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



  ANSWERING THE CALL: MEDICAL MONITORING AND TREATMENT OF 9/11 HEALTH 
                                EFFECTS

=======================================================================

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                           SEPTEMBER 18, 2007

                               __________

                           Serial No. 110-64


      Printed for the use of the Committee on Energy and Commerce

                        energycommerce.house.gov






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                    COMMITTEE ON ENERGY AND COMMERCE

                  JOHN D. DINGELL, Michigan, Chairman

HENRY A. WAXMAN, California            JOE BARTON, Texas
EDWARD J. MARKEY, Massachusetts            Ranking Member
RICK BOUCHER, Virginia                 RALPH M. HALL, Texas
EDOLPHUS TOWNS, New York               J. DENNIS HASTERT, Illinois
FRANK PALLONE, Jr., New Jersey         FRED UPTON, Michigan
BART GORDON, Tennessee                 CLIFF STEARNS, Florida
BOBBY L. RUSH, Illinois                NATHAN DEAL, Georgia
ANNA G. ESHOO, California              ED WHITFIELD, Kentucky
BART STUPAK, Michigan                  BARBARA CUBIN, Wyoming
ELIOT L. ENGEL, New York               JOHN SHIMKUS, Illinois
ALBERT R. WYNN, Maryland               HEATHER WILSON, New Mexico
GENE GREEN, Texas                      JOHN B. SHADEGG, Arizona
DIANA DeGETTE, Colorado                CHARLES W. ``CHIP'' PICKERING,
    Vice Chairman                          Mississippi
LOIS CAPPS, California                 VITO FOSSELLA, New York
MIKE DOYLE, Pennsylvania               STEVE BUYER, Indiana
JANE HARMAN, California                GEORGE RADANOVICH, California
TOM ALLEN, Maine                       JOSEPH R. PITTS, Pennsylvania
JAN SCHAKOWSKY, Illinois               MARY BONO, California
HILDA L. SOLIS, California             GREG WALDEN, Oregon
CHARLES A. GONZALEZ, Texas             LEE TERRY, Nebraska
JAY INSLEE, Washington                 MIKE FERGUSON, New Jersey
TAMMY BALDWIN, Wisconsin               MIKE ROGERS, Michigan
MIKE ROSS, Arkansas                    SUE WILKINS MYRICK, North Carolina
DARLENE HOOLEY, Oregon                 JOHN SULLIVAN, Oklahoma
ANTHONY D. WEINER, New York            TIM MURPHY, Pennsylvania
JIM MATHESON, Utah                     MICHAEL C. BURGESS, Texas
G.K. BUTTERFIELD, North Carolina       MARSHA BLACKBURN, Tennessee
CHARLIE MELANCON, Louisiana            
JOHN BARROW, Georgia                   
BARON P. HILL, Indiana               

                               -------

                           Professional Staff

             Dennis B. Fitzgibbons, Chief of Staff
               Gregg A. Rothschild, Chief Counsel
                Sharon E. Davis, Chief Clerk
             David L. Cavicke, Minority Staff Director

                                  (ii)























                         Subcommittee on Health

                FRANK PALLONE, Jr., New Jersey, Chairman
HENRY A. WAXMAN, California          NATHAN DEAL, Georgia,
EDOLPHUS TOWNS, New York                 Ranking Member
BART GORDON, Tennessee               RALPH M. HALL, Texas
ANNA G. ESHOO, California            BARBARA CUBIN, Wyoming
GENE GREEN, Texas                    HEATHER WILSON, New Mexico
    Vice Chairman                    JOHN B. SHADEGG, Arizona
DIANA DeGETTE, Colorado              STEVE BUYER, Indiana
LOIS CAPPS, California               JOSEPH R. PITTS, Pennsylvania
TOM ALLEN, Maine                     MIKE FERGUSON, New Jersey
TAMMY BALDWIN, Wisconsin             MIKE ROGERS, Michigan
ELIOT L. ENGEL, New York             SUE WILKINS MYRICK, North Carolina
JAN SCHAKOWSKY, Illinois             JOHN SULLIVAN, Oklahoma
HILDA L. SOLIS, California           TIM MURPHY, Pennsylvania
MIKE ROSS, Arkansas                  MICHAEL C. BURGESS, Texas
DARLENE HOOLEY, Oregon               MARSHA BLACKBURN, Tennessee
ANTHONY D. WEINER, New York          JOE BARTON, Texas (ex officio)
JIM MATHESON, Utah
JOHN D. DINGELL, Michigan (ex  officio)




























                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     1
Hon. Nathan Deal, a Representative in Congress from the State of 
  Georgia, opening statement.....................................     3
Hon. Eliot Engel, a Representative in Congress from the State of 
  New York, opening statement....................................     4
Hon. Mike Ferguson, a Representative in Congress from the State 
  of New Jersey, opening statement...............................     6
Hon. Marsha Blackburn, a Representative in Congress from the 
  State of Tennessee, opening statement..........................     7
Hon. Vito Fossella, a Representative in Congress from the State 
  of New York, opening statement.................................     8
Hon. Joe Barton, a Representative in Congress from the State of 
  Texas, opening statement.......................................     9
Hon. John B. Shadegg, a Representative in Congress from the State 
  of Arizona, opening statement..................................    11
Hon. John D. Dingell, a Representative in Congress from the State 
  of Michigan, prepared statement................................    12
Hon. Henry A. Waxman, a Representative in Congress from the State 
  of California, prepared statement..............................    12
Hon. Anna G. Eshoo, a Representative in Congress from the State 
  of California, prepared statement..............................    13
Hon. Jim Matheson, a Representative in Congress from the State of 
  Utah, prepared statement.......................................    14

                               Witnesses

John Howard, M.D., Director, National Institute for Occupational 
  Safety and Health, Department of Health and Human Services.....    14
    Prepared statement...........................................    15
John Vinciguerra, Fire Department of New York (retired), New 
  Egypt, NJ......................................................    29
    Prepared statement...........................................    32
Iris Udasin, M.D., associate professor, environmental and 
  occupational medicine, University of Medicine and Dentistry of 
  New Jersey, Robert Wood Johnson Medical School.................    34
    Prepared statement...........................................    36
Robin Herbert, M.D., associate professor, community and 
  preventive medicine, Mount Sinai School of Medicine, New York, 
  NY.............................................................    41
    Prepared statement...........................................    44
Cynthia Bascetta, Director, Health Care Issues, Government 
  Accountability Office..........................................    54
    Prepared statement...........................................    56
James Melius, M.D., administrator, New York State Laborers.......    79
    Prepared statement...........................................    80
Edward Skyler, deputy mayor, administration, city of New York, NY    84
    Prepared statement...........................................    87




























 
                       ANSWERING THE CALL: MEDICAL
                    MONITORING AND TREATMENT OF 9/11
                             HEALTH EFFECTS

                              ----------                              


                      TUESDAY, SEPTEMBER 18, 2007

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:00 a.m., in 
room 2322 of the Rayburn Office Building, Hon. Frank Pallone 
Jr. (chairman) presiding.
    Members present: Engel, Weiner, Deal, Shadegg, Pitts, 
Ferguson, Blackburn, and Barton.
    Also present: Representative Fossella.

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. The meeting is called to order. The hearing 
today is on ``Answering the Call: Medical Monitoring and 
Treatment of 9/11 Health Effects,'' and I now recognize myself 
for an opening statement.
    Today the subcommittee is meeting to discuss an issue of 
great importance, medical monitoring treatment of 9/11 health 
effects, which is the first time that the subcommittee is 
meeting to hear about these issues. We had originally intended 
to hold this hearing last Tuesday on the anniversary of the 9/
11 attacks, but due to the funeral of our colleague, Paul 
Gillmor, the hearing was postponed until today.
    Now, it is hard for me to believe that it has been 6 years 
since the attack on the World Trade Center and the Pentagon. It 
was an event that affected our country deeply and continues to 
have an impact on all of us, especially those who participated 
in the rescue, recovery, and restoration effort.
    It is important that, as a Nation, we recognize the 
extraordinary sacrifice of everyone who responded to the 
terrorist attacks and worked tirelessly in the hours, days, 
weeks, and months after 9/11 to help those in need and to begin 
clearing the site of the tragedy.
    From first responders, to iron workers, to crisis 
counselors, Americans from across the country put their lives 
on hold and rushed to the site of the World Trade Center on the 
day of the attack and stayed for months after in order to 
assist with the recovery effort. I happened to be at this site 
the Friday after President Bush visited, and I was amazed to 
see firefighters from all over. As we were listening to the 
President speak, I was standing next to a fire truck from 
Hialeah, FL, with all the firefighters from Hialeah. And I 
asked them how the truck got there, and they looked at me like 
I was an idiot and said well, of course, we drove it up from 
Florida. And to me, it was just amazing to see the turnout and 
the fact that so many people came.
    It's been estimated that more than 40,000 people responded 
to the crisis and participated in rescue, recovery, clean up, 
or restoration of essential services. And we are clearly 
indebted to them for their efforts.
    Now, 6 years later these brave men and women who helped 
lift our Nation up from one of its darkest hours are now in 
need of our help. Many of those who responded to the attacks on 
the World Trade Center have since been plagued by health 
problems. One of every eight responders has experienced 
symptoms of post-traumatic stress. They have developed asthma 
at 12 times the rate of other Americans. Nearly one in five has 
a respiratory or gastrointestinal illness as a result of their 
exposure to toxins.
    I have seen the impact firsthand. More than 1,000 
responders are currently receiving health services through the 
monitoring and treatment clinic in my home district in 
Piscataway, NJ. Furthermore, residents, workers, and students 
who were in the area at the time of the attack are also 
experiencing high rates of health problems. And I want to thank 
you, Mr. Engel, Mrs. Maloney, Mr. Nadler, Mr. Fossella.
    One of the things that the New Yorkers, I think, have been 
particularly adept at pointing out is that not only do we need 
to be concerned about first responders, but the people who 
lived and worked at the site, of which there may be as many as 
400,000 or more from what I understand who also may have been 
impacted. And we will hear about that today.
    Unfortunately, for too long the concerns of the first 
responders have been ignored here in Washington, and that has 
to change. As chairman of this subcommittee, I am not going to 
let these issues be ignored any longer. I want to be sure that 
there are accessible health programs in place for responders 
and adequate funding for those programs. We are here today to 
ensure that those who are suffering from health problems have 
access to the monitoring and treatment services they are 
entitled to as a result of the conditions they endured at 
Ground Zero.
    And I think we should be honest about the task in front of 
us. It is a big undertaking for us to ensure that adequate care 
is provided for those in need, but that is a responsibility we 
must fulfill. The cost of screening for and treating these 
illnesses is estimated at $8,000 annually per person, and it is 
expected to increase in the coming years. This cost should not 
be borne by the thousands of responders, workers, and health 
professionals who risked their health to do their job.
    And, of course, it is not just our job in Congress. The 
Bush administration has an important role to play here as well. 
Unfortunately, for the past 6 years, the administration has 
been dragging its feet, in my opinion, on this issue. It is sad 
to say, but I think that many of those who came to our aid in 
the days after 9/11 feel as though Congress and the President 
have failed to live up to the promises that have been made over 
the last couple years to not leave them behind.
    And this is the first year that the administration proposed 
funding in its annual budget in the amount of $25 million for 
the healthcare needs of World Trade Center responders. The 
House does not think that was enough, and we doubled the 
President's request to $50 million in our budget.
    The administration said the initial $25 million was only 
the beginning and that it would propose additional funds once 
it had a comprehensive plan in place. That comprehensive plan 
has yet to appear, but in a draft plan developed by the 
administration, they acknowledge that the current cost estimate 
for the program is nearly $200 million a year and that it is 
possible the cost could reach $712 million annually based on 
what they gave us.
    And that's why I joined with members of the New York 
congressional delegation and sent a letter to the Health and 
Human Services Secretary Mike Leavitt 2 weeks ago asking that 
they finalize their plans immediately. We need a comprehensive 
plan in place so that we can help treat and monitor all of the 
people whose health was impacted by 9/11. We also sent another 
letter to new OMB Director Jim Nussle, asking that he live up 
to his predecessor's promises and request the necessary funds 
to continue the process of helping these workers. And I would 
ask that these letters be made part of today's hearing record.
    In conclusion, today we will be hearing from a variety of 
people about the medical monitoring and treatment of health 
effects caused by the exposure to traumatic events and harmful 
materials. It is my hope that this hearing will shed some light 
on the problem and help us begin rectifying the situation. My 
idea is that we develop a legislative proposal that all of us 
can support. I know that the New York delegation put together 
different proposals. Obviously we want to look at those and we 
do need to develop legislation in my opinion so that the people 
who had their health affected by the 9/11 attacks are monitored 
and treated.
    And again I just wanted to thank the witnesses. I know many 
people have been trying to have this hearing for some time. 
Unfortunately our schedule with S-CHIP and PDUFA and everything 
else has made it difficult for us to do it until now. But I do 
want to thank all of you, and now I recognize Mr. Deal for his 
opening statement.

  OPENING STATEMENT OF HON. NATHAN DEAL, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF GEORGIA

    Mr. Deal. Thank you, Mr. Chairman. First of all, I would 
like to ask unanimous consent that Mr. Fossella, a member of 
the full committee, be allowed to participate in this hearing 
today.
    Mr. Pallone. So ordered.
    Mr. Deal. And thank all of the witnesses who will testify 
and members of the subcommittee for their presence. Certainly 
the tragedy of 9/11 and the aftermath of that event are going 
to be with us for a very long time, and today we simply deal 
with one of those manifestations of that aftershock.
    While some would criticize the administration for not 
having done enough, in reality, the reaction and the outpouring 
of Federal dollars for this event has been unprecedented in 
American history. Truly the event itself, however, was 
unprecedented in American history, and none of us wish to 
diminish that.
    The question is whether or not we have the information upon 
to make good decisions as to where we go from this point 
forward. One of the real concerns that I have is in the GAO 
report. It finds that much of the information relating to the 
health effects are unreliable, and the comments that despite 
the efforts of HHS to require the necessary information that 
much of that information is still incomplete. So to those who 
will testify today who are in a position to make that 
information available to us and to the administration, I would 
certainly call upon them to use their best efforts to do that.
    All of us are reminded frequently of this event. In fact, 
last week when I was being interviewed by reporter from my 
local newspaper, in the conversation, he reminded me that he 
was at Ground Zero immediately following the event as a part of 
a voluntary group from my church who came to assist with the 
efforts of helping people in their time of need. So our country 
has reached out. The question is are we now following up on 
those efforts. And thank you, Mr. Chairman, for having the 
hearing so we can make those inquiries here today. I yield 
back.
    Mr. Pallone. I recognize Mr. Engel who, like the other 
members of the New York delegation, has been very much out 
front on this issue. Thank you, Eliot.

 OPENING STATEMENT OF HON. ELIOT L. ENGEL, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF NEW YORK

    Mr. Engel. Thank you, Mr. Chairman. I want to thank you for 
holding this hearing. You and I had discussed this several 
months ago, and I requested this hearing and said that I 
thought it would be a good idea. And you responded very 
positively then, and I thank you for the hearing now.
    Six years, Mr. Chairman, as you pointed out, have passed 
since terrorism struck at the root of our Nation's soil on 
September 11, 2001. As devastating as that day was, there are 
few days I've been more proud to be an American than on 9/11. 
Now, within minutes of crashes into the Twin Towers, New York's 
first responders mobilized to save those trapped in the World 
Trade Center. First responders putting themselves in 
unspeakable danger, and too many lost their lives that day.
    Within days, as you pointed out, Mr. Chairman, over 40,000 
responders across the Nation descended upon Ground Zero to do 
anything possible to help with the rescue, recovery and 
cleanup. I remember those bittersweet days. I was in New York 
City when this happened. I was born and bred there, and 
remember seeing Americans lined up around blocks to donate 
blood. I remember the chaos as no one knew quite what to do, 
only that they had to do something, anything to help our Nation 
rise up from assault by the terrorists.
    And the past 6 years have not been kind to many, so many of 
the first responders who put themselves in harm's way. It is 
estimated that up to 400,000 people in the World Trade Center 
area on 9/11 were exposed to extremely toxic environmental 
hazards, including asbestos, particulate matter, and smoke. 
Years later, this exposure has left a significant number of 
first responders with severe respiratory ailments including 
asthma at a rate that is 12 times the normal rate of adult 
onset asthma.
    Also common are mental health problems including PTSD and 
depression. This has all been well documented in scientific, 
peer-reviewed published work regarding the long term health 
effects of 9/11 by Mount Sinai Hospital, the Fire Department of 
the City of New York, and the World Trade Center registry. 
People who have been exposed are not only first responders but 
people who live in the area. And frankly, I think the behavior 
on the part of the Federal officials borders on the criminality 
when we in New York were assured that the air quality was OK 
and we were assured that we could go to the World Trade Center 
area and were assured by Christine Todd Whitman that we had 
nothing to fear. That all turned out to be false.
    While these illnesses should sadden all of us, I am frankly 
outraged that 6 years later our Nation has really failed to 
provide the first responders with anything more than a 
fragmented and unreliable health care monitoring and treatment 
program that forces those who fearlessly volunteered for our 
country to fight within a myriad of bureaucracy to receive care 
that should be a given, and yet it is a struggle.
    The nonpartisan Government Accountability Office has 
criticized the U.S. Department of Health and Human Services for 
its failure to provide consistent availability of services to 
Federal responders through the World Trade Center Federal 
Responder Screening Program. Despite starting in 2003, service 
stopped between March 2004 and December 2005. It resumed again 
in March 2006, but suspended key services between April 2006 
and March 2007. It is truly shameful.
    GAO has also noted that those brave volunteers and first 
responders that came to help New York from other parts of the 
country have not had regular access to screening and 
monitoring. After years of starts and stops, there are only 10 
clinics in seven States where responders can receive services. 
It is just unconscionable. We can and must do better. I was 
proud to join with my New York City colleagues, lead by 
Representatives Maloney, Nadler, and Fossella, who is here with 
us this morning, and so many others last night in introducing 
the 9/11 Health and Compensation Act.
    This comprehensive bill would ensure that everyone exposed 
to the Ground Zero toxins has a right to be medically 
monitored. And all that are sick have a right to treatment. It 
would also rightfully provide compensation for loss by 
reopening the 9/11 Compensation Fund. No more fragmented health 
care. No more excuses. We must and shall do what is right.
    In conclusion, let me just say I still feel great sorrow in 
our remembrance of the tragedy of 9/11 and obviously will never 
forget what happened that day. But we must look forward and 
right the wrongs our Nation has perpetuated against our own 
heroes and provide them with the care and compensation they so 
desperately need and deserve.
    Mr. Chairman, I urge all Americans to pause and reflect on 
the tremendous loss of life that day and how so many sacrificed 
so much for their fellow Americans and make sure that our 
future actions are driven by these memories, and also remember 
that potentially still hundreds of thousands of people are 
being exposed to these toxic substances every day. And the 
Federal Government cannot wish that away. We need to respond, 
and we need to respond now. Thank you, Mr. Chairman.
    Mr. Pallone. Thank your, Mr. Engel. Our next opening 
statement is from Mr. Ferguson. Again we have two New Jersey 
people here today, one from each party, and I constantly remind 
everyone that we in our State, had a lot of people that died 
and were seriously wounded, and a lot of first responders as 
well. And we also have one of the treatment centers here. One 
of the witnesses today is from one of the monitoring treatment 
centers. So again we obviously are very concerned about this as 
well, in our State. So, Mr. Ferguson.

 OPENING STATEMENT OF HON. MIKE FERGUSON, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Ferguson. Thank you, Mr. Chairman. Thank you very much 
for holding this meeting. I want to thank Mr. Deal as well and 
member of the subcommittee and certainly the witnesses for 
being here today to address this very important issue regarding 
medical monitoring and treatment of September 11, 2001 health 
effects on residents and first responders.
    Addressing this issue is long overdue, and I am glad that 
we are giving it attention that it really does deserve. And the 
more that time goes by, the more we are learning about the 
after effects and the health effects of those who selflessly 
went to attend to this disaster. I am sure that we are going to 
be able to gain some valuable information from treatments and 
health effects from some of our witnesses today. I am pleased 
that we are having this hearing, and my hope is that the 
subcommittee will be able to use some of this information to 
help address some of the needs of the families who are 
suffering.
    In addition, we need to find out what went wrong with some 
of the information and some of the air quality information 
surrounding lower Manhattan and why better information wasn't 
made available in a more timely way. Of course, as the chairman 
referenced, this issue hits very close to home for many of us 
on the subcommittee. I know Mr. Fossella is here as well.
    In our district, we lost 81 people on the attacks of 
September 11, 2001. And to save others, approximately 40,000 
first responders answered the call, including many from New 
Jersey on September 11 and the weeks and months that followed, 
helping to try and find survivors. We have firefighters and 
police officers and construction workers and utility workers, 
all folks who were working tirelessly day and night on the pile 
in the hopes of finding one more survivor. These men and women 
didn't think twice about running into burning buildings or 
climbing through rubble to help save the lives of others, and 
we owe them the very best information that we have to assist 
with the health challenges that they are now facing because of 
those sacrifices.
    Dr. David Present, the chief medical officer for New York 
City's fire department has been studying the health effects on 
firefighters since September 11, 2001. In a recent interview 
with Katie Couric, he said this about the health effects of 
breathing the air at Ground Zero. I quote, ``the biggest 
problem was that it was pulverized building materials that wind 
up having a very high alkalinity, almost like lye, all right, 
or Drano, that when you inhale or swallow it, it's burning your 
entire nose and airway and stomach.''
    In a study that was published in many of the leading 
medical journals, Dr. Present concludes that working on the 
pile for an extended period of time decreased an individual's 
lung function by an average of 12 years. Six years later, those 
same heroes who risked their lives need our help. And we have 
to be there to answer their call. We need to make every effort 
to find out what is causing their illnesses and what can be 
done to treat them.
    There is no reason that with today's medical technology 
that we shouldn't be able to get some proper treatment to those 
who made these sacrifices. In the future, we have to work to 
ensure that our first responders are not put in further 
unnecessary jeopardy than they are already placing themselves 
by their own choice. Our first responders were heroes on 
September 11, and we owe them our very best efforts today. Mr. 
Chairman, I want to thank you again for holding this hearing. I 
yield back.
    Mr. Pallone. Thank you. The gentlewoman from Tennessee.

OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF TENNESSEE

    Mrs. Blackburn. Thank you, Mr. Chairman, and I thank you 
and Mr. Deal for holding the hearing. And I also thank our 
members from both sides of the aisle who have been so involved 
with this issue and continuing to keep the pressure on with 
this issue. I think that we all know what transpired September 
11, and we know that we have to be very vigilant going forward 
in how we protect our Nation and also how we protect those who 
are going to respond to any tragedy that we do have.
    There are lots of lessons learned, and, as you've heard in 
the opening statements, there is attention to what should be 
those lessons learned from members of this panel. And, as my 
colleague from New Jersey just stated, you had approximately 
400,000 people that were exposed to the environmental hazards, 
the asbestos, the smoke, the particulates, 40,000 first 
responders that were there on that day.
    Now, there is very little solid, quantifiable data from 
which we can operate as we look at the environmental factors 
and what the first responders were exposed to during those 
cleanups. What we do know is the damage that is there. Its 
detrimental physical effects, chronic respiratory, 
gastrointestinal conditions, anxiety, and other mental health 
problems. And these have severely impacted the lives of those 
that were at Ground Zero.
    For example, the city health department reports rescue and 
recovery workers now develop asthma at a rate 12 times that 
found in the general population. Among children that were 
exposed to the toxins, 53 percent reported breathing problems 
in the 3 years after 9/11. New York City officials estimate 
120,000 workers and volunteers and 550,000 other people may or 
may eventually need treatment.
    And I do commend the State of New York and the U.S. 
Department of Health and Human Services for establishing 9/11 
programs and resources to treat, track, and provide information 
about scientific research and services for people who have 
developed health problems as a result of the attack.
    However, the GAO does state that the Federal Government has 
had difficulty ensuring uninterrupted availability of services 
for our Ground Zero responders. We have to be certain that 
Federal and State bureaucracy does not prevent responders from 
receiving the medical treatment and the tracking that is 
necessary for meeting the demands of their illnesses.
    I look forward to hearing from our witnesses today. I 
welcome our witnesses and thank them for their time in 
preparing the testimony for us. And again, Mr. Chairman, I 
thank you and the Members who have been so diligent in 
continuing to keep the pressure on about the issue, and I yield 
back.
    Mr. Pallone. Thank you. And then last but not least, the 
gentleman from New York or Staten Island, again he has been one 
of the people, along with the rest of the New York delegation 
that continues to bring this to the attention of the 
subcommittee. I don't know, but I would venture to say that 
probably a lot of those first responders were from Staten 
Island. Mr. Fossella.

 OPENING STATEMENT OF HON. VITO FOSSELLA, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF NEW YORK

    Mr. Fossella. Well, thank you very much, Mr. Chairman and 
Mr. Deal, and thank you for allowing me to participate this 
morning on this panel. My colleagues, Mr. Ferguson, Mrs. 
Blackburn. Of course, Eliot Engel has been a true champion. 
Indeed, I think in Staten Island alone, we lost 78 fireman on 
that day. Twenty-two percent of all firefighters and more than 
240 people were killed, probably the heaviest toll of any 
county per capita in the country.
    And we still see the effects 6 years later. There is the 
old saying that time heals all wounds, and I think in this 
case, time exposes more wounds. And I thank you at the outset, 
Mr. Chairman, for shedding light on this issue, for ensuring 
that we never forget those who not just sacrificed on those 
days, but who continue to suffer. And I thank those in Congress 
and the executive branch for helping New York to rebuild the 
city, but I think there's a fundamental obligation to call upon 
our Federal Government to help people rebuild their lives.
    And at the outset, let me thank some individuals. I thank 
the panel, Mr. Howard. We will also hear from Deputy Mayor 
Edward Skyler, who is here on behalf of the mayor, who has 
truly been a good partner in helping us get the resources we 
need and, by extension, the fire department and the police 
department and Mt. Sinai and all those who are trying to ensure 
that New York doesn't shoulder disproportionately the burden 
here.
    Because we have to remember September 11 wasn't just a New 
York problem or a New York/New Jersey problem. It was an 
American problem. It was an attack on America, and I think 
America has a responsibility to respond in kind.
    I would like to thank my colleagues in the New York 
delegation, Mr. Nadler, but especially Mrs. Carolyn Maloney who 
has really been spearheading these efforts to date. People in 
the labor community in particular, Dennis Hughes in the AFL/CIO 
who has helped us coordinate and shepherd this legislation 
through.
    And I remind everyone that this is why we place so much 
emphasis on preventing another terrorist attack because one 
more exorbitant cost of terrorism is the individuals that we 
continue to have to help and treat.
    Again the message is never forgetting. We know so many 
successes, but the successes have been measured in small steps 
rather than giant leaps as critical needs continue to be unmet 
after 6 years. We have encountered obstacles along the way, but 
as mentioned with Congresswoman Maloney, we have restored $125 
million. Of that, $75 million was dedicated for treatment, the 
first ever Federal dollars to be directed for that purpose. We 
were able to get Dr. Howard to help coordinate and oversee the 
Federal response. And in addition, as Mr. Pallone mentioned, we 
included $50 million for the federally funded 9/11 health 
clinics in the Labor-HHS appropriations bill.
    In addition, as was mentioned by Mr. Engel, we introduced 
legislation last night that ensures that everyone exposed to 
the Ground Zero toxins has a right to be medically monitored, 
builds on the Center of Excellence, and expands care to the 
entire exposed community and provides compensation for loss by 
reopening the 9/11 Victims' Compensation Fund.
    And for those, Mr. Deal and Mrs. Blackburn, also asked 
some, I think, very pointed questions of where is the 
information, what do we need? I can tell you, as someone who 
lives in Staten Island and sees young guys in particular who 
used to run a 6-minute mile, 7-minute mile, now have difficulty 
walking up a flight of steps. I could point to those 
individuals with specificity, but the data is just 
overwhelming, whether it is from Mt. Sinai or the fire 
department, that this is a major problem, a major undertaking 
that demands a Federal response. And I think the Federal 
Government has an obligation to be at the table with us helping 
to coordinate, shepherd, and provide for long-term plan for all 
those who are affected.
    With that, Mr. Chairman, I thank you very much for holding 
this hearing. I yield back.
    Mr. Pallone. Ranking member, Mr. Barton, for an opening 
statement.

   OPENING STATEMENT OF HON. JOE BARTON, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF TEXAS

    Mr. Barton. Thank you, Chairman Pallone. I was downstairs 
at the Oversight Subcommittee hearing on monitors for nuclear 
equipment coming into this country. I appreciate you holding 
this hearing today. I appreciate my colleagues on both sides of 
the aisle from New York being involved with it.
    Before I talk about the specific hearing, I think it would 
be appropriate that we all contemplate our dear colleague Paul 
Gillmor who passed away several weeks ago. Paul was a 
distinguished member of this committee, and was chairman of the 
Environment and Hazardous Material Subcommittee in the last 
Congress. He took a leave of absence from the committee this 
Congress so that some of the more junior members of the 
minority side wouldn't have to be bumped off of the committee. 
So we are going to miss him, and we wish the best to his family 
in their time of sorrow.
    As far as the hearing today, I think it is important. We 
know what happened on 9/11/2001. Firefighters, police officers, 
ambulance crews, and all of the other first responders were 
exposed to health hazards because of the attacks on 9/11.
    Federal funding has been provided to Government agencies 
and to private organizations to screen and monitor responders 
for illnesses caused by that catastrophe. This hearing is going 
to provide some oversight for those programs. Many who 
responded to the disaster and then needed help themselves have 
been beneficiaries of various worker compensation, health 
insurance, and other Government coverage.
    Some say that what has been done is not enough. I don't 
really know where to draw the line. I don't know whether the 
entities that are legally obligated to provide or pay for 
health care monitoring or treatment have done all that they 
could to help the victims of 9/11.
    I know that we have appropriated Federal money and that we 
will continue to do so. I know that Federal dollars have been 
spent for the responders who responded on 9/11. Again I'm not 
sure exactly the effectiveness of those programs and the 
legality of some of those programs and what needs to be done. 
So I look forward to the hearing.
    Before I yield back, Mr. Chairman, I do think that, since 
this is the Health Subcommittee, we should mention something 
that has yet to be done, and that is a reauthorization of our 
S-CHIP program. Members on both sides of the aisle realize the 
importance of S-CHIP. I am introducing a bill today to 
authorize a clean bill at existing levels with a slight 
increase for inflation until we can work out the details of a 
new S-CHIP program. I would hope that my friends on the 
majority side would join us in reauthorizing for a short term 
the existing S-CHIP program because, as we all know, if we 
don't do something in the next 2 weeks, the program legally 
expires on September 30, the end of this month.
    So while we wrangle over the details of any new 
improvements or expansions in the program, if any, we at least 
ought to keep the existing program going. And I would hope that 
we could move that extension fairly quickly while we tackle the 
bigger issue.
    If the Democratic leadership in the House wants to accept 
the Senate bill, I do hope that this subcommittee would hold a 
hearing on that bill, a legislative hearing, where it would be 
open. We could look at the details and then have a markup 
subsequent to that so that we could actually make some changes 
in the bill before it went to the floor.
    With that, Mr. Chairman, I yield back.
    Mr. Pallone. Thank you, Mr. Barton. I appreciate your 
ongoing interest in S-CHIP, and I am about S-CHIP-ped out 
today. So I am not going to comment any further. The gentleman 
from Arizona.

OPENING STATEMENT OF HON. JOHN B. SHADEGG, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF ARIZONA

    Mr. Shadegg. Thank you, Mr. Chairman, and with your 
permission, I will insert my written statement in the record. I 
simply want to make some brief comments which may be a little 
bit different than others have made. I want to commend you for 
holding this hearing.
    And I want to recognize that, while the focus today is the 
technical issue of the care, treatment, and monitoring of the 
first responders who have been victimized, I think it is 
important to remind everyone at the dais and in the audience 
and elsewhere that we are talking about the victims of a 
vicious attack on America by radical Islamists who seek to kill 
us and who are out there and who want to keep going in their 
efforts who make their designs clear every day.
    That the people who are suffering--we all kind of 
internalize the numbers of those who were killed that day, and 
then we can extrapolate from that all the families that were 
affected by that attack. But as my colleague from New York Mr. 
Fossella pointed out we don't really know the number of 
victims. The issue we are looking at today demonstrates there 
are more victims being manifest every day by this attack on 
America.
    And I think it is important for those watching this hearing 
who are considering this effort to recognize that this is not a 
health problem, though it is a Health Subcommittee. This is the 
Nation's response to an attack by its enemies. And we can all 
be critical and say we should have responded this way or that 
way, or we should not have responded this way or that way.
    But at a minimum, I would hope that we can all come to 
agreement that when this Nation is attacked and there are 
people who suffer, whether it is the loss of life and the 
impact on the families, or whether it is ongoing health 
problems that manifest themselves months later or years later, 
that is something we need to be concerned about as a nation. 
That is a cost of failing to do what is necessary to defend 
ourselves. And we have an obligation to each of the people who 
are suffering as a result of those attacks today because that 
is a part of our national defense. That is a part of us 
standing together as a nation.
    I will just conclude by pointing out when the 9/11 attacks 
occurred, my daughter was in college. She now works on the 
Senate side, and I talked to her a few days after the event. 
And she said that she and many of her friends in college were 
going down to the local blood bank to donate blood for the 
victims. That is the spirit that we had as a nation when the 
attacks occurred. That is the spirit we should have or try to 
have as a nation in responding or figuring out the best way to 
respond to those who hate us and want to kill us. And that is 
certainly the spirit we should bring to this hearing and to 
doing the right thing by the people who are being victimized by 
this attack now years later.
    And with that, I yield.
    Mr. Pallone. Thank you. Thank you for those remarks. We are 
done now with our opening statements, and any other statements 
will be accepted for the record at this time.
    [The prepared statements follow:]

    Prepared Statement of Hon. John D. Dingell, a Representative in 
                  Congress from the State of Michigan

     Mr. Chairman, thank you for holding this important hearing 
today. I also want to thank the witnesses who are here to 
discuss the health effects of the World Trade Center collapse 
on first responders and workers.
    One week ago marked the sixth anniversary of the attacks 
against our Nation. Nearly 3,000 people perished as a result of 
the attacks, and many who participated in the clean up, rescue, 
and recovery efforts continue to suffer from lingering physical 
and mental health problems directly linked to their work in 
downtown New York City. While Congress has taken some initial 
actions to deal with this issue, adequate screening, treatment, 
and monitoring services for all of those brave men and women 
throughout the Nation who came to New York to work in the 
cleanup has been lacking.
     It is incumbent on our Nation not to forget these 
responders who placed their own well-being aside to help 
others. The administration's fiscal year 2008 budget request of 
$25 million for the current World Trade Center responder 
programs fell far short of the amount appropriated in either 
2006 or 2007. Over the long term, we must find a way to care 
for our heroes who answered the call and subsequently suffered 
severe health problems. In the short term, we must provide 
enough Federal resources to sustain the current monitoring, 
screening, and treatment programs in New York.
     I would note with particular concern the intermittent 
services provided by the World Trade Center Federal Responder 
Screening Program. The program, now run by the Federal 
Occupational Health Services, provides Federal responders to 
the attacks with screening and referrals to health clinics. 
However, the program suspended examinations from March 2004 to 
December 2005, and again from January 2007 to March 2007. This 
program encompasses Federal employees all across the country 
that came to New York in response to the attacks. As new health 
9/11 effects continue to emerge from latent conditions, it is 
especially important that all Federal employees who were 
exposed to the environmental hazards resulting from the WTC 
collapse be screened for problems.
     Another area of concern is the failure to screen and 
monitor those non-Federal workers who reside outside of New 
York City. While the National Institute for Occupational Safety 
and Health has made two separate attempts to contract with 
entities to provide service across the country, only a very 
limited number of places in the country have services.
     It is imperative that as Congress continues to work on 
these issues, we not forget the service our first responders 
and workers provided in those dark days following September 11.
     I want to thank Chairman Pallone for holding this 
important hearing, and I look forward to receiving the 
testimony from our witnesses.
                              ----------                              


    Prepared Statement of Hon. Henry A. Waxman, a Representative in 
                 Congress from the State of California

    Mr. Chairman, thank you for holding this important hearing 
today.
    Last week the Nation marked the sixth anniversary of the 
terrorist attacks of September 11. As a nation, we mourned all 
those people who lost their lives on that day in the attacks on 
the World Trade Center and the Pentagon, and the passengers who 
died on United Airlines flight 93 in Shanksville, Pennsylvania.
    But we also remember those people who continue to suffer 
from the attack on the World Trade Center--the men and women 
from all over the country who came to lower Manhattan to help 
clear the debris and to rebuild the site. Last week, Chairman 
Towns, chairman of the Subcommittee on Government Management, 
Organization, and Procurement of the Oversight Committee, held 
his third hearing on the impact of 9/11 on New York residents 
and first responders. We have also had a number of hearings 
over the years in the National Security Subcommittee of the 
Oversight Committee on the health effects of the 9/11 attacks.
    We know from these hearings that Congress needs to craft a 
long-term solution to the problem of how we will identify, 
treat, and compensate those people who are suffering from 9/11-
related illnesses. The current patchwork approach is clearly 
inadequate. That is why I am pleased that we are having a 
hearing today in this subcommittee. This is the subcommittee 
with legislative jurisdiction over the care of the first 
responders and others who continue to suffer because of the 9/
11 attacks. The involvement of this subcommittee is critical to 
moving forward on this important issue.
    I would like to commend my colleagues from New York, 
Representatives Maloney, Nadler, Fossella, who have worked 
together, across party lines, to develop a comprehensive 
approach to monitoring, treating, and compensating people who 
were exposed to the to the potentially toxic effects of the 
World Trade Center site. I look forward to working with these 
members and this subcommittee to make sure that all of the 9/11 
victims are taken care of.
    I thank the witnesses for coming today.
                              ----------                              


Prepared Statement of Hon. Anna G. Eshoo, a Representative in Congress 
                      from the State of California

    Chairman Pallone, thank you for holding today's hearing on 
the Federal response to the health problems faced by first 
responders, construction workers, residents, and others living 
and working at or near the World Trade Center site following 
the September 11, 2001 attacks on our country.
    In the haste to respond to the destruction of the World 
Trade Center buildings, the impact on public health was 
underestimated and diminished.
    In the early days after the attacks, the Federal Government 
failed to provide the public with sufficient warnings about 
potential risks. After the collapse of the two World Trade 
Center towers, the EPA told the public in a September 18, 2001 
announcement that the air was ``safe'' to breathe. The EPA 
Inspector General later concluded in an August 2003 report that 
``[EPA] did not have sufficient data and analyses to make such 
a blanket statement.'' The IG report also said, ``The White 
House Council on Environmental Quality influenced, through the 
collaborative process, the information that EPA communicated to 
the public through its early press releases when it convinced 
EPA to add reassuring statements and delete cautionary ones.''
    Regrettably, as the GAO has reported, there have been 
additional missteps in the operation of federally-supported 
programs that monitor 9/11 related health problems and treat 
victims.
    In one case, a screening program was suspended for 5 months 
earlier this year when there was a change in the agency 
overseeing the WTC Federal Responder Screening Program. 
Diagnostic services under the same program were suspended for 
11 months because of a contracting problem.
    Finally, the GAO notes that affected individuals living 
outside the New York metropolitan area have found it difficult 
if not impossible to participate in screening and monitoring 
programs due to a lack of nearby providers participating in the 
program. Getting treatment has been even more challenging.
    Although my congressional district is 3,000 miles away from 
Ground Zero, this aspect of the public health aftermath of the 
9/11 attacks has affected some of my constituents.
    The Urban Search and Rescue (USAR) team based in Menlo 
Park, California, was one of many to respond in the days after 
September 11th. Although members of the team were in New York 
for a relatively short time compared to others who worked on 
``the Pile'' some have experienced respiratory and other 
ailments in the ensuing years.
    For my constituents and for other first responders from the 
around the country who answered the call after 9/11, I believe 
we need a new comprehensive framework that provides the 
screening and the treatment they deserve, similar to the 
legislation that my colleagues Representatives Maloney, Nadler, 
and Fossella have recently introduced.
    Today, we'll hear from the witnesses who are attempting to 
address the health issues that have emerged after 9/11. I look 
forward to hearing their thoughts on getting the services and 
care to those who need and deserve them.
    Thank you, Mr. Chairman.
                              ----------                              


 Prepared Statement of Hon. Jim Matheson, a Representative in Congress 
                         from the State of Utah

    Thank you, Chairman Pallone and Ranking Member Deal.
    As many have noted, our world changed forever 6 years ago, 
when our Nation was attacked. Thousands of innocent people died 
and our national security was shaken to the core. We will never 
forget those who lost their lives in New York, at the Pentagon, 
and on a Pennsylvania field. We will never forget the heroes--
the first responders--who rushed to Ground Zero with no thought 
but to help with the recovery. In my State of Utah, the Salt 
Lake Urban Search and Rescue Team--also called Utah Task Force 
One--sent 62 people to New York City on September 18, 2001, to 
comb through the rubble of the World Trade Center. The team 
included specialized firefighters, search dogs and handlers, 
two physicians and several structural engineers. The Salt Lake 
City and Salt Lake County Fire Departments contributed, as well 
as the Rocky Mountain Rescue Dog organization. The Utah task 
force is one of 28 teams that participate in the national Urban 
Search and Rescue Response System. It's impossible to honor the 
victims of 9/11 without also making a commitment to our first 
responders who run toward danger while others try to escape it.
    Since the attacks, many rescue workers have reported an 
increase in illness as a result of exposure to toxic materials 
and debris, during their hours on the pile, amid the dust and 
soot. Many agency officials will provide testimony here today, 
confirming that we need to continue to examine the health 
exposure and work to make available physical and mental health 
screening programs, which should be available to all exposed 
first responders.
    I also believe that Congress should continue to support 
critical programs that improve access to emergency medical 
care. For my part, I have introduced legislation to reauthorize 
the Emergency Medical Services for Children (EMSC) Program. 
This program is designed to improve emergency medical services 
for our children. For more than 20 years, the EMSC program has 
improved emergency care facilities that treat sick and injured 
children across this country. Through grants to States and to 
accredited medical schools, the EMSC program has driven ``best 
practices'' in the care provided to kids every day at the scene 
of an accident, en route to the hospital and in the E.R. and 
other critical care facilities. These efforts also translate 
into better care for children when natural or manmade disasters 
strike. When disaster strikes, we all want the best care 
possible for these small patients--I am working to preserve 
this program dedicated to improving emergency medical care for 
our children.
    I look forward to the testimony today and with that, I 
yield back my time.
    Thank you Mr. Chairman.
                              ----------                              

    Mr. Pallone. We will now turn to our witnesses, and the 
first panel has one person, Dr. Howard. First of all, welcome. 
Dr. Howard is the director of the National Institute for 
Occupational Safety and Health with the U.S. Department of 
Health and Human Services. Let me mention that you may, in my 
discretion, submit additional brief and pertinent statements in 
writing for inclusion in the record after your comments. And I 
welcome you, and if you will begin your statement. Thank you, 
Doctor.

 STATEMENT OF JOHN HOWARD, M.D., DIRECTOR, NATIONAL INSTITUTE 
 FOR OCCUPATIONAL SAFETY AND HEALTH, DEPARTMENT OF HEALTH AND 
                         HUMAN SERVICES

    Dr. Howard. Good morning, Mr. Chairman, and members of the 
subcommittee, and Mr. Fossella. I am pleased to report on the 
progress that has been made in addressing the health needs of 
World Trade Center responders and volunteers.
    In 2002, the Department first funded medical screening for 
World Trade Center responders and volunteers. By 2004, medical 
evidence showed that periodic medical monitoring was indicated, 
and a monitoring program was added. In late 2006, treatment 
services were added because a significant portion of the 
responders and volunteers were experiencing physical and mental 
health problems.
    Both monitoring and treatment services are provided to 
those responders and volunteers in the New York City/New Jersey 
metropolitan area by Centers of Clinical Excellence at a 
consortium of five medical centers in New York and New Jersey, 
coordinated by the Mount Sinai School of Medicine, and at a 
clinic center at the fire department of New York City.
    These clinical centers have enrolled over 36,000 responders 
and volunteers in medical monitoring and have referred more 
than 7,600 of those responders for treatment of physical health 
ailments and nearly 5,000 for referral for mental health 
conditions. Even today, World Trade Center responders and 
volunteers are still coming forward to enroll in the federally 
funded monitoring and treatment program.
    In addition, over, 1,300 current Federal workers who 
responded have been medically screened by the Department's 
Federal Occupational Health. And 700 nationwide responders have 
received an initial monitoring examination by contractors of 
the Mount Sinai Data Coordination Center. Just over 400 
nationwide responders have received medical diagnosis and/or 
treatment from the Association of Occupational and 
Environmental Clinics supported by generous and continuing 
funding from the American Red Cross.
    Finally, in collaboration with the New York City Department 
of Health and Mental Hygiene, the Department of Health and 
Human Services funds the World Trade Center health registry. 
The registry tracks the health of 71,000 responders, residents, 
office workers, students, and school staff, passersby, those in 
the area of the World Trade Center on September 11, 2001. The 
registry's findings provide an important picture of the long-
term consequences of September 11 on the health of not only 
those who responded and volunteered, but also on those living 
and working around the World Trade Center site.
    Thank you, Mr. Chairman. I would be pleased to answer any 
of your questions.
    [The prepared statement of Dr. Howard follows:]

                 Statement of John Howard, M.D., M.P.H.

    Good morning, Chairman Pallone and other distinguished 
members of the subcommittee. My name is John Howard, and I am 
the Director of the National Institute for Occupational Safety 
and Health (NIOSH), which is part of the Centers for Disease 
Control and Prevention (CDC) within the Department of Health 
and Human Services (HHS). CDC's mission is to promote health 
and quality of life by preventing and controlling disease, 
injury and disability. NIOSH is a research institute within CDC 
that is responsible for conducting research and making 
recommendations to identify and prevent work-related illness 
and injury.
    Mr. Chairman, I would like to express my appreciation to 
you and to the members of the subcommittee for holding this 
hearing and for your support of our efforts to assist those who 
were affected by 9/11. I am pleased to appear before you today 
to report on the progress we have made in addressing the health 
needs of those who served in the response effort after the 
World Trade Center (WTC) attack on 9/11 and those in the 
affected communities.
    Since February 2006, I have served as the HHS WTC Programs 
Coordinator. Secretary of Health and Human Services Michael O. 
Leavitt determined that there was a ``critical need to ensure 
that programs addressing the health of WTC responders and 
nearby residents are well-coordinated,'' and charged me with 
this important task. Since receiving this assignment I have 
traveled to New York City (NYC) and Albany, New York, to assess 
the status of the existing HHS programs addressing WTC health 
effects, and meet with those we serve. Participating in these 
dialogues has enabled me to better understand the needs of 
those affected, and the steps we can take to meet those needs. 
As the HHS WTC Programs Coordinator I work to coordinate the 
existing programs and ensure scientific reporting to provide a 
better understanding of the health effects arising from the WTC 
attack. Today, I will focus my remarks on the progress we've 
made toward these tasks.

         WTC Responder Health Program--Monitoring and Treatment

    Since 2002, agencies and offices within HHS have been 
dedicated to tracking and screening WTC rescue, recovery and 
clean up workers and volunteers (responders).
    In 2004, NIOSH established the national WTC Worker and 
Volunteer Medical Monitoring Program to continue baseline 
screening (initiated in 2002), and provide long-term medical 
monitoring for WTC responders. In fiscal year 2006, Congress 
appropriated $75 million to CDC to further support existing HHS 
WTC programs and provide screening, monitoring and medical 
treatment for responders. Since these funds were appropriated, 
NIOSH has established a coordinated WTC Responder Health 
Program to provide annual screenings, as well as diagnosis and 
treatment for WTC-related conditions (e.g. aerodigestive, 
musculoskeletal, and mental health) identified during 
monitoring exams. The WTC Responder Health Program consists of 
a consortium of clinical centers and data and coordination 
centers that provide patient tracking, standardized clinical 
and mental health screening, treatment, and patient data 
management.
    To date, the WTC Responder Health Program has screened 
approximately 36,000 responders. The New York City Fire 
Department (FDNY) manages the clinical center that serves FDNY 
firefighters who worked at Ground Zero. As of July 31, 2007, 
FDNY had conducted 29,203 screenings, including 14,429 initial 
examinations and 14,774 follow-up examinations. The Mt. Sinai 
School of Medicine's Center for Occupational and Environmental 
Medicine coordinates a consortium of clinics that serve other 
response workers and volunteers who were active in the WTC 
rescue and recovery efforts. These clinics have conducted 
21,088 initial examinations and 9,101 follow up examinations. 
Of the 36,000 responders in the WTC Responder Health Program, 
7,603 have received treatment for aerodigestive conditions, 
such as asthma, interstitial lung disease, chronic cough, and 
gastro-esophageal reflux, and 4,868 have been treated for 
mental health conditions.
    In conjunction with these activities, CDC-NIOSH has funded 
the NYC Police Foundation's Project COPE and the Police 
Organization Providing Peer Assistance to continue providing 
mental health services to the police responder population. The 
availability of treatment for both physical and mental WTC-
related health conditions has encouraged more responders to 
enroll and continue participating in the WTC Responder Health 
Program, which will enable us to better understand and treat 
the long-term effects of their WTC exposures.

                WTC Federal Responder Screening Program

    In fiscal year 2002, the HHS Office of Public Health 
Emergency Preparedness (OPHEP)--which is now the Office of the 
Assistant Secretary for Preparedness and Response (ASPR)--
received $3.74 million through the Federal Emergency Management 
Agency (FEMA) to establish the WTC Federal Responder Screening 
Program to provide medical screening for all Federal employees 
who were involved in the rescue, recovery or clean up efforts. 
Current Federal employees in this program are screened by the 
HHS Federal Occupational Health (FOH), a service unit within 
HHS. FOH has clinics located in areas where large numbers of 
workers are employed. As of August 31, 2007, FOH had screened 
1,331 Federal responders. In February 2006, CDC-NIOSH and OPHEP 
(now ASPR) signed a Memorandum of Understanding to monitor 
former Federal workers via the WTC Responder Health Program. 
Since then, former Federal workers have been enrolled in the 
WTC Responder Health Program and served by the Mt. Sinai Data 
and Coordination Center and national clinic partners.

                            Nationwide Scope

    HHS is working with its partners to ensure that the 
benefits of all federally-funded programs are available to all 
responders, across the nation. Those responders who selflessly 
came to the rescue of NYC from throughout the country at the 
time of the WTC disaster should receive the same high quality 
monitoring and treatment as those who reside in the NYC 
Metropolitan Area. Enrollees in the WTC Responder Health 
Program who are not located in the NYC Metropolitan Area, 
receive monitoring and treatment via a national network of 
clinics managed by QTC, Inc. and the Association of 
Occupational and Environmental Clinics (AOEC), respectively. To 
date, 698 responders outside of the NY Metropolitan Area have 
been screened by the WTC Responder Health Program.
    Achieving such nationwide coverage for WTC responders is 
challenging; however, we are committed to serving all 
responders, regardless of their location or employment status. 
I am actively working with the medical directors of the WTC 
Health Program, the WTC Federal Responder Screening Program, 
QTC, Inc. and the AOEC to ensure that the services available to 
responders are uniform across programs.

                          WTC Health Registry

    In addition to the WTC Responder Health Program, the Agency 
for Toxic Substances and Disease Registry (ATSDR) maintains the 
World Trade Center Health Registry. In 2003, ATSDR, in 
collaboration with the New York City Department of Health and 
Mental Hygiene (NYCDOHMH), established the WTC Health Registry 
to identify and track the long-term health effects of tens of 
thousands of residents, school children and workers (located in 
the vicinity of the WTC collapse, as well as those 
participating in the response effort) who were the most 
directly exposed to smoke, dust, and debris resulting from the 
WTC collapse.
    WTC Health Registry registrants will be interviewed 
periodically through the use of a comprehensive and 
confidential health survey to assess their physical and mental 
health. At the conclusion of baseline data collection in 
November 2004, 71,437 interviews had been completed, 
establishing the WTC Health Registry as the largest health 
registry of its kind in the United States. The NYCDOHMH 
launched the WTC Follow-up survey in November, 2006. As of 
August 31, 2007, 39,703 adult paper and web surveys had been 
completed for nearly 60 percent response rate (58.7 percent). 
NYCDOHMH has begun a third phase of the follow-up survey to 
reach the registrants through direct interviewing by telephone, 
as well as initiated a separate mailed survey of registrants 
who are younger than 18 (approximately 2,200).
    The WTC Health Registry findings provide an important 
picture of the long-term health consequences of the events of 
September 11th. Registry data are used to identify trends in 
physical or mental health resulting from the exposure of nearby 
residents, school children and workers to WTC dust, smoke and 
debris. Two journal articles recently published reported 
findings on 9/11 related asthma and posttraumatic stress 
disorder (PTSD) (Environmental Health Perspectives, 8/27/2007; 
and American Journal of Psychiatry, 2007; 164:1385-1394) among 
rescue and recovery workers. Newly diagnosed asthma after 9/11 
was reported by 926 (3.1 percent) workers, a rate that is 12 
times the norm among adults. Similarly, the overall prevalence 
of PTSD among rescue and recovery workers enrolled on the WTCHR 
was 12.4 percent, a rate four times that of the general U.S. 
population. By spotting such trends among participants, we can 
provide valuable guidance to alert Registry participants and 
caregivers on what potential health effects might be associated 
with their exposures.
    The WTC Health Registry also serves as a resource for 
future investigations, including epidemiological, population 
specific, and other research studies, concerning the health 
consequences of exposed persons. These studies can assist those 
working in disaster planning who are proposing monitoring and 
treatment programs by focusing their attention on the adverse 
health effects of airborne exposures and the short- and long-
term needs of those who are exposed. The findings will permit 
us to develop and disseminate important prevention and public 
policy information for use in the unfortunate event of future 
disasters.

                                Funding

    I want to reaffirm the Department's commitment to work with 
the Congress to provide compassionate and appropriate help to 
responders affected by the World Trade Center exposures 
following the attacks.
    As you know, the Department of Defense, Emergency 
Supplemental Appropriations to Address Hurricanes in the Gulf 
of Mexico, and Pandemic Influenza Act of 2006 (P.L. 109-148) 
provide $75 million for the treatment, screening, and 
monitoring of the responders. With less than one month 
remaining in the fiscal year (FY) we are confident this funding 
will last at least until the end of fiscal year 2007.
    The President's fiscal year 2008 budget requests $25 
million for World Trade Center responders and in May 2007, the 
President signed the U.S. Troop Readiness, Veterans' Care, 
Katrina Recovery, and Iraq Accountability Appropriations Act of 
2007 (P.L. 110-128), which included an additional $50 million 
to support continued treatment and monitoring for World Trade 
Center responders. This funding will be awarded, as needed, to 
support continued monitoring, care, and treatment of responders 
through fiscal year 2008.
    From July 1, 2006, through June 30, 2007, the Federal 
grantees have reported to NIOSH spending approximately $15 
million total for treatment for World Trade Center related 
illnesses. This includes $6 million from American Red Cross 
funds and $9 million from the $42 million total Federal grants 
awarded in October 2006. Of this $9 million, the grantees have 
actually ``drawn down'' only $2 million in payments on the 
Federal grants.
    Over $90 million in appropriated funds remains available--
including the balance of the treatment funds appropriated in 
fiscal year 2006 and the $50 million appropriated in fiscal 
year 2007--before adding the $25 million included in the 
President's fiscal year 2008 budget request. HHS is gathering 
additional financial data from the Federal grantees in order to 
better understand the healthcare cost issues of the responders. 
Additional data will help inform our policies, ensure that the 
current program operates efficiently and effectively, and 
maximize the available resources to meet responders' medical 
needs. HHS will continue to monitor the work of the grantees as 
part of the fiscal year 2009 budget process.
    Since 9/11, HHS has worked diligently with our partners to 
best serve those who served their country, as well as those in 
nearby communities affected by the tragic attack. We have had 
great success in expanding our monitoring program to include 
treatment, which has encouraged more responders to enroll and 
receive needed services. We will continue to forge ahead in 
providing coordinated medical monitoring and treatment 
services, supported by the recent $50 million appropriation. 
Likewise, the WTC Health Registry continues to paint a picture 
of the overall health consequences of 9/11, including the 
effects experienced by the residents, school children and 
office workers located in the vicinity of the WTC. While we 
have made much progress, we must continue to gather and analyze 
data that will enable us to better understand the health 
effects we have observed so that we may better treat those 
affected. I appreciate your support of our efforts and look 
forward to working with you in the future as we continue to 
serve this deserving population.
    Thank you for the opportunity to testify. I would be happy 
to answer any questions you may have.
                              ----------                              

    Mr. Pallone. Thank you, Dr. Howard. I am going to recognize 
myself for some questions.
    You are familiar with the letters that myself and the New 
York delegation have sent to both Secretary Leavitt and Office 
of Management and Budget? Have you seen those?
     Dr. Howard. I think I have seen letters to the Department. 
I am not sure I have seen those you----
    Mr. Pallone. OK. Well, I mean essentially if I could 
summarize the concern, I mean the concern is that the 
administration had promised a comprehensive plan to deal with 
this. As you know, the New York delegation has submitted 
legislation which, I guess, could be intended to put together a 
comprehensive plan. But we were supposed to get something like 
that from the administration.
    We continue to be concerned about the level of budget 
requests that come from OMB, so we sent a letter to OMB. And 
the concern I have, and I guess the criticism is that the 
administration would appear to be dragging their feet. We don't 
have a comprehensive plan.
    We have budget requests that seem to be inadequate. I did 
get a draft, I guess, that I mentioned in my opening statement 
that has the figure, that the current cost estimate for the 
program is nearly $200 million per year. And yet there is an 
acknowledgement in the draft that it could cost as much as $712 
million annually. And yet the President's budget for fiscal 
year 2008 request is only $25 million. And I know that one of 
the administrators for this task force resigned, and no new 
person has been appointed.
    So I guess the question would be, one, what is happening 
with this comprehensive plan? Are we still getting it? Is it 
being held up because you don't have a person to replace the 
person who was the chair of the task force? And when are we 
going to get some real cost estimates because I think you would 
agree that the $25 million wasn't adequate.
     Dr. Howard. Mr. Chairman, let me start with the beginning 
of that list of questions. I think all of them are extremely 
important. I don't think there should be any doubt in anyone's 
mind that Secretary Leavitt of the Department of Health and 
Human Services is dedicated to this program and ensuring that 
these individuals who are being monitored and treated are not 
abandoned. That will not happen on his watch.
    I think one of the more serious issues with regard to 
developing a comprehensive plan, a multi-year plan, as opposed 
to a day-to-day operational plan, which we do in NIOSH every 
day with the grantees.
    The biggest problem with that, I think, from the point of 
view, not being a budget accountant et cetera, is being able to 
project over time what the true costs are. Right now on the 
monitoring side, it is very easy to do. We know that it costs 
$1,150 to monitor an individual. You tell me the number of 
individuals you want monitored. We do the math, and it comes 
out. Right now, we have 37,000 under monitoring, $1,150 per 
year. That's about a figure of $43 million. Easy to figure out. 
March that out to how many years you want.
    On the treatment side, that is the real conundrum. We put 
out the money for the treatment services in October 2006. It 
took a few months for the grantees to get capacity up and 
running. Probably around February or March, the grantees really 
started treating individuals. So we have a very limited amount 
of time right now to assess from an actuarial sense the costs 
of treatment because each individual is generating different 
costs, and there are different costs associated with treating 
physical health effects and mental health effects.
    So that is an extremely unstable number, and I think again 
from my point as a physician--I am not a professional in this 
area--but I think it challenges people who are looking at 
projecting costs through the years.
    Mr. Pallone. I only have 5 minutes even though I am the 
chairman. I just really want to know you are agreeing with me 
that there is a problem. The GAO report, that is the next 
panel, they agree that there is a problem. But I just want an 
answer to simple questions. Is the administration still going 
to give us a comprehensive plan so we don't just have to 
operate ad hoc? When? Is there a problem because there is 
nobody in charge of this anymore because the person resigned? 
And I mean just answer that. Are we going to get a 
comprehensive plan, yes or no?
     Dr. Howard. I would like to answer all three. Yes.
    Mr. Pallone. OK, when?
     Dr. Howard. We are developing comprehensive plans.
    Mr. Pallone. Can we have a date?
     Dr. Howard. The task force that Dr. Agwunobi reported to 
the Secretary in April. The conundrum, I think, we have, which 
I think has to be recognized is that we don't have solid cost 
estimates to do a comprehensive long-term plan at this point in 
time.
    Mr. Pallone. But can you give me an approximate date?
     Dr. Howard. In October at the end of this grant period for 
the treatment program, we will have exact numbers from the 
grantees about what they have spent in this first grant year. 
That will be extremely helpful for a comprehensive plan.
    Mr. Pallone. So can we get this comprehensive, in the next 
few months?
     Dr. Howard. Well, that I will take back to the----
    Mr. Pallone. Yes, I would like to have it, if possible, 
right after October 1. And then is there going to be a new 
person appointed to head this task force?
     Dr. Howard. The Secretary at this time--I am co-chair of 
that task force, so I am stepping in from the day-to-day 
operational standpoint to be able to fill that role.
    Mr. Pallone. So you don't know then?
     Dr. Howard. The Secretary will designate a chair at some 
point.
    Mr. Pallone. All right, well why don't you take it back to 
him that we would like that person sooner rather than later?
     Dr. Howard. Yes, sir.
    Mr. Pallone. OK. Mr. Deal.
    Mr. Deal. Thank you. Dr. Howard, talking about the 
treatment side of the issue and whether or not appropriate 
funds are available, just looking at your written testimony, I 
believe there is like $90 million in appropriated funds that 
remain available, including the balance of the treatment funds 
appropriated in the fiscal year 2006 and $50 million 
appropriated in fiscal year 2007, and that is before adding the 
$25 million that was included in the President's fiscal year 
2008 budget. I assume that is correct since it is in your 
testimony?
     Dr. Howard. Those numbers are generally correct. The $90 
million, because we have monies for monitoring, and then we 
have monies for treatment. So the $90 million is on the 
monitoring side, which was appropriated in 2003. The fifth year 
of that is coming up in fiscal year 2008. Otherwise, the 
numbers are perfectly correct.
    Mr. Deal. OK, so there is money that has already been 
appropriated that is not currently been expended. But the 
projection is it will be expended over the next several years?
     Dr. Howard. There is no doubt in my mind that medical 
treatment will be expend all the money that we have. The issue 
is the timing. As I mentioned to the chairman, we are looking 
at right now at the end of this fiscal year, September 30, we 
are looking at the certainty that we will have enough money to 
fund monitoring and treatment fully for anyone who needs it as 
of the end of this fiscal year.
    When we look to that fiscal year 2008, which I think is 
where you are looking, looking at approximately maybe $24 or 
$25 million carried over from fiscal year 2007, plus the $50 
million that the Congress generously appropriated us in the 
Iraq supplemental. So that is nearly $75 million. That is not 
counting the money that is currently in consideration by the 
Congress, which I think on the House side was $50 million.
    So we are entering fiscal year 2008 with funds, and again 
we will continue to monitor this very closely. The Department 
keeps a very close eye on this because, as I said, the 
Secretary's intention is that these patients are not abandoned. 
They do not run out of money. The programs will continue.
    Mr. Deal. Now, as I understand it, most of the money and 
the programs that you put in place go to grantees to carry out 
various functions of the overall picture. Is that correct?
     Dr. Howard. Yes, sir.
    Mr. Deal. And one of the criticisms that apparently GAO has 
made is the lack of documentation. Do you depend on those 
grantees to furnish the numbers and the documentation to you? 
Is that part of the grant function?
     Dr. Howard. Yes, sir. A grant is an unusual vehicle, and 
it is money given to grantees. They decide how to spend it. 
There are some deliverables that are attached, but the data 
really depends on the good working relationship between the 
funder, the Federal Government, and the grantee. It is not 
exactly like a contract, which is a little tighter deliverable.
    Mr. Deal. And in order to make projections for future 
needs, it would seem that you would need the kind of 
demographics and the data that the grantees presumably would 
have access to, but it appears in the GAO report that maybe 
that information is not being funneled back up through the 
system.
     Dr. Howard. No, I would say the grantees are bending over 
backwards to provide us with as much data at any time we ask. 
The issue is that within large hospital medical centers, it is 
not so easy to get actual cost accounting data from systems in 
any health care system. So you are talking about five large 
medical centers in the New York/New Jersey area. So our 
grantee, which is providing the services, must access large 
systems to be able to do that.
    And as you know and we all know, sometimes health billing 
isn't in real time. So there may be some lag, if you will, in 
getting that data. So we are working on setting up alternative 
systems so that we are able to set data in real time. Because 
that is the question, as the chairman asked, as my Department 
asked, as others in Congress asked. What is your cost estimate? 
We want to know that with some certainty.
    Mr. Deal. But it appears though that the effort to 
determine who is out there and who has needs as a result of 
this event of 9/11, the screening process is the largest search 
screening process that has ever happened in the history of this 
country in terms of outreach, is it not?
     Dr. Howard. Exactly right. We have never undertaken, to my 
knowledge, in the Federal Government this kind of process, 
either on a registry side with 71,000 registrants that the city 
is doing for us, or on the clinical side, the monitoring and 
treatment. We have never run this kind of system.
    And if I could add, sir, the 40,000 figure that is often 
quoted, an early figure in 2001 and 2002 for the denominator of 
responders and volunteers, is often used. But as you see, we 
are nearly up to that 40,000 figure in registered, enrolled 
responders and volunteers right now.
    It gives us some pause that that may not be the accurate 
total denominator. And in fact, the city Department of Health, 
utilizing estimation method with Research Triangle Institute in 
North Carolina has a number, an estimated number, 
mathematically estimated, but around 90,000.
    So somewhere between this 40,000 of enrolled individuals 
that we have now in our program and this theoretical 90,000, we 
will found out exactly how many because, as some of you have 
noted, we do not know exactly how many people responded to the 
World Trade Center disaster. We have no census track for those 
individuals.
    Mr. Deal. Thank you. Thank you, Mr. Chairman.
    Mr. Pallone. Mr. Engel.
    Mr. Engel. Thank you, Mr. Chairman. Dr. Howard, you heard 
my opening statement. I am wondering if you could respond to 
the criticism by the GAO that HHS has failed to ensure the 
uninterrupted availability of screening services with Federal 
responders. They have also commented that you failed to truly 
provide screening and monitoring to people in other areas of 
the country who came to Ground Zero. And, as you know, GAO said 
that NIOSH has only been able to establish a network of 
nationwide providers with 10 clinics in only seven States.
    Do you believe HHS has acted appropriately in providing 
services to responders? Because the evidence would seem not.
     Dr. Howard. I am certainly not going to dispute the fact 
that historically, as we have gone through establishing these 
programs for responders that are not physically in the New York 
City/New Jersey area, that we have had significant challenges. 
But right now, I think we are on a good trajectory with a 
contract through Mount Sinai for a large nationwide provider of 
monitoring services called QTC.
    So indeed, sir, I would agree that GAO has pointed out 
historically a lot of fits and starts that we have had with 
both the Federal screening program as well as the nationwide 
program. We have done a lot of work lately, and I am hoping 
that we are on the final trajectory to make sure that those 
individuals have monitoring and treatment services. Now, the 
treatment services, as I mentioned in my statement, are not 
federally funded. The generous support of the Red Cross through 
AOEC supports treatment.
    Mr. Engel. Let me ask you this, Dr. Howard. In September 
2006 Secretary Leavitt established an internal task force on 
what you said to provide him with an analysis of the data and 
options on how to address the health effects at Ground Zero.
    In April of this year, the task force briefed the Secretary 
on eight options that could be undertaken. We in Congress have 
yet to hear about these various options. Can you please tell us 
what the eight options are and if a decision has been made on a 
long-term comprehensive plan to care for those who are sick 
from 9/11?
     Dr. Howard. Well, I think that all of us know the ways 
health care is provided in the United States. I think we could 
all probably sit down and make a list of Medicare, Medicaid, 
the VA system, in addition to our own grant system through our 
Centers of Excellence. Those are the kind of ideas that were 
put in front of the Secretary. There are not any hidden ideas. 
There is no magic bullet here. And all those types of systems 
that are the systems by which health care is provided are ones 
that the Secretary is considering.
    Mr. Engel. And let me ask you a funding question. In July, 
the New York Times reported on an internal HHS document, which 
estimated yearly cost for the current World Trade Center 
Medical Monitoring and Treatment Program at $195 million per 
year. It also says that the costs will probably rise to $428 
million per year. Let me ask you. How much do you anticipate 
that the Medical Monitoring and Treatment Program will cost per 
year?
     Dr. Howard. First of all, as I emphasized to the chairman, 
a lot of costs right now are highly speculative. You have to 
start out with some assumptions. If we start out from the 
grantee data, and this is grantee data that we have. We don't 
have our own independent data.
    We rely on the grantees, but if the grantees are spending 
about $8,000 per patient per condition that they are treating, 
pharmacy costs, diagnostic costs, treatment costs. You multiply 
that times the number of people that are under treatment right 
now, which is about 12,000, you get to the figure of about $90 
or $100 million. So you build on those kinds of figures that 
the grantees are producing.
    By October, I am hoping that we will have more solid 
estimation, but even for treatment at $100 million without 
hospitalization--you have to add then hospitalization costs--
you can see that health care in America is not cheap whether it 
is for responders or anyone else.
    Mr. Engel. Well, let me ask you one final question with the 
chairman's indulgence. You mentioned Mount Sinai. I know we 
have people from New York City in the next panel. How does the 
manner in which Congress is currently funding the World Trade 
Center Medical Monitoring and Treatment Program, its piecemeal, 
its year-to-year funding, how does that affect the ability of 
grantees like the New York City Fire Department, Mount Sinai 
and others to collect medical and cost data? And how does it 
affect NIOSH's ability to administer the program in general?
     Dr. Howard. Sir, I think it is a challenge. Institutions 
would like consistent funding more than year to year despite my 
personal assurances and the assurances of my Department that 
the programs are not going to go away. If you are a CEO of 
Mount Sinai or another medical center and you are looking at 
space considerations, infrastructure development, they would 
like some idea that the program is more than just that year. I 
think that is a real challenge. We have to constantly reassure 
them the program is not going away despite the current year-to-
year funding. But it is a challenge, sir.
    Mr. Engel. Thank you, Doctor. Thank you, Mr. Chairman.
    Mr. Pallone. Thank you. Mr. Ferguson. I'm sorry. I 
apologize. Mr. Barton goes first.
    Mr. Barton. Well, Mr. Ferguson was here before me. I don't 
mind.
    Mr. Pallone. No, I think the rules are since you are the 
ranking member, I am supposed to call on you first.
    Mr. Barton. Well, thank you. I will try not to take my 
entire 5 minutes. Is the problem, the health problem with the 
World Trade Centers in New York, is it a scope problem? It's 
just the catastrophe was so large that it has overwhelmed the 
healthcare system? Or is there something unique about the 
problem itself from a health standpoint at the collapse of the 
Trade Center Towers?
     Dr. Howard. If I understand your question, sir, I don't 
think that it is overwhelming. We have responded, and when I 
say we, the entire family of grantees have responded I think 
magnificently to the challenge of developing infrastructure to 
be able to see this number of individuals in a monitoring 
program and then refer those who need help to treatment. We 
have some backlogs it is true, but I think the response from 
infrastructure development is extremely positive.
    On the issue of the uniqueness of the problem, I think we 
have an entire body of data very consistent from multiple 
investigators published in multiple peer review medical 
journals that looks at a very limited number of conditions. 
Chiefly those of the respiratory system, upper and lower 
respiratory system. Chiefly that of mental health issues, post-
traumatic stress disorder, anxiety, depression, some 
musculoskeletal disorders, some gastrointestinal disorders.
    That is really what we have seen consistently in elevated 
concentrations in these populations. So it is not a scope that 
we cannot deal with. One of the issues with regard to 
respiratory conditions is we don't exactly know what the nature 
of the respiratory condition is in many cases, and we don't 
know what the course is going to be. We don't know exactly how 
to treat them. So I think that is a medical challenge.
    Mr. Barton. But this WTC cough, is that just a 
colloquialism that is used in New York but it is not a unique 
condition caused by the specific type of environmental hazard 
at the Trade Center?
     Dr. Howard. Well, the World Trade Center cough was a name 
that was acquired very early in the course of this disaster. It 
really refers to one particular type of symptom that an 
individual manifests. But lung disease in general, lower lung 
disease in the lower part of the respiratory track always seems 
to have cough as a symptom. So there is nothing specific or 
unique about it.
    Mr. Barton. There is not a unique disease or condition 
associated with that specific location?
     Dr. Howard. We don't know that for sure because a lot of 
conditions that result in fibrosis of the lung, called 
interstitial fibrosis of the lung, you look at a medical 
textbook, there are 200 causes of it. Each one can be unique in 
terms of the cause. So in that sense, we are not far enough 
along the medical research line to be able to answer your 
question fully.
    Mr. Barton. OK, in terms of legal liability, is there a 
specific problem between the Federal responders, the non-
Federal responders, the city of New York, in terms of legal 
liability for work-related occupational accidents or conditions 
that resulted as a result of responding to that disaster?
     Dr. Howard. Sir, I am not sure I am qualified to address 
that issue.
    Mr. Barton. Well, that appears to be one of the primary 
issues that we are trying to--at least the people that come 
into my office, the private contractors have an indemnification 
problem. They claim that they went and did the work and were 
told by the city officials that they would be indemnified. And 
now after the fact, they are finding they have not been 
indemnified, and there are some potential lawsuits. And there 
are requests for some Federal legislation to indemnify them. I 
thought that was one of the primary reasons we are holding this 
hearing, but maybe I am mistaken in that regard.
     Dr. Howard. There are indeed lawsuits that are pending 
against the city and its contractors, but I don't know any----
    Mr. Barton. But I mean is there a generic Federal OSHA 
regulation on that?
     Dr. Howard. Not to my knowledge.
    Mr. Barton. OK. Thank you, Mr. Chairman.
    Mr. Pallone. Thank you. Let me just mention we have three 
votes coming up, and we have about 10 minutes left. So Mr. 
Ferguson will ask questions, and then we will recess Dr. Howard 
and come back maybe half an hour or so. And we will have a few 
more questions. Mr. Ferguson.
    Mr. Ferguson. Thank you, Mr. Chairman. Thank you, Dr. 
Howard, for being here. Your written statement appears to say 
that there are millions of dollars in funds that are still 
available under some of the Federal health programs. Is that a 
correct interpretation of your written testimony?
     Dr. Howard. Right, as I have indicated, we will probably 
know for certain at the end of the grant period, October 30, 
2007, how much money we will have expended and how much we will 
have that will be carried over to fiscal year 2007. Right now, 
we are estimating about $20 to $24 million will be carried 
over. We have $50 million from the Iraq supplemental. So 
already we have on hand $74 million. So we are not going to 
enter 2008 without funding.
    Mr. Ferguson. What is your best estimate as to when we will 
know if that is going to be sufficient to meet some of the 
health treatment requirements and challenges that these victims 
are facing?
     Dr. Howard. Exactly, and this is the question that 
everyone wants to know, and my answer is often inadequate 
because what I say is with time, as we gain more experience 
with the true cost, the average cost per patient for treatment, 
we are going to be able to give you a better number. Right now, 
it is hovering around $8,000 per patient.
    If you are seeing about 25 percent of the monitored 
patients that are in treatment, then you can estimate those 
costs. But they are relatively unstable right now. I would like 
to see some more time take place at least until our grant 
period at the end of October, maybe towards the end of the 
fall, until we have some more stable numbers.
    You can calculate any estimate at any time, but the 
stability of that estimate from actuarial level is often 
elusive.
    Mr. Ferguson. What is being done in terms of R&D on new 
treatments for some of these ailments? It seems like some of 
the ailments that first responders and others are dealing with 
are new and more difficult than perhaps other health challenges 
that have typically been faced by a large number of people. 
What sorts of new treatments are being developed? What are you 
aware of in terms of those efforts underway?
     Dr. Howard. We have no funds right now targeted 
specifically to research. All of our funds that we have 
appropriated go to monitoring and treatment. The grantee 
institutions, many of them are academic medical centers, and 
they have been very creative in looking at their clinical 
findings and trying to figure out the best ways to treat.
    But specifically, they do not have money to spend in 
research per se, and that is something that we hope in fiscal 
year 2008 to be able to utilize some of the already 
appropriated money to be able to give to the grantees to engage 
in research activities per se.
    Mr. Ferguson. That was going to be my next question. What 
is--do you have any specific recommendations at this point, or 
are those sort of informal conversations you are having with 
folks? I mean are we going to need to reprogram funds? What is 
your sense of how that can happen? It sounds like you believe 
it ought to happen.
     Dr. Howard. Yes.
    Mr. Ferguson. Do you have any further--kind of any more 
specific recommendations at this point, or are you developing 
those now?
     Dr. Howard. Well, within the day-to-day measurement 
structure that we do, our own plan that I administer, we are 
trying to set aside targeted funds so that grantees can look 
into some issues with regard to what is the exact nature of the 
respiratory conditions and how are they best treated.
    But we don't have money appropriated by the Congress 
specifically for that purpose; although, everyone that I have 
talked to within the Department, within Congress, of course, is 
very attuned to that issue. And I think the grantees might be, 
Mt. Sinai and others that are here on the other panel, might be 
best to ask about their efforts because they have done heroic 
efforts with very little money thus far to move the medical 
science along.
    Mr. Ferguson. Just in closing, Mr. Chairman, it seems like 
that might be an area that we really would want to examine 
further if we are experiencing these very significant health 
problems, if these folks are experiencing these very 
significant health problems. Perhaps we should also be looking 
at new and different ways of treating them in addition to just 
simply plowing resources into the current treatments that we 
have which may or may not be as effective as they need to be. 
Perhaps some of our efforts should be focused on some different 
and better treatments and some research into, perhaps we can 
take this terrible situation and create some good from it in 
terms of finding new treatments for ailments and illnesses and 
symptoms that maybe we otherwise wouldn't have an opportunity 
to find.
     Dr. Howard. Exactly, and in my subcommittee of the 
Secretary's task force, the Science Subcommittee, we have 
recommended a number of studies along those lines. So that is a 
very important point that you are making.
    Mr. Ferguson. Thank you. Thank you, Mr. Chairman.
    Mr. Pallone. Thank you. Dr. Howard, we are going to take 
about a half an hour recess to vote on the floor, and then we 
will have some questions when we come back. We won't have a 
second round though. We will just go through everybody. 
Everybody will have a chance, and then we will go to the second 
panel. Thank you. The subcommittee is in recess.
    [Recess.]
    Mr. Pallone. The subcommittee will reconvene.
    Dr. Howard, we left off with Congressman Fossella asking 
questions.
    Mr. Fossella. Thank you, Mr. Chairman, and thank you again, 
Dr. Howard, and thank you for all you have done. I know in your 
capacity you have been very vigilant and a very bright light, I 
think, within efforts to try to reconcile what we have been 
trying to reconcile for 6 years.
    And I could just characterize, maybe if you will for lack 
of a better phrase, the perception that--and I speak this on a 
personal level, and perhaps I speak for others--is there is a 
sense that we are constantly sort of dragging folks to the 
table. From securing just less than 2 years ago the Federal 
funding for treatment, to your appointment, to Dr. Agwunobi's
    I guess there is a perception that--I won't say perception. 
There is an understanding that we would love for, in this case, 
the executive branch to be more out front leading the charge. 
And what has happened in the last 6 years from the private 
sector to the health care centers to the Centers for Excellence 
to the mayor's office is just an understanding of this is too 
big and too important to wait for an answer and wait for the 
cavalry to come. So they have been doing the job.
    For example, we talk about the inability to truly estimate, 
and we are always going to have disagreements on the margins 
and whether the number is 50,000 or 51,000, 52,000. But I find 
it curious as to how New York City could estimate what 
treatment would cost.
    The mayor, if my understanding is correct, has committed 
$100 million until 2011. Why is it that the Federal Government 
can't come forward and say this is what we are going to commit 
until 2011 for the sake of argument? I recognize the nuances of 
the annual appropriations process. But wouldn't it be so much 
better if the cavalry came in and said whatever it is going to 
cost over the next 2, 3, 4, 5 years, until we get a sense of 
reliable data, it is going to happen?
    And along those lines, April 3 is our understanding 
pursuant to the letter Mr. Pallone cited. Did the task force 
provide recommendations to HHS regarding what they have 
determined to date?
     Dr. Howard. With regard to the latter question, the task 
force was divided into two groups, a finance group and a 
science group. I headed the science group, and we made 
recommendations to the Secretary from both of the 
subcommittees, from the finance side and from the science side.
    A lot of the science issues we are trying to 
operationalize, looking at research opportunities to move the 
science forward with the current grantees. From the finance 
side, I think again despite those issues of policy that you 
talked about, the Department is extremely interested in the 
stability of cost estimates so that they are able to be able to 
project beyond just this last 6 months that we have. I know 
that is a big issue in the Department.
    Budget people, which I am not one, want some certainty in 
those budget estimates. With regard to the policy options that 
you mentioned, they are beyond my task, and I will certainly 
take that back to the Department.
    Mr. Fossella. Well, because I think there has been a vacuum 
in a way, and it is being filled in different ways. It is an 
ultimate collaboration, especially, I think, reflecting the 
legislation we introduced last night. And we would love to have 
a comment from sort of HHS as to whether they would support, 
let us say, that legislation. Have you had a chance to review 
the legislation or at least an outline of it?
     Dr. Howard. No, I haven't had a chance to read the 
legislation, and, of course, the administration's position on 
legislation is decided at a level different than my own.
    Mr. Fossella. Well, we would love again some dialog. If the 
goal--and you heard it in a bipartisan way here from those who 
just declare it as an emergency and it demands a national 
response. To me, national dictates a Federal response.
    And it would also free up personnel and people at the city 
level, the municipal level. There is more litigation taking 
place. Why can't we get these individuals out of the courtroom, 
get the lawyers out of the courtroom and settle this case?
    I do think that with a strong Federal commitment, a lot of 
that would find its way to a swifter conclusion if there was a 
notion that the city of New York would not have to shoulder so 
much a burden. And likewise and most importantly again I get 
back to the insurance of monitoring and treatment that Mr. 
Ferguson brought up, and I think you would concur, the notion 
that research--why should we be 6 years later just talking 
about whether we should be providing funding for research? I 
mean it is a shame.
    One just quick question. Do you think--and maybe you have 
answered it, but if there is any other way you can answer it 
that will elaborate--the biggest problem adjustment the 
Department would recommend at this time to improve the health 
monitoring treatment program? You talked about the grantees. 
You talked about more data, more information.
    Is there any other thing that we should be doing in a 
legislative mechanism to free up flexibility at your end to get 
the answers or solutions we are looking for?
     Dr. Howard. From the scientific side, I have always said 
that the money that we have had to date goes to monitoring 
services and now treatment services because it is small amounts 
of money, and we are always trying to make sure that we have 
enough to get from year to year.
    We have not expended any significant amount of money on 
real research into the causes of some of these diseases or 
their best treatments because we have been trying to shepherd 
the money for services. So I think that is one area that we 
have spoken about already that, from my point of view as 
heading the Science Subcommittee that made recommendations to 
the Secretary, this is a really important issue. Otherwise, we 
are not going to know exactly what the contours of the problems 
are and how best to treat these people.
    Mr. Fossella. Mr. Chairman, again I would like just on a 
personal level thank Dr. Howard. He is very passionate about 
what he does, and again I said the bright light because you 
have been terrific in helping us all shepherd through this. And 
we would love to get more folks seeing it your way.
    Thank you, Mr. Chairman. I yield back.
    Mr. Pallone. Thank you. Thank you, Dr. Howard. We are done 
with your questions.
     Dr. Howard. Thank you.
    Mr. Pallone. And we appreciate this, and I know this is 
going to be an ongoing concern so. I will just repeat again we 
do want a plan from the administration, and we also would like 
to see someone appointed as the head of that task force as 
quickly as possible.
     Dr. Howard. Thank you.
    Mr. Pallone. If you will send that back. Thank you. And I 
will ask the second panel to come forward please.
    Thank you all for being here today. Let me just introduce 
everybody. Starting on my left is Mr. John Vinciguerra from the 
fire department of New York, although it says that you actually 
live in New Egypt, New Jersey. That is a long commute. And then 
we have Dr. Iris Udasin who is associate professor of 
environmental and occupational medicine at the University of 
Medicine and Dentistry, New Jersey, the Robert Wood Johnson 
Medical School. It is always a lot to say all that. She is 
actually from the clinical center that is in my district in 
Piscataway. Thank you for being here, and thank you for all 
that you do. And then we have Dr. Robin Herbert who is 
associate professor of the community and preventative medicine 
at Mount Sinai School of Medicine in Manhattan. And we have Ms. 
Cynthia Bascetta, who is director of health care issues for the 
Government Accounting Office for the GAO. Dr. Jim Melius who is 
administrator for New York State Laborers. And Mr. Edward 
Skyler who is the deputy mayor for administration in the city 
of New York, representing the mayor of New York.
    So let me mention again that each witness has 5 minutes for 
their opening statement. Obviously your written statements will 
be submitted for the record. So we would like to have you keep 
to the 5 minutes if you could. You may, if you wish, submit 
additional brief and pertinent statements in writing for 
inclusion into the record later as well. And I will start with 
you, Mr. Vinciguerra. Thank you for being here, and thank you 
for all that you have done.

  STATEMENT OF JOHN VINCIGUERRA, FIRE DEPARTMENT OF NEW YORK 
                    (RETIRED), NEW EGYPT, NJ

    Mr. Vinciguerra. Good morning. Thank you for having me. I 
was glad to hear the testimony from Dr. Howard. It was nice to 
sort of be reassured that the money is not going to be running 
out tomorrow. I would just like to read my testimony and take 
any questions you might have.
    My name is John Vinciguerra. I am 39 years old and a father 
of four. On January of this year, I was forced to retire as 
lieutenant with the fire department, New York City, EMS 
command, due to the lung damage that I sustained during the 
World Trade Center disaster rescue and recovery effort.
    It was one of the saddest days of my life when I had to 
turn in my badge and end an 18-year career. Prior to becoming 
ill, I was in good health, able to carry equipment and victims 
both up and down many flights of stairs. I love to be able to 
help people and felt I had one of the best jobs in the world.
    September 11 started like any other day. I picked up an 
overtime shift on the night tour. Left work early that morning. 
I went home, hopped into bed, tried to get a nap because I had 
the rest of the day off. Wanted to have time to spend with my 
family. My wife came up and woke me up to tell me what was 
happening. We watched the second plane hit the towers on TV. I 
was wide awake in an instant.
    Along with my wife, who was also an EMT, we grabbed our 
gear and drove to the city. I was told to report to my station 
just over the Brooklyn Bridge, began transporting equipment and 
personnel back and forth to Ground Zero. I worked at the World 
Trade Center site for many days, both on the piles as part of 
the bucket brigade, treating people who were injured at the 
site and supervising EMS crews from around North America.
    I averaged twice a week doing 16- to 24-hour shifts each 
time until about January 2002. At that point, it was just too 
difficult to be there anymore.
    While I do truly feel blessed to be here and be able to 
talk to you, and I know there are many others in much worse 
condition than myself, I also know that this has affected me in 
three major ways, both physically, mentally, and financially. 
As far as physically, like many others, I developed the World 
Trade Center cough. I was given medication by the fire 
department doctors, which was changed by my private doctor. 
When my breathing continued to deteriorate, another medication 
was added. I continued to work and watch my lung volumes drop 
on my annual physicals and became more and more run down but 
wanted to try to work through it.
    On April 30, 2005, that came to an end. After suffering at 
home for 24 hours hoping I just had a bad virus, I was taken to 
Robert Wood University Hospital in Hamilton. I was hospitalized 
for severe respiratory distress and admitted to the ICU in it. 
A scan in my lungs revealed a spot, and the oxygen profusion in 
my body was so poor that they thought I had a pulmonary 
embolus, which is a blood clot on my lungs.
    Unfortunately, this was not the case. What was happening 
was that the scarring in my lungs from breathing in all the 
toxins had become so bad that I was no longer able to move 
enough air, and my body was suffocating. I was also told that I 
know had high blood pressure, and I had stopped breathing 
several times during the night.
    I was loaded up with steroids, antibiotics, and many other 
medications, and discharged a few days later. I currently 
cannot walk up a flight of stairs without running out of 
breath. My lung volumes run between 30 to 60 percent of what 
they should be. I cannot run and play outside with my children. 
I need to be cautious when temperature or humidity changes. I 
am very sensitive to dust, pollen, and pollution, and I spend 
most of my time indoors with a hepa filter that is my best 
friend.
    I have to take at least seven medications a day every day 
that cause both fatigue and weight gain. Due to my sleep apnea, 
I now have to wear a mask over my face at night that blows air 
into my nose to keep my airway open. Every time I put it on, I 
feel my ears pop as if I am on an airplane. And it has also 
greatly diminished my sense of smell, but it is much better 
than the prospect of suffocating in my sleep and stopping 
breathing.
    Since becoming ill, I have been diagnosed with anxiety and 
depression, both related to post-traumatic stress disorder. I 
have tried medications, but the side effects only seem to make 
matters worse. Luckily for me, I have a strong marriage, and my 
wife has been there for me. But the stress this has put on me, 
my marriage, and our family is enormous.
    After I first reported of my illness to the city of New 
York, my claim was denied. I was told that since more than 2 
years has passed since September 11, I was no longer eligible 
for file a Worker's Compensation claim. As you could imagine, I 
was despondent. The thought of being left on my own. I felt 
that I had done all I could to help this city and this country 
in its time of need, and now I was being abandoned.
    Fortunately, the New York media was relentless in reporting 
both my case and the plight of others in similar situations. 
Legislation was introduced and passed in New York to extend the 
deadline to file for a claim. Fifteen months after becoming 
sick, as legislation was taking effect, on July 26, my case was 
finally approved on appeal. This event lead the way to me being 
retired and the end of my career. It was not how I pictured 
that it would end, and it is certainly a disappointment to me.
    Financially, here there is a light at the end of the 
tunnel, but things are going to get worse before they finally 
get better. Since it took 15 months for my case to get 
approved, I was responsible for all my doctors' visits and 
medication copays. I was not working and was unable to pay all 
the bills and continue to put food on the table. I was forced 
to sell my home to try to keep my head above water, and it 
didn't take long for the creditors to start circling.
    Even now, it has been over 2 years since I first became ill 
and a year since my case has been approved. But the New York 
City Law Department has still not paid the bills that have 
accumulated. My original pulmonologist told me a year ago that 
he would not be able to see me anymore because he has not been 
paid and still has not been paid to this day.
    In May 2007, I applied for Social Security disability. 
After following up with several phone calls, I was told in 
August that despite all the documentation and the fact that I 
was forced to retire from my respiratory problems, I would have 
to be sent for an anxiety evaluation. And the earliest 
appointment that was available was the end of September, the 
end of this month.
    On top of all this, although I was granted a pension, I 
will not come off payroll for the fire department until 
September 26 of 2007. Then I will have to wait until November 
to get my first pension check, and when that does come, it is 
only going to be a partial payment until they get the numbers 
spooled up, and they can adjust them.
    Since I have a biweekly pay mortgage, I am trying to work 
with my bank so that I won't be missing too many payments. I 
have also tried to take a pension loan, but since I am so near 
to retirement, it is not considered a disbursement. Since it is 
a disbursement, I can't take it until after my retirement date.
    After that, it won't arrive--they won't cut the check until 
after my retirement date and will take another 30 to 45 days to 
arrive on top of that. I also looked to refinance my current 
mortgage, but due to late medical bills, the banks want over 10 
percent for a new mortgage. It would be a long time before I 
recover financially.
    While I feel good that hearings such as this are taking 
place and it is comforting to know that so many people are 
concerned with me and my fellow recovery workers, there still 
remains much to be done. More money is needed, not just for 
monitoring, but for treatment of symptoms and conditions that 
are discovered. Financial assistance needs to be provided for 
those in need of help, whether temporary or permanently. An 
advocate should be appointed to help cut through the red tape 
that is facing not just the responders but also the residents 
and school children that were affected. Because what good is a 
program if the people that need it most don't know it is there 
and can't get it to work for them?
    Also the World Trade Center Captive Insurance Fund should 
be abolished and replaced with a compensation fund or another 
program that will put money to use where it is needed. It is 
disgraceful that the lead administrator is being paid $300,000 
a year to run a hostile fund that is throwing tens of millions 
of dollars at lawyers to prevent giving financial support to 
those it was created for. Thank you very much for your time and 
consideration.
    [The prepared statement of Mr. Vinciguerra follows:]

                     Statement of John Vinciguerra

     My name is John Vinciguerra. I am 39 years old and a 
father of four. January of this year I was forced to retire as 
a Lieutenant with the FDNY EMS command due to lung damage 
sustained during the World Trade Center disaster rescue and 
recovery. It was one of the saddest moments of my life when I 
had to turn in my badge and end an 18 year career. Prior to 
becoming ill I was in good health and able to carry equipment 
and victims both up and down many flights of stairs. I loved to 
be able to help people and felt I had one of the best jobs in 
the world.
     September 11, 2001 started for me like any other day. I 
had picked up an overtime shift on the night tour and left work 
in the early morning. I went home and climbed into bed to grab 
a quick nap. My wife came and woke me up to tell me what was 
happening, and we watched the second plane hit the towers. I 
was wide awake in an instant. Along with my wife who is also an 
EMT, we grabbed our gear and drove to the city. I was told to 
report to my station just over the Brooklyn Bridge and began 
transporting personnel and equipment back and forth to ground 
zero. I worked at the WTC site for many days on the pile as 
part of the bucket brigade, treating people who were injured at 
the site, and supervising EMS crews from around North America. 
I averaged about twice a week doing 16-24 hour shifts each time 
until January of 2002. After that, it was just too difficult to 
be there. And while I truly feel blessed to be here and able to 
talk to you, and I know that there are many others in much 
worse condition than myself, I also know that this event has 
effected me in three major ways, physically, mentally, and 
financially.
     Physically; like many others I developed the ``World Trade 
Center Cough'', and was given medication by the FDNY doctors. 
This was quickly changed by my private doctor. When my 
breathing continued to deteriorate, another medication was 
added. I continued to work and watch my lung volumes drop at my 
annual FDNY physicals. I became more and more run down but 
wanted to work through it. On April 30 2005 that came to an 
end. After suffering at home for 24 hours hoping I just had a 
bad virus, I was taken to Robert Wood University Hospital in 
Hamilton NJ. I was hospitalized for severe respiratory distress 
and admitted to the intensive care unit. A scan of my lungs 
revealed a spot, and the oxygen perfusion in my body was so 
poor that they though I had a pulmonary embolus, or blood clot 
in my lungs. Unfortunately this was not the case. What was 
happening, was that the scaring in my lungs from breathing in 
all of the toxins had become so bad that I was no longer able 
to move enough air, and my body was suffocating. I was also 
told that I now had high blood pressure, and I had stopped 
breathing several times during the night. I was loaded up with 
steroids, antibiotics, and many other medications, and 
discharged a few days later. I currently cannot walk up a 
flight of stairs without running out of breath. My lung volumes 
run from between 30 percent to 60 percent of what they should 
be. I can not run and play outside with my children, I need to 
be cautious when the temperature or humidity changes, I am very 
sensitive to dust, pollen, and pollution, and I spend most of 
my time in my room with a hepa air filter which is my new best 
friend. I have to take at least seven mediations a day that 
cause both fatigue and weight gain. Due to my sleep apnea I 
have to wear a mask over my face at night that blows air into 
my nose and keeps my airways open. Every time I put it on it 
causes my ears to pop as if I were on an airplane, and it has 
greatly diminished my sense of smell. But it is much better 
than the prospect of suffocating in my sleep.
     Mentally; since becoming ill, I have been diagnosed with 
anxiety and depression. Both related to post traumatic stress 
disorder. I have tried medication but the side effects only 
seemed to make matters worse. Luckily for me I have a strong 
marriage and my wife has been there for me. But the stress that 
has been put on me, our marriage, and our family is enormous. 
After I first reported my illness to the City of New York, my 
claim was denied. I was told that since more than two years had 
passed since Sept 11, 2001, that I was no longer eligible to 
file a workers compensation claim. As you could imagine, I was 
despondent at the thought of being left on my own. I felt that 
I had done all I could to help the City, and this country in 
its time of need, and now I was being abandoned. Fortunately 
the New York media was relentless in reporting both my case and 
the plight of others in similar circumstances. Legislation was 
introduced and passed in New York to extend the deadline to 
file a claim. Fifteen months after becoming sick and as 
legislation was taking effect, in July 2006 my case was 
approved on appeal. This event led the way to retirement and 
the end of my career. This was not how I pictured that it would 
end and is certainly a disappointment to me.
     Financially; here there is a light at the end of the 
tunnel, but things are going to get worse before they get 
better. Since it took fifteen months for my case to get 
approved, I was responsible for all my doctors visits and 
medication co-pays. I was not working, and I was unable to pay 
all of the bills and continue to put food on the table. I was 
forced to sell my home to try to keep my head above water. It 
didn't take long for the creditors to start circling. Even now 
it has been over two years since I became ill, and a year since 
the case has been approved, but the New York City Law 
Deptartment still has not paid the bills that accumulated. My 
original Pulmonologist told me a year ago that he would not be 
able to see me anymore because he had not been paid and he 
still has not been paid to this day. In May 2007 I applied for 
Social Security Disability. After following up with several 
phone calls, I was told in August that despite all of the 
documentation and the fact that I was forced to retire for my 
respiratory problems, I would have to be sent for an anxiety 
evaluation, and the earliest appointment was the end of 
September. On top of all of this, although I was granted a 
pension, I will not come off of payroll for the FDNY on 
September 26, 2007, then I will have to wait until November 
2007 to get my first check from the pension department. And 
when it does arrive, it will only be a partial payment (less 
than half) for the first 3 to 6 months until the final numbers 
can be adjusted. Since I have a bi-weekly pay mortgage, I am 
trying to work with my bank so as not to miss two payments. I 
tried to take a pension loan, but since I am so near 
retirement, It is now considered a ``disbursement'' and I 
cannot take it until I retire. On top of that, it needs to be 
sent out as a check and will not arrive for 30-45 days. I also 
looked into refinancing my current mortgage, but due to the 
late medical bills, the banks want over 10 percent for a new 
loan. It will be a long time before I recover financially.
     While I feel that it is a good thing that hearings such as 
this are taking place, and it is comforting that so many people 
are concerned with me and my fellow recovery workers, there 
still remains much to be done. More money is needed not just 
for monitoring, but for treatment of the symptoms and 
conditions that are discovered. Financial assistance needs to 
be provided to help those in need whether temporary or 
permanently. An advocate should be appointed to help cut 
through the red tape that is facing not just the responders, 
but also the residents and school children that were also 
effected, because what good is a program if the people that 
need it the most don't know it is there or cannot get it to 
work for them. The WTC Captive insurance fund should be 
abolished and replaced with a compensation fund or another 
program that will put the money to use where it is needed. It 
is disgraceful that the lead administrator is being paid 
$300,000.00 per year to run a hostile fund that is throwing 
tens of millions of dollars at lawyers to prevent giving 
financial support to those it was created for. Thank you very 
much for your time and consideration.
                              ----------                              

    Mr. Pallone. Thank you so much really. I would like to ask 
Dr. Udasin to go next if you would. Is there a concern?
    Ms. Udasin. Yes, I had some slides.
    Mr. Pallone. You have some slides?

     STATEMENT OF IRIS UDASIN, M.D., ASSOCIATE PROFESSOR, 
ENVIRONMENTAL AND OCCUPATIONAL MEDICINE, UNIVERSITY OF MEDICINE 
AND DENTISTRY OF NEW JERSEY, ROBERT WOOD JOHNSON MEDICAL SCHOOL

    Dr. Udasin. Chairman Pallone, Ranking Member Deal, and 
honorable members of the Energy and Commerce Health 
Subcommittee, I am Iris Udasin, associate professor at UMDNJ, 
Robert Wood Johnson School of Medicine, and New Jersey 
principal investigator of the World Trade Center Medical 
Monitoring and Treatment Program.
    I am board certified in internal and occupational medicine. 
My experience includes more than 20 years of practice as a real 
doctor, diagnosing and treating occupational and environmental 
illnesses. I have personally examined approximately 1,000 
patients who responded to the tragedy.
    The complex mixture of contaminated material present at the 
site has resulted in an unprecedented incidents of illness. 
Submitted with my testimony is a magnified dust particle, up 
there, that was collected at the site. Scientists from my 
institution were involved in characterizing this material. Even 
6 years after the tragic event, our patients present with 
significant respiratory and gastrointestinal illnesses 
complicated by mental health disorders. In order to fully 
appreciate the diseases in this population, I direct your 
attention to the photographs of Deputy Chief Lacey Wirkus and 
the other members of the Elizabeth Fire Department that 
responded to this tragic event.
    These photographs illustrate the roots of exposure and 
explain the mechanism of illnesses sustained by the population. 
Though the individuals in this photograph and the next one had 
respiratory protective equipment, the masks became weighted 
down by contaminated material and perspiration and did not 
offer sustained protection.
    As depicted in the picture, there were huge amounts of dust 
and smoke debris on his face, clothing, hair, and skin. The 
material was absorbed by breathing, skin contact, and 
ingestion, as workers were contaminated even as they ate and 
drank at the site.
    Most of our patients continue to work today despite 
suffering from conditions such as asthma, bronchitis, 
sinusitis, laryngitis, and gastroesophageal reflux. They have 
persistent shortness of breath, wheezing, cough, chest pain, 
sinus pressure, sore throat, indigestion, heartburn, decreased 
exercise tolerance. Many suffer from post-traumatic stress 
disorder and depression.
    Some have lost or limited health insurance benefits or 
financial hardship from loss of income. Uninsured patients 
clearly need the services of the medical monitoring and 
treatment program as they have minimal or no medical care. 
However, despite the fact that the majority of patients seen in 
New Jersey are insured, at least 60 percent are either 
untreated or undertreated for complicated medical and mental 
health illnesses.
    Furthermore, typical health insurance has insufficient 
coverage for mental health. In order to correctly diagnose 
World Trade-related illnesses, health professionals spend 
several hours evaluating the medical, occupational exposure and 
psychological histories and perform detailed physical and 
mental health assessments. These assessments require more time 
than insurance typically allows for these encounters.
    Specialized testing may be needed to appropriately diagnose 
our patients who have unusual presentations of asthma and other 
respiratory illnesses. Many community physicians do not have 
access to these tests or may lack of the knowledge of the 
unique aspect of diseases in this population.
    The diagnostic dilemmas we face can be appreciated by the 
following patient presentations. Patient No. 1 is a 31-year-old 
man who presented with a dry cough, sore throat, anxiety, and 
decreased ability to exercise. He was being treated for anxiety 
and had a nasal spray that didn't work and an asthma medication 
that he took occasionally. Further examination showed the 
presence of severe sinusitis and asthma.
    His respiratory symptoms have improved after sinus surgery 
and proper treatment of the asthma. His anxiety level has 
improved but still requires prescription medication. His 
exercise tolerance has returned to baseline.
    Patient 2 is a 46-year-old with severe coughing and 
heartburn. He took several cough medicines and nasal sprays 
with no relief. His examination and baseline breathing tests 
were normal, but his methacholine challenge test was diagnostic 
for asthma. And his endoscopy showed gastroesophageal reflux. 
He responded well to treatment but requires five prescription 
medications.
    Patient 3 is a 39-year-old previously healthy man who was 
extremely short of breath and had a chronic cough. His original 
diagnosis was pneumonia, which did not respond to antibiotics. 
Biopsy of his lungs showed sarcoidosis. He currently takes 
three prescription medications but is disabled from his work as 
a New York City police officer.
    Once the diagnosis is made, treatment can be complicated 
and frequently require several prescription medications. Even 
in patients who do have insurance, many have prohibitive copays 
or insurance constraints which prevent them from receiving 
brand name medications. Beyond the above conditions, there is 
concern about the possibility of life-threatening, long-term, 
chronic illnesses such as pulmonary fibrosis, sarcoid, cancer, 
and heart disease. The monitoring program provides the 
opportunity for early detection and intervention to potentially 
lessen the severity of these illnesses.
    It is our goal to improve the treatment of acute and 
persistent health problems, enabling a decrease in future 
illness and disability and hopefully more productive lives. As 
a concerned physician, I implore you to support the 9/11 Health 
and Compensation Act and continue the funding by NIOSH of a 
program which allows experienced physicians to treat these 
complicated illnesses as well as provide adequate diagnostic 
testing and prescription medications. We want to continue to 
provide physical and mental health care for those people who 
willingly took care of all of the rest of us.
    Thank you for the opportunity to appear before the 
committee.
    [The prepared statement of Dr. Udasin follows:

                   Testimony of Iris G. Udasin, M.D.

    Chairman Pallone, Ranking Member Deal, and honorable 
members of the Energy and Commerce Health Subcommittee. I am 
Iris G. Udasin, M.D., associate professor of Environmental and 
Occupational Medicine at University of Medicine and Dentistry 
of New Jersey-Robert Wood Johnson School of Medicine and New 
Jersey Principal Investigator of the World Trade Center Medical 
Monitoring and Treatment Program. I am board certified in 
internal medicine and occupational medicine and serve as 
director of employee health for the University, and course 
director for the medical student course in clinical prevention. 
My experience includes more than 20 years of clinical practice 
as a ``real doctor'' diagnosing and treating occupational and 
environmental illnesses. I have personally examined and treated 
approximately 1,000 patients who responded to the tragedy at 
the World Trade Center.
    The complex mixture of contaminated material present at the 
WTC site has resulted in an unprecedented incidence of illness. 
This material was highly alkaline, leading to the absorption of 
large particles of cement, glass, asbestos, and other fibrous 
materials as well as toxic gases from combustion. Submitted 
with my testimony is a magnified picture of a dust particle 
that was collected from the WTC site. It is noted that 
scientists at EOHSI (the Environmental and Occupational Health 
Sciences Institute, a joint project of UMDNJ and Rutgers 
University) were involved in characterizing this toxic 
material. Even 6 years after the tragic event, at least two 
thirds of our patients present with significant respiratory and 
gastrointestinal illnesses complicated by mental health 
disorders. In order to fully appreciate the diseases that are 
now prevalent in this population, I direct your attention to 
the photographs of Deputy Chief Lacey Wirkus and some of the 
other members of the Elizabeth, New Jersey Fire Department that 
responded to the tragic event. These photographs (see appendix) 
illustrate the routes of exposure to the toxic material and 
help to explain the mechanism of the illnesses sustained by the 
responders. Chief Wirkus donated these photographs for the 
purpose of representing all of the responders who included 
construction workers, communication workers, law enforcement, 
health care workers, as well as all of the paid and volunteer 
rescue and recovery personnel. Though the individuals in this 
photograph had respiratory protective equipment, you can see 
that the masks became weighted down by the contaminated 
material and did not offer sustained protection from the toxic 
material. As depicted in the picture, there were huge amounts 
of dust and smoke debris on his face, clothing, hair, and any 
other unprotected skin. The work was physically demanding, but 
these workers persisted, working shifts of 12 hours of more in 
the days that immediately followed the tragedy.
    The toxic material was absorbed by breathing, skin contact, 
and ingestion, as workers were contaminated even as they ate 
and drank at the site. This population continued to work at the 
site, and most of them continue to work today despite suffering 
from conditions such as asthma, bronchitis, sinusitis, 
laryngitis, rhinitis, and gastroesophageal reflux. They have 
persistent symptoms including difficulty breathing, shortness 
of breath, wheezing, chronic cough, chest pain, head 
congestion, sinus pressure, sore throat, indigestion, and 
heartburn. Some patients present with decreased exercise 
tolerance and fatigue, which potentially could disable them 
from sensitive law enforcement, fire fighting and construction 
work. Many of our patients suffer from post traumatic stress 
disorder and depression. Some of our patients are now not able 
to work, or are working at lower status jobs. Many have lost or 
have limited health insurance benefits as they are not able to 
work at their chosen jobs, or were forced to take early 
retirement.
    Uninsured patients and those without prescription benefit 
plans clearly need the services of the WTC Medical Monitoring 
and Treatment Program as they have minimal or no medical care. 
However, despite the fact that the majority of patients seen at 
our New Jersey site have at least some health insurance and do 
have primary care physicians, at least 60 percent of our 
patients are either untreated or under treated for complicated 
and comorbid medical and mental health illnesses. Furthermore, 
typical health insurance covers mental health issues separately 
and often has insufficient reimbursement rates, rendering 
mental health care extremely difficult to afford. In order to 
correctly diagnose these illnesses, it is necessary for the 
health professionals to spend significant amounts of time 
simultaneously evaluating the medical, occupational, exposure, 
and psychological histories, as well as performing a detailed 
physical and mental health examination. These medical 
monitoring assessments can take several hours to result in 
proper diagnosis of our patients, far longer than what 
insurance covers for typical community encounters. In many 
instances additional testing is necessary; including spirometry 
with flow volume loops, x-rays, and laboratory testing. Often 
specialized testing such as methacholine challenge testing, 
rhinolaryngoscopy, endoscopy, and overnight polysomnography is 
needed to appropriately diagnose our patients. The purpose of 
these specialized tests is to identify and treat unusual 
presentations of asthma and other respiratory illnesses which 
are described in the examples below. Many community physicians 
do not have access to these tests, while our UMDNJ specialists 
have built up a substantial hands-on knowledge of the unique 
aspects of routine diseases in this population. Additionally, 
because of the atypical presentations of our patients, it is 
difficult to assess these combination of conditions, even for 
physicians with extensive experience in the individual 
conditions.
    The diagnostic dilemmas faced by examining physicians can 
be appreciated by the following patient presentations:
    Patient 1 is a 31 year old man who presented with a dry 
cough, sore throat, anxiety, and decreased ability to exercise. 
He was being treated for anxiety and had a nasal spray that 
didn't work and an asthma medication that he took occasionally. 
Further examination showed the presence of severe sinusitis, as 
well as asthma. His respiratory symptoms have improved after 
sinus surgery and proper treatment of his asthma. His anxiety 
level has improved, but still requires prescription medication 
for his anxiety and asthma. His exercise tolerance has returned 
to previous levels.
    Patient 2 is a 46 year old man with severe coughing and 
heartburn. He had been on several prescription cough medicines 
as well as numerous nasal sprays with no relief. His physical 
examination was normal, as was his baseline breathing test. 
However, his methacholine challenge testing was diagnostic of 
asthma or reactive disease, and he responded well to 
prescription strength asthma medication, but does require three 
asthma medications on a daily basis and one medication on an as 
needed basis. He was also diagnosed with gastroesophageal 
reflux, and requires prescription strength medication.
    Patient 3 is a 39 year old previously healthy man who was 
extremely short of breath and had a chronic cough. His original 
diagnosis was pneumonia. He received several courses of 
antibiotics without relief. Biopsy of his lungs was consistent 
with sarcoidosis. He currently takes three prescription 
strength medications, but is unfortunately disabled from his 
work as a police officer.
    Once the diagnosis is made, treatment is also complicated 
and frequently requires the use of several prescription 
medications. This is clearly a burden to patients who do not 
have prescription drug coverage. Even in patients who do have 
coverage, many have prohibitive co-pays, or have insurance 
constraints which prevent them from receiving brand name 
medications which might better treat their illnesses.
    Beyond the common upper and lower respiratory conditions 
that affect the majority of our patients, there is concern 
about the possibility of life-threatening long term chronic 
illnesses such as pulmonary fibrosis, sarcoidosis, cancer, and 
heart disease. The monitoring program provides the opportunity 
for early detection and intervention to potentially lessen the 
severity of these illnesses. It is our goal to improve 
treatment of the acute and persistent health problems seen now 
in our patients, enabling a decrease in future illness and 
disability and hopefully more productive lives.
    In order to continue to allow experienced physicians to 
treat these complicated illnesses as well as provide adequate 
diagnostic testing and prescription medications that are 
needed, as a concerned physician I implore you to continue the 
funding of the program by the National Institute for 
Occupational Safety and Health. We continue to provide physical 
and mental health care for those people who willingly care for 
all of the rest of us.
    Thank you for this opportunity to appear before the 
subcommittee.


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    Mr. Pallone. Thank you, and again thank you so much for all 
that you have done. Next we have Dr. Robin Herbert from Mount 
Sinai. Thank you.

STATEMENT OF ROBIN HERBERT, M.D. ASSOCIATE PROFESSOR, COMMUNITY 
AND PREVENTATIVE MEDICINE, MOUNT SINAI SCHOOL OF MEDICINE, NEW 
                            YORK, NY

    Dr. Herbert. Thank you. Chairman Pallone and other esteemed 
members of the committee, thank you so much for inviting me to 
testify today. I want to thank the New Yorkers on the 
subcommittee, Congressman Weiner, Mr. Engel, and other members 
from New Jersey, Congressman Ferguson in addition to the chair. 
Finally I would like to extend my thanks to Congressman 
Fossella as well as Congresswoman Maloney and Congressman 
Nadler and the entire New York delegation for their steadfast 
support of World Trade Center responders.
    I direct the data and coordination center of the World 
Trade Center Medial Monitoring and Treatment Program. This is a 
consortium of five clinical Centers of Excellence in New York 
and New Jersey. The WTC Monitoring and Treatment Program 
diagnoses, treats, documents, and tracks the illnesses that 
have developed and the workers and volunteers who responded to 
9/11.
    We perform this work along with our sister Center of 
Excellence at the New York Fire Department. In the days, weeks, 
and months that followed September 11, 2001, more than 50,000 
hardworking Americans from across the United States came to 
serve selflessly without concern for their health and well 
being. These responders included both traditional responders, 
such as firefighters and law enforcement officers, as well as 
many non-traditional responders, such as members of the 
building trades, utility workers, building cleaners, and a vast 
array of other working groups. And when I talk about 
responders, I am talking about this broad array of workers and 
volunteers.
    In the months after the terrorist attacks, concerns grew 
about the potential health effects among the responders. In 
2001, as we began to see individuals who appeared to have 
developed illnesses after performing World Trade Center 
response work, Congress authorized funding to establish a 
medical screening program to identify possible World Trade 
Center related illnesses among responders.
    That funding lead to creation of a program that provided 
free comprehensive medical examinations to over 11,400 World 
Trade Center responders in the New York, New Jersey, and 
throughout the Nation. Between 2002 and 2006, as the monitoring 
and health needs of responders became clearer with the support 
of Congress, the medical monitoring program consortium, 
coordinated by Mount Sinai and the Fire Department of New York 
program, expanded and most recently in fall of 2006, received 
Federal funding to add comprehensive treatment services.
    Thus with your support over time, the programs have evolved 
into comprehensive, highly skilled centers of excellence for 
monitoring and treatment of World Trade Center responders. The 
goals of these monitoring treatment program Centers of 
Excellence are one, to provide free comprehensive monitoring 
examinations at regular intervals for responders. Two, to 
provide medical and mental health treatment for all responders 
with World Trade Center related illnesses, regardless of 
ability to pay. And three, to document and track diseases 
possibly related to exposure sustained at the World Trade 
Center.
    With Federal support, the Mount Sinai coordinated Center of 
Excellence has provided initial comprehensive medical and 
mental health monitoring examinations to over 22,000 
responders. Over 6,300 responders have received 47,000 medical 
and mental health treatment services through our New York and 
New Jersey consortium Centers of Excellence since 2003.
    Demand for these programs remains great today. Even now, 6 
years after September 11, about 400 new responders register on 
a monthly basis via the Mount Sinai phone bank to participate 
in the program. And in August 2007, 771 new participants signed 
up for the program.
    In September 2006, last year, our consortium published a 
paper in the highly respected, peer review journal 
``Environmental Health Perspectives.'' This detailed our 
findings from 9,442 responders who we examined between 2002 and 
2004. Key findings included--and this paper is appended to my 
testimony--46.5 percent reported experiencing new or worsened 
lower respiratory symptoms during their response work, and 62.5 
percent had new or worsened upper respiratory symptoms, with 
overall rates of upper and lower symptoms at 68.8 percent.
    At the time of examination up to two and a half years after 
the rescue and recovery efforts, 59 percent of responders were 
still experiencing upper and/or lower respiratory symptoms. 
One-third of the responders had abnormal breathing tests, and 
these are objective tests. And among non-smokers, the rate of 
abnormal breathing tests was double what was expected.
    These findings are very similar to what has been reported 
by the Fire Department of New York who have reported on 
symptoms in addition to diseases. For example, they reported 
that 40 percent of firefighters had persistent lower 
respiratory symptoms and 50 percent has persistent upper 
respiratory symptoms more than a year after September 11.
    I would also like to quickly, if I may, go over by about 1 
minute, present a snapshot in time of what we have been seeing 
with our consortium clinics in the 3 months from April to June 
2007 in a treatment program. During that time period, the 
consortium saw 2,323 patients in 4,693 visits. And this is now 
the treatment program, not the monitoring. So these are the 
people who are sick, who are cared for by Dr. Udasin and my 
other colleagues.
    Among that group, 40 percent were treated for lower 
respiratory conditions. The most common group of conditions 
were asthma and an asthma-like condition called RADS. Thirty 
percent had those conditions. Fifty-nine percent had upper 
respiratory conditions. Thirty-six percent of our patients in 
treatment had mental health problems, including post-traumatic 
stress disorder in 21 percent and depression in 15 percent.
    We also frequently found social and economic disability 
among our patients. More than 30 percent of our previously 
healthy responders were either unemployed, laid off, or on sick 
leave or disability. And 28 percent had no medical insurance at 
some time period during the 3 months.
    We still have two major unanswered questions about World 
Trade Center responders and what their health outlook is. 
Number one, we do not know and we need to know if the 
respiratory, gastrointestinal and mental health problems that 
we are currently observing will continue to persist. If so, for 
how long and with what degree of severity and associated 
disability.
    Second, we need to know if new health problems will emerge 
in future years in responders as a consequence of their 
exposures to the uniquely complex mix of chemical compounds 
that contaminated the air, soil, and dust of New York City and 
the aftermath of September 11.
    I would like to close by saying that we are very 
appreciative that we have had resources provided to serve the 
brave men and women who responded to the disaster. We are very 
honored to be able to provide treatment and monitoring. We do 
believe that these services need to continue into the future. 
Thank you very much.
    [The prepared statement of Dr. Herbert follows:]

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    Mr. Pallone. Thank you, Dr. Herbert. From the GAO, Ms. 
Cynthia Bascetta.

 STATEMENT OF CYNTHIA BASCETTA, DIRECTOR, HEALTH CARE ISSUES, 
        GOVERNMENT ACCOUNTABILITY OFFICE, WASHINGTON, DC

    Ms. Bascetta. Thank you, Mr. Chairman and members of the 
subcommittee. I am pleased to be here today to discuss the 
implementation of federally funded health programs for 
responders who served in the aftermath of the World Trade 
Center disaster.
    As we all know, these responders were exposed to numerous 
physical hazards, environmental toxins, and psychological 
trauma, and it is clear from numerous studies that these 
exposures continue to exact a toll for many of them 6 years 
after the attack.
    My testimony is based on our July 2007 report which was 
done for Mr. Fossella, Mrs. Maloney, and Mr. Shays, and four 
previous testimonies in which we discussed the different 
programs set up for various categories of responders and 
highlighted that the World Trade Center Federal responder 
screening program had accomplished little and lagged behind 
programs for other responders.
    Today, I would like to focus on the status of three things: 
NIOSH's awards for treatment to the World Trade Center health 
program grantees, the services provided for Federal responders, 
and NIOSH's efforts to provide services for non-Federal 
responders residing outside the New York City metro area.
    First, last fall NIOSH awarded and set aside funds totaling 
$51 million from its $75 million appropriation to pay for 
treatment services, the first time Federal funds were awarded 
for this purpose. About $44 million was for outpatient 
treatment, and about $7 million was set aside for inpatient 
hospital care. Most of the funding went to the fire department 
and the New York/New Jersey consortium.
    In addition to outpatient care, Federal funds paid for 34 
hospitalizations of responders so far. NIOSH is now planning 
how to use the $50 million emergency supplemental appropriation 
made in May 2007 to continue support for treatment in fiscal 
year 2008.
    Second, we reported this July that HHS has had continuing 
difficulties ensuring the uninterrupted availability of 
services for Federal responders who have been eligible only for 
one-time screening examination. The provision of these 
screening examinations has been intermittent. HHS suspended 
them from 2004 to December 2005, resumed them for about a year, 
then placed the program on hold and suspended scheduling exams 
from January to May 2007. The last interruption occurred 
because interagency agreements were not put in place in time to 
keep the program fully operational.
    In addition, the provision of specialty diagnostic services 
associated with screening has also been intermittent. 
Responders often need further diagnostic tests from ear, nose, 
and throat physicians, cardiologists, and pulmonologists. And 
the program had referred responders and paid for these 
diagnostic services; however, because the contract with the new 
provider network did not cover these services, they were 
unavailable from April 2006 until the contract was modified in 
March 2007.
    NIOSH has considered expanding the services for Federal 
responders to include monitoring examinations, the same follow-
up physical and mental health exams provided to other 
categories of responders. Without this follow-up, health 
conditions may not be diagnosed and treated, and knowledge of 
the health effects caused by the disaster may be incomplete.
    Third, NIOSH has not ensured the availability of screening 
and monitoring services for non-Federal responders who reside 
outside the New York City area, although it recently took steps 
to expand their availability. Similar to the intermittent 
service pattern for Federal responders, NIOSH's arrangements 
for a network of occupational health clinics to provide 
services nationwide were on again, off again. NIOSH renewed its 
efforts to expand the provider network, however, and in May of 
this year completed about 20 exams.
    Mr. Chairman, despite HHS's recent consideration of ways to 
add monitoring for Federal responders and to improve the 
availability of screening and monitoring services for Federal 
and non-Federal responders nationwide, its efforts remain 
incomplete.
    Moreover, the start and stop history of the Department's 
efforts to serve these groups does not provide assurance that 
the latest efforts to extend screening and monitoring services 
to these responders will be both successful and sustained over 
time.
    As a result, we recommended in our July 2007 report that 
the Secretary take expeditious action to ensure the 
availability of health screening and monitoring services for 
all people who responded to the attack on the World Trade 
Center, regardless of their employer or their residence. To 
date, HHS has not responded to our recommendation. That 
completes my statement. I would be happy to answer your 
questions.
    [The prepared statement of Ms. Bascetta follows:

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

    Mr. Pallone. Thank you. Dr. Melius.

STATEMENT OF JAMES MELIUS, M.D., ADMINISTRATOR, NEW YORK STATE 
                            LABORERS

    Dr. Melius. Chairman Pallone, other members of the 
subcommittee of Health, I greatly appreciate the opportunity to 
appear before you today. I have been involved with health 
issues at the World Trade Center since shortly after September 
11. Over 3,000 of our union members were involved in the 
response and cleanup activities on site, and I would add that 
includes many not only from New York, but also our members from 
State of New Jersey who came over to assist and who worked at 
the site.
    For the past 4 years, I have served as chair of the 
steering committee for the medical monitoring and treatment 
program and have been involved in oversight in working on 
outreach and other activities with Dr. Herbert and others with 
the New York City Fire Department on this program.
    I believe that they have already--the physicians involved 
in these programs already talked about some of the medical 
problems that people are experiencing. And given the focus of 
these hearings, I like to sort of briefly mention two other 
issues regarding why it is so important that there be Federal 
support for this medical monitoring and treatment program.
    One would expect--what are some of the other potential 
sources of funding that could pay for this? Well, one possible 
source of health insurance coverage; however, I think it is 
important to know that all health insurance plans exclude 
coverage for work-related injuries and illnesses. This is a 
basic part of health insurance. It extends even to the Federal 
Medicare program. They do not provide coverage.
    If an insurance company finds that a person is applying for 
what they believe to be a work-related health problem, they 
will deny that claim or certainly raise questions about that 
claim. So we cannot rely on it, for that reason, to provide 
coverage for everybody who has become ill by this program.
    We have also found that, as this program has evolved as 
people have sought treatment, that this use of health insurance 
today has put a great strain on the health insurance plans that 
cover these particular responders. In the case the city of New 
York has borne much of the cost through their health insurance 
plan to date. The various labor unions in New York, who operate 
either their own health insurance plans or provide partial 
coverage such as pharmaceutical coverage for their members, 
have also experienced severe financial strain from having to 
cover the medical costs for many of the responders.
    Another alternative to provide coverage is Worker's 
Compensation, but I think, as we have already heard today in a 
very difficult example of how problematic it is for many of 
these responders to obtain Worker's Compensation coverage. It 
is long delays in getting that coverage. The coverage is often 
incomplete. The coverage often questions the need for follow-up 
medical treatment and can involve many, hearings, 
administrative proceedings, and especially long delays. Three, 
4, 5, years or more before people can initially receive 
coverage under Worker's Compensation is not unusual.
    To rely on Worker's Compensation for coverage for these 
responders also shifts the burden for the cost to their 
employers and to the insurance companies involved. We have 
already heard the concerns about the contractors involved who 
thought they were indemnified for working at the World Trade 
Center site, for responding so quickly, and certainly the New 
York City itself, which is self-insured in regards to Worker's 
Compensation cost would end up picking up these very large and 
very significant medical costs if we try to rely only on 
Worker's Compensation coverage to cover all the health care 
needs.
    I believe that we need a comprehensive solution to address 
the health needs of these rescue and recovery workers. We 
cannot rely on a fragmented system and should not rely on a 
system that utilizes private philanthropy, like the Red Cross, 
health insurance, line-of-duty disability retirement, and 
Worker's Compensation to support the necessary medical 
monitoring treatment for the many thousands of people who have 
become ill because of their World Trade Center exposures.
    If we rely on this fragmented approach, we will inevitably 
leave many of these ill and disabled rescue and recovery 
workers without the needed medical treatment and will only 
worsen their health condition. I think testimony we have 
already heard on this panel, I think, illustrates the problems 
with a fragmented system that is not responsive to the needs of 
these responders.
    In my testimony, I have laid out what I think should be the 
key points in any Federal legislation that would provide 
comprehensive coverage that should extend not only to deal with 
the health issues but also to provide compensation for people 
who have become disabled because of their exposures at the 
World Trade Center.
    I believe that the legislation introduced last night by 
Representatives Maloney, Nadler, and Fossella and others really 
addresses all of these goals and provide the comprehensive 
framework needed to address these serious medical problems and 
would lay the basis for both comprehensive coverage as well as 
the long-term coverage that is required.
    I really want to thank Representative Fossella for your 
efforts, I think, on behalf of all the labor unions who 
represent people involved in this response. We greatly 
appreciate your efforts as well as those efforts of 
Representatives Maloney, Nadler, and the rest of the New York 
delegation to help address this. And I appreciate, Mr. Pallone, 
your efforts in holding this hearing. And hope we can move 
forward to get a comprehensive legislation that is so badly 
needed. Thank you.
    [The prepared statement of Dr. Melius follows:]

                    Testimony of James Melius, M.D.

    Chairman Pallone and members of the Subcommittee on Health. 
I greatly appreciate the opportunity to appear before you at 
this hearing.
    I am James Melius, an occupational health physician and 
epidemiologist, who currently works as Administrator for the 
New York State Laborers' Health and Safety Trust Fund, a labor-
management organization focusing on health and safety issues 
for union construction laborers in New York State. During my 
career, I spent over 7 years working for the National Institute 
for Occupational Safety and Health (NIOSH) where I directed 
groups conducting epidemiological and medical studies. After 
that, I worked for 7 years for the New York State Department of 
Health where, among other duties, I directed the development of 
a network of occupational health clinics around the state. I 
currently serve on the Federal Advisory Board on Radiation and 
Worker Health which oversees part of the Federal compensation 
program for former Department of Energy nuclear weapons 
production workers.
    I have been involved in health issues for World Trade 
Center responders since shortly after September 11. Over 3,000 
of our union members were involved in response and clean-up 
activities at the site. One of my staff spent nearly every day 
at the site for the first few months helping to coordinate 
health and safety issues for our members who were working 
there. When the initial concerns were raised about potential 
health problems among responders at the site, I became involved 
in ensuring that our members participated in the various 
medical and mental health services that were being offered. For 
the past 3 years, I have served as the chair of the Steering 
Committee for the World Trade Center Medical Monitoring and 
Treatment Program. This committee includes representatives of 
responder groups and the involved medical centers (including 
the NYC Fire Department) who meet monthly to oversee the 
program and to ensure that the program is providing the 
necessary services to the many people in need of medical 
follow-up and treatment. I also serve as co-chair of the Labor 
Advisory Committee for the WTC Registry operated by the New 
York City Department of Health. These activities provide me 
with a good overview of the benefits of the current programs 
and the difficulties encountered by responders seeking to 
address their medical problems and other needs.
    I believe that other physicians involved in the medical 
monitoring and treatment program for World Trade Center 
responders have already presented the medical findings from 
their respective medical program for these responders. The 
pulmonary disease and other health problems among both fire 
fighters and other responders are quite striking and quite 
worrisome. All of the medical programs have done an outstanding 
job in establishing their respective monitoring programs and in 
providing high quality medical examinations for many thousands 
of rescue workers and responders. These programs also 
recognized the problems that many of their participants were 
having paying for medical care for the conditions diagnosed in 
the medical monitoring programs and have made efforts to help 
the participants in obtaining necessary assistance. Given the 
focus of these hearings, I believe that it may be helpful to 
examine the reasons why so many of the participants need 
assistance for paying for their medical treatment.

                       Health Insurance Coverage

    The people who worked in the initial response to the 
September 11 disaster and the later recovery activities 
represented many different types of workers. On the public 
safety side, there were fire fighters, police, and emergency 
medical services workers. The response and recovery activities 
also included construction trades workers, utility workers, 
sanitation workers, transit workers, cleaning workers, and NYC 
municipal workers from many agencies. Many other people just 
volunteered to work at the site especially in the first few 
days after September 11th. Despite the diversity of backgrounds 
and job duties, these different groups are showing very similar 
patterns of illness. The pulmonary changes found in fire 
fighters have also been demonstrated in the rescue and recovery 
workers being monitored in the Mount Sinai medical program. 
Most recently, an independent study conducted by medical 
researchers at Penn State University of NYC police officers 
responding to the WTC disaster reported similar respiratory 
findings among the group that they examined. The other types of 
medical and mental health problems documented among WTC 
responders also appear to be similar across all groups of 
responders.
    However, given the diversity of this workforce, it is not 
surprising that their health insurance coverage might be quite 
variable. I will provide a general overview.
    All city workers are covered through the city's general 
health insurance plan which provides basic coverage including 
retirement coverage for long time workers. However, 
pharmaceutical coverage is provided through a different plan 
administered through each separate union. Construction trade 
workers are usually covered through their labor-management 
health insurance fund which provides basic health insurance 
coverage and some pharmaceutical coverage. The pharmaceutical 
coverage is often quite limited with high deductibles and co-
pays. These health plans require that the participant work a 
substantial number of days each quarter or year in order to 
maintain eligibility. An ill construction worker can easily 
lose their coverage by missing too many work days. Utility 
workers have general medical coverage including some 
pharmaceutical benefits. Cleaning workers (people who cleaned 
the residential and commercial buildings around the WTC) often 
worked for contractors who offered no health benefits at all. 
The majority of the people in the Mt. Sinai treatment program 
up to now have had no health insurance coverage or very limited 
coverage.
    All health insurance plans exclude coverage for work-
related injuries and illnesses. Even Medicare has an active 
program to identify and recover payments for work-related 
services. While it is recognized that there may be uncertainty 
about whether a condition being diagnosed is work-related or 
not, this consideration could easily lead to the denial of 
health insurance coverage for many people with WTC-related 
health conditions. New York State does have in place mechanisms 
for health insurance providers to be reimbursed for medical 
expense payments incurred for conditions that are ultimately 
determined to be eligible for workers' compensation coverage. 
However, these mechanisms are administratively complicated and 
do not necessarily prevent the health insurer from denying 
reimbursement for WTC-related health expense.
    Another problem with health insurance is the limitations on 
coverage of many of the health insurance plans that cover the 
participants. This is especially critical for pharmaceutical 
coverage. Treatment for many of the WTC-related conditions 
(asthma, mental health problems, et cetera.) requires 
substantial medication costs. These costs commonly range from 
$5,000 to nearly $15,000 per year for participants. Many of the 
plans covering WTC participants have high deductibles or co-
pays. Co-pays and deductibles can easily cost the participants 
with high medication costs several thousand dollars per year. 
These costs can severely strain the finances of a person with a 
moderate income especially if they have other health care costs 
and are missing significant time from their work due to 
illness. For those without any health insurance, the financial 
impact is even greater. Another potential problem is that many 
of these insurance programs have lifetime caps for each 
participant. Although these caps seem high ($500,000 to $1 
million or more), they can easily be exceeded with a long term 
serious illness.
    The medical and pharmaceutical costs for WTC-responders 
have also severely strained the health insurance plans for many 
of the responder groups, especially those providing 
pharmaceutical coverage. These funds are already stressed by 
the rapidly rising costs of health care. Those plans with a 
significant number of members who worked at the WTC response 
and clean-up have found that the overall medical and 
pharmaceutical costs for their plans have significantly 
increased due to the large number of participants with WTC-
related medical costs. This has even led some to consider 
cutting back on their benefits for all members in order to 
absorb the costs for the WTC group.

                     Workers' Compensation Coverage

    One alternative to health insurance coverage for WTC-
related conditions is workers' compensation insurance. Workers' 
compensation is supposed to be a no fault insurance system to 
provide workers who are injured or become ill due to job-
related factors with compensation for their wage loss as well 
as full coverage for the medical costs associated with the 
monitoring and treatment of their condition.
    Similar to health insurance, the WTC program participants 
are covered by a variety of state, Federal, and local programs 
with different eligibility requirements, benefits, and other 
provisions. Most private and city workers are covered under the 
New York State Workers' Compensation system. New York City is 
self insured while most of the private employers obtain 
coverage through an outside insurance company. Uniformed 
services workers are, for the most part, not covered by the New 
York State Workers' Compensation system but rather have a line 
of duty disability retirement system managed by New York City. 
A fire fighter, police officer, or other uniformed worker who 
can no longer perform their duties because of an injury or 
illness incurred while on duty can apply for a disability 
retirement which allows them to leave with significant 
retirement benefits. However, should a work-related illness 
first become apparent after retirement, no additional benefits 
(including medical care) are provided, and the medical benefits 
for even a recognized line of duty medical problem end when the 
person retires. Federal workers are covered under the 
compensation program for Federal workers. Coverage for workers 
who came from out of state will depend on their employment 
arrangements with their private employer or agency. However, 
volunteers from New York or from out of state are all covered 
under a special program established by the New York Workers 
Compensation Board after 9/11.
    The major difficulty with these compensation systems is the 
long delays in obtaining coverage. For example, the NYS 
Workers' Compensation system is very bureaucratic. The insurer 
may challenge every step of the compensation process including 
even diagnostic medical testing. This challenge usually 
requires a hearing before a Workers' Compensation Board (WCB) 
administrative judge to evaluate the case, and this hearing may 
often be delayed for months. Even once the case is established, 
the insurer can still challenge treatments recommended for that 
individual even for a medication that the individual may have 
been taking for many months for a chronic work-related 
condition. Thus, it may be many years before the case of a 
person with a WTC-related condition is fully recognized and 
adjudicated by the compensation system. Meanwhile, the claimant 
may not be receiving any medical or compensation benefits or 
may have had their benefits disrupted many times.
    In order to alleviate some of the problems for WTC 
claimants, last year New York State implemented some new 
programs that were deigned to improve coverage for WTC 
responders by providing medical coverage and salary 
compensation for responders while their WCB cases were being 
evaluated. However, these provisions must be initiated by the 
insurer carrier, and there is uncertainty as to who would be 
responsible for reimbursing these costs if the claims are 
ultimately denied. To date, these provisions do not appear to 
be widely used. There was also legislation passed last year 
that allows more New York City workers to obtain disability 
retirement benefits for WTC-related conditions. Currently, 
there is an advisory task force in place that is examining how 
best to implement this legislation. Finally, there was a bill 
passed allowing people who worked at the WTC site to register 
for Workers' Compensation benefits. Potential claimants were 
given a year to submit a registration form to the Board that 
makes them eligible to apply for benefits should they later 
develop a WTC-related health condition. Prior to that, 
claimants who later developed a WTC-related medical condition 
were not eligible to file claims because they were judged to 
have missed the filing deadline required by law. In addition, 
New York State has just passed broad workers' compensation 
reform legislation that makes many changes in the current 
system. Once implemented, this legislation could help to 
alleviate some of the delays in the current system. However, it 
will be some time before all of these changes assist WTC 
claimants. Meanwhile, claimants continue to face long delays 
and many hurdles in obtaining workers' compensation coverage 
for any conditions resulting from their WTC exposures. It is 
not clear that the recent changes in the system will adequately 
address these problems.
    I would also add that depending on workers' compensation 
and disability retirement systems to cover the medical costs 
for the monitoring and treatment program places the financial 
burden on the employers and insurance companies. New York City 
is self insured and thus would pay directly for all claims. The 
private employers involved will also have greater costs either 
by directly paying for claims if they are self insured or 
through higher premiums due to an increase in their experience 
rating.

                         Comprehensive Solution

    A comprehensive solution is needed to address the health 
needs of the 9/11 rescue and recovery workers. We cannot rely 
on a fragmented system utilizing private philanthropy, health 
insurance, line of duty disability retirement, and workers' 
compensation to support the necessary medical monitoring and 
treatment for the thousands of people whose health may have 
been impacted by their WTC exposures. This fragmented approach 
will inevitably leave many of the ill and disabled rescue and 
recovery workers without needed medical treatment and will only 
worsen their health conditions. The delays and uncertainty 
about payments would discourage many of the ill rescue and 
recovery workers from seeking necessary care and discourage 
medical institutions from providing that care.
    This is a critical time for the federally funded treatment 
programs. Their funding will soon run out, and Federal 
officials are already proposing sending letters informing the 
participants that they must seek alternative arrangements for 
their care. Attempting to provide this care through some sort 
of voucher system as is currently being considered by the 
Department of Health and Human Services would also be 
disruptive. Discontinuing or disrupting this high quality, 
coordinated medical treatment would only exacerbate the health 
consequences of the 9/11 disaster. Most of the participants in 
the monitoring and treatment program have medical conditions 
(asthma, mental health problems, etc.) that should be 
responsive to medication and other treatments. Hopefully, many 
of these people will gradually recover and not become disabled 
due to their WTC-related medical conditions. To the extent, 
that we can prevent worsening of the medical conditions and 
prevent many of these people from becoming too disabled to 
work, we can not only help these individuals, but we can also 
lower the long term costs of providing care and assistance to 
this population.
    We need Federal legislation that accomplishes the 
following:

     Provides long term medical monitoring program for 
all WTC responders and other workers exposed in the aftermath 
of September 11, 2007
     Supports long term medical treatment for those 
participants who have developed WTC-related medical conditions 
at no cost to the participants. This program should cover WTC-
related medical conditions that are currently recognized as 
well as those which might emerge in the future.
     Provides that monitoring and treatment at Medical 
Centers of Excellence that have the expertise and experience to 
provide high quality medical care.
     Extends that high quality medical care to WTC 
responders from throughout the United States
     Provides for the collection and analysis of these 
medical data in order to track the health of the participants 
and to detect emerging disease patterns.
     Establishes a medical monitoring and treatment 
program for residents, students, workers, and other people who 
were exposed to WTC contaminants in the aftermath to the 
September 11 attacks.
     Provides for appropriate compensation for those 
who have become disabled from their WTC-related illnesses.
     Provides administrative mechanisms that provides 
prompt and timely determinations and allows the proper 
oversight and management of the program.
     Provides for meaningful input and participation 
from representatives of the affected groups in the development 
and management of the program.

    The legislation just introduced by Representatives Maloney, 
Nadler, Fossella, and others addresses all of those goals and 
provides the comprehensive framework needed to address the 
serious medical problems being experienced by thousands of 
people in the aftermath to the September 11 terrorist attacks. 
Too often in the past, we have neglected to properly monitor 
the health of groups exposed in extraordinary situations only 
to later spend millions of dollars trying to determine the 
extent to which their health has been impacted. Agent Orange 
exposure in Vietnam and the current compensation program for 
nuclear weapons workers are only two examples of this problem. 
We have left those people to suffer, often without proper 
medical care and facing financial hardship due to their 
illnesses. We should learn the lessons from these past mistakes 
and make sure that we provide comprehensive medical monitoring, 
treatment, and compensation for those potentially impacted by 
the WTC disaster.
    I would strongly urge you to take immediate steps to ensure 
that there is adequate Federal funding for the current medical 
monitoring and treatment programs and to open up these programs 
or similar programs to the affected residents and to other 
affected workers. I would also urge you to support the Maloney-
Nadler-Fossella legislation to provide a comprehensive approach 
to give WTC workers and residents access to long term medical 
monitoring and treatment for their WTC-related medical 
conditions and compensation for their losses.
    I would be glad to answer any questions.
                              ----------                              

    Mr. Pallone. Thank you, Doctor. Mr. Skyler.

STATEMENT OF EDWARD SKYLER, DEPUTY MAYOR, ADMINISTRATION, CITY 
                        OF NEW YORK, NY

    Mr. Skyler. Good afternoon. I want to thank you, Chairman 
Pallone, Ranking Member Deal, Congressman Fossella and 
Congressman Weiner as well as Congressman Engel who was here 
earlier, and other members of the committee for convening this 
hearing for those who are still suffering from the effects of 
the September 11 attacks.
    My name is Edward Skyler, and I am the New York City deputy 
mayor for administration. And as the 5-year anniversary of the 
attacks approached, Mayor Bloomberg asked me to co-chair a 
panel of experts to determine what must be done to fully 
address the health impacts of 9/11. The mayor accepted all 15 
of the panel's recommendations.
    I have shared the report with your staff over the last 7 
months, and over that time, we have been working to put them 
into action. In particular, the city has been working closely 
with New York's congressional delegation, especially 
Representatives Maloney, Fossella, and Nadler; and Senators 
Clinton and Schumer to incorporate these recommendations into 
legislation that establishes a strong and comprehensive Federal 
response.
    And that is why I am here today. On behalf of Mayor 
Bloomberg and the city of New York, I have come to express our 
strong support for a piece of legislation that accomplishes 
much of what our panel recommended, the James Zadroga 9/11 
Health and Compensation Act of 2007. The bill is named after an 
NYPD detective who spent hundreds of hours at Ground Zero and 
later died too young at the age of 34 from respiratory failure.
    If adopted into law, it will provide the Federal funding 
needed to care for those who are sick or who may become sick. 
The bill would continue vital research that would help us 
better understand the health impacts of these attacks, and it 
would reopen the Victims' Compensation Fund, which will enable 
the city to get out of the courtroom and focus its energies on 
helping those who continue to struggle with the aftermath of 9/
11. In short, it recognizes fully and finally that providing 
health services to people who are physically injured and 
emotionally traumatized by an act of war and terror against the 
United States is in fact a national obligation.
    We have estimated that more than 400,000 people were 
potentially exposed to environmental hazards and psychological 
trauma of the attacks. The gross national cost to treat those 
people who are sick or who could become sick as a result of 9/
11 is $393 million per year. That estimate covers the entire 
potentially exposed population, including the thousands of 
rescue workers and others who came to our city to help in our 
time of need from all 50 States.
    We also estimate that the cost merely to sustain the 
current treatment programs in the New York City area at their 
present levels and to implement the remainder of the panel's 
recommendations is at least $150 million a year--not allowing 
for inflation, increased incidence of disease, or the emergence 
of new disease.
    The funding that this bill will provide is needed for two 
critical and interrelated purposes. First, to treat those who 
are sick or who could become sick as a result of 9/11. This 
bill provides the means to treat anyone anywhere in the country 
who was affected by the attacks. A core element of that 
treatment is sustained funding for the three Centers of 
Excellence that collectively monitor and treat the more than 
36,000 responders, residents, and others.
    Those Centers of Excellence are the FDNY World Trade Center 
program, WTC Monitoring and Treatment program coordinated by 
Mount Sinai, and the World Trade Center Environmental Health 
Center at Bellevue Hospital, which is the only treatment 
program currently open to residents and other non-first 
responders. I should note the fire department recently opened a 
treatment center on Staten Island in Congressman Fossella's 
district to better provide services to those who are injured as 
a result of the attacks and make it more convenient for them by 
supplying those services in their home borough.
    Second, this bill ensures that the critical 9/11 research 
continues. Long-term research is the only way we are going to 
be able to develop a full understanding of the health impacts 
of 9/11. The Centers of Excellence have all contributed to the 
research efforts, including studies released by clinicians at 
all of them.
    The city's health department has also partnered with the 
Federal Government to establish the World Trade Center Health 
Registry, the largest of its kind, which includes over 71,000 
people from every State in the country and from almost every 
congressional district. More than a quarter of the people in 
the registry, almost 20,000 individuals, are from outside New 
York State. This reflects the large number of people from 
throughout the country who came to New York's assistance after 
the attacks.
    Two large studies released last month based on registry 
data continue to show how serious the health impacts of 9/11 
are. They were referred by Congressman Fossella earlier today, 
which is the 3.6 percent of 25,000 previously asthma-free 
rescue and recovery workers who developed asthma after working 
at the site, which is 12 times the national average. And the 12 
percent of rescue and recovery workers, about one in eight, who 
developed post-traumatic stress disorder after working at 
Ground Zero. The national average is about 4 percent.
    This bill will provide the necessary resources to fund all 
of these services, but while we wait for Congress to act and 
the executive branch to act, the city is not waiting to make 
sure that the people get the health care they need. In fact, in 
response to the report, the mayor increased city spending for 
9/11 health-related programs sixfold to more than $27 million 
in the current fiscal year. And in the absence of long-term 
Federal support, he committed $100 million to these programs 
through fiscal year 2011.
    Nevertheless, all of these programs remain in danger of 
being discontinued unless they receive a full and reliable and 
sustained source of Federal funding which this bill provides.
    Finally, let me talk about how this bill will fulfill 
another core recommendation of our panel. The urgent need for 
Congress to reopen the Victim Compensation Fund. Between 2001 
and 2004, under the leadership of Special Master Ken Feinburg, 
the fund provided compensation to nearly 3,000 families of 
those who were killed or injured on 9/11 or in the immediate 
aftermath of the attacks. It was a fair and efficient process 
that provided a measure of relief to victims' families.
    Now, it is imperative that the fund be reauthorized to take 
care of those who are not eligible to benefit from it before it 
closed in 2003. The fact that their injuries and illnesses have 
been slower to emerge should not disqualify them from getting 
the help they need.
    Even if we provide them health care, many of these people 
have suffered other losses. Some can no longer work or are in 
financial distress. They shouldn't be forced to go to court to 
get compensation. That not only compounds their pain, it would 
result in costly and protracted litigation that is distracting 
us from our primary mission of giving real help to those in 
need.
    The fundamental point is that compensating people who were 
hurt on 9/11 shouldn't be based on a legal finding of who is to 
blame. We all know who is to blame: 19 savages with box 
cutters. I am here today because New York City would rather 
stand with those who filed suit than against them in a 
courtroom, but we need your help to do that.
    There is no reason why people injured on 9/11 should now 
have to go to court and prove liability. Proof of harm should 
be enough to receive fair and fast compensation. What is more, 
reopening the fund would send a clear message that if, God 
forbid, America suffers another terrorist attack, the private 
sectors and our first responders could respond with the same 
kind of determination that we saw on 9/11, knowing that their 
Government will always stand with them.
    If we leave the issue of compensation to the courts and the 
tort system, we risk bankrupting those who responded--either 
the individuals or the companies. We simply shouldn't be so 
callous to those who responded in the Nation's time of need.
    In sum, the James Zadroga Act represents a vital lifeline 
to the men and women who risked everything and helped lift our 
Nation and our city back onto its feet during its time of need. 
That is why it has gained the support of New York State's 
entire congressional delegation. That is why Speaker Pelosi, 
who met with Mayor Bloomberg and me last week, expressed her 
support of it. And that is why Mayor Bloomberg and his 
administration are pledging to work with Congress to do 
everything possible to make it a reality.
    Thank you for your attention. I would be happy to answer 
any questions you might have.
    [The prepared statement of Mr. Skyler follows:]

                       Testimony of Edward Skyler

     Good morning. I want to thank Chairman Pallone, Ranking 
Member Deal, and the other distinguished members of the 
Committee for convening this hearing about those who are still 
suffering the effects of the September 11 attacks. I also want 
to take this opportunity to thank Speaker Pelosi for coming to 
New York last week on the eve of the sixth anniversary of the 
attacks. Speaker Pelosi met with Mayor Bloomberg to discuss a 
number of critical 9/11-related issues, and she expressed her 
support for addressing the urgent and unmet health needs that I 
will talk to you about today.
     My name is Ed Skyler, and as New York City's deputy mayor 
for administration, I've been directly involved with the city's 
response to 9/11-related medical conditions. As the 5-year 
anniversary of the attacks approached, Mayor Bloomberg asked me 
and our city's Deputy Mayor for Health and Human Services--
Linda Gibbs--to chair a panel of experts to determine what must 
be done to fully address the health impacts of 9/11.
     The mayor accepted all 15 of the panel's recommendations--
I gave congressional testimony about them in February--and over 
the past 7 months we've been working to put them in action. In 
particular, the city has worked closely with New York's 
Congressional delegation--especially Representatives Maloney, 
Fossella, and Nadler, and Senators Clinton and Schumer--to 
incorporate these recommendations into legislation that 
establishes a strong and comprehensive Federal response.
     That's why I'm here today. On behalf of the city, I've 
come to express our strong support for a piece of legislation 
that accomplishes much of what our panel recommended, the James 
Zadroga 9/11 Health and Compensation Act of 2007. This bill is 
named after an NYPD detective who had spent hundreds of hours 
at Ground Zero, and later died at the age of 34 from 
respiratory failure. If adopted into law, it would provide the 
Federal funding needed to care for those who are sick, or who 
may become sick.
     The bill would also continue vital research that will help 
us better understand the health impacts of the attacks, and it 
would re-open the Victim's Compensation Fund, which will enable 
the city to get out of the courtroom and focus its energies on 
helping those who continue to struggle with the aftermath of 9/
11. In short, this bill recognizes, fully and finally, that 
providing health services to people who were physically injured 
and emotionally traumatized by an act of war against the United 
States is in fact a national obligation.
     We've estimated that more than 400,000 people were 
potentially exposed to the environmental hazards and 
psychological trauma of the attacks, and that the gross 
national cost to treat those who are sick or could become sick 
as a result of 9/11 is $393 million per year. That estimate 
covers the entire potentially exposed population, including the 
thousands of rescue workers and others who came to our city 
from all 50 states.
     We also estimated that the cost merely to sustain the 
current treatment programs in the New York City area at their 
present levels and to implement the remainder of the panel's 
recommendations is at least $150 million a year--not allowing 
for inflation, increased incidence of disease, or the emergence 
of new diseases.
     The funding this bill would provide is needed for two 
critical, interrelated purposes: first, to treat those who are 
sick or who could become sick as a result of 9/11. This bill 
provides a means to treat anyone, anywhere in the country who 
was affected by the attacks. A core element of that treatment 
is sustained funding for three ``Centers of Excellence'' that 
collectively monitor and treat more than 36,000 responders, 
residents and others.
    Those Centers of Excellence are: the FDNY World Trade 
Center program; the WTC Monitoring and Treatment program 
coordinated by Mt. Sinai; and the World Trade Center 
Environmental Health Center at Bellevue Hospital--the only 
treatment program currently open to residents and other non-
responders. I should note that the Fire Department recently 
opened a treatment center in Staten Island--in Congressman 
Fossella's district--to provide better services to those who 
were injured as a result of the attacks.
     Second, this bill ensures that critical 9/11-related 
research continues. Long-term research is the only way that 
we're going to be able to develop a full understanding of the 
health impacts of 9/11. The Centers of Excellence have all 
contributed to research efforts--including studies released by 
clinicians at FDNY, Mt. Sinai and the Bellevue program.
     The city's Health Department has also partnered with the 
Federal Government to establish the World Trade Center 
Registry--the largest effort of its kind in history--which 
includes over 71,000 people from every state in the country and 
from almost every Congressional district. More than a quarter 
of the people in the Registry--almost 20,000 individuals--are 
from outside New York State. This reflects the large number of 
people from throughout the country who came to New York's 
assistance after the attacks.
     Two large studies released last month based on Registry 
data continue to show how serious the health impacts of 9/11 
are. One shows that 3.6 percent of 25,000 previously asthma-
free rescue and recovery workers in the Registry developed 
asthma after working at the World Trade Center site--12 times 
the national average. And a second study shows that more than 
12 percent of rescue and recovery workers--about 1 in 8--
developed Post-Traumatic Stress disorder after working at 
Ground Zero.
     The James Zadroga 9/11 Health and Compensation Act will 
provide the necessary resources to fund all of these services--
but while we wait for Congress to act, the city is not waiting 
to make sure that people get the health care they need. In 
fact, in response to the Panel's Report, the Mayor increased 
city spending for 9/11-health related programs six-fold in the 
current fiscal year, to more than $27 million. And, in the 
absence of long-term Federal support, he committed nearly $100 
million to these programs through FY 2011. Nevertheless, all of 
these programs remain in danger of being discontinued unless 
they receive the full and predictable source of Federal funding 
which this bill provides.
     Finally, I'd like to address how this bill will fulfill 
another core recommendation of our panel: the urgent need for 
Congress to reopen the Victim Compensation Fund. Between 2001 
and 2004, the Fund provided compensation to nearly 3,000 
families of those who were killed or injured on 9/11 or in the 
immediate aftermath of the attacks. It was a fair and efficient 
process that provided a measure of relief to victims' families.
     Now it is imperative that the Fund be reauthorized to take 
care of those who were not eligible to benefit from it before 
it closed in December 2003. The fact that their injuries and 
illnesses have been slower to emerge should not disqualify them 
from getting the help they need.
     Even if we provide them health care, many of these people 
have suffered other losses. Some can no longer work. Some have 
lost their homes. They shouldn't be forced to go to court to 
get compensation. That would not only compound their pain; it 
would also result in costly and protracted litigation that 
ultimately would distract us from our primary mission of giving 
real help to those in need.
     The fundamental point is that compensating people who were 
hurt on 9/11 shouldn't be based on a legal finding of who is to 
blame. We know who is to blame--19 savages with box cutters. I 
am here today because New York City would rather stand with 
those who've filed suit, rather than against them in a 
courtroom. There is no reason why people injured on 9/11 should 
now have to go to court and prove liability. Proof of harm 
should be enough to receive fair and fast compensation.
     What's more, reopening the Fund would send a clear message 
that if--God forbid--America suffers another terrorist attack, 
the private sector and our first responders could respond with 
the same kind of determination that we saw on 9/11, knowing 
that their government will always stand by them. If we leave 
the issue of compensation to the courts and the tort system, we 
risk bankrupting those who responded--either the individuals or 
the companies. We simply shouldn't be so callous to those who 
responded in the nation's time of need.
     In sum, the James Zadroga Act represents a vital lifeline 
to the men and women who risked everything, and helped lift our 
Nation back onto its feet during our time of greatest need. 
That's why Mayor Bloomberg and his administration are pledging 
to work with you all and do everything possible to make it a 
reality.
                              ----------                              

    Mr. Pallone. Thank you. I thank you all. I am going to 
start with the questioning.
    My view, and I think most of you, if not everyone here, 
sort of shared the same view, although I don't want to put 
words in your mouth, is that if we had a situation where every 
one of the first responders, or even those who were not first 
responders that might have been victims because they live or 
work near the World Trade Center--but at least let us focus on 
the first responders, if we had a system where all the first 
responders could go to a specialized treatment center, where 
they have the expertise like what UMDNJ or Mount Sinai do, and 
they could be screened and monitored, and they could be treated 
there by those experts who have the expertise, and the 
Government was paying for it because there wouldn't be any gaps 
because of your private insurance, if you have it or don't, 
that would be the best situation.
    But the problem with that, of course, is that for 
ideological reasons or whatever, our system doesn't work that 
way. Everything is done stop-gap, and you have to rely on 
private insurance and who has and who hasn't. So if we set 
something up like that, although it might be the ideal--there 
are all the ideological problems that go with it. So what I 
would like to know is how far do you think we need to go?
    In other words, we obviously need a comprehensive plan. 
Would you argue that this comprehensive plan should allow 
everyone who is either a first responder or a victim in some 
other way to go to one of these centers? That they should be 
fully covered by the Federal Government without any recourse to 
private insurance? Is there any other way to help people like 
Mr. Vinciguerra without having to go that far?
    I mean, this is the committee of jurisdiction that would 
have to report out that legislation, and we have some bills out 
there that are sort of similar to that. But we also have to 
think about what is possible to get passed here.
    And so I guess I would just like to ask a basic question 
about is that the way we need to go? Is there some way to 
continue to rely on private insurance, or let people go to 
their individual doctors, or is this really what we are talking 
about? And I know it is sort of a broad question. I am not sure 
we have time for everybody to answer it, but I would like to at 
least ask that of Dr. Udasin, Dr. Herbert and the GAO person in 
that order and then we will see. If we can start that way.
    Dr. Udasin. Well, I would like to answer that question by 
saying that most of the patients in New Jersey actually have 
private health insurance, and so many came in with either 
incorrect diagnoses or they couldn't get the medications that 
they needed because the insurance company said you had to have 
this medication, not the one that actually works for what is 
wrong with you. I am no expert on figuring out how to fund a 
program, but I feel like the people that were there that did 
the kind of work that Mr. Vinciguerra did need the kind of 
medical care that we are able to provide for them.
    Mr. Pallone. And if they can't go to your center, then 
there is a danger that they won't get the specialty care, 
correct?
    Dr. Udasin. That is correct, and we do work with physicians 
all over the--actually we work with physicians all over the 
country. And we do give a lot of medical advice to people who 
can't get into our centers, and at the very least, it is making 
the diagnosis that is so complicated that takes such a long 
time figuring out what people need. And that is actually where 
the trouble is, in my opinion, that a lot of people that do 
have correct health insurance are coming in with the wrong 
diagnosis. And that is what I feel like we can do for them is 
at least get them started on the path to the correct treatment.
    Mr. Pallone. See, that is, Dr. Herbert, my concern is that 
if you look at Mr. Vinciguerra, he went to Hamilton. Did they 
necessarily know what the problem was? It seems to me that if 
they are not going to one of your centers and then they are not 
being able to get the full monitoring and treatment over a long 
period of time under somebody that has the expertise, they are 
going to have incomplete care. And, then you get into all the 
insurance problems.
    Dr. Herbert. I agree exactly with what you said and with 
what Dr. Udasin said. The other features of this kind of system 
are the ability to track symptoms, physical findings, breathing 
test results from the monitoring examination so that we can 
identify disease and symptom patterns over time, A. And, B, in 
the treatment programs, we have a real-time system to capture 
not just the single billable diagnosis that you are going to 
find from a private physician but all of the conditions for 
which that responder is being treated.
    So I think without this kind of center, A, you would lose 
the ability to provide the highly specialized treatment that 
the responders need. And, B, you would lose the opportunity to 
identify the patterns of disease going forward in time, and you 
would lose the responders as a group. And that would be a huge 
loss.
    Mr. Pallone. And I will ask Dr. Melius because my time is 
actually up, but the problem that I see is that when you talk 
about the insurance, unless the Government is actually saying 
we are going to pay for your screening and treatment at one of 
these centers, there is going to be just a gap. There is no way 
for private insurance to make up the difference. Or is there 
some way for us to still rely on private insurance to pay for 
some of this?
    Dr. Melius. The answer to that is twofold. One is I don't 
think it is fair or appropriate to rely on private insurance 
because that cost is getting then passed back either to the 
victim or his fellow workers who are part of the same plan or 
to the employer who is having to provide that.
    Second, I don't think it works. It leads to fragmented 
care. Mr. Vinciguerra, I think, was a good example of the 
problems that that causes. And there are countless other 
examples like that in this program. People that delay 
treatment, don't get the right medications, uncertainty about 
whether it is covered or not.
    And I really think the only way to provide timely 
comprehensive care is to do it through the system that is 
proposed in the legislation, that sets up the Centers of 
Excellence, that tracks people, provides the care at Centers of 
Excellence or in coordination with Centers of Excellence, and 
assures that people get the best care as early and in as timely 
a fashion as possible.
    Mr. Pallone. And I agree with you, but I mean the problem 
is when you try to move a bill like that, you are basically 
saying you want a Government sponsored plan, paid-for plan for 
these people. And the question is can we accomplish that.
    Dr. Melius. Well, this is, I think, extraordinary 
circumstances.
    Mr. Pallone. Right, thank you.
    Dr. Melius. Yes.
    Mr. Pallone. Mr. Deal.
    Mr. Deal. I would sort of like to follow up on that. Does 
anybody know how many of these responders have been provided 
care and benefits under their Worker's Compensation plans? Yes, 
Mr. Skyler?
    Mr. Skyler. I would just point out from the city's 
perspective, worker's comp actually doesn't apply to members of 
the uniform service, such as police department and fire 
department. So, as a matter of course, the 50,000 or so police 
officers and firefighters wouldn't get any care through their 
worker's comp system.
    Mr. Deal. So you don't have any worker's comp system for 
your uniformed officers?
    Mr. Skyler. Not for our uniformed officers. It only affects 
the civilian cohort of the workforce.
    Mr. Deal. So what benefits do they have then if they are 
injured in the line of duty?
    Mr. Skyler. They have different benefits provided by 
pension plans, and there are different levels of care depending 
on the agency. For example, the Bureau of Health Services was a 
part of the fire department set up before 9/11 that monitored 
firefighter health before 9/11. They used their data to compare 
against the patients that came in after 9/11.
    Mr. Deal. So that is why Mr. Vinciguerra had such a hard 
time is because the normal processes that would be in place in 
most instances that I am aware of across the country, 
apparently you didn't have those for a uniformed person injured 
in the line of duty?
    Mr. Skyler. No, I would submit and I think the doctors on 
the panel would agree that the fire department Bureau of Health 
Services is one of the Centers of Excellence that has gotten 
Federal funding that we want to see funding continued for. The 
advantage----
    Mr. Deal. Well, I know you wanted the Federal Government to 
pick up the tab. My concern is when you have got local folks 
who should be covered by some kind of local policy, why is not 
that the first line of resources?
    Mr. Skyler. Well, it has been the first line, and the mayor 
put up money despite a lack of Federal long-term commitment on 
this issue--$100 million over the next 3 years.
    Mr. Deal. If a fireman is injured in my hometown, he is 
covered by an insurance policy. He has got a retirement benefit 
plan. Why does a man like this gentleman here have such 
difficulty in New York?
    Mr. Skyler. I believe Mr. Vinciguerra actually has been 
treated by our Bureau of Health Services. One of the gaps that 
was exposed was a lack of prescription drug care, which we have 
remedied since the panel's report came out.
    Mr. Deal. Mr. Vinciguerra?
    Mr. Vinciguerra. Yes, if I may, the reason I think there is 
some confusion is I worked for the EMS division of the fire 
department, and it is sort of considered a civilian component 
even though it is a uniformed service now. It works under 
compensation, not the pension component.
    Mr. Skyler. Well, Dr. Melius's testimony here says that 
depending on a Worker's Compensation disability retirement 
system to cover the medical cost for the monitoring and 
treatment programs, placed a financial burden on the employers 
and the insurance companies.
    Mr. Deal. Well, yes, that is true. Any time you write an 
insurance policy or create a system, when you have a claim that 
comes forward, whether they be of the magnitude we are talking 
about here or even minor claims that same statement could be 
true. Let me ask specifically about how we are spending money.
    Ms. Bascetta, in your testimony, I am looking at the 
portion where you talk about the contracts that NIOSH has 
entered into for those outside of the metropolitan area. And 
you say in June 2005, they began a second effort by awarding 
$776,000 to Mount Sinai School of Medicine to provide screening 
and monitoring for non-Federal responders residing outside the 
metropolitan area.
    And then in June 2006, they awarded an additional $788,000 
to provide screening for these first responders. And you 
conclude the paragraph by saying that they ultimately 
contracted with 10 clinics in seven States and that as of June 
2007, 10 clinics were monitoring 180 responders. That is an 
awful lot of money for a very few people. Am I reading this 
wrong?
    Ms. Bascetta. No, you are correct. The system wasn't 
working well at all, and in fact to update that, NIOSH has gone 
to a different system with a different contract with QTC, I 
believe. Dr. Howard referred to that, and they have piloted it. 
They have done about 20 exams under that program, but the first 
program did not work well at all.
    Mr. Deal. OK. Well, let us go to more recent. You say here 
in June 2007, NIOSH awarded $800,600 for DCC to coordinate 
provisions of screening and monitoring exams, to provide 1,000 
screenings and monitoring examinations through May 2008. And 
they began the screening process, and by the end of August, 18 
non-Federal responders had completed screening and 33 others 
had been scheduled. Here again, that appears to be a lot of 
Federal dollars for a very few people that are being affected 
by it. I mean we would be better off to take that amount of 
money and give all those people that amount of money in cash, 
wouldn't we?
    Ms. Bascetta. It is a very good question. Again that is the 
same program that you were just referring to. The money was 
there, but the administrative logistics were not in place to 
serve the people well. And it didn't happen.
    Mr. Deal. And yet we are going to be anticipating the same 
kind of funding or even at greater levels for this fiscal year, 
are we not?
    Ms. Bascetta. Yes, but those funds were for screening and 
monitoring, and the discussion that we were just having was 
about treatment, which is actually where even more of the funds 
would be required. The screening and monitoring are a smaller 
proportion, and they are known costs. Once you get the 
mechanisms in place to do the screening and monitoring, then 
you know per person what that is going to run.
    Mr. Deal. But using that same logic, if the cost per person 
just to do the screening and monitoring is so exorbitant and 
out of kilter it seems to me, then we would expect the 
treatment phase of it to be even more exorbitant, would we not? 
I mean why is it costing so much to do so little for so few?
    Ms. Bascetta. Well, I don't think we know at this point 
what the full treatments costs are going to be. One of our 
findings was that HHS has just last year begun asking for the 
actual cost data from the grantees. Last year was also the 
first year that there was Federal money awarded to grantees, 
and prior to that, it was all philanthropic funds from the Red 
Cross. So there wasn't a requirement for the grantees to be 
reporting actual cost data.
    We would hope that one of the lessons learned from this 
situation is that in the future the requirements for screening 
and monitoring, who is responsible for that, where the funding 
streams will come from, how those programs will be 
administered, and how the various funding streams for treatment 
would be made available to pay for treatment if that were 
necessary, would be planned in advance to avoid this kind of 
situation after the fact.
    Mr. Deal. Well, I don't mean to diminish the importance of 
what we are all talking about here by my questions, but I do 
think that we can't just simply all say take a simplistic 
answer of let the Federal tax payer pick up the burden. Let us 
forget about asking the private insurers to contribute. They 
have been paid premiums for that, but it is too cumbersome to 
do that. Let us forget about the Worker's Compensation system 
because it takes too long to go through system.
    I can assure you that every injured employee in this 
country who has a Worker's Compensation claim would tell you 
yes, the system does take a while. But just to say let us 
forget about that and throw up our hands and ask the Federal 
Government to pitch in millions, perhaps billions of dollars, I 
think, doesn't show the kind of responsibility that I think all 
of these responders showed when the responded to the emergency 
before them.
    I think there is a responsibility at every level for us to 
make sure that we are doing what is best for the people who 
need the help and that we are not just throwing dollars out 
there that don't seem to wind up in the right place. That is 
the concern that I have.
    Mr. Pallone. Mr. Engel.
    Mr. Engel. Thank you, Mr. Chairman. Let me just say before 
I ask my question in view of some of the comments that my 
friend Mr. Deal has been making. The President talks a lot 
about America being attacked on 9/11 and talks a lot about it 
being as part of the overall fight on terror. He mentions Iraq 
and everything else and that the United States of America was 
attacked.
    Well, we in New York don't believe that we were attacked 
simply by random. New York was obviously a symbol of the 
country, and the terrorists wanted to hit us hard. Therefore, 
we believe that the Federal Government has an enormous 
responsibility above and beyond. It is not just simply worker's 
comp or private insurance plans.
    Sure, it would be helpful, but the bottom line for me is 
that the Federal Government needs to be responsible. We were 
attacked. New Yorkers were killed and maimed and injured, and 
the Federal Government needs to have a response. And I think 
pushing it off on private companies or whatever--and I am not 
trying to absolve them of responsibility, but the bottom line 
for me is again that the Federal Government needs to step in.
    Mr. Skyler, let me just ask you. I don't know if you were 
here when I gave my opening statement, but I talked a lot not 
only about first responders but about other New Yorkers and 
people from the metropolitan area who were exposed to these 
poison toxins, people who live within the area, residents, 
students. These people who were exposed to the toxins of Ground 
Zero are not eligible for the federally funded World Trade 
Center Medical Monitoring and Treatment programs.
    We have just introduced a bill lead by Mrs. Maloney, Mr. 
Fossella, Mr. Nadler, but many of us also co-sponsored and 
signed on, which would help the entire exposed community. I am 
wondering if you could give us some of your insights on how 
that bill would help and why it is so necessary.
    Mr. Skyler. Absolutely, and I think the bill addresses one 
of the fundamental challenges, also something that Congressman 
Deal essentially stated, which is that we have different 
populations, and we have different systems that handle 
different populations. But we have the same health effects 
caused by the same disaster, an environmental disaster, and I 
am not aware of one on American soil that was greater than this 
one. It is an environmental disaster, not just a terrorist 
attack.
    But we have populations where different standards apply 
depending on what their pension benefits are, depending whether 
they are on worker's comp or not, depending on what union they 
are in sometimes, depending on what resources that union has 
available, depending on where they live.
    So one of the things that the report recommended was to 
establish an enhanced funding for a World Trade Center 
environmental health center in Bellevue Hospital. It is a 
hospital in New York City, Manhattan, that anybody can go to, 
whether you are a resident--and there was no treatment program 
available for residents before this was established--whether 
you are a firefighter or police officer, whether you are a 
worker, whether you worked in the cleanup as a contractor or 
whether you worked in the building cleaning up the interior of 
a building that was damaged.
    Anybody can walk in there and get care, and we have had 
about 1,600 people go in. And that is a gap that needs to be 
filled. There are other gaps throughout the populations that we 
have also sought to fill, but that was a huge one that nobody 
had focused on. And we are gratified to see that Congresswoman 
Maloney's bill, the Zadroga Act, which I am here to support, 
actually identifies that population as one deserving funding.
    Mr. Engel. Thank you. I think that is very important. Dr. 
Herbert, let me ask you something specifically about the Mount 
Sinai program. Many of the responders who are now in medical 
monitoring programs, these are run by their employer, the fire 
department or the police department. And a lot of the problems 
are mental health related, and due to the presence of these 
issues among the population, might it not be possible that some 
of these workers fear sharing this information with their 
employer due to potential adverse work consequences and things 
like that?
    Now, let me ask you about the Mount Sinai program. Should 
you be assisting in helping in monitoring those employees who 
may be uncomfortable with being monitored by their employer?
    Dr. Herbert. Thank you for asking that question. To clarify 
with respect to the two federally funded monitoring and 
treatment programs for responders, distinct from the additional 
program that Mr. Skyler spoke about, one is employer based, the 
program for New York firefighters or employees of FDNY is based 
at the Bureau of Health Services.
    The other federally funded program does exactly what you 
have suggested might be important. The way the program works is 
that we have exposure-based eligibility criteria. Any responder 
can choose the Center of Excellence that he or she prefers to 
go to, and the examinations are highly confidential. We are 
very well aware that we are collecting very sensitive 
information. We adhere to all pertinent HIPA regulations. So, 
in fact, I think it is very important, and it is one of the 
reasons that I believe--we have had enormous success in 
combining mental health screening and treatment with physical 
health screening and treatment in a group of workers who 
probably would not seek mental health care.
    Mr. Engel. Let me ask you this. You have your program, the 
fire department's medical monitoring program, the World Trade 
Center Health Registry, the World Trade Center responders, 
Fatality and Investigation program, and Project Cope to name a 
few. All these programs seem to be working within their own 
silos. Are there any plans to merge data, save resources, share 
expertise, to examine the overall health effects related to the 
World Trade Center rather than just limited populations?
    Dr. Herbert. Yes, indeed there is, and we think that is 
very important. Presently, the New York/New Jersey consortium 
group of clinical centers and the FDNY programs use virtually 
identical questionnaires for the follow-up visits and the 
monitoring program.
    Because of a number of privacy issues, it is sometimes 
difficult to actually have the same data systems, but we are 
collecting virtually identical data. And so we will be able to 
compare the experiences of different groups of responders, and 
that is essential.
    We, in the Mount Sinai consortium, and Dr. Prazant at the 
FDNY program are also working very closely both with the World 
Trade Center registry and with the New York State fatality 
investigation. So we agree that it is critical that resources 
be used in as prudent as possible so there is not redundancy.
    Mr. Engel. Thank you. Thank you, Mr. Chairman.
    Mr. Pallone. Mr. Fossella.
    Mr. Fossella. Thank you, Mr. Chairman. I thank the panel 
again for your testimony, particularly Deputy Mayor Skyler. And 
this gets back to the overarching issue of the city of New York 
has stepped in to fill this breach, and many of us feel that it 
should have been the Federal Government stepping in immediately 
to help fill the breach. And the panel is consisting of people 
who have had to deal with the first responders and others, Mr. 
Vinciguerra from day one. And I used it before Dr. Howard as we 
are waiting for the cavalry.
    And there are some legitimate concerns, I guess, one could 
point to if they are looking in after the fact and say where 
are the problems? And I think we have a responsibility to ask 
those questions to make improvements. But if I believe the 
Federal Government was up front early on, perhaps we could 
avoid asking those questions today because we would have had 
them at the table.
    If I am not mistaken, with respect to some of the issues 
that have been raised, for example, workman's comp is designed 
through actuarial tables and doesn't necessarily take into 
account the scope and size of this catastrophe, the thousands 
and tens of thousands. 400,000 people thought to be affected 
would be one of the largest cities in this country, larger than 
the population of Minneapolis is, for example, people who have 
been affected by this.
    So the system design does not, I think, take into account 
that radical number. And, in fact, some of the money we secured 
last year was helping the workman's compensation system 
facilitate and minimize the delays of those who partitioned the 
program.
    Second, this is not totally unwarranted or unprecedented. 
After Pearl Harbor, there were programs that were put in place 
to help sailors who were called in to respond and came down 
with certain illnesses. So the Federal Government recognizing, 
although it took place in Hawaii, that this was a national 
catastrophe and demanded national scope.
    Similarly, we can make that argument that flood insurance 
should be held by everybody or homeowner's insurance. But we 
know that major hurricanes, tornadoes, fires, other, FEMA steps 
in some way, shape, or form to help people through that system.
    And finally there are those, we have noticed--and I would 
like to ask the deputy mayor for maybe expounding a little bit 
on this--we kept emphasizing that although it took place in New 
York City, this is a national problem in scope. You mention 
that there are 20,000 people who don't even live in New York 
City, again this would be larger than many towns and cities and 
villages across this country, 20,000 people.
    So if you were a firefighter from Hialeah, FL, as Mr. 
Pallone said, or came in from New Orleans or California, and 
then went back to work and now suffering, common sense would 
dictate that that individual would show the similar signs of 
ailments and illnesses and manifestations of those diseases, 
let us say, or illnesses as someone who lives in New Jersey or 
Staten Island, New York. And yet that person is probably on his 
own right now, and we don't even know whether that person 
becomes eligible for satisfaction under workman's comp.
    So, Deputy Mayor Skyler, can you expand or illuminate, 
elaborate if you will, on the number who do not live within New 
York City?
    Mr. Skyler. The World Trade Center registry, through their 
modeling, estimated--and a lot of what we deal with in this 
subject is estimates--there are 410,000 people that qualified 
for the World Trade Center Health Registry, and that is based 
on where they lived, where they worked, where they were that 
day. We estimate that of those 410,000, 45,000 of them live 
outside not only New York State but New Jersey, which I believe 
has the second most members in the registry.
    Of the 410,000 that we estimate, we had over 71,000 people 
signed up, we believe, of the 410,000 that qualified. And about 
10,000 of them live outside New York and New Jersey. And at 
least one of them lives in Congressman Deal's district in 
Georgia. There is literally at least one person in almost every 
congressional district in the country.
    So it is absolutely a national problem, and it is not just 
because New York was attacked because of its symbolism, because 
it is the financial and media center of the country. But people 
come to New York. Sometimes they live in New Jersey. Sometimes 
they live in Connecticut. Sometimes they are there for the day. 
Sometimes they are working there for a couple months or 
visiting.
    We have a population that is, to some extent, always 
changing, and people relocate. And we also had a great amount 
of people that came from all over the country to help when we 
needed. And this is a recovery that just wasn't a couple of 
days or weeks. It was months.
    So we believe that the Federal Government has a 
responsibility to help the city take care of its own. The city 
has stepped up. The city takes care of its firefighters. We 
take care of our police officers. We have done the best we can. 
What we are asking for is some Federal assistance so we have 
the long-term funding in place not only to maintain the great 
levels of care that we have established in our centers of 
excellence, but make sure that people that aren't parts of 
those populations also get the care they need.
    If you were hurt because of 9/11, it shouldn't be just 
because you worked for the city or responded. If you were hurt 
because you lived across the street and breathed in the air 
potentially, then you also should be deserving the same 
assistance. And we have been hard at work. Since this panel 
report came out, there is only, I believe, two or three of the 
15 recommendations that fall outside of the city. They are 
essentially requests for the Federal Government to help.
    One is the Victims' Compensation Fund, which I mentioned 
before, that Speaker Pelosi voiced her support for earlier. I 
am not sure whether she supports the whole James Zadroga Act. I 
would refer you to her office, but she voiced support for the 
Victims' Compensation Fund.
    The second is getting long-term funding from the Federal 
Government. The rest of the report was the city government 
taking a hard look at itself and saying it wasn't doing a good 
enough job explaining to the city workers what resources were 
available, coordinating services, encouraging people to get 
checkups, establishing communications within city government, 
and establishing protocols so that we have emergencies that 
have environmental impacts, whether it is Deutsche Bank 
building or the steam pipe explosion, that we have 
environmental professionals on scene that can help guide the 
emergency response.
    So we have tried to learn from this disaster and do what we 
can do to improve our response. But what we are also saying is 
we are in need of a Federal commitment so that the people that 
were hurt don't have their care jeopardized by the fiscal 
stability or health of New York City. In tough times, programs 
get cut back.
    We would like to see an established program, a sustained 
commitment, so that people that were hurt continue to get the 
care they need. It is possible that some of these illnesses--
doctors could speak better than I could--will improve over 
time. It is also possible that things will get worse. We don't 
know. There are a lot of illnesses that we would not have a 
sense at this point of whether they will materialize. And we 
are talking about hundreds of thousands of people here, and it 
is unlike something that the country has ever experienced. And 
it is impossible for the health insurance mechanism, as set up 
now, to absorb it and care for it properly.
    Mr. Fossella. Thank you, Mr. Skyler. Thank you, Mr. 
Chairman.
    Mr. Pallone. Sure. I have to apologize to Mr. Weiner 
because he was supposed to go next because Mr. Fossella is not 
on the subcommittee. I apologize. Your turn.
    Mr. Weiner. Well, I am gratified then that Mr. Fossella did 
such a good job in his time. I thank you, Mr. Chairman. I think 
that it is very important that we address fully Mr. Deal's 
concerns because we want this effort to be one that is 
bipartisan. There are a lot of people who are not living with 
these issues day to day like we are who perhaps don't 
understand the nuance and raise similar questions.
    And perhaps, Mr. Skyler, you can expand a little bit on 
this notion that the programs that have been set up for the 
fire department, for example, take a State program, the 
disability insurance program, and say we as New York City 
residents, we are going to do even better. We are going to 
provide them even better care. We are going to step in and 
provide better care.
    I don't think that the failure of the fire fighters to go 
through the disability program is any way the shirking of New 
York City's responsibility. It is taking on in addition. I just 
want to make sure that is clear for the record.
    Mr. Skyler. Right, the level of care provided by the Bureau 
of Health Services, the fire department, is the gold standard. 
And if we can provide every person that was affected by these 
attacks with that level of care, we would be in a lot better 
shape than we are currently.
    Mr. Weiner. And I think it is also worth noting one of the 
tools that many of the medical community have to determine what 
is going on is the monitoring that went on of firefighters long 
before September 11 that allow people to look at healthy 20-
year-old lungs and 23-year-old lungs that look like they should 
be on a 70-year-old person. That is one of the reasons that 
that is available.
    I think it is also important that we understand that what 
we are suggesting here is exactly what Congress--and I don't 
know the record of my colleagues on the committee or Mr. Deal--
I know Mr. Fossella and Mr. Engel's on this. We looked at a 
very similar problem when we created the Victim's Compensation 
Fund. We said well, how do we deal with what could be long-term 
lawsuits that go on ad infinitum. How do we deal with a 
community that has so many victims coming from so many places? 
How do you deal with them expeditiously, compassionately? How 
do we deal with this when the Victims' Compensation Fund was 
created?
    And with that in mind, I just want to ask--and I will just 
go one by one on the panel--is there any doubt based on either 
your experience, your friendships with other people, your 
research that you write, is there any doubt in your mind--I 
will go from left to right--that people today are dying from 9/
11-related illnesses? Why don't we start to the left, just a 
quick yes no. Is there any doubt in your mind?
    Mr. Vinciguerra. Yes, people are dying.
    Mr. Weiner. Doctor?
    Dr. Udasin. Yes.
    Dr. Herbert. I agree with Dr. Udasin.
    Ms. Bascetta. There is a large part of peer-reviewed 
literature that documents the health effects.
    Mr. Weiner. Doctor?
    Dr. Melius. Yes, absolutely.
    Mr. Weiner. Mr. Skyler?
    Mr. Skyler. I am not a doctor, but clearly there is 
tremendous amount of harm that was caused by the attacks.
    Mr. Weiner. And the Victims' Compensation Fund was created 
for people who died from the attacks. So the only question is 
Congress's instinct and Congress's desire to try to figure who 
the universe of people is, set up rules and parameters, and 
then go out and take care of them. The only thing that the city 
is asking is that the one parameter, December 2003, be changed. 
And that we know now that there is a whole universe of people 
who themselves didn't know that they were dying from September 
11 related diseases and figuring out the correct place to place 
that December 2003 date.
    We are asking essentially--what the city is asking, what 
residents are asking us to do--and what the residents of 40 or 
so States or all 50 States who are asking who are in this 
additional group, to do what all of us voted for. And at the 
time, those 2,800 or so that were in the known class of people 
that had died at the time, they had insurance. They had 
lawyers. They had someone to sue. They had a lot of people to 
sue, and we made a decision, you know what, it is probably 
better for everyone involved that rather than fighting in the 
courts for perhaps the better part of a generation over this, 
let us figure out what our responsible role is. And it had 
broad bipartisan support in its institution.
    And I should say something else. If the Federal Government 
says no, Congress says no, we are not going to do any of these 
things we are going to do what we can. All of the people who 
are here testifying are going to keep doing their good work. We 
are going to keep advocating. We are going to do what we can to 
embrace one another. We are going to try to figure out a way to 
take care of these people.
    The question is: Is this the best way to care for people 
who are dying because of their heroism or their simple presence 
on September 11 at a certain place? Is that the way we want to 
respond as a Congress and as a people? Up to now, the American 
people, through their Congress, have said no, we don't believe 
that we want to respond. And we let people kind of go fend for 
themselves. If they are fortunate enough to have good insurance 
or to have been further away from the plume or to be a 
firefighter that has good monitoring, if that is where--
Congress could wind up being there.
    But I want to make it clear that what we are suggesting 
here and what sponsors of the bill are suggesting and what 
Mayor Bloomberg is suggesting is not this cosmically different 
way of looking at the problem. It is the same way that Mr. Deal 
and I and others in this Congress looked at it after September 
11. We were attacked. Let us figure out a smart, compassionate, 
comprehensive way to deal with it.
    We are not rewriting everything here. We are not 
reinventing the wheel with this legislation. The mayor's desire 
to reopen the compensation fund, all of our desire to do that, 
is trying to figure out a way--and let me just end--I know I am 
a little bit over time.
    If you are concerned, as I know so many of my colleagues 
are about the courts being clogged up with lawsuits and that us 
using the courts as the way we solve even the most basic 
disagreement about interpretations--and I know many of my 
colleagues on the judiciary committee have that feeling. Well, 
the Victims' Compensation Fund is a way, in the words of Mr. 
Skyler, to get us working together rather than fighting one 
another.
    It would be a shame if we are all sitting here in 10 years 
talking about and reading about the horrible lawsuits going on 
as families sue the city of New York which desperately wants to 
try to provide help. And I think the questions that Mr. Deal 
asked are exactly the right ones, and that we have to embark on 
trying to explain to people what we are doing here is not 
transformative. It is just tweaking a system that we have 
already created.
    The city has taken on an enormous amount of responsibility. 
Whoever the next mayor is is going to have to deal with those 
responsibilities as well, but it is imperative that we, the 
Federal Government, take this opportunity to continue the job 
that we began. And I want to commend Mr. Fossella and Ms. 
Maloney, Mr. Nadler, Mr. Engel, and the chairman, Mr. Pallone, 
for helping us get to that place and for all of you for 
testifying here.
    Mr. Pallone. Thank you. Let me say before we conclude that 
this was just a beginning. This was not a legislative hearing 
per se. I mean we didn't have a piece of legislation before us, 
but it is my intention, and I think I can hear that there is a 
bipartisan concern that the current system is broken in terms 
of handling the health concerns of both first responders as 
well as other people that may have been impacted because they 
lived or worked in the vicinity of the World Trade Center.
    So it is our intention to follow up on this and come up 
with some legislative initiative. But I think you can all see 
that even though, on a bipartisan basis, we realize that the 
status quo doesn't work as well as we would like, that it is 
difficult to figure out exactly how to put something together.
    So we are probably going to rely on all of you and follow 
up with phone calls and other things to help us out as we 
proceed, but we do intend to try to put something together 
legislatively.
    And let me just say also that the Members, as always, can 
submit additional questions for the record to be answered by 
all of you. The questions should be submitted to the clerk 
within the next 10 days, and then we would notify you about 
those questions. So you may get some follow up in that respect.
    And without objection, this meeting of the subcommittee is 
adjourned. Thank you all.
    [Whereupon, at 1:30 p.m., the subcommittee was adjourned.]

                                 
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