr. Murphy. Thank you, Mr. Chairman. I don't have a formal
    opening statement, either, except to say that it is a great
    honor, as a new Member, to be sitting here with both you and
    Ranking Member Bilbray as well as our colleagues from New York
    who have led this fight so valiantly, paying no attention to
    party or ideology. My only point of introduction is to say that
    Connecticut also sent many brave men and women down in those
    days, weeks, and months, following that tragic event and are
    now suffering from those same very effects that have befallen
    those in the districts of Mr. Nadler and Mr. Fossella and so
    many others who have fought for this issue.
        So I am very happy and honored to be part of this
    subcommittee and very glad that this is our opening salvo as a
    subcommittee into an issue which has great regional importance
    for the Connecticut-New York-New Jersey region. Thank you.
        Mr. Towns. Thank you. Let me turn to my colleague from New
    York, Congressman Fossella.
        Mr. Fossella. Thank you, Mr. Chairman.
        [The prepared statement of Hon. Vito Fossella follows:]
        [GRAPHIC] [TIFF OMITTED] 34912.005

        [GRAPHIC] [TIFF OMITTED] 34912.006

        [GRAPHIC] [TIFF OMITTED] 34912.007

        [GRAPHIC] [TIFF OMITTED] 34912.008

        Mr. Towns. Thank you very much, Mr. Fossella.
        The attacks that destroyed the World Trade Center on
    September 11, 2001 created a human tragedy on an enormous
    scale. That day we knew immediately that thousands had lost
    their lives in the collapse of the Twin Towers. What we now
    know is that the toxic environment created when the towers
    collapsed claimed still more victims. First responders, rescue,
    recovery and clean-up workers, volunteers from all 50 States,
    area residents, office workers, and school children. All may
    have been exposed to a range of dust, smoke and toxic
    pollutants.
        Sometimes when people are hurt or killed in an accident, we
    say that they were in the wrong place at the wrong time. For
    the responders who rushed to the scene of the World Trade
    Center on 9/11, and those who worked on and around the pile
    afterwards, it is just the opposite. They were in the right
    place at the right time, doing their jobs, coming to the aid of
    their fellow citizens at the hour of greatest need. Now many
    are suffering from a wide range of diseases and disabilities
    and require medical care. It is our obligation as a Nation to
    make sure they get the care they need.
        The range of people who are now ill goes beyond just those
    responders who were working at or around Ground Zero right
    after the attacks. The collapse of the towers created an
    enormous dust cloud that covered lower Manhattan, then blew
    east across the river and through Brooklyn. New York City
    residents and workers were exposed to these toxins with some
    developing serious illnesses. They too, are victims of 9/11.
    The Government has an obligation to treat people who have
    become sick and monitor those who were exposed to toxins so we
    can identify, and prevent if possible, diseases that emerge
    from people whose lives have been greatly disrupted.
        Today's hearing will examine what the Federal Government is
    doing to help those suffering from 9/11-related illnesses. The
    answer is ``not enough.'' More than 5 years have passed since
    9/11, and just recently the Federal Government has finally put
    in place some medical monitoring and treatment programs. These
    programs are doing good work and we will hear from the doctors
    who are treating patients with 9/11-related diseases.
        But why has this happened so late? The Federal programs we
    have right now suffer from two serious flaws. The first is that
    they are not inclusive enough. The programs cover those who
    worked and volunteered on the rescue and recovery effort, but
    there is no Federal program for residents who were affected by
    the toxins in the air. Not only is there no Federal plan to
    treat these residents, there is not even a program to monitor
    them and gather essential data that may help us track and treat
    9/11-related illnesses.
        The second problem is that the existing programs lack
    sufficient and sustained funding. The programs are running out
    of money and will have to shut down if this shortfall isn't
    addressed. We have a temporary fix from the administration,
    which is helpful, but we need something more permanent. Some of
    the serious health effects from 9/11 are illnesses like post-
    traumatic stress disorder. The last thing people suffering from
    these types of illnesses need is fear and uncertainty that
    their treatment will be cutoff due to lack of funding.
        The administration says they are working on a plan, but
    even now it is not clear if that plan will include everyone who
    was exposed and everyone who is sick. Five and a half years
    after 9/11, we need to have something better than what we have
    now, and we need to have it right now.
        I look forward to hearing from our doctors and first
    responders about what the medical needs are, and from our
    government witnesses what they are doing to create inclusive
    and sustainable medical monitoring and treatment programs.
        The government has to do more to help people who are still
    suffering from the effects of 9/11. I hope we can learn more
    today about how to help, and then work together to make sure it
    happens.
        [The prepared statement of Hon. Edolphus Towns follows:]
        [GRAPHIC] [TIFF OMITTED] 34912.009

        [GRAPHIC] [TIFF OMITTED] 34912.010

        [GRAPHIC] [TIFF OMITTED] 34912.011

        Mr. Towns. At this time, I would like to ask the witnesses
    to please stand to be sworn in.
        [Witnesses sworn.]
        Mr. Towns. Our first panel is made up of two physicians and
    leaders from the Department of Health and Human Services, Dr.
    John Agwunobi, Assistant Secretary for Health at the Department
    of Health and Human Services. He is also an Admiral leading the
    Commissioned Corps of the U.S. Public Health Service.
        We also have with us Dr. John Howard, who is the Director
    of the National Institute for Occupational Safety and Health at
    HHS. He is a board certified specialist in internal medicine
    and occupational medicine, as well as an attorney, and serves
    as a Federal 9/11 health coordinator at HHS.
        Why don't we just start with you, Dr. Agwunobi?

        STATEMENTS OF ADMIRAL JOHN O. AGWUNOBI, M.D., MBA, MPH,
    ASSISTANT SECRETARY FOR HEALTH, DEPARTMENT OF HEALTH AND HUMAN
    SERVICES; AND JOHN HOWARD, M.D., MPH, J.D., DIRECTOR, NATIONAL
    INSTITUTE FOR OCCUPATIONAL HEALTH, CENTERS FOR DISEASE CONTROL
        AND PREVENTION, DEPARTMENT OF HEALTH AND HUMAN SERVICES

                     STATEMENT OF JOHN O. AGWUNOBI

        Dr. Agwunobi. Good afternoon, Chairman Towns and
    distinguished members of the subcommittee. As was just
    indicated, my name is John Agwunobi and I am indeed the
    Assistant Secretary for Health for the U.S. Department of
    Health and Human Services.
        Beside me is a close colleague and friend, Dr. John Howard.
    He is the Director of NIOSH.
        I thank you for holding this hearing on the Federal
    response to the health impacts of 9/11. On September 11, 2001,
    within hours of that terrorist attack, HHS, our Department,
    dispatched the first group of emergency medical and mortuary
    teams to the New York City area to assist local emergency
    personnel and health providers in caring for those affected by
    the terrorist attacks on the World Trade Center.
        Within 8 days of the attacks, the Federal Government and
    the State of New York jointly created and implemented a
    disaster relief Medicaid waiver. Now, this Federal Government
    waiver, which was provided to the State of New York as a
    Medicaid program, was to the tune of about $333 million. It was
    designed to support the treatment of individuals affected. Over
    340,000 individuals eventually enrolled and were able to access
    the full array of medical benefits and treatments that were
    offered through that waiver.
        Between 2001 and 2002, the Department released over $239
    million, which went to support health centers and hospitals,
    mental health programs and environmental monitoring, and
    research in and around New York City for that same purpose. In
    early 2002, NIOSH developed a baseline medical screening
    program to address the gap in medical screening of World Trade
    Center responders. This program was subsequently expanded in
    2004 to provide long-term medical monitoring for the World
    Trade Center rescue and recovery workers and volunteers,
    including current and retired New York City firefighters. The
    medical monitoring program has now conducted more than 30,000
    initial examinations and 17,000 followup examinations since its
    inception back in 2002.
        In 2002, the World Trade Center health registry was
    established. This registry collects self-reported survey data
    to evaluate potential short and long-term physical and mental
    health effects of the exposure to the disaster. So far, more
    than 71,000 individuals are currently enrolled in that
    registry.
        In 2006, $75 million was provided to further support
    existing HHS World Trade Center programs and to provide
    treatment to responders, rescue workers and recovery workers.
    Thus far, based on the reports from those responders and our
    partners and our analysis of some scientific analysis,
    Secretary Leavitt decided that we needed to do more. He
    established an internal task force which I chair, and Dr. John
    Howard is the task force's co-chair.
        The mission of the task force is to provide the Secretary
    with an analysis of all the available data that we can get our
    hands on related to the World Trade Center associated health
    conditions, so that the administration can devise a pathway to
    the future, a pathway that addresses the needs of care and the
    needs for more research. The World Trade Center task force is
    comprised of top science and health policy experts from
    throughout the Department of Health and Human Services. It
    actually began meeting back in October of last year.
        HHS continues to collect information pertaining to 9/11
    health effects and is committed, absolutely committed, to
    providing passionate and appropriate support to the responders
    affected by the World Trade Center, those that were exposed
    following the terrorist attacks. The President's fiscal year
    2008 budget does indeed include $25 million for the
    continuation of treatment for the World Trade Center
    responders. The administration intends to review this budget
    request, using all the data that we gather in our analysis, the
    task force's work, as we look to the future.
        Sir, I thank you again for this opportunity. I know that
    Dr. Howard and I would be happy to answer questions. I would
    just end by saying, we believe that this is a very important,
    very, very important duty that we have been given, to analyze
    and review the data in order to further advise the Secretary. I
    have no doubt that he, upon hearing from us, will enter into
    dialog with Congress and the administration. I look forward to
    working alongside all of you, sir.
        [The prepared statement of Dr. Agwunobi follows:]
        [GRAPHIC] [TIFF OMITTED] 34912.012

        [GRAPHIC] [TIFF OMITTED] 34912.013

        [GRAPHIC] [TIFF OMITTED] 34912.014

        [GRAPHIC] [TIFF OMITTED] 34912.015

        [GRAPHIC] [TIFF OMITTED] 34912.016

        [GRAPHIC] [TIFF OMITTED] 34912.017

        [GRAPHIC] [TIFF OMITTED] 34912.018

        [GRAPHIC] [TIFF OMITTED] 34912.019

        [GRAPHIC] [TIFF OMITTED] 34912.020

        [GRAPHIC] [TIFF OMITTED] 34912.021

        [GRAPHIC] [TIFF OMITTED] 34912.022

        Mr. Towns. Thank you very much.
        Dr. Howard.
        Dr. Howard. Mr. Chairman, I don't have a written statement,
    I am in a supporting role today.
        Mr. Towns. We thank you very much.
        Let me begin by asking a few questions about the task
    force. First of all, when will we get the report from the task
    force?
        Dr. Agwunobi. Mr. Chairman, the task force, our work is
    largely analytical in nature. We gather data, we review that
    data and we are supposed to advise and inform the Secretary
    with what we find. We currently are not engaged in the writing
    of a report for public dissemination. We are actually engaged
    in trying to review all the information so that we can advise
    the Secretary.
        Mr. Towns. Now, are you including the area residents in
    this? This is a serious problem, as you heard from some of our
    colleagues in the opening statements.
        Dr. Agwunobi. Very clearly there are many unanswered
    questions that relate to residents. I have no doubt that there
    will be much dialog and discussion going forward on that
    subject. But the work of the task force that John and I chair,
    Dr. Howard and I chair, is focused on the responders to the
    event, firefighters, volunteers, retired workers, those that
    responded to the event, in the day of and the days following.
        Mr. Towns. Well, there is a school that was in the area and
    they are complaining. It is a high school, and they are saying
    that as a result of 9/11, that many young people now are having
    health problems. So I was just wondering, would you include
    them in it somehow? I am saying I think we should make
    treatment and care inclusive.
        Dr. Agwunobi. Yes, sir. The Secretary has asked us to
    report back to him quickly with the data that we have, the
    analysis of the information that we have. We will do that. If
    the Secretary then asks us to go on and review further data or,
    I have no doubt, as I have said, that there will be dialog on
    that issue going forward.
        Mr. Towns. When will residents have access to the Federal
    programs?
        Dr. Agwunobi. Following our completion of our analysis and
    our presentation to the Secretary, Michael Leavitt, as to the
    breadth, the scope, the issues involved in this particular
    situation, I have no doubt, as I have said, that he will engage
    in dialog. That dialog will no doubt include Congress and the
    rest of the administration. It is a little unclear to me, sir,
    as to the exact time lines, as to that process. I imagine you
    will be a part of that process as well.
        But the current programs, as they were appropriated, the
    appropriations for the current programs focus the programs on
    responders, not on the residents. We are speaking now about the
    program at Mount Sinai and the associated program at FDNY. My
    understanding is that the Bellevue program, which has funding
    from, I think a little bit of funding from the Federal
    Government, most of its funding is from the city. That program
    does actually allow residents into access for treatment.
        Mr. Towns. Right. Well, will we know about it within 3
    months, 6 months, a year? I hate to push you, but we need to
    know.
        Let me just say this. I don't see this as a blame
    situation. I think we all have to work on this together. I
    think that we need certain information for us to be of
    assistance. I think that we are talking about the lives of
    people from all over this country, all 50 States. We are
    talking about young people in high school, and of course, they
    are now complaining.
        And these are issues that I think we have to recognize and
    have to find ways and methods to deal them. So that is the
    reason why I am really trying to push you on a timeframe.
        Dr. Agwunobi. Sir, I would concur that urgency is important
    in this situation. There are real people out there suffering
    and there are individuals who are in need. Our process is
    designed to try and gather data so we can use that data to
    design programs for the future.
        The Secretary has been very, very straight on this with me.
    He wants us to go as fast as we can, but he wants our analysis
    to be based on data, as much data as we can gather. He has
    indicated that he wants us to brief him in March, and we will.
    But that, as I have said, is a part of a process that would no
    doubt include dialog with the administration and indeed, with
    Congress.
        Mr. Towns. Thank you. I yield to the ranking member, Mr.
    Bilbray.
        Mr. Bilbray. Thank you, Mr. Chairman. I apologize for
    turning your mic off. Like everything else in this town,
    everything operates opposite of the rest of the world.
        Mr. Towns. Oh, you turned my mic off? [Laughter.]
        Mr. Bilbray. Yes, I just turned myself off, too. It's
    typical, this is the only town where you un-push something to
    get it to turn on.
        Let me first ask, the city of New York and the locals seem
    to be doing a very aggressive approach to this health risk
    assessment. Frankly, as somebody who comes from the local, I
    was a disaster preparedness chairman for a small, intimate
    group of 3 million people in San Diego County. I prefer to have
    the local people do as much as humanly possible, because they
    tend to be more efficient, more sensitive and more effective.
    But there is a situation where this impacted and affected not
    just one municipality, it had a broad, regional impact. What
    are we doing about monitoring the impacts on the areas outside
    of the city of New York, in the adjacent areas? What kind of
    response are we getting there?
        Dr. Agwunobi. If I may, I am going to turn over to my
    colleague who has been involved in the monitoring from the very
    beginning. But I will say that the work of the task force today
    does contemplate what you just said, the fact that even if it
    is not a big portion of the individuals that are affected that
    live outside of New York today, in the future it might be, as
    people retire and move around the country. So as we think this
    through, as we perform this analysis, we are contemplating the
    notion that it might need to be something that has, whether it
    be quality, access or cost, it needs to have a national scope
    to it in terms of our thinking and our planning.
        I will turn over to my colleague, Dr. Howard, if you want
    to add on what we have done so far.
        Dr. Howard. Sure. Mr. Bilbray, as a fellow San Diegan, I am
    certainly very much aware of all the search and rescue and
    disaster medical assistance teams that came from all over the
    United States. Actually, when we have looked at that population
    of national responders, we find them in about 2,000 different
    zip codes throughout the United States. So it is one of our,
    probably our greatest challenge, is to be able to provide
    medical monitoring services and now treatment to that highly
    dispersed population.
        So since the program began with both private as well as
    Federal moneys, we have developed a network of clinics which
    are coordinated through Mount Sinai in which responders that
    are in other States can avail themselves of medical monitoring
    services as well as now treatment services. So that is
    probably, as I want to emphasize one more time, that is a
    significantly challenging area of our program development.
    Because we are trying to put together a national set of
    clinics, the only kind of model for that in this country is the
    Veterans Administration, for instance. There is really no
    national clinics that we have to rely on. So we are putting
    that together as we have gone through the last few years.
        Mr. Bilbray. The task force, how frequently has it met
    since its inception in 2006?
        Dr. Agwunobi. The task force has a structure where most of
    its work is done not unlike here, in subcommittee. So we have a
    full task force that has met three times since October and will
    probably meet a couple of other times, maybe one more time
    before we are completely done. But most of the work has been
    actually farmed out to two subcommittees, one that focuses
    mostly on science and research with a view to the future, what
    are we going to need in the future in terms of research, in
    terms of clinical systems, clinical issues and Dr. Howard has
    very kindly chaired that subcommittee.
        The other subcommittee focuses on the issues of health
    financing, the different, what are the costs and what are the
    projections into the future and what are the different health
    financing models that we need to study in order to fully inform
    the Secretary. Between the different subcommittees, and there
    are small groups that break off of them and meet, there have
    actually been quite a few meetings in between each, in the
    order of tens of meetings between the main subcommittee
    meetings. So there has been a fair amount of meeting going on.
    A lot of our work, because we are all in the same department,
    is actually done in the hallways and in sidebars as we meet
    continuously across the course of our business day. We are all
    colleagues within the Department.
        Mr. Bilbray. As pointed out before, this is sort of a
    unique situation. In all fairness, from a disaster preparedness
    point of view, it is so different because unlike people that
    live out west and know they are moving into an earthquake area,
    know that is part of the decision they are making as
    individuals, or people that move down south into a hurricane
    area, you know there is an exposure there. This is one that was
    totally unforeseen and can't be foreseen. But more importantly,
    the people in New York don't have to worry about earthquakes,
    and people in Chicago don't worry about hurricanes.
        But everybody has to worry about, in the future, the same
    situation could occur in any city. In San Diego, we have three
    nuclear carriers, one of them with a big name across it called
    Ronald Reagan. It is a sitting target. So the big key there is
    what do we learn for future applications? What do we learn that
    can help us prevent the kinds of long-term problems that we are
    seeing here and the next response that we may have?
        And let's just stop a second and say, one thing we don't do
    enough of in this country is say, thank the Lord, thank the
    system, thank the Government for doing the right things we do.
    And one of the right things is, we haven't seen this happen
    again. I think we take it too much for granted that it hasn't
    happened. But what are we doing to prepare in case it happens
    again, if Chicago is hit, if San Francisco is hit? Where are we
    looking at this kind of thing?
        And I can just imagine the respiratory issue. Don't send
    anybody in unless they have the right equipment. Does that mean
    that we try to provide this equipment to every local responder?
    Is that going to be cost effective? Or are we talking about
    having a mobile capability to bring in this kind of equipment
    to be available wherever it happens? We are looking at that
    prevention in the future if another incident occurs.
        Dr. Agwunobi. One of the tasks of the science subcommittee
    of our task force is to see through research whether or not
    there are lessons that we can learn from those that are
    tragically affected today, lessons in terms of diagnosis,
    lessons in terms of treatment. The task force, however, is not
    performing an after-action, a review, an audit of the events
    that occurred on 9/11 and the days that transpired. Those
    after-actions were done or are being done, I would imagine, at
    the different levels of agencies, cities, State, and the
    Federal Government when they work on how they did and how can
    they do it better. Our focus has been on the victims that are
    suffering as a result of exposure today and how can we learn
    from their experience going forward in order to assure that the
    systems that we use to, in these circumstances in the future,
    are responsive to the needs of the victims.
        Mr. Bilbray. Mr. Chairman, I appreciate the time. I just
    want to say that one of the problems for those of us who will
    be at the local government level or the local community level,
    if we don't know the health risks, at least some projection of
    risk out there, how do we know a good example of downwind, do
    you shut down the schools like we would with an air response,
    don't let the kids out or do we move them out of the area.
    Those kinds of questions, we need to have the health data on to
    be able to make those local decisions in case it happens again.
        Dr. Agwunobi. Sir, that is exactly the sort of thing that
    the science subcommittee is learning and hopefully we are going
    to have research going forward that helps us answer many of
    these questions.
        Dr. Howard, did you want to add to that?
        Dr. Howard. I will just add that the World Trade Center
    health registry, which is operated by the New York City
    Department of Health and Mental Hygiene, is envisioned to be a
    20 year project that will gain a lot of data about population
    health.
        The issue that you mentioned is really huge. When you look
    at it from the perspective of the responders and what we are
    dealing with now in terms of their symptomatology, their lung
    function abnormalities, in the Department, what we are doing is
    looking at pre-deployment preparation, during deployment
    services that are necessary for responders and post-deployment,
    debriefing, medical evaluations, etc. So we are looking from
    all the lessons that we are deriving from the medical and
    scientific literature from this event and trying to design a
    program that will cover all three phases of responder
    deployment.
        Mr. Towns. Thank you.
        I recognize Mr. Murphy.
        Mr. Murphy. Thank you, Mr. Chairman.
        I come at this from a slightly different perspective than
    some people sitting around this table. I wasn't a Member of
    Congress when this happened, I was a member of the public going
    through it with my community in Connecticut, like everyone else
    did. And so Doctor, when I hear you talk about the need for
    urgency here, and then I also hear that 5 years after the fact,
    we are convening the first task force that is going to start to
    look into a comprehensive health care strategy, there is a
    disconnect there for me, there is a disconnect for the folks in
    my district, there is a disconnect for the folks in Connecticut
    who went down and assisted in this effort.
        And so my question is very simple. What is your answer to
    people who say that 5 years after the fact, after putting in
    very small, relatively small amounts of money that simply don't
    comport with the estimates that have been given by Dr. Howard's
    organizations and others, as to the full cost of this, how do
    you provide an answer to people who have said that the only
    reason we are even here today is that you have come kicking and
    screaming to the table, being dragged there by members of the
    New York delegation and advocates? What is your answer to folks
    who just don't buy that there is a sense of urgency coming from
    the administration?
        Dr. Agwunobi. The administration's commitment is to make
    sure that where there are unmet needs, that those needs are
    met, and where there are lessons learned from science, that
    those lessons are applied. Many of the conditions, I will defer
    to my colleague to give you detail on this, but many of the
    World Trade Center related illnesses are an emerging phenomena,
    in that we are learning with the passage of time that No. 1,
    they are related, and that No. 2, that there are needs that are
    specific to that population, to those specific conditions, that
    need to be met.
        We recognize that over the long run, there are going to be
    needs that our work has to meet. But we are committed to trying
    to use data and science that has been gathered, that is
    gathering over time. The data will improve even going forward.
    Our commitment is to use that data to construct systems and
    responses that are sustained and that make a difference.
    Because they are founded in science, founded in what we have
    learned.
        Mr. Murphy. Here is the problem as I see it, or one of the
    problems. It sounds to me as if what you are saying is that you
    want to very methodically and carefully make sure that the
    diseases and the complications, the health complications are
    directly related to what happened on that site. But for the
    folks that rushed down there, they didn't wait to see the data
    or the science on what those chemicals were going to do to
    their body. They saw this as a national emergency. And the
    response back that we are hearing today is, well, we have to be
    very careful about how we go about the treatment to make sure
    that the science is right.
        Well, the folks that went down there didn't make sure the
    science was right and they are suffering for it. So shouldn't
    there be a sense that maybe we should err on the side of
    inclusiveness instead of erring on the side of making sure the
    science is exactly right?
        Dr. Agwunobi. Sir, indeed, the Federal Government, the city
    especially and philanthropy, in a very real way, provided care
    from the very beginning. What we are talking about here today
    is what do we design for the future? What do we design to
    assure that the needs of the individuals that are being met
    today are met 60, 50, 40 years from now? It is true that in
    response to 9/11, these heroes, and that is what they were,
    responded without second thought, emergently, to the event. It
    is also true that the health community responded right on their
    heels, whether it was Federal programs, State programs,
    philanthropic programs. The world rallied, the health world
    rallied to the site. That is why Mount Sinai, that is why FDNY,
    that is why other programs have been there working pretty much
    from the beginning.
        Now, what our job is going forward is to make sure that
    Government, all of us, that we make sure that these programs,
    that programs are there for people to meet their needs in the
    future.
        Mr. Murphy. I yield back the balance of my time, Mr.
    Chairman. I guess my point is that I think it is hard to make
    the case when we are seeing estimates that this is going to
    have an annual cost of anywhere from $250 million to $390
    million, that a President's budget that includes $25 million is
    evidence of our national Federal health care community rallying
    to the cause. I hope that is a placeholder, because we know and
    you know, Dr. Howard certainly does, because he has looked at
    these numbers, know that it is going to take a lot more to
    convince a lot of us in Congress that we are indeed putting our
    money where our mouth is on this issue.
        So I yield back the balance of my time, Mr. Chairman.
        Mr. Towns. You don't have anything to yield. [Laughter.]
        Congressman Duncan.
        Mr. Duncan. Thank you, Mr. Chairman.
        Dr. Agwunobi, you mentioned the figure 340,000 at one
    point. Was that the number eligible? Or maybe I misunderstood
    that.
        Dr. Agwunobi. Yes.
        Mr. Duncan. That is what I thought you said. The staff said
    that was the number eligible, but you have 340,000 actually
    enrolled.
        Dr. Agwunobi. Following the attack, the Federal Government
    provided the State of New York, through its Medicaid program,
    pretty quickly, within weeks, a $330 million waiver to help
    support the care of individuals in the months and years that
    followed. Over 340,000 individuals enrolled in that program and
    received care as a result of that program.
        Mr. Duncan. Well, let me ask you this. I have seen in
    Tennessee and throughout the country, we have this sick workers
    program for the Department of Energy. We have found that many,
    many people, because there is a big pot of money there, they
    are coming in and claiming money, even family members, of
    people who weren't exposed. So we are finding that we have to
    be somewhat skeptical of some of these claims to be fair to the
    taxpayer.
        Now, I know every Government agency wants to expand its
    mission and expand the number of people that it is taking care
    of or helping out. But is somebody being at least a little bit
    skeptical about whether all these things are related to 9/11?
    In other words, what I am getting at is this: I sure don't want
    to sound mean, but if 9/11 had never happened, all of these
    people would have gotten sick, would have gotten various types
    of diseases, would have gotten cancer or other forms of
    disease. Everybody would, all of them would have died at some
    point, hopefully after a long life.
        But are we at the point now where anything that ever goes
    wrong with these people is going to be in some way tied in to
    9/11? I mean, if somebody comes in with measles, where we do
    draw the line here? Is this a program that you are talking
    about it lasting 50 or 60 years, you are talking about it
    already ballooning to, one of our colleagues just said $390
    million. Is it going to be a multi-billion dollar program in
    the very near future?
        Dr. Agwunobi. Sir, the task force, our work, analyzing
    information and bringing together data in order to inform the
    Secretary and the administration, we haven't approached this
    with skepticism. We have approached this with a deep-seated
    respect for science and for data. One of the reasons we are
    being deliberative about this is that we believe you should
    start with a foundation of solid data, where you have that
    available to you, and with science. As to the rest of your
    question, related to the kinds of diseases, we are very proud
    of the work that NIOSH has done, we are very proud of the work
    that clinicians and others across the community have done in
    gathering data.
        Dr. Howard, did you want to talk a little bit to the kinds
    of conditions, the kinds of patterns that you are seeing?
        Mr. Duncan. You are going to have to do it very quickly,
    because we have votes unfortunately that are starting. I
    apologize.
        Dr. Howard. I will just mention, Mr. Duncan, that also
    being in the same institute that handles the Energy Employees
    Occupational Compensation Program, it is extremely important
    that we have the best, the most fulsome, the most robust
    science. Right now what we are seeing are associations between
    exposure and certain populations.
        I would have to look chiefly, and I would be happy to give
    you information, and the fire department medical officers are
    here today. If we look at that cohort of individuals, all of
    which are being examined, all of which were exposed, we look at
    the literature that has come out of that particular experience.
    We see people not only with symptomatology, primarily
    respiratory, but we see lung function abnormalities, objective
    tests. And that is our best indicator, these are the people
    that were maximally exposed.
        Then we go from there to other cohorts, then to other
    affected populations. As we go through that sort of transition,
    there are variable levels of association that we are seeing.
        Mr. Duncan. Well, all I am saying is, we need to take care
    of things that are directly attributable to the events of 9/11.
    But we can't just take care of anything that happens to anybody
    just because there happens to be a pot of money there and they
    happen to be in this pool. I had a group of these sick workers
    from Oak Ridge who came to see me one time. One woman broke
    down and cried and said that the work at Oak Ridge killed her
    father. And I started asking here what his story was, and he
    had retired at the age of 62 and had died 27 years later. I can
    tell you, almost every man around would say 89 good healthy
    years of living is a pretty good deal.
        But at any rate, I think some people just need to look at
    this very closely before it just balloons totally out of
    control. Thank you very much.
        Mr. Towns. Congressman Welch.
        Mr. Welch. I yield my time to my colleague from New York.
        Mr. Nadler. I thank you very much.
        Let me say that I am very cognizant of the very important
    need to increase the funding and make it a reliable stream to
    the centers of excellence in New York, to Mount Sinai, to
    Bellevue, which by the way, Bellevue has not received any
    Federal funding as far as I know, and to expand other programs
    that would treat a huge percentage of the 9/11 health cases.
    But I have a couple questions.
        No. 1, how do we deal with the fact going forward 15, 20,
    30 years from now that the current Federal funding approach is
    subject to the whims of an annual appropriation process?
    Shouldn't we be looking at setting up some sort of an ongoing,
    automatic system, so that people who because of 9/11 are still
    struggling with emphysema or cancer or whatever, 30 years from
    now don't have to worry about an annual appropriation process?
        Dr. Agwunobi. Sir, I am poorly qualified to comment on the
    annual appropriations process. It is one that I work for and
    live under and respect greatly. I do believe, however, that it
    is important that we give this planning, this process, a long-
    term horizon, that we focus not just on today's needs or on
    today's population, but on the needs of that population in the
    future.
        Mr. Nadler. Thank you. Second, your task force is focusing
    very strongly and properly so, as far as it goes, on the first
    responders, the people who worked on the pile and many of whom,
    70 percent of whom, according to the Mount Sinai report, are
    getting sick. But my concern is and has been for a long time,
    what about residents in the area? What about workers who come
    in to work in that area, not only that day, but subsequent? We
    know some people who have gotten sick because they work for the
    SEC, the Securities and Exchange Commission, in a building
    nearby. And they have lung-related problems now, because they
    worked in a building that was not a Federal Government
    building, not properly cleaned up after the disaster.
        So what is your task force doing about looking at the
    question of residents, workers, students, living in New York on
    the day of the disaster, or in Connecticut or New Jersey, and
    after the disaster? In particular, we know that the Inspector
    General of EPA said that they never did a proper cleanup, that
    thousands of buildings may still be contaminated, and that
    people may be being poisoned on an ongoing basis. Are you
    looking at that question, at implementing perhaps the EPA
    Inspector General's recommendations for how to deal with that
    question, and if not, why not?
        Dr. Agwunobi. Sir, the task force's charge is very clear.
    We look at issues that relate to responders.
        Mr. Nadler. So in other words, there is nobody in the
    executive branch now that you know of of the Federal Government
    looking beyond the responders?
        Dr. Agwunobi. I have no doubt, however, that information on
    residents will be a part of the dialog on the data and science
    at the Department of Health and Human Services.
        Mr. Nadler. Well, in terms of being a part of that dialog,
    you do realize that the EPA abolished the Office of Ombudsman
    of the EPA, because they told them what they should be doing.
    They have disregarded the EPA's Inspector General, who 3 years
    ago told them what they should be doing. They have disbanded
    scientific advisory panels, who also told them what they should
    be doing. And they have ignored every single recommendation and
    conducted so-called cleanups that the EPA Inspector General
    characterized as phony cleanups. And that as far as we know,
    the Federal Government is doing nothing to protect the health
    of people who live and work in the New York area from the
    ongoing contamination that every scientific body that has
    looked at it at the request of the Federal Government said is
    ongoing and is not being dealt with.
        Dr. Agwunobi. Sir, I represent the Department of Health and
    Human Services.
        Mr. Nadler. Let me then apologize for unloading on HHS what
    is really a question for EPA and for the President and for the
    Federal Government. I do that because we have been stonewalled
    for 5 years so far when we try to raise this question anywhere
    else. It is, as far as I am concerned, two cover-ups were
    conducted. One cover-up was of the health effects of the first
    responders. That cover-up started unraveling a year ago with
    the Mount Sinai report and then with some very good work done
    by, in particular, the Daily News of New York. And now at least
    we are talking about it, the task force is appointed, etc.
        But the other cover-up is still going on. And that cover-up
    is of the fact that large areas, well, we don't know if there
    are large areas, but potentially large areas of New York City,
    New Jersey, etc., were contaminated, were never properly
    cleaned up and are poisoning people to this day, so that we may
    see thousands of cancer, asbestosis, lung cancer, whatever, 15
    years from now. We have to uncover that cover-up and get it out
    to the public and have the Federal Government deal with that,
    as well as the fact that the Federal Government is first
    beginning to deal with the first responder problem.
        Thank you.
        Mr. Towns. Let me thank the gentleman. At this time, we
    will hear from Mr. Fossella. We have votes on the Floor, and
    immediately after Mr. Fossella, we will adjourn until 1:30.
        Mr. Fossella. Thank you, Mr. Chairman. I think part of this
    hearing process is education, judging by some of the questions
    and speculation. Clearly, as someone who always wants to insure
    that taxpayer money is spent wisely, I think we have an
    education process. I would like to submit for the record Mayor
    Bloomberg's report. On page 3, it lists the eligibility
    criteria that was established by Mount Sinai for those who can
    participate in the program.
        Mr. Towns. Without objection.
        [Note.--The referenced information entitled, ``Addressing
    the Health Impacts of 9-11, Report and Recommendations to Mayor
    Michael R. Bloomberg,'' may be found in subcommittee files.]
        Mr. Fossella. Thank you, Mr. Chairman. Because it is clear
    that still many Americans don't fully appreciate the tens of
    thousands, if not hundreds of thousands of people who were left
    exposed and are suffering as a result of 9/11. And they will
    continue to do so for years to come. I think it is essential
    that we get and build that support.
        Dr. Agwunobi, has HHS completed its internal cost estimate,
    or at least has a project of what it would cost in this coming
    fiscal year and beyond?
        Dr. Agwunobi. Sir, we have. Our process involves, as I
    said, reviewing all the data, doing an analysis of that,
    informing the Secretary. He will then take the next step, which
    is to engage in dialog. Let me just say that we don't stop at
    costs, we look at what are the ways to assure quality care for
    these people. Then you move to what is the best way to assure
    access to that quality care, the structure of the system, how
    it lays out across the Nation, what are the best ways to assure
    access to that quality care. Only then do we say, OK, of the
    different ways this might be done, what are the different
    costs.
        Mr. Fossella. OK. I am going to try to ask you, and I
    appreciate, given the time, if you could shorten those answers,
    if you can. The data example compiled by the fire department
    and Mount Sinai, is that not sufficient data to date to at
    least say something publicly or declare publicly what it is
    going to cost, at least in the short-term or the next couple of
    years, do you think so?
        Dr. Agwunobi. Sir, that is one data point.
        Mr. Fossella. What other data points exist?
        Dr. Agwunobi. We look at every source of data you have
    talked about, Mount Sinai, data from other systems, in the
    past, we are looking at every source of data.
        Mr. Fossella. So you don't think, for example, the fire
    department, where I think 96 percent of the responders who
    participated in that program is a pretty good or significant
    data point?
        Dr. Agwunobi. I think we are absolutely in our system going
    to have data from the authority events, port authorities and
    subsequently. However, to fully inform the Secretary, we need
    to look at all the data we can get our hands on.
        Mr. Fossella. You say in terms of developing cost
    estimates, do you anticipate supporting the current programs,
    for example, Mount Sinai, Fire Department and Bellevue centers
    of excellence already in place, or do you anticipate using
    different sources to fund the health needs?
        Dr. Agwunobi. I'm sorry, sir?
        Mr. Fossella. Are there programs, other than the existing
    ones that are currently treating the vast, vast majority of 9/
    11 responders, are you considering creating or funding those
    programs to treat 9/11 World Trade Center victims?
        Dr. Agwunobi. We are going to look at all of them, from all
    the data that we have, including the mayor's report. But I
    can't say what that net result in terms of the decision will
    be.
        Mr. Fossella. Is it safe to say that anyone receiving
    treatment in any of these centers of excellence for this coming
    what is called fiscal year will continue to receive treatment
    and will not be let go as a result of diminished Federal
    funding?
        Dr. Agwunobi. Our focus is on the people who are in need.
        Mr. Fossella. But can you say that anybody receiving
    treatment this year will receive that treatment, they will not
    be denied as a result of lack of Federal funding?
        Dr. Agwunobi. I think we have recommended to assure that
    everyone that has a need that is not met that they are taken
    care of.
        Mr. Fossella. At least for this fiscal year, as you begin
    to develop the long-term, and I don't think anyone is denying
    that there is a long-term commitment, for those triage people
    who need work on a day to day basis, the names of, for example,
    the people who can't breathe, for the sake of argument, we are
    not saying, the Federal Government is not telling them they are
    going to be denied?
        Dr. Agwunobi. I misunderstood your question. Funding for
    the current program will get us through the end of this fiscal
    year.
        Mr. Fossella. Second, do you think that there is an effort
    or a noble or national effort that we can say that these
    centers of excellence, we can look to for research or for
    registry purposes that will help to serve a national population
    that is already moving, whether it be to California or Florida
    or Connecticut, that health care professionals in those areas
    can turn to these centers of excellence to help treat those
    individuals that ultimately, if not now, will need care?
        Dr. Agwunobi. Sir, I would say that lessons learned,
    information we acquire, that we would share freely and openly
    with every one of these centers.
        Mr. Fossella. Thank you, Mr. Chairman.
        Mr. Towns. We will recess until 1:30. We will discharge
    this panel, and panel No. 2 will be at 1:30.
        [Recess.]
        Mr. Towns. Let me apologize for being late. There were a
    lot of votes on the floor and it lasted much longer than we
    ever anticipated. So may I now ask all of you to stand and be
    sworn.
        [Witnesses sworn.]
        Mr. Towns. I would like to welcome our second panel. I will
    briefly introduce each witness. Linda Gibbs is the deputy mayor
    of New York City for health and human services. We are
    delighted to have you. Ed Skyler is the deputy mayor of New
    York City for administration. We are delighted to have you as
    well. Together they chair the City's World Trade Center health
    panel and will be presenting the recommendations of the panel
    which Mayor Bloomberg has endorsed.
        They are accompanied by three physicians who have been
    treating New York City responders and residents: Dr. Joan
    Reibman, director of the World Trade Center Environmental
    Health Center at Bellevue Hospital. Welcome. Dr. David Prezant
    represents the fire department; Dr. Eli Kleinman represents the
    police department of New York.
        Dr. Robin Herbert is another experienced physician who
    leads a program to monitor and treat 9/11 illnesses. Dr.
    Herbert is with Mount Sinai Hospital, serves as director of the
    World Trade Center Medical Monitoring Program Data and
    Coordination Center.
        We have also with us John Sferazo, who was one of the
    workers at Ground Zero on the morning of September 12th, before
    sunrise. He worked on search and rescue and burned iron on the
    pile in search of survivors of the disaster. For more than 30
    days he worked at Ground Zero. Mr. Sferazo has diminished
    breath and lung capacity from the exposure to 9/11 pollutants.
    He has been unable to work since August 2004 because of his
    health impairments.
        We also have with us paramedic Marvin Bethea, who was
    buried in debris when the first World Trade Center Tower fell,
    but he got out. As the second building started to collapse, he
    helped an older woman across the street into a hotel and was
    covered in debris again. He returned to provide more aid on
    September 14th. Five weeks later, he suffered a stroke
    attributed to 9/11 stress. Later he was diagnosed with adult
    onset asthma, post-traumatic stress disorder and chronic
    bronchitis.
        We are honored to have such a distinguished panel here with
    us today. As with the first panel, of course, let me just say
    that we will go right down the line. We will start with you,
    Deputy Mayor Gibbs.

      STATEMENTS OF LINDA I. GIBBS, CO-CHAIR OF MAYOR BLOOMBERG'S
    WORLD TRADE CENTER HEALTH PANEL AND NEW YORK CITY DEPUTY MAYOR
    FOR HEALTH AND HUMAN SERVICES; EDWARD SKYLER, CO-CHAIR OF MAYOR
     BLOOMBERG'S WORLD TRADE CENTER HEALTH PANEL AND NEW YORK CITY
     DEPUTY MAYOR FOR ADMINISTRATION, ACCOMPANIED BY JOAN REIBMAN,
        M.D., ASSOCIATE PROFESSOR OF MEDICINE AND ENVIRONMENTAL
      MEDICINE, DIRECTOR NYU/BELLEVUE ASTHMA CENTER, DIRECTOR OF
    BELLEVUE WTC ENVIRONMENTAL HEALTH CENTER; DAVID PREZANT, M.D.,
    CHIEF MEDICAL OFFICER, OFFICE OF MEDICAL AFFAIRS, CO-DIRECTOR,
     WTC MEDICAL MONITORING AND TREATMENT PROGRAMS, NEW YORK CITY
       FIRE DEPARTMENT; ELI J. KLEINMAN, M.D., SUPERVISING CHIEF
       SURGEON, NEW YORK POLICE DEPARTMENT; ROBIN HERBERT, J.D.,
     DIRECTOR, WORLD TRADE CENTER MEDICAL MONITORING PROGRAM DATA
      AND COORDINATION CENTER, ASSOCIATE PROFESSOR, DEPARTMENT OF
       COMMUNITY AND PREVENTIVE MEDICINE, MOUNT SINAI SCHOOL OF
      MEDICINE; JONATHAN SFERAZO, DISABLED UNION IRON WORKER; AND
                        MARVIN BETHEA, PARAMEDIC

                      STATEMENT OF LINDA I. GIBBS

        Ms. Gibbs. Thank you, Chairman Towns, Ranking Member
    Bilbray, Congress Members from New York and additional members
    of the subcommittee, thank you so much for convening this
    hearing today and inviting me and Deputy Mayor Skyler to
    testify.
        We are accompanied here today by Dr. Joan Reibman of
    Bellevue, Dr. David Prezant of the fire department and Dr. Eli
    Kleinman of the police department. We would ask that you submit
    their testimony to the record.
        Mr. Towns. Without objection, so ordered.
        Ms. Gibbs. Thank you.
        I am here today as the co-chair, with Deputy Mayor Skyler,
    of a panel that Mayor Bloomberg convened in September 2006, the
    fifth anniversary of 9/11, to examine the health effects of the
    9/11 attacks and attack the sufficiency of resources devoted to
    World Trade Center-related health needs. The result of the
    panel's efforts was the most exhaustive examination of the
    health impacts of 9/11 to date and it was laid out in an 83-
    page report, co-authored by panel directors Rima Cohen and Cas
    Holloway, who are also with us here today.
        In this process, the panel started with the evidence. Let
    me summarize some of that for you. Over the past 5 years,
    medical researchers and clinicians have reported in peer review
    studies and from their own treatment experiences that thousands
    of people endured physical and mental health conditions that
    were caused or exacerbated by the 9/11 exposure. While many
    have recovered, others continue to suffer from a range of
    ailments. The most common are respiratory illnesses, such as
    asthma, and mental health conditions, such as post-traumatic
    stress disorder, anxiety and depression. We do not yet know the
    extent to which these conditions will remain or can
    successfully be resolved with treatment.
        We also know that the health issues associated with 9/11
    affect not only New Yorkers but tens of thousands of volunteers
    and workers from across the Nation, including every State
    represented on this subcommittee, who responded to the call to
    help and participated in the unprecedented rescue, recovery and
    cleanup effort that followed the terrorist attacks. These
    rescue and recovery workers are those most likely to experience
    ill health related to the exposure. For example, more than
    2,000 of the fire department's 14,000 first responders, 15
    percent, that is, have sought treatment for respiratory
    conditions since September 11th. More than twice that number
    have sought services for mental health care. Among a sample of
    9,400 rescue and recovery workers examined at the World Trade
    Center Health Program, coordinated by the Mount Sinai Medical
    Center, 32 percent self-reported lower respiratory system and
    50 percent reported upper respiratory systems near the time of
    their initial medical evaluation.
        Area residents, school children, commercial workers and
    others also reported a variety of illnesses in the aftermath of
    9/11, including acute breathing problems, worsening of asthma,
    nausea, headaches and stress-related illness and anxiety. Data
    from the New York City Department of Health World Trade Center
    Registry, the largest public health surveillance effort of this
    kind, has been documenting the physical and mental health
    conditions reported by over 70,000 participants. Its data
    showed that two-thirds of adult enrollees reported new or
    worsened sinus or nasal problems after the exposure to 9/11,
    two-thirds.
        Fortunately, help is available for many of those in need.
    Among the dozens of health and mental health programs that
    developed over the years since the attack, three have emerged
    as centers of excellence in diagnosing and treating World Trade
    Center-related health conditions. You have heard a lot about
    them here already today. The first at the New York City Fire
    Department, serving firefighters and EMS workers; the free
    monitoring and treatment program coordinated by Mount Sinai
    Medical Center is the second, which meets the needs of all
    other first responders, workers and volunteers; and third, the
    World Trade Center Environmental Health Center at Bellevue,
    which has served all the area residents, commercial workers and
    other non-first responders.
        These programs have provided a virtual lifeline to
    thousands of individuals from across the Nation. Equally
    important, the data generated by these programs and research
    efforts by the Registry and the New York City Police Department
    have led to important scientific studies, and have also
    informed the development of clinical guidelines for diagnosing
    and treating 9/11-related health problems. That is the good
    news.
        But the panel also found that these efforts and the
    critical research they generate are in serious jeopardy. Each
    of these programs faces a bleak future unless we secure ongoing
    Federal funding. Even with President Bush's recent pledge of
    $25 million, the fire department and Mount Sinai clinical
    programs are expected to run out of funds before the end of
    this fiscal year. The Federal Government has provided no
    support to the Bellevue program, the only program available to
    the thousands of residents, school children, Chinatown
    businesses and commercial workers who may have 9/11-related
    conditions.
        That is why the Mayor's panel recommended that New York
    City vigorously pursue Federal funding to support the programs
    that form the cornerstone of our response to 9/11 health
    impacts. As Mayor Bloomberg said when he accepted our report,
    ``Individuals who are now suffering from 9/11 health effects
    were responding to an act of war against this Nation.''
    Congressman Bilbray spoke eloquently about this this morning,
    that the Government is responsible for assisting them, and New
    York City cannot bear the responsibility on its own, especially
    for those who aided New York in its time of need, but now live
    in other States.
        We are asking the Federal Government to step up to the
    plate, stand shoulder to shoulder with us to support these
    brave men and women. Let me turn this over now to Deputy Mayor
    Ed Skyler.
        [The prepared statement of Ms. Gibbs follows:]
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                       STATEMENT OF EDWARD SKYLER

        Mr. Skyler. Thank you. Good afternoon. My name is Edward
    Skyler. I am the New York City deputy mayor for administration
    and I co-chair the Mayor's World Trade Center Health Panel with
    Deputy Mayor Gibbs.
        I want to first echo Mayor Gibbs' thanks to you, Chairman
    Towns, Ranking Member Bilbray, members of the subcommittee,
    such as Congresswoman Maloney, Congressman Murphy, as well as
    members of the New York delegation who are here, Congressman
    Nadler, Congressman Fossella, especially members of the New
    York delegation and their staffs, who have long made this issue
    a top priority.
        I also want to note that we have copies of the Mayor's
    report here for you and your staff.
        Deputy Mayor Gibbs walked you through some of the panel's
    medical data, existing treatment and research options and the
    core recommendations. I want to cover two related topics: what
    we need from the Federal Government at a minimum to provide the
    direct treatment, research and information that people
    suffering from 9/11-related health effects need; and the urgent
    need for Congress to reopen the Victim Compensation Fund.
        The Federal Government contributed substantially to New
    York's economic and physical recovery from the 9/11 attacks.
    Mayor Bloomberg and the people of New York City are grateful
    for the Federal Government's strong support. But Federal
    support has been slow in coming to address the health care
    needs of those who responded on and after 9/11, and of the
    residents and other people of New York City, who have remained
    since the attacks and have done so much to contribute to the
    city's resurgence. And the aid that has come is far less than
    is needed.
        Based on informed but necessarily contingent assumptions,
    the estimated gross annual costs to provide health care to
    anyone who could seek treatment for potentially 9/11-related
    illness, whether through the fire department, Mount Sinai,
    Bellevue programs or from a personal physician or any other
    source, is $393 million a year. That $393 million covers the
    cost to treat anyone anywhere in the country for a potentially
    9/11-related illness, including the thousands of responders and
    others who answered New York City's call from 50 States. We
    estimate that 45,000 people from outside New York City and New
    Jersey were exposed on 9/11.
        If you assume that number is a reliable estimate of gross
    costs in each of the 5-years since 9/11, then the total cost of
    9/11 health impacts has already surpassed $2 billion. We
    estimated that the minimum amount of Federal support needed,
    just to sustain and expand existing treatment and research
    programs, and to implement the rest of the panel's
    recommendations is $150 million next year, increasing to $160
    million by fiscal year 2001. Put another way, that $150 million
    is the amount needed to fill the gaps in available information
    and treatment for 9/11-related health needs.
        What will that money pay for? Sustaining the fire
    department's monitoring and treatment program at current
    levels; sustaining the Mount Sinai program, which is monitoring
    and treating thousands of NYPD responders and other workers and
    volunteers who participated in recovery operations at the World
    Trade Center site; sustaining and expanding the Bellevue
    program to evaluate and treat up to 12,000 patients over the
    next 5 years, the only program that treats residents in lower
    Manhattan; sustaining and expanding mental health services made
    available through the city's health department; expanding the
    treatment and research capacity of the police department and
    implementing the remainder of the panel's recommendations.
        The health impacts of 9/11 are substantial and will be with
    us for years to come. Without the help of Congress and the
    administration, there is a real risk that health care needs of
    those who responded on 9/11 or who stayed with the city to help
    us and the Nation rebuilt will go unmet. We should work
    immediately and urgently to prevent this entirely preventable
    outcome.
        Second, I want to briefly talk about the panel's
    recommendation to reopen the Victim Compensation Fund. When
    Congress created the Victim Compensation Fund in 2001, it chose
    a no-fault compensation program. Those injured were compensated
    without any need to establish negligence or fault. Those who
    did not meet the eligibility criteria or did not sign up in
    time had no choice but to go the traditional litigation route.
    Congress worked with the city to create the World Trade Center
    captive insurance company, to insure the city and its
    approximately 150 contractors whose construction and other
    workers played a critical role in the World Trade Center
    cleanup for claims arising from those operations. The insurance
    company was funded with $1 billion of the $20 billion that
    Congress and President Bush made available to the city after
    the 9/11 attacks.
        But this insurance mechanism is not suited for what we are
    faced with today. More than 6,000 city employees and other
    workers have already sued the city and its contractors,
    alleging harm in connection with the operations at Ground Zero.
    Taken together, those lawsuits allege damages that the city
    conservatively estimates to be in the billions of dollars. And
    we don't know who or how many people may allege they are harmed
    because of 9/11 in the future.
        I should note that Congress capped the city's liability at
    $350 million, but the potential liability of contractors who
    participated is not capped by statute.
        The insurance company cannot just hand out the $1 billion
    Congress provided for insurance coverage. As with any fault-
    based insurance mechanism, plaintiffs must not only show they
    were harmed, but must also prove fault. The city and its
    contractors have strong defenses for what was clearly a
    necessary response to a national attack.
        New Yorkers have always been proud of the way the city came
    together after 9/11. But this drawn-out and divisive litigation
    is undermining that unity. The fundamental point is,
    compensating people who were hurt on 9/11 should not be based
    on a legal finding of who is to blame. We all know who is to
    blame: 19 savages with box cutters. We are here today because
    New York City would rather stand with all those who filed suit
    than against them in a court room. At its core, reopening the
    Victim Compensation Fund is about fairness. There is no reason
    why people harmed as a result of 9/11 should now have to go to
    court and prove liability. Proof of harm should be enough to
    receive fair and fast compensation.
        Simultaneously with the reopening of the fund, it is
    essential that Congress eliminate any liability of the city and
    its contractors arising from the recovery and cleanup. Congress
    could then move the $1 billion now available to captive
    insurance to the newly reconstituted Victim Compensation Fund.
    Only by taking these steps can we ensure that those who were
    harmed by 9/11 get compensation quickly. Only by taking these
    steps can we ensure that in the event of another terrorist
    attack, whether in New York, San Diego, Boston, Chicago,
    anywhere on American soil, the private sector will come to the
    country's aid as swiftly and with the same selflessness, energy
    and determination that was brought to bear on September 11,
    2001. Reopening the funds and eliminating liability to the
    contractors is not just about providing health care and
    compensation, it is necessary to our country's safety in the
    future.
        Thank you for the opportunity to testify before you today.
        [The prepared statements of Mr. Skyler, Dr. Reibman, Dr.
    Prezant, and Dr. Kleinman follow:]
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        Mr. Towns. Thank you very much, Deputy Mayor Skyler and
    also Deputy Mayor Gibbs, for your testimony.
        Now we will move to Dr. Herbert.

                       STATEMENT OF ROBIN HERBERT

        Dr. Herbert. Thank you. Honorable Chairman Towns, Ranking
    Member Bilbray, Mrs. Maloney and other members of the
    subcommittee, as well as the members of the New York delegation
    who are here, Mr. Nadler and Mr. Fossella, thank you so much
    for inviting me today. My name is Dr. Robin Herbert. I am an
    associate professor in the Department of Community and
    Preventive Medicine of the Mount Sinai School of Medicine and
    currently serve as the Director of the World Trade Center
    Medical Monitoring Program Consortium Data and Coordination
    Center.
        In light of our growing understanding of the health
    consequences that have resulted from an unprecedented attack on
    the Nation, it is an apt time to take stock of how well we as a
    Nation care for World Trade Center responders and the many
    others who have fallen ill or may become ill in the future. The
    environment in lower Manhattan following the collapse of the
    Twin Towers was unlike anything previously witnessed. But
    caring for affected populations of critical need is not
    unprecedented nor unearned by those involved with this
    particular tragedy.
        It is estimated that well over 50,000 people worked or
    volunteered in the aftermath of the attacks in and around the
    World Trade Center area and the Staten Island landfill. This
    group included both traditional first responders, such as
    firefighters, police officers, paramedics, but it also included
    a large and very diverse population of other responders, heavy
    machine operators, laborers, iron workers, many others from the
    building inspection trade, telecommunication workers, transit
    workers, sanitation workers and a wide range of volunteers.
        Our Nation has celebrated these responders as heroes.
    Unfortunately, in the course of their selfless work, they have
    been exposed to a complex mix of toxic chemicals and to
    physical hazards and extreme psychological trauma. Because of
    this many suffer from persistent respiratory and mental health
    consequences, as well as a chronic sequelae of injuries.
        I think many of us here at the table agree that the
    physical and mental health consequences of the disaster have
    been very well documented. We, from Mount Sinai, were proud to
    release in September 2006 a report that detailed findings from
    our federally funded program. We examined 9,442 World Trade
    Center responders between July 2002 and 2004. Among the key
    findings, fully 69 percent of the responders reported having
    new or worsened respiratory symptoms at the time of their
    response work. Fifty-nine percent still had those symptoms as
    long as 2\1/2\ years after September 11, 2001.
        In particular, one of the most worrisome findings, I think,
    was an increased rate of breathing test abnormalities when
    compared with the general U.S. population. In our non-smoking
    patients, we found five times the expected rates of a breathing
    test abnormality called low forced vital capacity. This is a
    finding that can be caused by a number of different conditions.
    It can be caused by asthma with something called air trapping,
    it can be caused, frankly, by being overweight. But it also can
    be caused by interstitial lung disease of the type that
    unfortunately we know that some responders have already
    developed and unfortunately a few have died from.
        When this kind of abnormality is found, this is a screening
    test. What you need to do is then go and followup to figure
    out, what is the cause of that abnormality. And that is the
    reason that I believe, and I believe that my colleagues,
    certainly the physicians with whom I have worked, Dr. Reibman
    and Dr. Prezant, feel very strongly that centers of excellence
    are the way to go to take care of responders. We see a
    responder with a low force vital capacity, we need to get that
    responder rapidly into treatment with diagnostic tests and with
    somebody who is an expert in World Trade Center-related
    diagnosis and treatment to find out what the cause of the
    problem is. I would certainly say the same would be for
    residents, not just responders.
        We have also found that in our treatment program, there are
    very similar types of patterns of disease as has been seen and
    reported in other groups. In our treatment program at Mount
    Sinai, where we have seen over 3,600 responders, 86 percent
    have upper respiratory problems that are not going away, such
    as sinusitis. Half have lower respiratory problems, such as
    asthma. About a third have problems like gastrointestinal
    conditions. Almost a third have persistent musculoskeletal
    problems from injuries and almost 40 percent have persistent
    mental problems. So this is, again, this is 3,600 people
    receiving medical care to date for these problems.
        We have also found in our treatment program that 44 percent
    have no health insurance. If we didn't have our federally
    funded treatment program now, and if we hadn't previously had
    philanthropically funded programs, these folks would have
    nowhere else to go.
        In addition to the 44 percent uninsured, about 20 percent
    are under-insured. So access to medical care for responders has
    been a huge difficulty.
        Basically at this point, given what we know about the
    health consequences of the disaster, we believe that regular
    monitoring and screening examinations and treatment will be
    necessary for responders for their lifetimes. We would advocate
    a program in which we are able to develop, actually what we
    have done is develop an approach to medical care of responders
    where we link screening examinations to treatment and to
    disease surveillance. Because the idea is that you want to do
    the screening exams to identify health problems early and get
    people into treatment. But you also want to be able to use the
    information from those examinations to identify emerging
    disease patterns. Because we know that responders have been
    exposed to a range of toxins, including cancer-causing agents
    such as asbestos, PCBs, dioxins, and we frankly do not know
    what the long-term health consequences will be for the
    responders.
        Because of that, again, we advocate the centers of
    excellence model. Right now what we do is we offer standardized
    comprehensive examinations to identify both possible World
    Trade Center-related physical and mental health consequences.
    We then gather the information on the health impacts and get
    people into treatment.
        We feel that dissemination of information derived from the
    disease monitoring and screening and treatment is really
    important to improve treatment for World Trade Center
    responders. And we are so grateful that we have received
    Federal funding to date to do these activities.
        In 2002, Mount Sinai received funding for the World Trade
    Center worker and volunteer medical screening program in
    response to growing concerns about health effects among
    responders. And our program based at Mount Sinai coordinates a
    consortium throughout New York, New Jersey, Long Island and
    nationally. That program has been continued as a medical
    monitoring program. We have seen over 20,000 responders to
    date, more than 7,000 have had followup examinations. We have
    seen people from all over the United States. We have been
    working with a variety of programs to provide national exams,
    and have examined more than 800 responders nationally. It is
    very challenging, and I really appreciated your comments
    earlier today about that.
        Recently the funding that we have received has enabled us
    to add treatment to our medical monitoring program. This
    integration has been critical in affording responders
    streamlined access to high quality standardized and diagnostic
    and treatment services with clinicians who have unsurpassed
    diagnostic and treatment experience. Thus, needed service
    provision for responders and programs have already been
    developed and established with successfully operating federally
    funded initiatives. The New York Fire Department and Mount
    Sinai centers of excellence are led by NIOSH-CDC and are
    coordinated and operated by expert clinicians well versed in
    the complex nature of World Trade Center health effects and
    outcomes.
        The existing programs are models and they need to be
    preserved and expanded for the sake of those affected. Today we
    must choose to continue to help thousands of those affected by
    September 11th as we are best able, through coordinated,
    experienced and expanded World Trade Center centers of
    excellence, by providing responders with excellent medical and
    mental health services, we can help them to stay in their jobs
    or begin to work again. We can help them return to their normal
    lives and we can provide with some hope for the future.
        As you are likely aware, Federal funding for the World
    Trade Center treatment services is due to run out before the
    end of this fiscal year. Federal funding for the monitoring
    program, which was provided for the first 5 years of what we
    anticipate will be 20 to 30 years of needed funding, will also
    run out in July 2009. We implore you to keep these programs
    alive, as a lifeline for the World Trade Center responders.
        Thank you very, very much.
        [The prepared statement of Dr. Herbert follows:]
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        [GRAPHIC] [TIFF OMITTED] 34912.058

        Mr. Towns. Thank you.
        Mr. Bethea.

                       STATEMENT OF MARVIN BETHEA

        Mr. Bethea. Good afternoon, Mr. Chairman. I would like to
    take this time to thank our elected officials for giving me the
    opportunity to testify at this hearing.
        My name is Marvin Bethea and I was a New York City 911
    Paramedic for the private hospitals. When I was dispatched by
    the New York City Fire Department from the borough of Queens to
    respond to the World Trade Center, I did. As I crossed the 59th
    Street Bridge, I was informed by phone that a big jetliner had
    crashed into the second tower. We knew that this was no
    accident, this was a terrorist attack.
        Did we say, ``We shouldn't go to this, it is a terrorist
    attack?'' Absolutely not. Because we understood we had a duty
    to act and a responsibility to protect the city, State and
    country that we loved so much. I survived the collapse of both
    towers, and here we are 5 years later and we are fighting for
    health care and financial compensation. Can you imagine if it
    took me 5 years to respond to the World Trade Center? What
    would my city, State and country think of me? I, like so many
    others, did what President Kennedy asked of us when he said,
    ``Ask not what your country can do for you; ask what you can do
    for your country.''
        What did doing for our country get us? We got sick, we got
    injured, and financially ruined. I went from being a happy,
    hard-working paramedic to becoming a disabled paramedic with
    numerous health problems. The last I worked was January 8,
    2004. I went from taking two medicines, as you see before you,
    to currently now I am taking 15 medicines. And yet they say we
    are not sick. I am a broken man that has been given a slow
    death sentence. And I pray to God every day that I don't
    develop any new health problems, like cancer.
        I saw and heard my government promise on a city, State and
    Federal level that we wouldn't be forgotten. They forgot. You
    can't tease us now by allocating some funds for treatment that
    will only last maybe a few months. People are starting to get
    treatment, only to be threatened with the fact that it may not
    last for only a few months. That is cruel. This is equivalent
    to man who hasn't eaten for the past 3 weeks and now you give
    him steak. You ask him, do you like that steak? And he has
    three bites out of that steak and tells you that it is the best
    steak he has ever had, and then your response is, enjoy it,
    because you are not going to get any more. Like I said before,
    that is very cruel.
        I am extremely grateful for the $25 million President Bush
    has pledged. Here is the problem with that. Senators Clinton
    and Shumer's 9/11 Heroes Health Improvement Act calls for $1.9
    billion in funding. Giving $25 million, it is like me asking
    you, can I borrow $100,000 and you say, see me today and I will
    take care of you. When I see you, you give me $10 and act as if
    you are doing me a favor. It is imperative that treatment
    centers like the Mount Sinai Health for Heroes Program are
    continually funded. Mount Sinai and other programs like them
    are for occupational health doctors. These doctors are
    specially trained and know what to look for and treat the
    horrible things that we have been exposed to.
        Financial compensation is another absent component of this
    equation. It is no fault of our own that we cannot work any
    more. We need to pen up the 9/11 Victims Compensation Fund like
    it was. What good is treatment if I am sleeping in my car and I
    have lost my family? If I don't have high blood pressure or
    depression, I will have it now for sure. The military has a
    saying, we leave no soldier behind. September 11th was an act
    of war against this Nation. You must not leave anyone affected
    by 9/11 behind.
        I would like to take a special opportunity to thank the
    elected officials that I have personally worked with, Senator
    Clinton, Congresswoman Maloney, Congressman Fossella,
    Congressman Nadler, Congressman Hinchey and Congressman Shays
    for their support and staying with us. God bless all of you.
        Thank you again for this opportunity.
        [The prepared statement of Mr. Bethea follows:]
        [GRAPHIC] [TIFF OMITTED] 34912.059

        [GRAPHIC] [TIFF OMITTED] 34912.060

        Mr. Towns. Thank you very much, Mr. Bethea, for your moving
    testimony.
        Mr. Sferazo.

                     STATEMENT OF JONATHAN SFERAZO

        Mr. Sferazo. Chairman Towns and our bipartisan subcommittee
    congressional members, I say thank you. Hello, everyone. I am
    honored to have been asked to give testimony today to the
    experiences I have had with the September 11, 2001 tragedy. My
    name is Jonathan Sferazo, I am a disabled union iron worker
    from Local 361, Brooklyn, NY. We have created the metropolitan
    area's skyline.
        I responded to the disaster on the morning of September
    12th. The Brooklyn Battery Tunnel was our avenue of approach.
    We opened up West Street with the removal of collapsed cars and
    trucks and debris, all the way to the South Tower. I am typical
    of anyone who stayed approximately 29 to 32 days at that site.
    My medical and psychological conditions are reactive airway
    disease, restrictive airway disease, sinusitis, continual lung
    infections, PTSD, anxiety, depression, sleep apnea, and
    gastroesophageal reflux disease.
        None of this you would have expected from someone who ran a
    5 minute and 30 second mile when I was in high school. I never
    had a pulmonological problem, and I want everybody to make sure
    they understand that, prior to 9/11. Nor would I ever have been
    certified by the New York State Department of Environmental
    Conservation for wildland search and rescue, certified by the
    New York State DEC and Stonybrook.
        So you see, I went to Ground Zero because I wanted to help
    find and save human life. If I am to be the voice of the
    responder, then know that I am outraged by the lack of
    responsibility and the loss of obligation that this
    administration has taken toward us. We are clearly being shown
    that we are expendable. President George Bush came to the Trade
    Center site and told us, we will never forget. Mr. Chairman, he
    forgot, sir.
        We want to know if those of us who are so severely
    afflicted have to lose all we have worked for to be eligible
    for social services or if we will ever be given what we were
    promised?
        We have heard too many times, as I have heard here today
    myself, why weren't you wearing a mask? Now, hear my answer and
    the answer loud and clear. Because we were given paper masks
    after several days that continually clogged up and we were told
    by our mayor at that time, and I am not referring to our Mayor
    Bloomberg presently, members of the Centers for Disease
    Control, members of the EPA and Christy Todd Whitman that the
    air quality was acceptable.
        Also, I ask you to put yourself in our place. When we got
    to the Trade Center site, most of us had never been thrown in
    this kind of a situation before. You had fighter jets flying
    overhead with their sonic boom, helicopters hovering above the
    skyscrapers. You had emergency whistles blaring above the noise
    of the equipment that we were operating, military personnel,
    police. Do you honestly think, and I look at you all and ask
    you directly, do you honestly think, knowing that there were
    people in that pile, do you think we were concerned with our
    health, after we had been given a silent message that it was
    safe and acceptable?
        I am here today, Mr. Chairman, Members of Congress, and all
    the members who are listening to this voice of mine, I am here
    because I care and I have cared from the beginning. If I
    didn't, I never would have gone down there. We are trying,
    because of our experiences, to get this much-needed health
    care. Marvin Bethea and myself, we created a not-for-profit
    organization called the Unsung Heroes Helping Heroes. We are a
    licensed 501(c)(3) and we did this because we saw no response
    from our administration and we saw the funding was going to be
    running out, starting in 5 years.
        I am also here to express the outrage from all of us that
    were involved in that disaster in that something hadn't been
    done immediately. I thank everybody here for their involvement
    and for hearing me today.
        [The prepared statement of Mr. Sferazo follows:]
        [GRAPHIC] [TIFF OMITTED] 34912.061

        [GRAPHIC] [TIFF OMITTED] 34912.062

        Mr. Towns. Thank you very much, Mr. Sferazo.
        I will call on the ranking member to go first, then I will
    call on you, Mrs. Maloney.
        Mr. Bilbray. No, I will yield, Mr. Chairman.
        Mr. Towns. Mr. Bilbray yields.
        Mrs. Maloney. Thank you. First of all, I really want to
    thank the chairman and Ranking Member Bilbray for holding this
    hearing. It is critically important. I requested it, along with
    my colleague, Vito Fossella. I regret that I was on the floor
    with a bill that was one that I authored that actually passed,
    which was exciting, also very important to the city of New
    York, the CFIUS process to have a better review of challenges
    that may harm our homeland security and encourage foreign
    investment. There is another meeting back on the floor, so I am
    going to have to get back, I apologize.
        I want to thank everybody on this panel. You are really
    true heroes and heroines. Many of our friends and neighbors who
    perished on 9/11, they were victims. But the men and women who
    went down there to work, that was their choice, and to protect
    and work to save other people. So in my opinion, they are the
    true heroes and heroines, along with the people that have made
    a commitment with their life work to help them and to protect
    them and to try to make them well again.
        I have a few questions. I first want to say, we have been
    making some progress, not enough. We were really pleased with
    the $25 million that was a placeholder for treatment. This was
    the first time we had gotten a line in the Federal budget, and
    we were pleased with it, but I do want to say that it has been
    a long, hard fight. The administration has really fought us
    every step of the way. First, they opposed the original $90
    million in funding for medical monitoring, then they actually
    rescinded, it is hard to believe, but rescinded the $125
    million in the 2006 budget for 9/11 help. The administration
    resisted, when the New York delegation worked successfully with
    our two Senators to restore that funding and to get the first
    $75 million dedicated for treatment. They fought us when Mr.
    Fossella and I pushed to have one person put in charge and
    responsible for 9/11 health. And after the administration
    finally appointed someone to coordinate the 9/11 health issues,
    6 months later, in September they recreated the wheel and
    started a brand new task force, chaired by Mr. Agwunobi.
        Five and a half years after the attacks, we still do not
    have a plan to monitor everyone who was exposed to the deadly
    toxins and to treat everyone who is sick. I understand that Dr.
    Agwunobi made clear in his testimony this afternoon that area
    residents, workers, and school children would not be included
    in any plan they came up with. This is unacceptable. Everyone
    exposed should be monitored and everyone who is sick should be
    treated. That is the least that we can do as a group as a
    grateful Nation for the sacrifices of others.
        As for maintaining the current programs that you have
    testified about, I have concerns that for ideological reasons
    or others that they will not intend to fund the centers of
    excellence, which many of you represent. Can you tell me why
    that would be a mistake, not to fund the centers for
    excellence? I open it up to Drs. Herbert, Prezant and Reibman,
    since you are in direct line of these centers for excellence.
    What would it mean if these centers for excellence were not
    funded?
        Dr. Prezant. This is Dr. David Prezant from the New York
    City Fire Department. I very much appreciate your support and
    your question. We are one of three centers of excellence and
    also along with the New York City Police Department that have
    spent a tremendous amount of time taking care of these
    patients. The New York City Fire Department, each one of these
    centers of excellence is unique. I am going to talk about the
    unique aspects of my center of excellence.
        The New York City Fire Department is unique for a variety
    of reasons. Our cohort, our group of 16,000 firefighters, EMS
    workers and retired firefighters that came to the 9/11 site on
    those days was the highest exposed group. They were there, most
    of them, over 2,000 during the collapse, nearly 8,000 during
    the next 36 hours and the rest of them over the next days of
    the first week. They continued to work there until the end of
    the year. They are the group with pre-9/11 data. And because of
    that pre-9/11 health data, we have been able to compare in an
    objective fashion, scientifically, what has happened to them
    after 9/11. We were able to document that in the first year,
    the average drop in pulmonary function for our work force was
    375 milliliters. That is 11 times what we saw annually in the 5
    years before 9/11.
        Only through a center of excellence with pre-9/11 data and
    then with longitudinally repeated data, can you come up with
    that type of science. In the meetings that we had earlier
    today, before the session went into temporary recess, we heard
    that there was not adequate science. We disagree with that. The
    New York City Fire Department has published nearly 20 papers,
    scientific peer-reviewed papers, documenting these problems. We
    are very soon going to be coming out with a paper showing that
    sarcoidosis, a lung disease, was increased in the years after
    9/11 in our cohort.
        The only way to do that is through a center of excellence
    that is able to keep the group together. A fee for service
    program that would destroy the centers of excellence and
    prevent this work from going forward, both scientifically and
    from a treatment perspective, in terms of serving our group,
    providing them the very necessary expert work that Dr. Herbert
    has been talking about in her testimony.
        Mrs. Maloney. Thank you.
        Dr. Reibman, would you like to add to that?
        Dr. Reibman. Thank you very much for inviting me. Let me
    begin to answer that by explaining where we are coming from and
    the group that we have been taking care of. Again, earlier this
    morning we heard that there is not data, or not adequate data
    on the health of the population.
        Including the residents. And we run an asthma program at
    Bellevue Hospital, which is a public hospital associated with
    New York University Medical Center. At that time, we were
    concerned that there wouldn't be adequate lung protection for
    the residents in lower Manhattan. So in cooperation with the
    New York State Department, we were able to document in a
    controlled study the increase in symptoms of residents living
    in lower Manhattan, compared to residents a distance away. In
    fact, there was an almost sixfold increase in symptoms of
    asthma in the residents who lived in Lower Manhattan.
        Because of that, we began looking at a number of community
    treatment programs for residents that were not funded by anyone
    in our city or not the Federal Government. A year ago, we were
    funded by the American Red Cross for our program to care for
    residents, as well as responders. And this September, we were
    very pleased to receive funding from New York City to take care
    of the responders and residents, as well as office workers.
        We now currently have a program in place for responders,
    residents, and office workers, many of whom returned to work 1
    week after the collapse of the buildings. What this has enabled
    us to do, as you heard from both Dr. Herbert and Dr. Prezant,
    is that we can see people so we can start to understand that
    there are diseases in individuals who have been exposed. This
    is particularly important for the residents who may have been
    going to a diverse number of physicians and may not be plugged
    into a treatment program. But because we are seeing postures of
    disease and patterns of disease, it allows us to see the full
    effects of exposure. That is a very important reason for a
    center of excellence.
        The second reason, we keep talking about treatment, but we
    actually don't really completely understand what the disease
    are we are treating or how to treat them. So unless we work
    with the centers of excellence and work on ways to understand
    the diagnosis and look at treatment to see whether treatments
    are working or not working, we will not know how to treat the
    disease symptoms.
        Finally, the third reason for centers of excellence is that
    we need to continually monitor these diseases. We will not be
    able to keep up with the emergence of diseases, hopefully not
    cancerous, but we would like to be ready in case we see that,
    other diseases that might not be as common, we will not be able
    to identify those unless we are seeing them in centers of
    excellence.
        Mr. Towns. We are going to give a second round, we would be
    glad to do so. But you are way over your time.
        Mrs. Maloney. I appreciate the chairman's indulgence. I
    appreciate it very much. Thank you so much for having this
    hearing. My constituents, I would say, all New York City and
    all those who suffer are deeply grateful, Mr. Chairman, for
    your leadership. Thank you.
        [The prepared statement of Hon. Carolyn B. Maloney
    follows:]
    [GRAPHIC] [TIFF OMITTED] 34912.063

    [GRAPHIC] [TIFF OMITTED] 34912.064

        Mr. Towns. I appreciate your moving it forward, too. Thank
    you so much.
        I now yield to the ranking member.
        Mr. Bilbray. Thank you, Mr. Chairman.
        Dr. Herbert, I will give you the shot.
        Dr. Herbert. Thank you so much.
        In addition to Dr. Prezant and Dr. Reibman's comments, I
    would add a few other things that I completely agree with what
    they laid out. I mean, first, frankly, I think it would be
    inhumane to end these programs now. I don't know a better way
    to describe it.
        In terms of the group that we are seeing, which is a very
    diverse group, and we have in our monitoring program about 15
    percent of our patients do not speak English, they work for
    multiple employers. We have people, as I said earlier, who came
    in from around the Nation. We would lose the ability to track
    and identify disease in this very disparate group.
        The other thing is that as Dr. Reibman was alluding to, the
    diagnosis and treatment of World Trade Center illnesses is not
    straightforward. It is very complex. We are seeing emerging
    conditions, we don't fully understand the entire nature of what
    we are seeing. We know at Sinai, we have seen unfortunately
    responders who have gone to other providers, as Dr. Reibman
    mentioned, maybe had seen doctors who were not so tuned in to
    the nature of World Trade Center health problems. We frankly
    have patients who are being seen by other doctors and were
    either not ever diagnosed correctly or were misdiagnosed. That
    has had very serious consequences for some of our patients.
        Finally, with respect to the folks, and we are seeing the
    20,000 plus responders from the New York, New Jersey,
    Connecticut metropolitan area and the Nation, we know that our
    patients are going to age, they are going to retire, they are
    going to be diffusing across the Nation. If we don't have a
    center of excellence with the capacity to track people
    nationally, we will lose the ability to follow that group over
    time, and they will lose access to the state-of-the-art
    screening and treatment that we feel they need so desperately.
        Mr. Bilbray. Following upon the long-term impacts, I think
    we all agree that one of the major things we can do to reduce
    the adverse impact after exposure has occurred is behavioral
    activities that may aggravate that. We all know what the No. 1
    behavioral activity that aggravates particular exposures are.
    What percentage of the at-risk population do you think are
    engaged in smoking at this time?
        Dr. Herbert. I can look in our environmental health
    perspectives paper that I referred to. It was lower than the
    population norms. Now, it may have been that people had smoked
    previously, and have become ill and have stopped.
        Mr. Bilbray. But that is in the past, right? My biggest
    concern here is what can we do to proactively now to avoid
    problems in the future? I think there is too much assumption
    that the damage has been done, and not enough assumption of,
    there is a whole lot of things we can do now that can help to
    reduce the risks, not only for those who are exposed, but of
    future exposure.
        Dr. Herbert. I can pull out the number of smokers in our
    population. But also I would say, additionally, we have also
    found that because our patients are getting depressed, they are
    also tending to sometimes not eat----
        Mr. Bilbray. Just so you know my background, I was a member
    of the State Air Resources Board in the State of California.
    Those of you in New York have been smart enough to follow our
    leadership on a lot of stuff when it comes to air exposure.
    [Laughter.]
        And the one thing we have run into is that the level of
    risk for exposure just skyrockets when you fall into the
    population that is continuing to smoke. I hear you guys are
    finally catching up with us on the smoking issue, too. I am
    just wondering if anybody is out there talking about, and this
    is where we get in the conflict, because the mental health
    people will justify not doing the cessation programs and
    actively pursuing getting people off of that behavior, because
    of the mental health problems that drive them toward the
    behavior.
        Are we talking out there openly and frankly about trying to
    make sure that those who are exposed get off of the consumption
    of tobacco products because of the huge increase in exposure?
        Dr. Herbert. I would like to defer the question to Dr.
    Prezant, who I think has been a leader in that area.
        Mr. Bilbray. OK, Doctor.
        Dr. Prezant. And then of course, if there is time, other
    people can tell about their cohorts. We actually have asked
    that question from day one in our cohort in our group of
    firefighters. We know exactly how many smoke, 15 percent, which
    is less than the 24 percent that is on average in New York
    City. We instituted, along with some help from the Department
    of Health of New York City and various different expert
    organizations throughout the country. We instituted an
    aggressive tobacco cessation program in the first year and were
    able to reduce that smoking rate by half, and continue to offer
    that tobacco cessation program for free to every one of our
    members.
        But most importantly, in addition to this, and I agree with
    you completely, long-term health effects may have a synergy
    with tobacco smoking, we have learned that from California and
    from every other study.
        Mr. Bilbray. Asbestos exposure.
        Dr. Prezant. Absolutely. But I do want to stress to you one
    thing and one thing right away, is that we have statistically
    analyzed the group that is medium sick and the group that is
    most sick in the New York City Fire Department from the World
    Trade Center. Tobacco smoking was not a statistically
    significant co-variant. It will be in the future, and that is
    why we are taking these proactive steps.
        Mr. Bilbray. I am glad you clarified that, because we know
    that the impact does not show up in 5 or 10 years. But it will
    show up in the future. I just think here is one place where a
    little tough love, and we run into it with firefighters again
    and again. A little tough love about doing everything we can to
    get them away from the behavior that is going to hurt them
    severely, not just treating those things that have happened to
    them, but what they are doing to themselves, too.
        I just bring that up as a child of a victim of tobacco
    consumption. My father passed away very early in life because
    he didn't do the right thing and get off that. But now we have
    an exposed population that is at such an aggravated risk that
    there is no justification, they try to avoid it.
        Ms. Gibbs, let me shift way over in saying the coordinator
    that the Mayor wants, what kind of collaborative, how can we
    coordinate with the coordinator? Where is the coordinator going
    to go and what is the coordinator's job being proposed for?
        Ms. Gibbs. I think this is an example of how the centers of
    excellence and the registry work will benefit not only the
    people who are able to walk through the doors of the three
    centers of excellence, but in fact serve those that are
    suffering from the conditions who live in places far across the
    United States. And your example of the treatment regimens that
    people should be following who have suffered the positions is a
    good one to bring light to, to how the coordinator will use the
    resources of the office of health and mental hygiene, the
    creation of our Web based application that will provide
    knowledge to not only those who are suffering, but physicians
    as to what the medical guidelines are to help to assess the
    conditions and to understand the best treatment interventions.
        So the work of the coordinator will be not just to assist
    those who are in the city government that are working with
    agencies and continue to have direct contacts, but are living
    far and wide and need to be kept abreast with the latest
    developments.
        Mr. Bilbray. Thank you very much. My time has expired.
        Mr. Towns. Thank you very much.
        Let me just ask a few questions, then we will go to our
    colleague from New York. Let me begin with you, Dr. Kleinman. I
    understand that NYPD did a followup study for individuals who
    were exposed to toxins. What did that study indicate?
        Dr. Kleinman. Good afternoon, Mr. Chairman and members of
    the subcommittee. Thank you for permitting me to present our
    case here.
        The NYPD had 34,000 emergency responders since 9/11, all of
    whom have been monitored and tracked by the NYPD's medical
    division since that time. In 2002, a study of 644 emergency
    service members of the Department was performed and the initial
    results of that study, the preliminary data, revealed that 38
    percent of the people who had been tested suffered from
    abnormalities. Of those 38 percent, approximately 25 percent
    were respiratory, another 25 percent were psychological, and
    the remainder were due to either hearing, orthopedic problems
    or other miscellaneous problems. A second followup study to
    that study is scheduled for the spring of 2007.
        But in addition, the NYPD medical division has undertaken
    two 5-year followup studies of two cohorts of individuals that
    represent the largest group of responders that represent a
    cross-section of the population of New York City. One group of
    responders are the emergency service workers for whom we have
    pre-9/11, post-9/11 data. That study should be completed by the
    end of the summer.
        The other 5-year study is a study of other members of the
    Department who have either persistent respiratory symptoms or
    new onset respiratory symptoms. That will be completed in the
    same timeframe.
        The importance of these studies, as I mentioned, is that it
    is the largest group of individuals that responded to the 9/11
    attacks at the various exposure sites. It represents the cross-
    section of the general population of New York. The data that
    will emerge from those studies will have wide applications and
    may be extrapolated and may be useful to scientists and
    physicians in terms of planning for monitoring in the future
    and for treatment. I cannot over-emphasize the importance of
    funding that kind of activity. I remind the subcommittee that
    the NYPD medical division has not received any Federal funding
    for any of its undertakings. It has been self-sustained since
    9/11.
        I thank you for the opportunity.
        Mr. Towns. Thank you very much for your comments.
        Dr. Reibman, the Bellevue program is the only program open
    to residents, office workers and others. Are the conditions in
    the group the same as what Dr. Prezant and Dr. Herbert are
    seeing among their group of first responders, workers and
    volunteers?
        Dr. Reibman. The Bellevue program is open to people who
    have symptoms. So it is not a screening program. You have to
    have some complaint to get into the program. The complaints
    that we are seeing are very similar to those that have been
    identified in the FDNY and in the Mount Sinai groups. They
    consist, again, of sinus, cough, shortness of breath, wheezing
    and also probably lower extent, but still some gastroesophageal
    reflux.
        Mr. Towns. Mr. Bethea and also Mr. Sferazo, you have talked
    about the problems you have had with health care. Let me ask
    you this, have you experienced any problems dealing with
    workers compensation?
        Mr. Sferazo. Mr. Chairman, to answer your question, sir, it
    has greatly accentuated the problem. And as you ask me this
    question, about workers compensation, I wish to bring to light
    that not only has this given us a great deal of stress and has
    created a multiple amount of further problems, health-wise and
    psychologically, by the members not getting their workers comp.
    But due to the fact that some of these afflictions,
    sympotomatics if you will, are of a latent nature, if I am
    correct, I am not a medical professional, but I am only
    speaking from what I am finding out, our Governor of the State
    of New York in relation to the workers compensation situation,
    sir, has just created legislation to do away with permanent
    partial disability.
        Now, this, we find, is such a direct blow, because of the
    latency of the type of afflictions received by many New Yorkers
    and members who come from other States who have to file through
    New York workers compensation and their afflictions and
    symptomatic may not show up for a time to come. And being this
    is not something, as in my own particular case and in many
    others, this is not something that we throw to the wind.
    Because this is not something we take for short-term medical
    care and we are going to be resolved of that issue. These are
    going to be long-term health effects.
        Mr. Towns. Let me switch the question to you, Mr. Bethea.
    What has that done to your income? Are you making basically the
    same amount now?
        Mr. Bethea. No, not at all. Before I retired I was making
    about maybe $95,000 a year. Now I am down to, I get about maybe
    $40,000, a little less than that. And I live in New York. And
    again, I lived well, I made a good living, I worked hard. I
    worked three jobs to make the $95,000, because people say,
    paramedics making $95,000, maybe I will be a paramedic. But no,
    that was working very hard with three different hospitals.
        But getting back to the workers comp, it has been an
    absolute nightmare. First of all, I actually had the insurance
    company, the workers comp company wouldn't pay my company that
    supplies my medicine. So my medicine was $1,300 a month, so
    they stopped sending my medicine.
        Finally, they did start paying for my medicine, but this is
    one of the common problems we have. My medicine bill had run up
    to $8,000. I don't fault the company that supplied the
    medicine, they have a right to get paid, and the insurance
    company just would not pay it. I have had to sue my employer
    just to get information turned over to my union so I could get
    a disability benefit from my union.
        So you have to look at the New York City workers comp
    system which has been atrocious, as well as, some of the
    behavior on some of the employers. We are trying to heal and
    trying to move on with our lives. But with the little basic
    things that we are unable to get, it is very hard to do that,
    so this makes you more angry, makes you more depressed and that
    is really unfortunate, because again, we all stepped up to the
    plate and did what we were supposed to do that day. Now
    everyone from the Government, on the city, State and Federal
    level, well, the city has been showing more progress, I must
    say, in all fairness. But the State and Federal Government is
    really lacking. So how do we begin to heal, when we are not
    getting the basic things that we should be entitled to?
        Mr. Towns. Thank you both. I really appreciate hearing
    about that from you personally.
        Now, I turn to a person who has probably done more to keep
    this alive, to make certain that we do not forget what happened
    on 9/11, and the people that really, really responded and of
    course, make certain that they get the proper care. He has been
    fighting very hard, Jerry Nadler.
        Mr. Nadler. Thank you, Mr. Chairman.
        Let me say, before I start asking questions of this panel,
    to all of you, it is good to see you again. You are to be
    congratulated for selflessly taking up this cause and letting
    people know what is going on, for testifying. And to all the
    people from Mount Sinai and Bellevue and so forth, we wouldn't
    be where we are today with recognition, of at least part of the
    problem, the work that is being done at Sinai and Bellevue and
    research that has been done over the years helping people,
    basically eliminated what was a conspiracy by the State and
    Federal Governments to hide this under a rock, to pretend there
    was no real problem, not huge numbers of people sick, just
    wanted the issue to go away and the people to go away. If it
    weren't for the work that some of the people sitting here had
    done, we would be debating that question. There is very little
    denying the reality of this problem.
        I also wanted to say that the work being done at the
    centers of excellence is extremely important. The scientific
    reasons why we want as much direct response as possible will be
    obtained through the centers of excellence, for two reasons.
    No. 1, because you have a lot of doctors who rarely see these
    symptomatology and they are misdiagnosing and not treating
    properly some of the subjects. And the centers where they are
    specializing in these problems are the obvious best treatment
    modality.
        Second, the research component, which is documented. Only
    if people go through these treatment centers will we get proper
    treatment and followup for the studies. So whatever we know, we
    know the funding has to be there. The only way to look at this
    and recognize this, we have to continue that.
        Let me ask you this. First of all, right now, if someone
    wants to be treated at Mount Sinai, be seen at Mount Sinai, and
    by the way, we have to obviously make sure that, that is the
    whole point of this hearing, that there is adequate funding,
    whether it is the $1 billion figure, or the Mayor's $50 million
    dollar figure, there has to be annual treatment that is
    guaranteed for a long time, maybe decades. It should not
    ultimately be dependent on an annual appropriations cycle.
        But let me ask this question now. Let's say someone comes
    to Mount Sinai, and is treated and is given a prescription for
    medicines. Who pays for that medicine?
        Dr. Herbert. Prior to the receipt of the Federal funding
    for the federally funded treatment programs, which was released
    in November 2006, we were fortunate at Mount Sinai to have
    received some philanthropic funding. So essentially we had to
    rely on charity to pay for medication. Now, because there has
    been funding, Federal funding for treatment of responders, we
    are able to use that Federal funding to pay for medications.
    The costs are huge.
        Mr. Nadler. So we have to make sure, because I was struck
    by what Martin Bethea said earlier about the cost of his
    medications. We have to make sure we deliver funding for the
    medications, because of paying for the doctors and the
    equipment.
        Dr. Herbert. May I add something? I think that often there
    is a perception that if people have insurance it means they
    have access to the necessary medications. I think any of us,
    the drug co-pays alone for some of my patients who have what we
    consider Cadillac insurance can be $1,500 a month. I know the
    same is true for FDNY.
        Mr. Nadler. Let me ask Dr. Reibman, talk about the work you
    have done with the studies. Do these studies, do they include
    people who are basically there on 9/11, or do they also include
    people who may not have been there on 9/11 but came back to
    work or live nearby? And have you differentiated, do you have
    data as to the effects, not as their having been there, but
    having worked in the area or lived in the area in months or
    years after?
        Dr. Reibman. The studies that we have published to date
    were of residents. They weren't necessarily people who worked
    in the area, they lived in the area. Some of them, we didn't
    differentiate in those studies whether they were in the dust
    cloud or not. Many of them were not in the dust cloud. Many of
    them moved out of their apartments, or some of them moved out
    of their apartments but came back over the next several months.
    They had to have been back in their apartment by December.
        Mr. Nadler. Do you have data with which you could say with
    any degree of likelihood that there is or is not, in which you
    can evaluate the impact of people living there after the
    attack?
        Dr. Reibman. We cannot do that at this point.
        Mr. Nadler. Granted everything that has been said about the
    necessity and utility, what about people who move away, they go
    to Florida or go elsewhere, or have come here and then gone
    back after a few weeks, would it be a good idea to have centers
    elsewhere. But I presume there will be people who will live
    elsewhere who will not be subject to, or maybe some who remain
    in New York, who will not live near a center of excellence.
    What can we do for those people?
        Dr. Reibman. We have been thinking a lot about that. This
    is a really challenging problem. What I think makes the most
    sense, based on our current health care system within the
    country, is at least for the responders, the 20,000 plus in our
    cohort, is that we have mapped by zip code and we know that we
    have 2,000 plus zip codes, but we also know that many in the
    country, outside of New York, this is nationally. But within
    that group there are clusters. So many of the people who are
    currently in New York are likely to retire to certain areas.
        I think that probably the most rational approach, and one
    that we are working on right now, is to identify sort of mini-
    centers of excellence that would be connected to the existing
    centers of excellence that are based at academic medical
    centers, that we do continuing medical education and work very
    closely with providers there. I think you need to have
    oversight, though, central oversight of diagnosis and
    treatment.
        And then I think parallel to that, you would want to work
    with some network of health care providers who could receive
    continuous medical education but who would be more
    geographically accessible for people who live in more outlying
    regions. I know there is one State, for example, where we have
    one responder. We are not going to set up a center of
    excellence there.
        Mr. Nadler. Thank you. We are obviously going to reopen the
    Victims Compensation Fund. We had that, it worked. The Mayor
    has suggested the $1 billion that is sitting there could be
    used in there. That would not necessarily be the only funding
    for it. When we had the Victims Compensation Fund originally,
    people had a choice, they could go to the Victims Compensation
    Fund, or they could use the captive insurance fund.
        Are you suggesting that the mayor's suggestion to re-
    establish the Victims Compensation Fund would allow the choice,
    give people the choice to go to the fund or the captive
    insurance fund?
        Mr. Skyler. That is a good question, Congressman. What the
    report recommends is that we eliminate the city's liability,
    liquidate the captive insurance fund, transfer it to the
    Victims Compensation Fund. Because we recognize in one sense
    that resources are scarce. The panel, Deputy Mayor Gibbs and I
    are sitting before you asking for $150 million, $160 million
    annually in Federal funding. That is not just for the city, it
    is for the city, it is for Mount Sinai, the program at
    Bellevue. We believe that if we had the $1 billion, we want to
    use that as basically a first installment in the Victims
    Compensation Fund. When talking about this, there is a
    fundamental issue of fairness. I don't see, especially having
    spent some time with Marvin, John and other first responders,
    why somebody who is hurt needs to show fault. If somebody is
    hurt, the Government should help them and we should compensate
    them for lost earnings, for example. If we don't eliminate the
    city's liability, the city will need to keep the captive
    insurance the way it is currently constituted and then have a
    separate Victim Compensation Fund.
        We also can't ever, because we need a long-term solution to
    this issue, as you suggested in your remarks, this is subject
    to annual appropriations, to some extent. We need a fund that
    can exist year to year. We don't know who is going to come
    forward in the coming years and become a plaintiff against the
    city. The Victims Compensation Fund that existed could handle
    that.
        Mr. Towns. I will have to cut you off. I tried not to.
        Let me just ask, just before I go to Mr. Fossella, I must
    say, I am troubled by something. Why is it all the programs are
    established in Manhattan? I am a Brooklyn Congressman. I am
    just curious.
        Mr. Skyler. I believe that the centers of excellence
    actually have sites outside Manhattan. I believe Robert Wood
    Johnson in New Jersey, the Mount Sinai program especially is a
    consortium, although it is known as the Mount Sinai program. It
    is a consortium of other----
        Mr. Towns. Where is the one in Brooklyn?
        Dr. Prezant. It is the New York City Fire Department
    program, that is centered in the world famous Borough of
    Brooklyn.
        Mr. Towns. Tell me where.
        Dr. Prezant. Nine Metrotech Center, a few blocks from the
    Brooklyn Bridge on the corner of Flatbush and Tillery.
        Mr. Towns. Thank you. I feel a lot better. [Laughter.]
        Now I yield to Mr. Fossella.
        Mr. Fossella. Where is the one on Staten Island?
    [Laughter.]
        Dr. Kleinman. Mr. Chairman, if I may respond, the NYPD's
    treatment program is set up such that members of the NYPD can
    seek treatment from the physician of their choice anywhere, and
    it will be paid for.
        Mr. Fossella. Well, let's jump to that NYPD, Doctor. First
    of all, I didn't say it before, I want to thank my colleague,
    Carolyn Maloney. She is not here now, but for the record, she
    has been instrumental in bringing this together. Thanks for
    your patience throughout this whole hearing, all of you.
        How many NYPD participated in the World Trade Center
    rescue, recovery and cleanup operations, and why do you think
    it is important for NYPD to get separate funding for monitoring
    and research of police officers who were exposed on 9/11?
        Dr. Kleinman. Thank you, Congressman, for that question and
    the opportunity to respond. The NYPD's brave men and women had
    34,000 responders since 9/11, either responding at Ground Zero
    or at one of the other designated exposure sites. At this time,
    there have been 2,500 medical claims made by those responders.
    There are 300 applications for disability due to problems that
    arise from, potentially have arisen from World Trade Center-
    related exposures.
        As I mentioned earlier, perhaps when you were out of the
    chamber, the 34,000 members of the largest single responder
    group that has been exposed, and as such, monitoring, tracking
    and obtaining data on those individuals is of vital importance
    to the scientific and medical community and impacts directly on
    our ability to determine what our appropriate measures for
    further monitoring and for treatment. The data that will emerge
    from the studies that will be forthcoming later this year,
    looking at 5-year followups with pre and post-9/11 data will
    help inform the medical community and, I daresay, HHS, which is
    desperately looking for data, will have the largest group that
    represents a cross-section of the population of the city of New
    York from which to make some determinations regarding future
    monitoring and treatment.
        Mr. Fossella. Would anyone else like to add to that?
        All right. For Deputy Mayor Skyler, two questions. You said
    that the estimated gross cost to treat those with potential 9/
    11-related illness is $393 million per year. If you can
    explain, what does that mean or elaborate. And related to that,
    you said that the Federal Government will need a minimum of
    $150 million to fill the gaps in treatment and research for 9/
    11 treatment and illness. What will that $150 million pay for,
    and how does it relate to the $393 million figure?
        Mr. Skyler. The $393 million, that figure is essentially an
    economic impact on the health care system of 9/11. So that
    includes somebody getting treatment at Bellevue, somebody
    getting treatment at the Fire Department, a police officer, it
    can be a resident. But it can also be somebody who worked in
    lower Manhattan, who lived in New Jersey at the time, was a
    commuter and possibly even moved to Chicago or another part of
    the country, but who has an illness because of 9/11 and is
    seeking care because of that illness, and it associates that
    cost and the estimate. So it is in a sense a national figure of
    how much money is being spent in the health care system, based
    on 9/11 illnesses.
        The $150 million request that the report recommends
    basically says that there are centers of excellence that are
    working that we need to continue and expand. We see an
    increased demand for services at Bellevue. We want to make sure
    we can provide for that, that $150 million assumes that cost.
    It also says that we need to recognize the Federal Government
    has not spent a dime on the police department's health
    monitoring services, and we want to rectify that inequity. It
    also would expand the mental health services available, with
    the findings of the report of the widespread mental health
    impacts of 9/11. And it also will make available a resource to
    the city to advertise and promote the programs it has, to make
    resources available through the Internet, and a couple of other
    smaller recommendations that would have smaller costs than the
    actual treatment.
        Mr. Fossella. Thank you, Mr. Chairman. I yield back.
        Mr. Towns. Let me thank all of you, we really, really
    appreciate your testimony. As you have clearly indicated, we
    still have a long way to go. We look forward to working with
    you in terms of trying to get there.
        So let me thank all of you, and this hearing is adjourned.
        [Whereupon, at 3:50 p.m., the subcommittee was adjourned.]
        [The prepared statement of Hon. Christopher Shays follows:]
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