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

    PROTECTING THE PROTECTORS: ENSURING THE HEALTH AND SAFETY OF OUR FIRST
                RESPONDERS IN THE WAKE OF CATASTROPHIC DISASTERS

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

                                  FULL HEARING

                                     of the

                         COMMITTEE ON HOMELAND SECURITY
                            HOUSE OF REPRESENTATIVES

                           ONE HUNDRED TENTH CONGRESS

                                 FIRST SESSION

                                   __________

                               SEPTEMBER 20, 2007

                                   __________

                               Serial No. 110-71

                                   __________

           Printed for the use of the Committee on Homeland Security

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

      Available via the World Wide Web: http://www.gpoaccess.go/congress/
                                   index.html

                                   __________

                      U.S. GOVERNMENT PRINTING OFFICE
    48-966 PDF                WASHINGTON : 2009
    -----------------------------------------------------------------------
    For sale by the Superintendent of Documents, U.S. Government Printing
    Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC
    area (202) 512-1800 Fax: (202) 512-2104  Mail: Stop IDCC, Washington, DC
    20402-0001

                         COMMITTEE ON HOMELAND SECURITY

                   BENNIE G. THOMPSON, Mississippi, Chairman

    LORETTA SANCHEZ, California,         PETER T. KING, New York
    EDWARD J. MARKEY, Massachusetts      LAMAR SMITH, Texas
    NORMAN D. DICKS, Washington          CHRISTOPHER SHAYS, Connecticut
    JANE HARMAN, California              MARK E. SOUDER, Indiana
    PETER A. DeFAZIO, Oregon             TOM DAVIS, Virginia
    NITA M. LOWEY, New York              DANIEL E. LUNGREN, California
    ELEANOR HOLMES NORTON, District of   MIKE ROGERS, Alabama
    Columbia                             BOBBY JINDAL, Louisiana
    ZOE LOFGREN, California              DAVID G. REICHERT, Washington
    SHEILA JACKSON-LEE, Texas            MICHAEL T. McCAUL, Texas
    DONNA M. CHRISTENSEN, U.S. Virgin    CHARLES W. DENT, Pennsylvania
    Islands                              GINNY BROWN-WAITE, Florida
    BOB ETHERIDGE, North Carolina        MARSHA BLACKBURN, Tennessee
    JAMES R. LANGEVIN, Rhode Island      GUS M. BILIRAKIS, Florida
    HENRY CUELLAR, Texas                 DAVID DAVIS, Tennessee
    CHRISTOPHER P. CARNEY, Pennsylvania
    YVETTE D. CLARKE, New York
    AL GREEN, Texas
    ED PERLMUTTER, Colorado

           Jessica Herrera-Flanigan, Staff Director & General Counsel
                         Rosaline Cohen, Chief Counsel
                         Michael Twinchek, Chief Clerk
                    Robert O'Connor, Minority Staff Director

                                      (II)

                                C O N T E N T S

                                  ----------
                                                                       Page

                                   STATEMENTS

    The Honorable Bennie G. Thompson, a Representative in Congress
      From the State of Mississippi, and Chairman, Committee on
      Homeland Security..............................................     1
    The Honorable Peter T. King, a Representative in Congress From
      the State of New York, and Ranking Member, Committee on
      Homeland Security..............................................     2
    The Honorable Gus M. Bilirakis, a Representative in Congress From
      the State of Florida...........................................    16
    The Honorable Donna M. Christensen, a Delegate in Congress From
      the U.S. Virgin Islands........................................    20
    The Honorable Yvette D. Clarke, a Representative in Congress From
      the State of New York..........................................    24
    The Honorable Henry Cuellar, a Representative in Congress From
      the State of Texas.............................................    26
    The Honorable Charles W. Dent, a Representative in Congress From
      the State of Pennsylvania......................................    29
    The Honorable Bob Etheridge, a Representative in Congress From
      the State of North Carolina....................................    18
    The Honorable Nita M. Lowey, a Representative in Congress From
      the State of New York..........................................    61
    The Honorable Eleanor Holmes Norton, a Delegate in Congress From
      the District...................................................    30
    The Honorable Mark E. Souder, a Representative in Congress From
      the State of Indiana...........................................    21

                                   Witnesses
                                    Panel I

    Ms. Cynthia A. Bascetta, Director, Health Care, Government
      Accountability Office..........................................    12
    John Howard, MD, Director, National Institute for Occupational
      Health and Safety, Centers for Disease Control and Prevention,
      Department of Health and Human Services:
      Oral Statement.................................................     8
      Prepared Statement.............................................     8
    Jon R. Krohmer, MD, F.A.C.E.P. Deputy Chief Medical Officer,
      Department of Homeland Security:
      Oral Statement.................................................     4
      Prepared Statement.............................................     6

                                   Panell II

    Philip J. Landrigan, MD, MSc, Professor and Chairman, Department
      of Community and Preventive Medicine, Mount Sinai School of
      Medicine:
      Oral Statement.................................................    33
      Prepared Statement.............................................    35
    Mike D. McDaniel, PhD, Secretary, Louisiana Department of
      Environmental Quality:
      Oral Statement.................................................    47
      Prepared Statement.............................................    50
    Deputy Chief Nicholas Visconti, International Association of Fire
      Fighters:
      Oral Statement.................................................    39
      Prepared Statement.............................................    41

                                    Appendix

    Additional Questions and Responses:
      Responses from Ms. Cynthia A. Bascetta.........................    71
      Responses from John Howard, MD.................................    72
      Responses from Jon R. Krohmer, MD..............................    74
      Responses from Philip J. Landrigan, MD.........................    78
      Responses from Mike D. McDaniel, PhD...........................    80

    PROTECTING THE PROTECTORS: ENSURING THE HEALTH AND SAFETY OF OUR FIRST
                RESPONDERS IN THE WAKE OF CATASTROPHIC DISASTERS

                                  ----------

                          Thursday, September 20, 2007

                         U.S. House of Representatives,
                                Committee on Homeland Security,
                                                        Washington, DC.
        The committee met, pursuant to call, at 10:04 a.m., in Room
    311, Cannon House Office Building, Hon. Bennie G. Thompson
    [chairman of the committee] presiding.
        Present: Representatives Thompson, Sanchez, Lowey, Norton,
    Christensen, Etheridge, Cuellar, Clarke, King, Souder, Dent,
    Bilirakis, McCaul and Lofgren.
        Chairman Thompson. The Committee on Homeland Security will
    come to order.
        Good morning. On behalf of the members of the committee,
    let me welcome our witnesses.
        The committee is meeting today to discuss how we can ensure
    the health and safety of our first responders following
    disasters, whether they are manmade or natural.
        Following the collapse of the World Trade Center,
    approximately 40,000 responders involved in the rescue,
    recovery and cleanup were exposed to a mixture of dust, debris
    and smoke-filled lethal substances. As time has gone on,
    firefighters, law enforcement officers, EMTs and workers in the
    construction trades increasingly have gotten sick, most often
    with respiratory illnesses.
        I look forward to hearing from our witnesses on the status
    of the various medical monitoring and treatment programs that
    have been put into place to address these issues at the site of
    the World Trade Center.
        Subsequently, in August of 2005, Hurricane Katrina
    devastated the Gulf Coast, flooding 80 percent of the city of
    New Orleans with up to 15 feet of water. Millions of gallons of
    oil were released from storage facilities, and tons of wreckage
    from abandoned cars, homes and refrigerators were left in its
    wake. First responders who came from all over the country to
    help the residents of Louisiana and my home State of
    Mississippi were exposed to filthy flood water filled with
    agricultural and industrial waste and sewage. However, there
    currently is not a system in place to adequately track their
    health, and I worry that the long-term impacts may never be
    completely known.
        In addition, we cannot forget the psychological trauma of
    our first responders, who are exposed to tragedies like 9/11,
    Katrina and Oklahoma City bombings. While working in these
    situations, they see things and have experiences that take a
    serious toll on their mental health being. This often leads to
    post-traumatic stress disorder. Currently, FEMA will fund
    short-term crisis counseling, but Federal assistance does not
    extend to psychiatric and, often, long-term treatment for
    conditions that stem from disasters. We need to examine whether
    the Federal Government should do more in this area.
        Effective health and safety should not be limited to
    monitoring and treating our heroes after they get sick; we
    should also be focused on preventive measures. No firefighter,
    law enforcement officer or EMT should go without the personal
    protective equipment or training they need to be safe. The
    various Federal first responder grant programs are critical in
    accomplishing this goal, and we must reverse the trend of
    budget cuts we have seen in recent years for many of those
    programs.
        In addition, while the issues of interoperable
    communication is not often considered a health and safety
    issue, it absolutely is. Many firefighters who lost their lives
    in the World Trade Center on 9/11 could have been saved if they
    had better communications.
        Finally, while I believe it is critical to examine what
    went wrong in past disasters and how we are taking care of our
    sick emergency workers, I hope we can translate the lessons
    learned from these tragedies into positive changes. However, I
    still have my doubts whether there has been sufficient planning
    and coordination between and among all the relevant Federal
    agencies. Everyone needs to know their respective roles and
    responsibilities in the areas of worker safety and medical
    monitoring. Unfortunately, this country again will have to face
    another 9/11 or Katrina. We must act now to ensure that we
    protect those who bravely put their lives on the line to
    protect us.
        I want to thank the witnesses again for their testimony.
        And the Chair now recognizes the ranking minority member of
    the full committee, the gentleman from New York, Mr. King, for
    any statement he may have.
        Mr. King. Thank you, Mr. Chairman. Thank you for
    recognizing me. More importantly, thanks for holding this
    hearing on an issue which is very important and certainly must
    be addressed.
        My own district in New York lost almost 150 constituents on
    September 11. In addition to those who were lost, there are
    also many who are still suffering and an increasing number who
    are suffering health effects from the recovery effort and the
    rescue work that went on on September 11 and in, literally, the
    months and months that followed that.
        Obviously, there is a significant role for Congress to
    play. There is also a significant role for local and State
    governments to play, and it is important that we recognize and
    acknowledge the situation that does exist.
        New York was probably as well-prepared as anyone could be
    for a disaster of this type, and yet we saw much more that had
    to be done that wasn't. The FDNY, the NYPD, were as well-
    trained as any units in the country could be, yet no one was
    quite ready for an attack of this magnitude, of this enormity.
    And, certainly, what was done in the days and weeks after did
    contribute to lingering and, in too many cases, actual fatal
    effects from what went on during the recovery effort.
        I am supporting legislation, along with Congresswoman
    Maloney and Congressman Fossella, to enable those who do suffer
    from the effects of September 11 to be able to be compensated
    from the Victim Compensation Fund, because that fund was made
    available to people who were injured or wounded on September
    11, and many of the illnesses we are finding now were not known
    as of the time the deadline for filing claims expired. I think
    it is important we go forward with that.
        I want to commend Mount Sinai Hospital in New York for the
    program that they have. They really have stepped up on this and
    are doing an extraordinary job of monitoring and analyzing the
    effects of September 11.
        Also, fortunately, the FDNY had a program in place which
    makes it easier--I don't know if ``easier'' is the right word
    or not, but I will say easier--to notice effects of September
    11, since they have a backdrop against which they can base
    their current analysis, current health conditions, because of
    the history of examinations that are being held by the FDNY.
        But this is a very significant hearing. We have to, in
    planning for the future of September 11--as tragic as it was,
    it could have been worse--it could be worse in the future. We
    have to, when we are preparing for catastrophes, use September
    11 as an example of just how bad it can be and even worse. And
    we have to be better prepared for all contingencies: to stop
    the attack or the natural disaster, as happened in Katrina; to
    prevent it to the extent that it can be done; to address it at
    the time it is happening; and then to be ready in the immediate
    and subsequent aftermath to address the first responders who
    put their lives and health on the line to protect so many
    people, to rescue so many people and to recover the remains of
    those who do not survive the attack or the natural disaster.
        So I look forward to the hearing. Unfortunately, I will not
    be able to stay throughout the hearing, but if Congressman
    Bilirakis will fill in for a while, I would certainly
    appreciate it. My staff will be updating me, and I will
    certainly study all the testimony and the transcript.
        Mr. Chairman, I yield back. Thank you for holding this
    hearing.
        Chairman Thompson. Thank you very much, Ranking Member
    King.
        Other members of the committee are reminded that, under
    committee rules, opening statements may be submitted for the
    record.
        I welcome the panel of witnesses.
        Our first witness, Dr. Jon Krohmer is the Deputy Assistant
    Secretary for Health Affairs and Deputy Chief Medical Officer
    for the Office of Health Affairs in the Department of Homeland
    Security. Dr. Krohmer is a physician trained in emergency
    medicine and has been a real leader in this field. He has held
    a variety of leadership positions, including president of the
    National Association of EMS Physicians. His work in setting
    standards for EMS providers of all types is well-recognized.
        Our second witness, Dr. John Howard, is Director of the
    National Institute for Occupational Safety and Health and a
    fellow coordinator for the World Trade Center health issues.
    Dr. Howard is an occupational physician who has emphasized both
    occupational health and public safety during his career.
        Our third witness is Ms. Cynthia Bascetta, Director of the
    Health Care Division of the Government Accountability Office,
    at the GAO. Ms. Bascetta has addressed a number of issues,
    including bioterrorism preparedness, veteran affairs, military
    health care, as well as health-related issues generated by the
    situations of concern to us today, Hurricane Katrina and the
    WTC.
        We thank all three of our witnesses for their service to
    the Nation and for being here today.
        Without objection, the witnesses' full statements will be
    inserted in the record.
        I now ask each witness to summarize his or her statement
    for 5 minutes, beginning with Dr. Krohmer.

       STATEMENT OF JON R. KROHMER, MD, F.A.C.E.P, DEPUTY CHIEF
            MEDICAL OFFICER, DEPARTMENT OF HOMELAND SECURITY

        Dr. Krohmer. Mr. Chairman, Ranking Member King and members
    of the committee, as you noted, I am the Deputy Assistant
    Secretary of Health Affairs and the Deputy Chief Medical
    Officer in the Department of Homeland Security. Thank you for
    the opportunity to testify before the committee on this
    critical issue of first responder health and safety.
        On behalf of Secretary Chertoff, Dr. Runge, the Acting
    Assistant Secretary and Chief Medical Officer, and the
    Department, thank you for your continued leadership and
    willingness to work with the Department to address the issues
    facing our Nation's health care security.
        The Office of Health Affairs serves as the Department's
    principal agent for all medical and public health issues and is
    responsible for ensuring a unified program for medical support
    of the Department's missions, to include the integration of
    occupational medicine and workforce protection principles
    whenever DHS personnel are deployed during a critical incident.
        Our goal in the Office of Health Affairs is to work closely
    with our safety and environmental sciences colleagues to have a
    comprehensive approach to health and safety for all employees
    of the Department, regardless of their work setting. My role
    today is not to discuss the overall approach to health and
    safety of first responders nationally, but to focus on that of
    DHS employees.
        Within the emergency response community, there is an axiom
    that we must care for those who care for others. Ensuring
    scientifically sound, compassionate and comprehensive health
    and safety support for emergency responders is a priority for
    all government agencies.
        In the aftermath of the attacks of September 11 and the
    Gulf Coast hurricanes, emergency personnel were exposed to a
    number of environmental contaminants and irritants. We have
    learned a great deal from those events, but we still have
    progress to make.
        Our DHS first responder role is actually fairly minimal. In
    general, the first people on site in any incident will be the
    local and State emergency services personnel. However, once
    Federal assistance is requested, DHS will deploy early
    responder personnel while incidents are still in flux and do
    not have a typical safety and support system in place.
    Consequently, we must have the same concerns for our early
    responders that we do for the local communities' first
    responders.
        At the Department level, we now have two offices that work
    together to provide policies, requirements, standards and
    metrics to support safety and health functions. In addition to
    the Office of Health Affairs, the Office of Safety and
    Environmental Programs, or OSEP, provides guidance, oversight
    and advocacy for the safety and health needs of the components.
    Collectively, our role is to facilitate and coordinate
    occupational health issues and the expanding functions to
    improve specific responder safety across components.
        Within the Office of Health Affairs, we have recently
    established the Office of Component Services to focus on
    optimizing health-related services and consultations in DHS.
    This program will partner with OSEP to ensure that occupational
    medicine principles are incorporated throughout the Department.
    This partnership, with each office bringing specific
    complementary skill sets to the program, increases program
    benefits. Additionally, by placing the head of the Component
    Services Office, a physician, as a direct report to the
    Assistant Secretary for Health Affairs, we are ensuring that
    these critical issues have high visibility and a well-
    positioned advocate within DHS.
        The first new position we have filled within Component
    Services is the Director for Workforce Health Promotion and
    Wellness. This position will address such issues as medical and
    physical recommendations for deployment to critical incidents
    and the health and safety training requirements for those
    responders.
        With OSEP, this branch will also develop standards and
    policies for environmental and safety assessments of areas to
    which DHS personnel are deployed and the resulting requirements
    for appropriate personal protective equipment. Soon, we will
    also be hiring an occupational medicine physician, who will
    work to provide medical guidelines and recommendations for the
    physical and medical preparations of responders and to develop
    plans for medical and psychological assistance for personnel
    during and after deployments.
        Direct medical support for DHS personnel responding to
    critical situations is also a primary consideration of our
    office. We recognize that there will be certain intensive
    operations which are unique to these responders. We are in the
    process of hiring a physician director for emergency medical
    services, who will have a specific goal of ensuring that the
    operational personnel of the Department have the appropriate
    medical support services in place, to give them the confidence
    that DHS will do everything in our power to take care of them
    medically.
        We also recognize the need for horizontal and vertical
    integration and will strive to work across the Federal
    Government and through our State, territorial, tribal and local
    partners to ensure that there is a integrated approach to the
    health and safety issues of all first responders.
        Mr. Chairman, I appreciate the opportunity to outline for
    the committee the importance that DHS puts on ensuring the
    health and safety of our responders, and we will look forward
    to answering any questions you might have.
        [The statement of Dr. Krohmer follows:]

              Prepared Statement of Jon R. Krohmer, MD, F.A.C.E.P.

        Mr. Chairman, Ranking Member King, and Members of the Committee:
        I am Dr. Jon Krohmer, the Deputy Assistant Secretary for Health
    Affairs and Deputy Chief Medical Officer within the Department of
    Homeland Security. Let me begin by thanking you for the opportunity to
    testify before the Committee on these critical issues related to
    ensuring the health and safety of our nation's first responders. In
    addition, on behalf of Secretary Chertoff, Dr. Runge--the Acting
    Assistant Secretary and the Chief Medical Officer--and the rest of the
    Department, thank you for your continued leadership and willingness to
    work with the Department to address many of the issues facing our
    nation's security.
        My office, the Office of Health Affairs, serves as the Department's
    principal agent for all medical and public health matters and is
    responsible for ensuring a unified program for medical support of the
    Department's missions, including the integration of occupational
    medicine and workforce protection principles into the occupational
    health and safety programs of DHS and its components. Importantly, this
    includes ensuring that these principles are applied whenever DHS
    personnel are deployed in a response role during any critical incident.
        One point that I would like to make at the outset is that while
    today's hearing is focused on ``first responders,'' our goal in the
    Office of Health Affairs is to work hand-in-hand with our safety and
    environmental sciences colleagues to have a comprehensive approach to
    health and safety for employees of the Department, from those who are
    working in a climate controlled office, to those protecting our borders
    and airports, to those who are deploying on no-notice to the worst
    imaginable disasters, both natural and man-made. Importantly, my role
    here today is not to discuss the overall approach to health and safety
    of first responders nationally, but to focus on how the Department of
    Homeland Security is working to ensure the health and safety of early
    responders from the component agencies of DHS, including TSA, CBP,
    Coast Guard, FEMA and others.
        Within the emergency response community, it is an axiom that we
    must ``care for those who care for others.'' Ensuring scientifically
    sound, compassionate, and comprehensive health and safety support for
    emergency responders is a priority for all government agencies involved
    in emergency response. In the aftermath of the attacks of September
    11th and Hurricane Katrina, emergency personnel and others involved in
    the response effort were exposed to a number of environmental
    contaminants and irritants. These were, obviously, large scale events
    for the responder community, and even for the greater public health
    community, but, as you know, today we must think about the unthinkable.
    Initial safety assessments and the safety measures applied to incident
    management of those events were not what they would be today, based on
    the lessons we have learned from those events. We have learned a great
    deal from those events, both in terms of how we protect our first
    responders and in the long-term management of those involved, but we
    still have progress to make. My colleagues testifying today will detail
    many of the lessons learned and actions that have been taken in
    response to those events. I have been asked to discuss how DHS has
    taken those lessons-learned and what is being done now to ensure that
    responder health and safety advances are moving forward.
        Let me also add that our DHS ``first responder'' role is actually
    fairly minimal, as we know that, in general, the first people on site
    in any incident will be the local and state emergency services
    personnel. However, once assistance from the Federal Government is
    requested DHS will deploy ``early responder'' personnel to respond to
    incidents that are still in flux and do not have the usual safety and
    support systems in place. Consequently, we must have the same concerns
    for these ``early responders'' that we do for the local community's
    first responders.
        DHS occupational safety and health programs, including those
    supporting personnel who respond to major disasters and other
    catastrophies, have historically been a function of management because
    they directly affect the efficiency and productivity of the workforce
    and because they are often seen primarily as responsive to laws and
    regulations related to the Occupational Safety and Health Act. These
    functions are managed primarily by the safety offices within the
    individual operating components. At the Department level, we have two
    offices that work in close coordination to provide policies,
    requirements, standards and metrics to support the safety and health
    functions at the component level. In addition to the Office of Health
    Affairs, the Office of Safety and Environmental Programs, or ``OSEP,''
    provides guidance, oversight and, importantly, advocacy for the safety
    and health needs of the components. Collectively, our role is to
    facilitate and coordinate the occupational health issues across
    components. It is a combination of oversight management (e.g. ensuring
    OSHA rules are applied in all situations) and the more recently
    expanding functions to improve specific first responder safety across
    all components.
        Within the Office of Health Affairs, we have recently established
    the Office of Component Services to focus on optimizing health related
    services and consultations for component agencies of DHS. I would like
    to take a few moments to outline the objectives of the office that bear
    on the health and safety of our response personnel.
        The Office of Component Services will partner with OSEP to ensure
    that occupational medicine principles are incorporated. This
    partnership, with each office bringing specific complimentary skill-
    sets to the program, increases program benefits throughout the
    Department. Additionally, by placing the head of the Component Services
    office as a direct report to the Assistant Secretary for Health
    Affairs, we are ensuring that these critical safety and health issues
    have high visibility and have a well positioned advocate within DHS.
        The first new position we have filled within Component Services is
    a Director for Workforce Health Promotion and Wellness, who will
    directly address the concerns of our response personnel. Staffed with
    an Industrial Hygienist and supported by the physician staff of the
    Office, this position will address such issues as medical and physical
    recommendations for deployments to critical incidents, including
    vaccination and preventive medicine services, as well as the health and
    safety training requirements for responders. Additionally, in
    conjunction with OSEP, this branch will be well-positioned to develop
    standards and policies for environmental and safety assessments of
    areas to which DHS personnel are deployed, and the resulting
    requirements for personal protective equipment, or PPE, for our
    personnel.
        Over the coming weeks, we will also be bringing on board an
    Occupational Medicine Physician who will work with the Human Capital
    Office and the individual DHS components to provide medical guidance
    and recommendations for the physical and medical preparation of
    responders and to develop plans for medical and psychological
    assistance for personnel during and after deployments.
        Direct medical support for DHS personnel, particularly those
    responding to critical situations, is also a primary consideration in
    the event that prevention efforts are overwhelmed in a disaster
    situation. In general, medical systems established in a disaster
    setting will take care of both victims and responders. At the same
    time, however, we recognize that there will be certain intensive
    operations which are unique to responders, including aviation response,
    wilderness rescue, toxic environments, and so on. We are in the process
    of hiring a Director for Emergency Medical Services who will have the
    specific goal of ensuring that the operational personnel of the
    department, in either a law enforcement role, or a responder role, have
    the right medical support services in place to give them the confidence
    that DHS will do everything in our power to take care of them
    medically.
        Finally, I would like to note that we also recognize the need for
    horizontal and vertical integration of response to early responder
    health and safety issues. This response is not just a local issue, nor
    a state issue, nor an HHS issue, nor a DHS issue. Instead, ensuring the
    safety of our first responders is a shared obligation that the entire
    response community has to those who put themselves in harm's way for
    the betterment and safety of others. We will always strive to work
    across the federal government and through our state, territorial,
    tribal, and local partners to ensure that there is an integrated
    approach to ensuring the health and safety of all first responders.
        Mr. Chairman, I appreciate the opportunity to have outlined for you
    today the importance that the Department of Homeland Security places on
    ensuring the health and safety of our response personnel and look
    forward to answering any questions you may have on these matters.

        Chairman Thompson. Thank you for your testimony.
        I now recognize Dr. Howard to summarize his statement for 5
    minutes.
        Dr. Howard?

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

        Dr. Howard. Thank you, Mr. Chairman and members of the
    subcommittee. I am from the National Institute for Occupational
    Safety and Health, NIOSH, in the Centers for Disease Control
    and Prevention, of the Department of Health and Human Services.
        I am pleased to be here today to share with you some on
    observations about ensuring responder safety and health based
    on my experience in coordinating programs of the Department for
    World Trade Center volunteers.
        Over 36,000 World Trade Center responders and volunteers
    from across the country are currently enrolled in a federally
    funded medical monitoring and treatment program. Just over
    7,000 of these responders are being treated for physical health
    ailments and nearly 5,000 for mental health conditions
    associated with their heroic response to the World Trade Center
    attacks.
        Also, in collaboration with the New York City Department of
    Health and Mental Hygiene, the Department funds the World Trade
    Center Health Registry. The registry tracks the health of
    71,000 responders, residents, office workers, students, school
    staff and those present in the area of the World Trade Center
    on September 11, 2001. The registry's findings provide an
    important picture of the long-term physical and mental health
    consequences of September 11.
        These programs, as well as NIOSH-funded studies since 2001,
    have generated a body of knowledge that indicates the
    importance of ensuring the safety and the health of disaster
    responders before they are deployed, while they are deployed
    and after deployment.
        Before deployment, it is critical to provide pre-event
    training about likely hazards and hands-on instruction in the
    use of personal protective equipment.
        While responders are deployed, it is critical, at a
    minimum, to: one, compile a list of responders and their daily,
    individual disaster site exposure profiles; two, reinforce
    training with on-scene training, especially for spontaneous or
    unaffiliated responders who volunteer their services; three,
    establish integrated safety management among all responding
    agencies; four, set up tight disaster site perimeter control;
    five, rigorously track responder entry and exit from that site;
    six, employ shift rotation to enable shorter duration of
    service at the site; and, seven, engage in real-time exposure
    assessment and hazard control.
        After deployment, it is critical to screen responders for
    health effects based on exposure assessment findings or the
    occurrence of symptoms. Positive findings would then lead to
    long-term medical monitoring and treatment, as necessary.
        Thank you, Mr. Chairman. I would be pleased to answer any
    questions you might have.
        [The statement of Dr. Howard follows:]

                 Prepared Statement of John Howard, MD, M.P.H.

        Good morning, Chairman Thompson and other distinguished Members of
    the Committee. 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
    addressing the critical need of ensuring the health and safety of our
    first responders. 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 NIOSH's ongoing activities to protect responders in
    general.
        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 towards these tasks, lessons
    learned, and NIOSH's efforts to address responders' needs for future
    disasters.
        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.
        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--which is now the Office of the Assistant Secretary for
    Preparedness and Response (ASPR)--received $3.74 million through
    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 Federal 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 to assist in rescue efforts 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 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 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
    and mental health resulting from the exposure of nearby residents,
    school children and workers to WTC dust, smoke and debris.
        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.
        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. 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.

        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) provided $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.

        Lessons Learned
        In December 2001, NIOSH convened a conference to explore lessons
    about preserving the safety and health of emergency responders in the
    context of terrorist attacks, organized and led by the RAND Science and
    Technology Policy Institute in New York City. This conference and
    subsequent evaluations of response efforts to large-scale disasters
    concluded that there is a critical need for:
             Accessibility to protective and practical personal
            protective equipment (PPE) and hazard monitoring technologies;
             Interagency training to aid in the effective
            implementation of health and safety measures and PPE
            enforcement;
             Quick and effective establishment of a command
            authority over the disaster site and perimeter control; and
             Tracking of responders.
        In my experience as WTC Health Coordinator, I have learned that we
    must address responder safety and health in three stages: pre-
    deployment, deployment and post-deployment. During the pre-deployment
    stage, prior to the initiation of a response, all responders need to be
    adequately trained to recognize and protect themselves from health and
    safety hazards. Adequate preparation is especially important for
    spontaneous or unaffiliated responders who volunteer their services. As
    reported in findings based on WTC Health Registry data, these
    responders are often more adversely affected, possibly due to a lack of
    health and safety training (American Journal of Psychiatry, 2007; 164;
    1385--1394). During the deployment stage, when responders are actively
    engaged in the response effort, it is critical to track responders'
    access to the disaster site and conduct real-time exposure assessment.
    Knowing where responders have gone and their potential exposures will
    enable us to more accurately assess their health effects and determine
    their post-deployment needs. During post-deployment, once the response
    effort is completed, responders should be screened for health (physical
    and emotional) effects, if exposure assessment or the occurrence of
    symptoms indicates. These findings could then be used to determine if
    long-term monitoring and treatment are necessary. To ensure responder
    safety and health during future disaster events, we must address each
    of these stages.

        Additional NIOSH Programs
        In addition to WTC-related programs, NIOSH continues to conduct
    research and make recommendations to protect the health and safety of
    first responders and recovery workers through various program
    activities.
        In the aftermath of disasters, NIOSH actively participates in the
    response effort and identifies staff to provide technical expertise to
    meet immediate worker protection needs. As outlined by the Worker
    Safety and Health Annex of the National Response Plan, NIOSH provides
    assistance on occupational exposure assessments, provides guidance on
    personal protective equipment, and develops and disseminates guidelines
    to integrate worker safety and health into site operations. NIOSH works
    with multidisciplinary occupational safety and health teams to develop
    procedures for follow-up evaluations of worker injuries, conduct health
    hazard evaluations (HHEs) and provide technical assistance to local,
    state, and Federal governmental agencies to assess potential health
    effects from workers' exposures in the recovery zone.
        NIOSH also conducts research to address the critical need for
    effective personal protective technologies, such as respirators,
    chemical-resistant clothing, hearing protectors, and safety goggles and
    glasses that provide a barrier between the worker and an occupational
    safety or health risk. Building upon NIOSH's longstanding respiratory
    certification and evaluation program for respirators used in
    traditional work settings, NIOSH scientists test and approve
    respirators for use by responders against chemical, biological,
    radiological, and nuclear (CBRN) agents. Since 9/11, NIOSH has approved
    77 different models of CBRN respirators. Our work has led to an
    increase in the national inventory of respiratory protection equipment
    and supports the long-term development of standards and technologies
    for protecting the health and safety of workers, especially first
    responders.
        NIOSH addresses hazards specific to fire fighters through the Fire
    Fighter Fatality Investigation and Prevention Program. Through this
    program NIOSH conducts in-depth evaluations of fire fighter line-of-
    duty deaths to formulate recommendations for preventing future deaths
    and injuries. The goals of the program are to: better define the
    characteristics of line-of-duty deaths among fire fighters, develop
    recommendations for the prevention of deaths and injuries, and
    disseminate prevention strategies to the fire service.
        Additionally, NIOSH has developed an aggressive Research Portfolio
    to address a wide range of research needs in the emergency response
    community. Examples of proposed research include developing tools to
    improve safety climate, advances in personal protective equipment,
    enhanced medical surveillance methods for responders and recovery
    workers, and advancing environmental sampling strategies.
        NIOSH is committed to protecting the health and safety of workers,
    and is actively working to address the critical needs of first
    responders. 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.

        Chairman Thompson. Thank you very much, Dr. Howard, for
    your testimony.
        I now recognize Ms. Cynthia Bascetta to summarize your
    statement for 5 minutes.

       STATEMENT OF CYNTHIA A. BASCETTA, DIRECTOR, HEALTH CARE,
                    GOVERNMENT ACCOUNTABILITY OFFICE

        Ms. Bascetta. Thank you, Mr. Chairman and members of the
    committee. I am happy to be here to participate in your hearing
    today on protecting the protecters.
        As you know, the 9/11 responders were exposed to numerous
    physical hazards, environmental toxins and psychological
    trauma, which continue to exact a heavy toll for many of them 6
    years after the World Trade Center attack.
        My testimony is based primarily on our July 2007 report and
    our prior work, which found that the screening program for
    Federal responders had accomplished little and lagged behind
    programs for other responders, and highlighted similar problems
    with the provision of services for non-Federal responders
    residing outside the New York metro area. We also identified
    lessons learned from the World Trade Center health programs
    that could be helpful in responding to future disasters.
        My remarks today focus on the status of services for
    Federal responders and non-Federal responders who came from
    across the Nation in the aftermath of the attack. I will also
    highlight three lessons learned that were common to the World
    Trade Center and the Hurricane Katrina disaster.
        Regarding 9/11 Federal responders, we reported, this July,
    that HHS has had continuing difficulties ensuring the
    uninterrupted service for them.
        First, the availability of screening examinations has been
    intermittent. HHS suspended screening exams from March 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 arranged in time to keep the program fully
    operational.
        Second, the provision of specialty diagnostic services
    often needed for ear, nose, throat, heart and lung problems has
    also been intermittent. 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 services for Federal
    responders to include monitoring exams, the same follow-up
    physical and mental health exams provided to other categories
    of responders. Unlike other responders, whose programs were
    designed to monitor their health over time, Federal responders
    are only entitled to a one-time screening examination. Without
    monitoring, their health conditions may not be diagnosed and
    treated, and knowledge of the health effects caused by the
    World Trade Center disaster may be incomplete.
        We also found that NIOSH has not ensured the availability
    of screening and monitoring services for non-Federal responders
    outside the New York City area, although it recently took steps
    to expand their availability. Similar to the intermittent
    service patterns for Federal responders, NIOSH's arrangements
    for a network of occupational health clinics to provide
    services nationwide were on-again, off-again. This May, NIOSH
    renewed its efforts to expand a provider network and has
    completed about 20 exams.
        The start-and-stop history of HHS'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 successful and sustained over time. As a result, we
    recommended in July 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 this
    recommendation.
        Mr. Chairman, our testimony also highlights three lessons
    learned from the World Trade Center health programs that could
    improve future responses to disasters.
        First, having a roster of who responded is key to
    identifying and monitoring health effects that they may have
    experienced. This seems obvious, yet 4 years after 9/11, no one
    was assigned the responsibility for collecting data on the
    total numbers of response and recovery workers deployed to the
    Gulf in the aftermath of Hurricane Katrina.
        Second, health monitoring could benefit from centrally
    coordinated planning to facilitate compatible data collection
    among monitoring efforts. Our work on Hurricane Katrina noted
    that, in general, no systemic health monitoring for responders
    occurred, and we recommended that Federal agencies resolve
    their disagreement over who should fund medical monitoring of
    responders.
        And finally, efforts to address health effects should
    include both physical and mental health. The New York/New
    Jersey World Trade Center consortium officials told us that
    initial Federal funding was not sufficient to cover mental
    health needs, but they were able to obtain philanthropic funds
    to address psychiatric screening and more extensive evaluations
    when necessary.
        This concludes my remarks, and I would be happy to answer
    any questions you or the other committee members might have.
        [The statement of Ms. Bascetta follows:] \1\
    ---------------------------------------------------------------------------
        \1\ See GAO, ``SEPTEMBER 11: Problems Remain in Planning for and
    Providing Health Screening and Monitoring Services for Responders'',
    GAO-07-1253T, Thursday, September 20, 2007.
    ---------------------------------------------------------------------------
        Chairman Thompson. Thank you very much.
        I want to again thank the witnesses for their testimony.
        I will remind each member that he or she will have 5
    minutes to question the panel.
        I will now recognize myself for the first questions.
        Dr. Krohmer, what has the Office of Health Affairs done, to
    date, to address the needs of people who respond to disasters
    like 9/11 or Katrina?
        Dr. Krohmer. Well, you are aware, Mr. Chairman, the Office
    of Health Affairs really stood up and started to address some
    of the issues just in March of this year, and through some
    supplemental funding and reprogramming that was provided to us
    by the Congress just a couple months ago, are really in the
    process of building up to address those issues.
        As I mentioned, the Office of Component Services that we
    have, headed by Dr. Bill Lang, has some very aggressive plans
    that we hope to start implementing this fall, looking at some
    of the issues that have been identified, finding out how those
    specifically apply to our employees within DHS.
        Chairman Thompson. So before, say, March, who had that
    responsibility?
        Dr. Krohmer. Within DHS?
        Chairman Thompson. Yes.
        Dr. Krohmer. I think it was addressed somewhat peripherally
    by the Office of the Chief Medical Officer regarding input into
    some of the DHS programs. But other than that, there was not
    any direct involvement.
        Chairman Thompson. Okay.
        Dr. Howard, you talked about some experiences in things as
    coordinator of the World Trade Center health issues. Have you
    found the long-term monitoring and resources necessary to do
    that to be a problem?
        Dr. Howard. Mr. Chairman, at this time, no.
        Chairman Thompson. Well, at this time. Before this time?
        Dr. Howard. Beginning in 2001, very early, when the defense
    authorization bill for 2002 was being worked on in the
    Congress, money was provided to FEMA, which allowed us to begin
    a medical screening program within months of the disaster,
    which we began at Mount Sinai Medical Center.
        Chairman Thompson. Thanks. So you are saying that there
    were no problems associated with monitoring of first responders
    to the World Trade Center, it was not a resource, everything
    was done in a timely manner?
        Dr. Howard. In terms of resources, yes. We have had no
    shortage of resources to provide monitoring, and now adding
    treatment services in 2006.
        Chairman Thompson. Well, then I guess I need you to respond
    to what the GAO person said, which was kind of contradictory to
    your answer to me.
        Dr. Howard. Right. We have had difficulties, as GAO has
    pointed out, in interagency arrangements with regard to
    starting and stopping of the Federal program as well as the
    national program. There is no doubt of that, sir.
        I think, right now, we are on a good trajectory to screen
    all Federal responders. We are also working on a plan to, as
    Ms. Bascetta mentioned, get the Federal responders into the
    monitoring program that we run with our grantees, because one
    screening appointment, we do not feel, is enough.
        The national program--we now have a national contractor.
    Before, one of our issues was the geographical distribution of
    the responders that came from all 50 States, Puerto Rico and
    many U.S. territories, and the location of the services that
    they could avail themselves of. We now have a national
    contractor for that.
        Chairman Thompson. All right.
        Ms. Bascetta, can you shed a little light on that same
    issue?
        Ms. Bascetta. I don't disagree with what Dr. Howard said,
    regarding the resources. For monitoring in particular, there
    has been adequate funding. Ninety million dollars was provided
    by FEMA shortly after the attack, and that money was used to do
    the monitoring that he discussed.
        The problem, as he said, has been in the interruptions in
    services because of administrative failures to assure that
    provider networks and the like were put in place to spend that
    money.
        Chairman Thompson. So maybe I asked the wrong question. So
    why have we heard from a number of people involved in both
    situations that they were not getting the services? So, now, is
    your testimony that the Federal Government failed to provide
    the monitoring services because certain agencies weren't
    talking to each other, or that Congress provided the resources
    but the agencies didn't talk to each other to get it done?
        Dr. Howard. I am not sure that either one of those
    explanations--I think it is a matter of administrative
    capability.
        What we have never done in NIOSH is establish a nationwide
    monitoring program. So individuals, wherever they are in the
    country, can travel just a small distance to be able to get a
    monitoring exam.
        That has been a real challenge, but it hasn't been a lack
    of financial resources. It is infrastructure implementation and
    coordination with a network of providers, because we have to
    have the physician network in order to see the monitoring exam
    patients.
        Chairman Thompson. So your testimony now, that if a 9/11 or
    Katrina--type event occurred today, all those necessary
    building blocks to monitor and follow the Federal responders
    are in place, and that would not be an interruption of any of
    the monitoring?
        Dr. Howard. Yes, sir, that is what I am saying.
        Ms. Bascetta. I am not as convinced. It seems to us, on our
    reading of the annex in the National Response Framework, that
    there are still questions about HHS and OSHA getting together
    to figure out when long-term monitoring needs to occur and who
    will pay for that and how that will be set up. We have concerns
    because the operational details of the annex aren't in place.
        So while I think that the situation at the World Trade
    Center actually worked pretty well for the people who could get
    services in New York, our work has shown that it has not worked
    well at all for those outside the New York City area or for
    Federal workers. And I am not convinced that future disasters
    will be much better.
        We know that, for a fact, in Katrina, there hasn't been
    long-term monitoring.
        Chairman Thompson. At all?
        Ms. Bascetta. Systematic, long-term monitoring. I believe
    one or two agencies may have done some monitoring on their own,
    including the Coast Guard.
        Chairman Thompson. Are you prepared to respond to GAO's
    comment with respect to that, Dr. Howard?
        Dr. Howard. I think GAO is talking about a larger global
    issue. I was talking about the narrow issue of just World Trade
    Center responders right now, in terms of Federal and nationwide
    responders being able to access monitoring services.
        I think what Ms. Bascetta was talking about is a very large
    issue, which I am not as well-versed in, in terms of the
    overall national plan. I know that, from our agency's
    viewpoint, at CDC and NIOSH, we work cooperatively with OSHA,
    who works cooperatively with DHS, to look at some of these
    long-term issues. We are primarily a research agency supplying
    our research findings to any Federal department that is
    interested in responder safety and health.
        Chairman Thompson. So is your testimony, Ms. Bascetta, that
    presently there is no Federal operational manual for the long-
    term care and monitoring of Federal first responders?
        Ms. Bascetta. That is correct. We haven't seen the
    operational details for that plan, as Dr. Howard said, on a
    global scale. I would agree that they are on a better
    trajectory, with regard to the World Trade Center, but, again,
    you know, because of the past history, we really need to see a
    track record of following through with uninterrupted services
    for the Federal responders and for the non-Federal responders
    who don't live in the New York City area.
        Chairman Thompson. Thank you.
        I yield to the ranking member.
        Mr. Bilirakis. Mr. Chairman, I appreciate it very much.
        To follow up on your comments, Mr. Chairman, this is for
    all three panelists.
        In your view, does the National Response Plan, soon to be
    known as the National Response Framework, adequately assign
    roles and responsibilities, with respect to protecting the
    health and safety of first responders in the wake of a
    disaster?
        Dr. Krohmer. I guess I will take a stab at that one first.
        As you are aware, ESF-8, the Emergency Support Function 8
    that addresses public health and medical services as that
    annex, does include provisions for worker safety and health.
    Within the framework and the annex itself, there are general
    guidelines and observations of issues that need to be
    addressed, but it doesn't get down into the very specific
    operational issues.
        We would look forward to the opportunity of working both
    with HHS, NIOSH and ASPR, as well as the Department of Labor,
    to try and address some of those specific things. But I don't
    think it is the intent specifically of the National Response
    Framework to get down into the operational issues.
        Dr. Howard. From my perspective--and I have to give you a
    disclaimer: I am an occupational safety and health physician by
    profession, so I care very much about responder safety and
    health. And I would prefer to see that responder safety and
    health issue elevated a bit within the larger structure of the
    national response network.
        I can't speak for OSHA, who we partner with as technical
    support to OSHA, as they implement the safety and health
    support annex. But elevating the support annex to an essential
    support function is something that we at NIOSH would like to
    see, because we want to make sure that responder safety and
    health is put on par with victim safety and health and rescue.
        Mr. Bilirakis. Ms. Bascetta?
        Ms. Bascetta. I would say that, without the operational
    details that Dr. Krohmer said are not in place yet, we can't
    evaluate the adequacy of the framework. But we would certainly
    have concerns about the ability to protect first responders, or
    responders, without some assurance that those kinds of details
    are in place and that they would work well.
        Mr. Bilirakis. Thank you.
        Dr. Krohmer, in your written testimony, you said that DHS
    is working across the Federal Government and through State,
    territorial, tribal and local partners to ensure that there is
    an integrated approach to ensuring the health and safety of all
    first responders.
        How does the Office of Health Affairs coordinate with other
    Federal, State and local agencies to ensure that first
    responders receive adequate training and guidance to protect
    their health and safety?
        Dr. Krohmer. Well, this is a process and an activity that
    we are just now becoming involved with. As I mentioned earlier,
    a lot of the work that has been done in the Office of Health
    Affairs since we stood up in March has really been done at the
    senior management level.
        With the reorganization that we have undergone, we now have
    the Office of Medical Readiness, which is starting to ramp up.
    Up until very recently, it had a small staff with the associate
    chief medical officer, a couple of public health officers and a
    couple of Federal employees.
        But as we move into these activities, we will be working,
    really, in two areas. The first is as the subject matter
    experts for the various Homeland Security grant programs--the
    MMRS program, the U.S. Fire Administration grants and the
    general Homeland Security grants--to ensure that there are
    components within those grants that address issues of training,
    personnel protective equipment and the like for first
    responders, to make sure that their health and safety issues
    are addressed.
        In addition, within this Office of Medical Readiness, we
    are standing up a Division of First Response, that will work
    specifically through the FEMA regions with State and local
    first responder representatives to make sure that the health
    and safety issues of the first responders are addressed both at
    the State and local levels.
        So this is very much a program in evolution based on our
    ability to start to move forward in those areas.
        Mr. Bilirakis. Thank you, Mr. Chairman. I would like to
    take another round after, if that is okay. Thank you.
        Chairman Thompson. Thank you.
        We now yield 5 minutes to the gentleman from North
    Carolina, Mr. Etheridge.
        Mr. Etheridge. Thank you, Mr. Chairman.
        And let me thank you for being here today.
        A recent Harvard University study found that a significant
    link between firefighters and coronary heart disease was
    significant in the study. They pointed out that firefighters
    face up to 100 times their normal risk of heart attacks while
    working on a fire, and that accounts for roughly 45 percent of
    all the deaths of firefighters, volunteer and full-time paid
    professionals. Clearly, this is a concern with firefighters or
    anyone else who is considering a career or volunteer position
    in a local fire department.
        Congress has taken action to deal with that issue.
    Unfortunately, we can't seem to get the administration to seem
    to understand and read the language that Congress has passed. I
    think they have now paid about four of the 200-and-some claims
    that are still outstanding. So I would encourage you in the
    health area to work with the Department of Justice to see if we
    can't get this rock moved, to move it.
        If it just was last week, I wouldn't be as concerned. It
    was passed in 2003 and the President signed it, and it is still
    lounging around, and we can't seem to get anything done.
        My question to you is a little bit broader than that, as
    important as that is, because we have added emergency funding,
    fire grants, et cetera. What advice would you give the
    firefighters and other first responders through the rest of the
    country as they prepare to be volunteers? Because ultimately
    the bulk of our first responders are volunteers.
        And I believe, in your testimony, you said the Federal
    first responders. Well, if you look at the people who respond
    across America, they aren't Federal first responders. They are
    a very small part of it.
        Now, granted that is our first step, but a broader issue
    is, if we are going to ask people to respond along the
    interstate highways of this country and the airports, et
    cetera, et cetera, my guess is they aren't Federal folks; they
    are local first responders. What do we say to these folks and
    what is our obligation to them to help?
        So let me ask you first, Dr. Krohmer, what else should the
    Federal Government do to be prepared to address the health
    needs of first responders when they respond to the next
    catastrophe, if we aren't keeping a good list of those who
    responded in the past? When I just heard you testify that
    across the country, we don't have that list. What do we say to
    them?
        Dr. Krohmer. Well, I think your point about the responders
    in the country being first responders from the local
    communities is right on, I think, sir. I spent 20 years as an
    EMS physician and worked very closely with folks in the fire
    service and emergency medical services. I think that we have to
    continue to be very sensitive to their needs. We need to
    continue to work very closely with them----
        Mr. Etheridge. What does that mean, when you say ``being
    sensitive''?
        Dr. Krohmer. I think we need to work very closely with them
    to identify the issues that are of concern to them, figure out
    ways that we, at the Federal level, can support those.
        I mean, I don't know that it is any of the Federal
    agencies' responsibilities to dictate to a local police
    department, fire department or EMS agency that they need to do
    particular things. I think that we can establish standards and
    metrics to identify and highlight best practices and provide
    them with potential resources to do that.
        Mr. Etheridge. Well, let me ask the question a different
    way then.
        There are Federal highways, Federal aviation, there are
    Federal arteries in this country. And since 9/11, we have asked
    the local responders to respond. Now, they go, they get
    injured, they have long, lingering consequences. Do we not have
    an obligation, in some way, to help there, to their families?
    In most cases, these are single wage earners; they don't have a
    lot of money; they are volunteers.
        Dr. Krohmer. Well, I think probably more importantly than
    working with the individual first responders is working with
    the agencies that employ them, and identify ways that we can
    help agencies.
        Mr. Etheridge. A lot of these folks come from small,
    independent businesses.
        Dr. Krohmer. Well, but they are part of an organized
    response structure, whether that be a local fire department or
    volunteer fire department or local EMS----
        Mr. Etheridge. Are we doing anything to do that now?
        Dr. Krohmer. I am not familiar with programs----
        Mr. Etheridge. Would you get back to me on anything in that
    regard? It seems to me that is what the Department ought to be
    doing, if we are depending on them as our backbone, which,
    seems to me, that is how we are going to get there. Otherwise,
    because we can put all the people we want to in big buildings
    and we can do all the paperwork we want, but unless they
    respond to the call, the job doesn't get done.
        Dr. Krohmer. Correct.
        Mr. Etheridge. And they are doing a marvelous job. I mean,
    let's face it.
        Dr. Krohmer. They are.
        Mr. Etheridge. But I think, in a lot of cases, we don't
    really follow through. We finish up and talk about the last
    disaster, and then we start talking about getting ready for the
    next one. And unfortunately, we aren't always ready, and that
    bothers me greatly. I think that is what the chairman was
    getting to.
        And I have some other questions, Mr. Chairman, if we get to
    a second round.
        Chairman Thompson. Thank you very much.
        We have about 4 minutes left for votes. We have four votes.
    We will adjourn the hearing and reconvene in about 20 minutes.
    Thank you.
        [Recess.]
        Chairman Thompson. We would like to reconvene the hearing.
        Our next questioner is Dr. Christensen from the Virgin
    Islands, for 5 minutes.
        Mrs. Christensen. Thank you, Mr. Chairman, and thank you
    for having this hearing. This is a very important issue.
        Let me try to get in about three questions, if I could.
        Doctors Howard and Krohmer, I am not sure that--I do not
    think we quite answered this question. During the World Trade
    Center disaster and Hurricane Katrina, there was not an agency
    directed to coordinate and identify a greater roster of all of
    the respondents. In the future, which agency is responsible for
    this, for creating that roster, the list of all of the
    responders?
        Dr. Krohmer. Of all of the responders who were taking part
    in the response or who were----
        Mrs. Christensen. Who were on the ground, taking----
        Dr. Krohmer. That is an interesting idea, and I do not know
    that that has occurred to us.
        Mrs. Christensen. How do you keep track of who came and who
    responded so that we can do the exams and the monitoring and so
    forth? Which agency keeps track?
        Dr. Howard. One of the issues from the World Trade Center
    experience is that many governmental agencies, both on the
    city, State and Federal levels, did keep track. We have some
    good census data from those agencies. Where we really do not
    have good data is in the affiliated and unaffiliated
    volunteers. The Red Cross and the Salvation Army did a pretty
    good job, but a lot of folks in New York and for any disaster,
    they just come to help, and they are not affiliated with a
    particular agency. So, a lot of times, we do not capture those
    individuals.
        But my answer to that question would be the incident
    commander of the disaster really is the census-taker, in my
    view.
        Mrs. Christensen. Is that worked into exercises now? We
    have one coming up in October. Is there something in the
    National Response Framework that speaks to coordinating a list
    of responders so that we can follow them?
        Dr. Krohmer. As Dr. Howard mentioned, it is the
    responsibility of the incident commander of the event. I do not
    know if there is a Federal agency that has assumed
    responsibility for that.
        Mrs. Christensen. Do I understand that we still do not have
    any way of reaching those who came from outside of New York
    City and who are not Federal responders, to have them examined
    and monitored? If that is true, what is going to be done about
    that?
        I know I had responders. I am sure just about everybody on
    this committee had people going to New York, for example, to
    help, and to Katrina as well.
        Dr. Howard. Well, certainly, you make an excellent point.
    If we do not have a total census, then you cannot really know
    afterwards who was there at the time. So what you have to do is
    use alternative mechanisms. You have to look into the search
    and rescue logs of responders, who are by State, and see if any
    of them came. You have to reach out to them. You have to do a
    lot of outreach. For instance, in the Virgin Islands and in
    Puerto Rico, we have had to reach out to individuals who were
    part of that response structure and say, ``Were you there in
    New York? We want to make you aware----''
        Mrs. Christensen. So you have done that?
        Dr. Howard. We have tried very hard to make sure that
    everyone who we think might have shown up at least is aware of
    our monitoring program. But it is after the fact.
        Mrs. Christensen. Okay. Well, we realize that there was not
    what needed to be in place at the time, so that it had to be
    after the fact.
        I am concerned. I do not think I heard much about mental
    health today, and during both of those events and probably many
    others the mental health needs of the responders have not been,
    I think, adequately addressed.
        So what steps are being taken to better coordinate mental
    health needs during a response? Given that we still do not have
    mental health parity, what about those who are affected for the
    long term? What is in place for that?
        Dr. Howard. I think the mental health effects, the
    emotional health effects, of being a disaster responder are the
    real frontier in the area of responder safety and health.
        As an example, in the Annals of Psychiatry this month, the
    New York City World Trade Center Health Registry did a paper
    showing that the average post-traumatic stress disorder in
    responders went from about 6 percent in police officers up to
    21.2 percent in unaffiliated volunteers, and this speaks to the
    issue. For an unaffiliated volunteer, someone whose profession
    is not disaster response, we have to be very careful with those
    individuals in making sure that they have some pretraining and
    that, at the time, they are not exposed to some of the
    stressors, the mental health stressors, at any disaster. And at
    the World Trade Center, they were quite severe over prolonged
    periods of time. Because, then, what will happen is that we
    will get a higher prevalence of PTSD afterwards.
        So that is, to me, one of the most central lessons learned,
    in terms of folding in mental health both at the time of the
    deployment and then afterwards to assess a responder about what
    symptoms he or she might be feeling in terms of mental health
    issues.
        Mrs. Christensen. Thank you.
        Thank you, Mr. Chairman.
        Chairman Thompson. Thank you very much.
        I will now yield 5 minutes to the gentleman from Indiana,
    Mr. Souder.
        Mr. Souder. Thank you, Mr. Chairman.
        I am sorry I missed the opening statements. I did my best
    to catch up there as I came back.
        I am interested a little bit in the differences--obviously,
    when you are doing rescue, you are at higher risk than when you
    are doing recovery. Could you discuss that briefly?
        Then, in the Katrina situation, obviously, people pour in,
    and they start seeing the needs. I would like you to expound a
    little bit more on how you deal with the people both in rescue
    and recovery and how it might differ.
        Also, in Katrina, when our first group of Members were
    allowed in, they took us to a site in Mississippi, showed how
    the government was dealing with all of these things. And what
    we quickly learned on the ground, which, to my understanding,
    what is typical is that the nonprofit religious organizations
    were there roughly 7 days before the first government people
    were really getting involved. And I had people pour in from my
    churches down in there.
        How in the world--I mean, you talked a lot about what we do
    with government employees, and then you have State and local
    employees. But what about even the nonprofit sector, which, in
    recovery, almost anybody who looks at it--and when I challenged
    FEMA as to why they represented this as the model FEMA recovery
    effort, they said, ``Well, of course the religious groups are
    usually there as much as a week before we are all set up.'' I
    even visited a Buddhist organization that is often among the
    first there at these sites. And the government does not even
    necessarily know they are there, but clearly, they are facing
    all kinds of health risks in these kinds of situations.
        Do you view, as part of your mission, to deal with the
    nonprofits, as well as the State and local responders and the
    Federal? Then, if you can separate that, your answers, a little
    bit into rescue response in the nature of risks.
        Thank you.
        It is to any of you who want to take parts of that.
        Dr. Krohmer. Well, I think, certainly, from a techniques
    perspective, there are issues in terms of activities we would
    employ for rescue versus recovery. I think, in terms of the
    overall health and safety issues, they are probably fairly
    similar based on the environment that the folks are working in.
    I think one of the things----
        Mr. Souder. Let me see if I have a layman's understanding.
    If you think somebody is trapped in a house and they are going
    to die if you do not enter, you are likely to take more risks
    of whether that water is dangerous to your life, whether it is
    dangerous to your health, in order to save another life in a
    matter of minutes as opposed to recovery afterwards.
        Dr. Krohmer. Oh, certainly, from that perspective, that is
    very true. I was looking at the environment as being not
    terribly different from a rescue phase versus a recovery phase.
    You are still faced with the same environmental and potential
    health and safety risks.
        The issue of----
        Mr. Souder. Well, I am still confused. This is kind of a
    fundamental thing, but wouldn't the health and safety risks be
    substantially higher in the initial rescue than the recovery?
    Because, partly, you would have more time, you would have more
    time to calculate your decision. The place may be on fire. The
    intensity has not been dispersed as much in the pollutants that
    enter the water. Why would you say the risks are roughly the
    same, health risks?
        Dr. Krohmer. The risks are the same. How the rescuers
    respond to them, I think, is different in those two scenarios.
    You are correct. In a rescue scenario, there are a lot of
    situations where folks may not take the time to put on all of
    the personal protective equipment that they may have available
    to them during a recovery operation. We need to look at all of
    the environmental factors and make sure that the first
    responders have the appropriate PPE available during the rescue
    phase that they would likely also have available during the
    recovery phase. So, from a rescuer perspective, I think that
    there are some issues that we need to address.
        I think, in many situations, the environmental threats that
    they are faced with are very similar, okay? You may have a fire
    in a rescue situation and not have a fire in a recovery
    situation, but a lot of the other environmental issues are very
    typical.
        Mr. Souder. Would it be a different case, then, with smoke
    and chemicals, as to whether it is a water scene or it is the
    ashes that came out of 9/11? You are going to have dissipation
    over days that you do not have in the intensity of the first.
        Dr. Krohmer. Correct, but there may also be other
    environmental issues that would develop over a period of days
    that do not occur during--these are all things----
        Mr. Souder. Briefly, because I know I am out of time, and I
    cut into the answer: Could somebody address nonprofits briefly?
    Because they are not going to have as much equipment when they
    are there, but they play such a critical role, particularly in
    the earliest days.
        Dr. Howard. Yes, sir. I think your question is extremely
    complex. The way that I would break it down is between trained
    responders and untrained responders.
        For an emergent situation, trained responders obviously can
    evaluate the risk and take the proper precautions, but if you
    have an emergent situation or even a less-than-emergent
    situation, when you have untrained responders, good-thinking
    people from churches, nonprofits, et cetera, who want to do
    their best, they need to know that they may not be aware of all
    of the risks that that rescue or recovery that they are
    involved in present. And that is why it is critically important
    that all individuals/entities, whether they are nonprofit or
    governmental or whatever, have the proper training.
        One of the things that we are trying to do at NIOSH is to
    bring all of that experience together. We have a four-volume
    set of information that we provide to local fire departments,
    volunteer and otherwise, and to local response agencies so that
    they can then cascade that down to all types of volunteers,
    including churches, private sectors, et cetera.
        Mr. Souder. The government had no water. You can sit there
    and say they were not trained, but bringing water was essential
    in those first days, and it was not there from the government.
    Hopefully, we will improve those kinds of things.
        But particularly, I am interested in follow-up on what you
    are doing with the faith-based groups, which is clearly the big
    element of the first responders that has not really been
    officially acknowledged as much.
        Dr. Howard. Right, and I agree with that. I think the key
    is educating any kind of responder about the risks of response.
        Dr. Krohmer. Agreed.
        Chairman Thompson. Thank you.
        I will now yield 5 minutes to the gentlelady from New York,
    Ms. Clarke.
        Ms. Clarke. Thank you very much, Mr. Chairman.
        As you are aware, being a New Yorker from New York City,
    this is a matter of deep concern to me and to my constituents.
        Many tens of thousands of first responders who heroically
    came to the scene and helped New York and the entire country
    recover from the worst attack in U.S. history are now either
    getting sick or are in danger of doing so because the Federal
    Government failed--and I emphasize ``failed``--in its duty to
    protect first responders who worked at the World Trade Center.
    Part of the Government's failure was due to the fact that the
    Occupational Safety and Health Administration, which possesses
    the expertise to help keep workers safe, was not used
    immediately, and when it was brought in, its role was not
    clearly defined.
        Now, DHS has the NRF, a new plan for coordinating responses
    to disasters, which I hope would improve the role of an agency
    that is designed to keep first responders safe. However, last
    week, I attended a hearing in another committee where OSHA
    testified that their response role remained minimized and that
    they have minimal input in planning.
        Dr. Krohmer, I would like to direct this question to you.
    Can you tell me exactly what is the role of OSHA in the new
    National Response Framework? Has its role been modified at all,
    and has it been granted a stronger voice in this process?
        Dr. Krohmer. It is my understanding that its role had not
    been modified at all, but I will check with you and make sure.
    I have not looked specifically into that, but I will find out
    and get back with you.
        Ms. Clarke. Mr. Chairman, I would ask that we make sure
    that that material is given to us, because, as a member of the
    Education and Labor Committee, it was testified that their role
    has been modified.
        Chairman Thompson. Well, maybe the GAO can help with OSHA's
    role as they saw in their review.
        Ms. Bascetta. I only have current information as of what
    occurred at Hurricane Katrina, and I do not have current
    information about the most recent articulation of their role in
    the National Response Framework. But it is a very important
    question, and it needs to be resolved.
        Chairman Thompson. We will make sure the question is
    answered.
        Ms. Clarke. Thank you very much, Mr. Chairman.
        Ms. Bascetta, I understand that the GAO was told that FEMA
    assigns and funds specific responsibilities for many agencies
    only after a disaster. Does this grant agencies enough time to
    mobilize after FEMA calls?
        And how capable is FEMA of assigning these responsibilities
    and in coordinating a response quickly after a disaster? After
    all, we all recall how poorly FEMA coordinated the responses to
    the hurricanes 2 years ago.
        Ms. Bascetta. That is a good question.
        I think there has been a mixed experience with that. I can
    say that, in the work that we did, looking at long-term
    monitoring, that there was a delay that caused problems in
    terms of setting up monitoring programs and that, in fact, in
    New Orleans, monitoring did not happen at all. And one of the
    disagreements was between OSHA and FEMA about who was
    responsible for doing this, whether it should be done and how
    it would be funded.
        Ms. Clarke. Dr. Krohmer, the response of the Federal
    Government to the health concerns faced by many of the first
    responders impacted by the debris of the World Trade Center is
    to provide screening but nearly nothing in the way of providing
    actual care for the maladies many of them face. This has led
    many people to question whether they could respond in the same
    way in the future, putting their health and their families at
    risk.
        Do you feel that the Government must be able to guarantee
    that we will help first responders with related health problems
    if we are to get a full response to disasters in the future?
        Dr. Krohmer. I think we need to look very closely at the
    issue of being able to include treatment as part of the
    response that is offered to folks. Yes, I agree with you.
        Ms. Clarke. Has that conversation begun, as of yet? I mean,
    this is clearly something that we must be prepared for. We do
    not know what happens, day to day, in our Nation. We hope that
    we can put all kinds of prohibitive actions in place to make
    sure that we are safe in the homeland, but you know, at any
    given moment, given the world we live in today, I think these
    are issues that have to really be in the forefront of our
    minds, given what we know and what we have experienced already.
        Has there been the type of conversation that you feel
    comfortable with that would address what we know will be a
    challenge for those who respond to the call of duty, that is,
    that we can guarantee that their health concerns will be
    addressed in a timely fashion and that we will not see the type
    of hesitancy that seems to be a part of our culture right now
    that needs to be addressed?
        Dr. Krohmer. As I mentioned in an earlier part of the
    testimony, many of the activities that the Office of Health
    Affairs has been involved with and is in the process of
    developing have just started over the last couple of months. We
    have had some internal discussions about those, but they are
    extremely complicated, in terms of private insurance and public
    insurance and who all is going to cover what.
        We have had those internal discussions and fully plan to
    continue having those discussions, but they have been very
    preliminary on the part of our office.
        Ms. Clarke. I would like to suggest to you, Doctor, that
    this should be a priority. You know, we want to get ahead of
    the curve, with respect to this matter. Again, we are not
    determinants of what can happen in our Nation, be it a natural
    disaster, be it a terrorist attack, but we can learn from, you
    know, the experiences we have had and be prepared to address
    it.
        I would hate to be in a situation where my life is in
    jeopardy and there are individuals who have the expertise and
    the know-how to be there at my aid, and they are thinking, you
    know, ``Do I enter this dangerous situation because my personal
    health and well-being will be at risk and there will be no one
    there to support me at the end of the day?'' This has to become
    a part of our culture.
        Dr. Krohmer. Oh, I agree with you completely. I have been
    there, yes.
        Ms. Clarke. Thank you very much, Mr. Chair.
        Chairman Thompson. Thank you very much.
        I will now yield 5 minutes to the gentleman from Texas, Mr.
    Cuellar.
        Mr. Cuellar. Thank you, Mr. Chairman.
        One question for all three of you: If I were to have one of
    my constituents ask me this question, how would you answer this
    without going into specifics? As you know, I did not have the
    opportunity to be here and to listen to the details and get
    copies of the testimonies in advance, but if I asked you--as
    you know, the title of this hearing is ``Protecting the
    Protectors'' and ``Ensuring the Health and Safety of our First
    Responders'' in the wake of, you know, these types of
    disasters.
        What would be the top three things that we have done to
    ensure their safety and their protection, number one?
        The second part is: What are the three deficiencies? Where
    do we need to go?
        I need a one, two and three outline on each of them, the
    strengths where we have done well and where the deficiencies
    are. And it is the same question to each of you.
        Dr. Krohmer, do you want to go first?
        Dr. Krohmer. I think there are three issues that we have
    done to ensure their safety. We have improved the incident
    management system, which is very critical to coordinating the
    overall response, and it addresses some of the other issues
    that you had identified earlier. We have identified what
    additional issues there are, in terms of some of the
    environmental things.
        Mr. Cuellar. You are now on number two----
        Dr. Krohmer. Correct, number two.
        Mr. Cuellar. --for the strengths? Okay.
        Dr. Krohmer. We have much closer coordination now among the
    medical aspects, among the medical components--public health
    and health care.
        In terms of deficiencies, I think that there is still a
    large part of the response community, some of the unsolicited
    volunteers who Dr. Howard has referred to, who are still not
    well-incorporated into that. And we need to address that.
        Mr. Cuellar. That is number one?
        Dr. Krohmer. That is number one.
        Mr. Cuellar. Okay. So what do you call that, ``better
    integration''?
        Dr. Krohmer. Better integration of unsolicited volunteers.
        Mr. Cuellar. Okay.
        Dr. Krohmer. I think probably one of the other
    deficiencies--and I am not sure I can come up with three. A
    second one is, although our surveillance programs are better
    now than they were previously, I think we still have room to
    improve them from a pre-exposure assessment to continued
    monitoring throughout the event and post-event.
        Mr. Cuellar. So how do you summarize number two?
        Dr. Krohmer. More coordinated in structured surveillance
    programs throughout the continuity of the event.
        Mr. Cuellar. All right.
        Dr. Howard?
        Dr. Howard. My turn for the pop quiz. Okay.
        So, number one, I would put the emphasis that we now have
    on responder safety and health through the Worker Safety and
    Health Annex in the National Response Plan. I think that is a
    positive step.
        The second I would put is our own work at NIOSH to
    emphasize that integrated safety management, bringing all of
    the responder agencies--private, public, whoever shows up--into
    the same safety management structure is a very important
    advantage that we have discovered, and we have incorporated
    that. DHS has incorporated it into their targeted capabilities
    list.
        Three, at NIOSH, we have done a lot of work in ensuring
    that respirators are suitable for the kind of work that long-
    duration disasters require. We were not prepared for that
    before the World Trade Center. We are better prepared.
        I think the things that we still have to do, and on the
    flip side, are, number one, that I do not think we have
    elevated worker safety and health within the National Response
    Plan high enough. Even though we have an annex for it, I think
    it needs to even move higher.
        I think the second issue is the same one that----
        Mr. Cuellar. Let me ask you, how do we elevate that?
        Dr. Howard. Well, you can make it an emergency support
    function. You can make it an ESF, as opposed to an annex to an
    ESF. That would be very--that is what I am talking about.
        Mr. Cuellar. Can I interrupt you for a second?
        Dr. Howard. Sure.
        Mr. Cuellar. Homeland, how do you respond to that?
        Dr. Krohmer. I think there are a little bit of semantics
    there. We can very easily elevate the importance of it, the
    focus on it, and still allow it to be a support function, a
    support annex. Well, actually, I would have to look at it,
    because it applies to enough of the----
        Dr. Howard. The issue of the annex is only triggered by the
    keeper of the ESF, and that is FEMA. So OSHA has to wait until
    FEMA activates their ESF. If it is an ESF, OSHA does not have
    to wait for FEMA to do it. That is the important distinction
    here.
        Mr. Cuellar. Do you agree with that distinction, Dr.
    Krohmer?
        Dr. Krohmer. Well, it would be. Then we would need to
    identify who the lead agency for that particular ESF would be.
    From my perspective, there is enough overlap. That may be a
    little bit difficult, but we could work on that.
        Mr. Cuellar. Could I ask, maybe, Mr. Chairman, to follow up
    on that and then follow up with the committee on that
    conversation?
        Chairman Thompson. Okay. Sure. Absolutely.
        Are you prepared, Dr. Krohmer, to follow up with the
    committee on that?
        Dr. Krohmer. Yes.
        Dr. Howard. Let me point out that it has to be followed up
    with OSHA, not NIOSH. This is an OSHA issue.
        Mr. Cuellar. I am sure you all have good working
    relationships with them.
        Dr. Howard. We do.
        Now, I think I was just getting over number two, and number
    two is the same issue Dr. Krohmer mentioned. Unaffiliated
    volunteers, spontaneous volunteers, people who show up at a
    site, they may not be associated with any particular entity. We
    need to grab those people as soon as their hearts lead them in
    the right direction. These are heroes in waiting. They are
    doing wonderful things. They think they are indestructible.
    They may not be aware of the hazards associated with
    responding. Somehow, we have to have a structure where we can
    grab those people, and if they are untrained--and many of them
    are--we have to grab them before they actually go on the site
    and train them. And that is a real tough one, and I am not sure
    I have the answer to that.
        Then the third one, I think, is the mental health issue,
    which we have talked about this morning here. People imagine
    themselves capable of doing things emotionally and mentally
    that, once they get into a situation, they find out they are
    not indestructible from a mental health perspective. And that
    is a part of training that we need to do, both for trained
    volunteers, people who do this for a living, whether you are
    police or fire or Red Cross or whatever, as well as and
    especially for people who do not do this for a living but
    decide to respond. This is an area that we really need to spend
    some time on, too.
        Mr. Cuellar. Gentlemen, I am out of time.
        Chairman Thompson. Thank you. We have been very liberal
    with the time, so do you want to ask another question or----
        Mr. Cuellar. No. I just wanted her to finish the question.
    I am not going to ask any more questions. I would just like to
    give her the courtesy to finish that question.
        Chairman Thompson. Thank you.
        Ms. Bascetta. I would be happy to answer.
        I think that positives are that we know how to do
    monitoring, both during the response and we know how to do
    long-term monitoring. We know how to do good research to
    monitor what the long-term health effects might be.
        And I think we are making more progress as a society in
    acknowledging the importance of mental health. We see this with
    our Armed Forces. We see this with our firefighters and police
    officers. So, while there is a lot of work to do, I think there
    is a growing acknowledgment of the importance of mental health.
        I think the biggest problems are operationalizing what we
    know how to do and making sure that it, in fact, gets done and
    that some of the most basics, like keeping track of who has
    responded, are accomplished. Because if we do not know the
    denominator, it is going to be very hard to track these people
    and to figure out what kinds of health effects they truly did
    experience in a scientifically valid way.
        I also think that handling the treatment issue in advance
    is very important. People need to know how they are going to be
    cared for and where the financial responsibility is going to
    lie, whether it is going to be with Workers' Comp or with their
    own health insurance or some mix of payers.
        Mr. Cuellar. Thank you, Mr. Chairman.
        Chairman Thompson. Thank you very much.
        I will yield 5 minutes to the gentleman from Pennsylvania,
    Mr. Dent.
        Mr. Dent. Thank you, Mr. Chairman.
        Good morning.
        I guess my question is really to all three of you. In your
    view, what do you think are the most important lessons learned
    from the response to the World Trade Center site regarding
    first responders' health and safety? I thought, maybe, we would
    just go right down the list there.
        Dr. Krohmer?
        Dr. Krohmer. This is probably a personal perspective.
        The issue of--we have touched on it several times already--
    identifying who all of the rescuers are. The unsolicited
    volunteer was a very critical issue. And then the surveillance
    programs, as we have talked about.
        Dr. Howard. Similarly, I would also emphasize those.
        Very tight perimeter control, central safety management,
    and a responsible party who determines total responder census
    so that we can identify these individuals after they leave the
    site if we need to medically monitor them.
        Ms. Bascetta. We have noted three in our work so far, and
    those include quickly identifying and contacting responders and
    others, centrally coordinating an approach for assessing the
    individuals' health effects, and addressing the importance of
    both physical and mental health.
        Mr. Dent. Based on what you just said, do you believe that
    steps have been taken to address those lessons? Do you think we
    are where we need to be in the event of a future disaster?
        Ms. Bascetta. No, we do not think so.
        Mr. Dent. Okay. That is true of all three, that we are not
    where we need to be?
        Dr. Krohmer. Correct. I think we have made some very nice
    progress, but we are not where we need to be.
        Mr. Dent. Okay.
        Then, I guess, my next question would be to Dr. Krohmer:
    What guidance does the Department of Homeland Security provide
    to its State and local partners to help them protect the health
    and safety of our first responders?
        Dr. Krohmer. Most of the guidance that we have provided
    historically has been based on the guidances that have been
    provided in the grants. As resources become available--and it
    is probably going to be in the next year or 2 and in the
    outyears--through the Office of Health Affairs, we are looking
    at developing a program of specific outreach to the State and
    local folks that will be working through the FEMA regions,
    working in coordination with the HHS regional preparedness
    coordinators but, much more specifically, making sure that the
    State and local folks, from a health care and a public health
    perspective, are much more integrated into the emergency
    management community and in the planning activities that occur.
        Mr. Dent. Okay. Thank you.
        My final question is this: The SAFE Port Act of 2006
    contains a provision requiring the Secretaries of HHS and DHS
    and, I think, the EPA Administrator to jointly enter into a
    contract with the National Academy of Sciences to conduct a
    study and to prepare a report on disaster area health and
    environment protection and monitoring.
        What is the status of this initiative?
        I guess we should again start with you, Dr. Krohmer.
        Dr. Krohmer. Quite honestly, sir, I was not aware of the
    provisions of that act until we started to do some of the
    background information for this hearing. And we are in the
    process of trying to identify the current status, so I will
    have to get back with you on that.
        Mr. Dent. Dr. Howard?
        Dr. Howard. My understanding is it was authorized, not
    appropriated. But I would like to point out that it is really a
    remarkably excellent roadmap for a medical monitoring program
    post-disaster.
        Mr. Dent. Ms. Bascetta?
        Ms. Bascetta. I do not have current information on the SAFE
    Port Act.
        Mr. Dent. Thanks, Mr. Chairman. I yield back.
        Chairman Thompson. Thank you very much.
        I will now yield 5 minutes to the gentlelady from the
    District of Columbia, Ms. Norton.
        Ms. Norton. Thank you very much, Mr. Chairman.
        This is an important hearing. I think it is important to
    have, particularly here in the District of Columbia, where we
    have already had incidents where it is its own version of
    Ground Zero for, particularly, first responders who rush to the
    scene, often without--almost always without--any thought of
    their own health.
        I am wondering if you know of any health officials who were
    contacted when the first issues involving formaldehyde in
    trailers in Louisiana were raised. Do you know of any health
    officials who were contacted before the Government responded on
    that issue?
        Dr. Krohmer. We were contacted by folks at FEMA, I believe,
    in May of this year. We did not have any prior contact.
        Ms. Norton. I ask because, on the day the story broke, I
    was having a hearing with FEMA on another issue, and I, of
    course, inquired about this formaldehyde that was hitting the
    news, and they told me that they were sure that the
    formaldehyde had absolutely no negative effects.
        Subsequently, in another hearing, the oversight hearing,
    very harmful, harmful testimony came out about the suppression
    of the possibility of harm in formaldehyde in those trailers.
    And evidence was brought forward in which it was said that
    lawyers said that it was best to move ahead and not to make
    inquiries because of liabilities that might arise. Well, the
    liability is going to arise now because it is clear that people
    knew or should have known that there was harmful formaldehyde
    in those trailers, so they really made it worse.
        My question to you is: Before anybody opines or makes a
    policy judgment when there is a health issue related to a
    natural event or to a terrorist event, shouldn't there be a
    link to some health professionals before any administration
    decides what to do? Is there any link that you know of? Or are
    policymakers free to just move forward without contacting
    anyone to get an expert medical or health opinion on whether
    there is a danger to public health?
        Dr. Krohmer. I think the concerns that you bring up are
    very important concerns, and at least based on my
    understanding, they are one of the issues that led to the
    formation of the Office of Health Affairs within Homeland
    Security. Within our office, our Office of Component Services
    is going to be specifically looking at workforce protection and
    occupational health issues.
        I would note that, since we brought on board the Associate
    Medical Officer in January of this year, the Associate Medical
    Officer for Component Services, he has been working very
    closely with FEMA and with other DHS components. And I think,
    much to his credit, he is being called very frequently within
    the Department for public health and health care issues.
        So it is a critical issue, from our perspective, and that
    is why we are moving forward with this office.
        Ms. Norton. It was clear to me that the policymakers did
    not know what to do and saw an issue foaming up, and when you
    do not know what to do and you do not know where to turn, there
    are people who just suppress it.
        And of course, there were hundreds of people in these
    trailers. I was very concerned, not only for that reason but
    because, when the trailer issue came before us in another
    circumstance, what we wanted to know was why they were
    stockpiling all of these trailers and not trying to offload
    some of them and sell some of them. Now we come to find out
    that they are really not trailers that probably should be sold
    to anybody.
        It does seem to me that the implications here are certainly
    for the workforce, but here, where FEMA has to take personal
    responsibility for people it puts into such trailers and then,
    in a panic, suppresses or is told to suppress, that is where
    the evidence was just as clear. They had the memos where the
    lawyers said, ``Do not press this. If you press this, you might
    expose us to liability.''
        First of all, you need to get another lawyer, because the
    question of liability does not go to suppression; it goes to no
    one should have known. And so, the notion that it would never
    come out is very poor legal advice, but it is the kind of
    advice you give first when you are not entirely honest but also
    when you do not have any resource to go to. Because the first
    instinct should have been to say, ``Get somebody in there who
    knows something about health issues and formaldehyde to see if
    we have any liability and to do something about it quickly so
    as to mitigate any liability.''
        Dr. Krohmer. If I may, Mr. Chair, it is my understanding
    that, when the issue first came up, representatives from FEMA
    did contact representatives from the CDC. In the information
    that we have been able to identify, there is some conflicting
    information in the scientific literature about the significance
    of sensitivities. A lot of it has the potential of being very
    individualized.
        Having said that, we are in the process now of working very
    closely--FEMA, with some consultation from us, is in the
    process of working very closely with the CDC, some consultation
    with NIOSH, to do some specific environmental monitoring and
    environmental sampling to try and get a better handle
    specifically on these trailers, what the levels are and what
    the issues may be.
        Ms. Norton. Thank you.
        Thank you, Mr. Chairman.
        Chairman Thompson. Thank you very much.
        We would like to thank the first panel of witnesses for
    their valuable testimony and members for their questions.
        The members of the committee have additional questions for
    the witnesses, and we ask that you respond expeditiously in
    writing to any of those questions.
        Thank you again.
        Let me, before you leave, say that, as Chair, I am
    concerned that we do not keep a roster of Federal responders to
    natural disasters. That is absolutely critical. Now, that is
    what I heard from the testimony today. I stand to be corrected
    if we do not.
        Dr. Krohmer?
        Dr. Krohmer. I would just observe that I do believe we keep
    a roster of Federal responders. What becomes difficult is when
    there are additional citizens and unsolicited volunteers who
    respond. It is more difficult to catalog those.
        Chairman Thompson. So we keep Federal, but State and locals
    is left to State and locals?
        Dr. Krohmer. Correct.
        Chairman Thompson. No one keeps the other roster of other
    volunteers who respond to disasters; is that correct?
        Dr. Krohmer. As the volunteers become incorporated into the
    response structure, they are cataloged--it is my understanding
    that they are cataloged. But if they are not a part of the
    response structure, if they do not identify themselves to folks
    on scene, they may not be included. Correct.
        Chairman Thompson. Thank you.
        GAO, I am going to give you the last response on that.
        Ms. Bascetta. Thank you.
        I am not aware of a requirement for the keeping of a roster
    of the Federal employees who responded. It is true that some
    agencies kept track on their own, but it was not through a
    centralized process. It needs to be explicit that that be done.
    It is absolutely fundamental.
        Chairman Thompson. So there is no uniformed process to keep
    up with the Federal responders to any disaster, be it 9/11,
    Katrina, the Pentagon situation----
        Ms. Bascetta. Right. That is correct.
        Chairman Thompson. --to your knowledge?
        Ms. Bascetta. That is correct. That responsibility has not
    been assigned. That is correct.
        Chairman Thompson. I yield to the gentleman from North
    Carolina for the last comment.
        Mr. Etheridge. Very, very quickly. Wouldn't it be just as
    easy, in working with these local folks and in working with
    State and local officials, to ask them if they have people at
    these major catastrophes to submit that to the Federal and have
    a place where we could keep that, along with our Federal folks,
    as to who has responded to these natural disasters?
        Dr. Krohmer. Well, I think that is something we could
    easily pursue, yes.
        Chairman Thompson. Thank you.
        Again, we thank the panel.
        And we call up the second panel of witnesses.
        I welcome the second panel of witnesses, and I appreciate
    your indulgence for the questions, but as you can see, there
    were some things we needed, I think, to get on the record in
    anticipation of this panel, because I think your testimony
    flows right into some of the overall reasons for having this
    hearing.
        I welcome you, as I said.
        Our first witness will be Dr. Philip Landrigan, who is the
    professor and chair of Community Preventative Medicine at the
    Mount Sinai School of Medicine, who you heard referred to by
    our ranking member in his opening statement. Mount Sinai runs
    one of the centers in the World Trade Center Worker and
    Volunteer Medical Screening Program that provides medical
    screening exams for first responders, workers and other
    volunteers who worked at Ground Zero. In addition to this work,
    Dr. Landrigan spent time at the CDC, where he directed research
    for the global smallpox eradication program, among other
    efforts.
        Our second witness is Nicholas Visconti, Deputy Fire Chief,
    Fire Department, City of New York. Chief Visconti, who I see
    Representative Clarke knows very well, was there on September
    11, responding after the attacks on the World Trade Center.
    Chief Visconti has also worked extensively with the Uniformed
    Fire Officers Association in New York. He has been a New York
    firefighter for nearly 39 years.
        Congratulations.
        Our third witness is Dr. Mike McDaniel, Secretary of the
    Louisiana Department of Environmental Quality. Dr. McDaniel is
    an environmental scientist who has worked for more than 35
    years doing environmental investigations and ensuring
    regulatory compliance. Prior to his current position, he served
    as executive director of the Baton Rouge's Clean Air Coalition
    and as president of DOE, the Greater Baton Rouge Clean Cities
    Coalition.
        We thank all three of you for being our witnesses here
    today and for your service to the cities and States you
    represent, as well as the Nation.
        Without objection, the witnesses' full statements will be
    inserted into the record.
        I now ask each witness to summarize his statement for 5
    minutes, beginning with Dr. Landrigan.

        STATEMENT OF DR. PHILIP J. LANDRIGAN, MD, PROFESSOR AND
      CHAIRMAN, DEPARTMENT OF COMMUNITY AND PREVENTIVE MEDICINE,
                     MOUNT SINAI SCHOOL OF MEDICINE

        Dr. Landrigan. Good morning, Mr. Chairman. Thank you for
    having convened this hearing and for having invited me. And my
    thanks also to the other representatives from New York who have
    been present here this morning, Ms. Clarke and, earlier, Mr.
    King. And I also wish to thank those members of the Congress
    under the leadership of----
        Chairman Thompson. Excuse me. Is your mike on?
        Dr. Landrigan. Now it is, sir.
        Chairman Thompson. Thank you very much.
        Dr. Landrigan. I wish to thank those members of the
    Congress, under the leadership of Congresswoman Maloney,
    Congressman Jerry Nadler, Congressman Fossella and the whole
    New York delegation, who have introduced legislation supporting
    medical care for the 9/11 responders.
        Well, as you mentioned, I am the chairman of Community and
    Preventative Medicine at Mount Sinai, and the World Trade
    Center medical responder programs are based in the department
    that I chair.
        Let me speak first about the nature of the workforce who
    converged at Ground Zero after 9/11. The witnesses on the
    previous panel touched on this same point. The key point here
    is that it was a very diverse workforce. It included the
    uniformed services, such as the firefighters, the police and
    the National Guard, who came with a structure and with a high
    degree of organization. But in addition to those trained
    responders, there was a wide array of uncounted volunteers.
    Indeed, we only know within an order of magnitude the total
    number of people who were there. Estimates range from a low of
    40,000 to a high of 90,000, with no clear way of deciding
    precisely what the number is. And they obviously varied greatly
    in their training.
        Secondly, I would like to say a word about the exposures to
    which these people were exposed. It changed over the course of
    the days following the attacks on the World Trade Center. The
    exposures were most intense, not surprisingly, in the first 24
    hours. We all saw the dense cloud on TV, and we now know that
    65 percent of the material that was in that cloud consisted of
    very alkaline pulverized cement from the destruction of the
    concrete in the towers.
        The reason we believe that the dust was so toxic is that
    that alkaline dust had a pH of 10 or 11. My colleague Dr. David
    Prezant, who is the chairman of the medical program at the fire
    department, has described this as pulverized lye, and on
    another occasion, he described it as pulverized Drano. And it
    was extremely irritating to the upper and lower respiratory
    tracts of the men and women who responded. The toxicity of the
    dust was further magnified by virtue of the fact that it
    contained millions of microscopic shards of glass from all of
    the windows, and those are clearly evident on the microscope,
    and they further led to the irritation in the respiratory
    tracts.
        Our group at Mount Sinai began to stand up the medical
    response to 9/11 on the 13th of September, 2001. Two days after
    the attack, our doctors gathered; they plotted a course and
    began seeing patients within weeks. We first received funding
    from the Federal Government through the National Institute for
    Occupational Safety and Health in June/July 2002, and that
    funding, initially for screening and now, today, for monitoring
    of the workers, continues. We have seen close to 22,000 workers
    total, and we have seen more than 7,000 for a second time. And
    the plan is to continue to see each and every eligible worker
    and volunteer every 18 months for as long as funding continues.
        Also, since 2006, since approximately 1 year ago, we have
    had Federal funding for the treatment of these workers and
    volunteers. Prior to that, treatment had to be done using
    philanthropic money. And we have treated approximately 7,000 of
    the men and women for a range of conditions that include upper
    and lower respiratory, GI and mental health.
        Briefly, let me summarize the principal medical findings.
    Forty-six percent of the workers whom we have examined, or the
    first 9,700 whom we have examined, were documented to have
    symptoms of their lower respiratory tract. Sixty-two percent
    had symptoms involving their upper respiratory tract. In the
    aggregate, 69 percent had one, the other or both.
        Dr. Landrigan. A high percentage have had gastroesophageal
    reflux disease, and a high percentage have had continuing
    mental health problems, depression, post traumatic stress
    disorder. In a number of these workers, those symptoms continue
    to the present.
        There are, in my mind, two major unanswered questions. The
    first is how long and with what degree of severity will these
    conditions that I have just described continue. We don't know
    the answer to that on this day, and the only way we can come to
    know that is to continue to follow them at regular intervals
    and track and monitor and record the data.
        Then the second medical question concerns the issue of what
    new diseases might emerge in these brave men and women in the
    years ahead, diseases of long latency such as chronic lung
    diseases, such as malignancies. We know that there was asbestos
    in the dust. We know that there was dioxin in the dust. The
    question is what may or may not be the long-term consequences
    of those exposures.
        I think a couple of lessons learned that I would like to
    summarize in closing are, first of all, it was incredibly
    important that we had some pretty good monitoring of exposures,
    beginning shortly after 9/11. It could have been better, but it
    was nonetheless good, and I am able to talk with a high degree
    of confidence about the nature of the exposures, because
    records were kept.
        Secondly, it is a lesson learned is that we can expect that
    responders who rush into these disasters are going to become
    sick and plans have to be put in place in advance for
    monitoring and for treatment, can't be left to chance, it can't
    be reinvented with each new disaster.
        Thank you very much.
        [The statement of Dr. Landrigan follows:]

              Prepared Statement of Philip J. Landrigan, MD, M.Sc.

        Good morning.
        Mr. Chairman and Members of the Committee, I thank you for having
    invited me to present testimony before you today on the issue of
    ``Protecting the Protectors: Ensuring the Health and Safety of our
    First Responders in the Wake of Catastrophic Disasters''
        My name is Philip J. Landrigan, MD. I am Professor and Chairman of
    the Department of Community and Preventive Medicine of the Mount Sinai
    School of Medicine in New York City. I am a board certified specialist
    in Occupational Medicine as well in Preventive Medicine and Pediatrics.
    My curriculum vitae is attached to this testimony.
        In my capacity as Chairman of Community and Preventive Medicine at
    Mount Sinai, I oversee the World Trade Center (WTC) Medical Monitoring
    and Treatment Program as well as the World Trade Center Data and
    Coordination Center, two closely linked programs that are based in my
    Department and supported by grants from the National Institute for
    Occupational Safety and Health (NIOSH). It has been the responsibility
    of our programs at Mount Sinai and of WTC Centers of Excellence in New
    York, New Jersey and across the United States, with which we
    collaborate closely, to diagnose, treat and document the illnesses that
    have developed in the workers and the volunteers who responded to 9/11.
        Today, I shall present a summary of our medical findings in the 9/
    11 responders. I shall comment also on the critical need for continuing
    support for Centers of Excellence that have the expertise and the hard-
    won experience that is essential to sustain high-quality medical
    follow-up and treatment for these brave men and women.
        The Diverse Population of 9/11 Responders. In the days, weeks, and
    months that followed September 11, 2001, more than 50,000 hard-working
    Americans from across the United States responded selflessly--without
    concern for their health or well-being--when this nation called upon
    them to serve. They worked at Ground Zero, the former site of the World
    Trade Center, and at the Staten Island landfill, the principal
    depository for WTC wreckage. They worked in the Office of the Chief
    Medical Examiner. They worked beneath the streets of lower Manhattan to
    search for bodies, to stabilize buildings, to open tunnels, to turn off
    gas, and to restore essential services.
        These workers and volunteers included traditional first responders
    such as firefighters, law enforcement officers, paramedics and the
    National Guard. They also included a large and highly diverse
    population of operating engineers, laborers, ironworkers, building
    cleaners, telecommunications workers, sanitation workers, and transit
    workers. These men and women carried out rescue-and-recovery
    operations, they sorted through the remains of the dead, they restored
    water and electricity, they cleaned up massive amounts of debris, and
    in a time period far shorter than anticipated, they deconstructed and
    removed the remains of broken buildings. Many had no training in
    response to civil disaster. The highly diverse nature of this
    workforce, and the absence in most of the groups who responded of any
    rosters to document who had been present at the site, posed
    unprecedented challenges for worker protection and medical follow-up.
        The 9/11 workforce came from across America. In addition to tens of
    thousands of men and women from New York, New Jersey, and Connecticut,
    responders from every state in the nation stepped forward after this
    attack on the United States and are currently registered in the WTC
    Medical Monitoring Programs. Particularly large numbers came from
    California, Massachusetts, Ohio, Illinois, North Carolina, Georgia, and
    Florida.
        The Exposures of 9/11 Responders. The workers and volunteers at
    Ground Zero were exposed to an intense, complex and unprecedented mix
    of toxic chemicals. In the hours immediately after the attacks, the
    combustion of 90,000 liters of jet fuel created a dense plume of black
    smoke containing volatile organic compounds--including benzene, metals,
    and polycyclic aromatic hydrocarbons. The collapse of the twin towers
    (WTC 1 and WTC 2) and then of a third building (WTC 7) produced an
    enormous dust cloud. This dust contained pulverized cement (60-65% of
    the total dust mass), uncounted trillions of microscopic glass fibers
    and glass shards, asbestos, lead, polycyclic aromatic hydrocarbons,
    hydrochloric acid, polychlorinated biphenyls (PCBs), organochlorine
    pesticides, furans and dioxins. Levels of airborne dust were highest
    immediately after the attack, attaining estimated levels of 1,000 to >
    100,000 mg/m3, according to the US Environmental Protection Agency.
    Firefighters described walking through dense clouds of dust and smoke
    in those first hours, in which ``the air was thick as soup''. The high
    content of pulverized cement made the dust highly caustic (pH 10-11).
        The dust and debris gradually settled, and rains on September 14
    further diminished the intensity of outdoor dust exposure in lower
    Manhattan. However, rubble-removal operations repeatedly reaerosolized
    the dust, leading to continuing intermittent exposures for many months.
    Fires burned both above and below ground until December 2001.
        Workers and volunteers were exposed also to great psychological
    trauma. Many had already lost friends and family in the attack. In
    their work at Ground Zero they commonly came unexpectedly upon human
    remains. Their stress was compounded further by fatigue. Most seriously
    affected by this psychological trauma were those not previously trained
    as responders.
        The World Trade Center Medical Monitoring and Treatment Program.
    Although New York has an extensive hospital network and strong public
    health system, no existing infrastructure was sufficient to provide
    unified and appropriate occupational health screening and treatment in
    the aftermath of September 11. Local labor unions, who made up the
    majority of responders, became increasingly aware that their members
    were developing respiratory and psychological problems; they initiated
    a campaign to educate local elected officials about the importance of
    establishing an occupational health screening program. In early 2002,
    Congress directed the Centers for Disease Control and Prevention (CDC)
    to fund the WTC Worker and Volunteer Medical Screening Program.
        In April 2002, the Irving J. Selikoff Center for Occupational and
    Environmental Medicine of the Mount Sinai School of Medicine was
    awarded a contract by the National Institute for Occupational Safety
    and Health (NIOSH), a component of the CDC, to establish and coordinate
    the WTC medical program. The Bellevue/New York University Occupational
    and Environmental Medicine Clinic, the State University of New York
    Stony Brook/Long Island Occupational and Environmental Health Center,
    the Center for the Biology of Natural Systems at Queens College in New
    York, and the Clinical Center of the Environmental &
        Occupational Health Sciences Institute at UMDNJ-Robert Wood Johnson
    Medical School in New Jersey were designated as the other members of
    the regional consortium based at Mount Sinai. The Association of
    Occupational and Environmental Clinics was designated to coordinate a
    national examination program for responders who did not live in the New
    York/New Jersey metropolitan area
        In addition to this consortium, there is a parallel program based
    at the Fire Department of New York (FDNY) Bureau of Health Services,
    also supported by the federal government through NIOSH. This program
    has provided medical examinations to over 15,000 New York City
    firefighters and paramedics. The FDNY and Mount Sinai programs
    collaborate closely and use closely similar protocols for monitoring
    the health of 9/11 responders. A great strength of the FDNY program is
    that it had collected extensive baseline data on the health of each
    firefighter and paramedic through a periodic medical examination
    program that long predated September, 2001.
        Nearly all of what we know today about the health effects of the
    attacks on the WTC has been learned through these medical programs that
    were developed in Centers of Excellence funded by the federal
    government.
        The Centers that comprise the consortium based at Mount Sinai
    provide free comprehensive medical and mental health examinations for
    each responder every 18 months. Examinations are undertaken according
    to a carefully developed uniform protocol, and all of the data obtained
    on each responder are entered into a computerized database. The goals
    of the program are two:
            1. To document diseases possibly related to exposures sustained
            at the World Trade Center;
            2. To provide medical and mental health treatment for all
            responders with WTC related illnesses, regardless of ability to
            pay.
        To date, thanks to federal support, over 21,000 WTC responders have
    received initial comprehensive medical and mental health monitoring
    evaluations in the Centers of Excellence that comprise this consortium.
    More than 7,250 of these responders have also received at least one
    follow-up examination. Demand for the program remains strong. Even now,
    six years after 9/11, approximately 400 new workers and volunteers
    register for the program each month. In August 2007, 771 new
    participants, persons whom we had never previously seen, registered for
    the program through our telephone bank.
        Our WTC Medical Treatment Program has also been active. We launched
    this program in 2003 with support from philanthropic gifts.
    Philanthropic support provided the sole financial base for the
    treatment program from 2003 to 2006. Since September, 2006, we have
    begun to receive support for this program from the federal government.
    To date over 6,300 responders have received 47,000 medical and mental
    treatment services through this program.
        Health Effects Among WTC Responders. Documentation of medical and
    mental health findings in 9/11 responders followed by timely
    dissemination of this information through the peer-reviewed medical
    literature are essential components of our work. Documentation of our
    findings enables us to examine trends and patterns of disease and to
    assess the efficacy of proposed treatments. Dissemination of our
    findings and our recommendations for diagnosis and treatment to
    physicians across the United States permits us to share our knowledge
    and to optimize medical care. Such documentation and dissemination
    would be well nigh impossible in the absence of federally funded
    Centers of Excellence.
        In September 2006, the Centers of Excellence that comprise our
    consortium published a paper in the highly respected, peer-reviewed
    medical journal Environmental Health Perspectives, a journal published
    by the National Institutes of Health. This report detailed our medical
    findings from examinations of 9,442 WTC responders whom we and our
    partner institutions had assessed between July 2002 and April 2004. I
    have appended this report to my testimony for your review, and I would
    like to direct your attention to a few key findings:
             Among these 9,442 responders, 46.5% reported
            experiencing new or worsened lower respiratory symptoms during
            or after their work at Ground Zero; 62.5% reported new or
            worsened upper respiratory symptoms; and overall 68.8% reported
            new or worsened symptoms of either the lower and/or the upper
            respiratory tract.
             At the time of examination, up to 2 + years after the
            start of the rescue and recovery effort, 59% of the responders
            whom we saw were still experiencing a new or worsened lower or
            upper respiratory symptom, a finding which suggests that these
            conditions may be chronic and that they will require ongoing
            treatment.
             One third of responders had abnormal pulmonary
            function test results. One particular breathing test
            abnormality--decreased forced vital capacity ? was found 5
            times more frequently in WTC responders than in the general,
            non-smoking population of the United States.
             We found that the frequency and severity of
            respiratory symptoms was greatest in responders who had been
            trapped in the dust cloud on 9/11; that frequency and severity
            were next greatest in those who had been at Ground Zero in the
            first week after 9/11, but who had not been caught in the dust
            cloud; and that frequency and severity were lower yet in those
            who had arrived at Ground Zero after the first week. These
            findings fit well with our understanding of exposures at the
            site and thus lend internal credibility to our data.
             Findings from our program released in 2004 have
            attested to the fact that in addition to respiratory problems,
            there also exist significant mental health consequences among
            WTC responders.
        External Corroboration of our Findings. The peer-reviewed article
    that we published one year ago in Environmental Health Perspectives\1\
    gains further credibility by virtue of the fact that the findings we
    report in it are consistent with findings on 9/11 responders that have
    been reported by highly credible medical investigators outside of our
    consortium. The FDNY has published extensively on the burden of
    respiratory disease among New York firefighters. They have seen a
    pattern of symptoms that closely resembles what we observed. Forty
    percent of FDNY firefighter responders had persistent lower respiratory
    symptoms, and 50% had persistent upper respiratory symptoms more than
    one year after 9/11. FDNY noted that rates of cough, upper respiratory
    irritation and gastroesophageal reflux were highest in those
    firefighters who had been most heavily exposed on 9/11. FDNY physicians
    have also noted reactive airways disease, and highly accelerated
    decline in lung function in firefighters as well as in other responders
    in the year following 9/11.
    ---------------------------------------------------------------------------
        \1\ See Environmental Health Perspectives The World Trade Center
    Disaster and the Health of Workers: Five-Year Assessment of a Unique
    Medical Secreening Program Volume 113 / Number 12 / December 2006
    ---------------------------------------------------------------------------
        Our findings receive further corroboration from reports released
    recently by the New York City Department of Mental Health and Hygiene
    from the WTC Registry that the health department has established with
    support from CDC. These reports noted increased rates of asthma and of
    post-traumatic stress disorder.
        Future Health Risks and Unanswered Questions. Two major unanswered
    questions confront us as we consider the future health outlook for the
    brave men and women who responded to 9/11:
            1. Will the respiratory, gastrointestinal and mental health
            problems that we are currently observing in responders continue
            to persist? For how long? And with what degree of severity and
            associated disability? These questions are especially important
            in the case of those responders who sustained very heavy
            exposures in the dust cloud on 9/11, in those who served in the
            first days after 9/11 when exposures were most intense, and in
            those who had prolonged exposures in the weeks and months after
            9/11?
            2. Will new health problems 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 in the aftermath of 9/11?
            Responders were exposed to carcinogens, neurotoxins, and
            chemicals toxic to the respiratory tract in concentrations and
            in combinations that never before have been encountered. The
            long-term consequences of these unique exposures are not yet
            known.
        Concluding Comments. Six years following the attacks on the World
    Trade Center, thousands of the brave men and women who stood up for
    America and who worked on rescue, recovery, and clean up at Ground Zero
    are still suffering. Respiratory illness, psychological distress and
    financial devastation have become a new way of life for many.
        The future health outlook for these responders is uncertain. The
    possibility is real that illnesses will persist, at least in some, and
    that new conditions--diseases marked by long latency--will emerge in
    others.
        Only continuing, federally supported medical follow-up of the 9/11
    responders through Centers of Excellence that are equipped to
    comprehensively evaluate responders, to document their medical
    findings, and to provide compassionate state-of the-art treatment will
    resolve these unanswered questions.
        Thank you. I shall be pleased to take your questions.

        Chairman Thompson. Thank you very much. I am sure you can
    expect some questions based on your testimony once we have
    completed.
        Chief Visconti, please.

      STATEMENT OF DEPUTY CHIEF NICHOLAS VISCONTI, INTERNATIONAL
                      ASSOCIATION OF FIREFIGHTERS

        Deputy Chief Visconti. I thank you, Chairman Thompson and
    distinguished members of the committee for the opportunity to
    testify before you today.
        My name is Nick Visconti, and I serve as the Deputy Chief
    of the New York City Fire Department. I am pleased to appear
    before you today on behalf of the International Association of
    Firefighters and the more than quarter million full-time
    emergency response personnel who comprise our organization.
        Like virtually every other member of the FDNY, I responded
    to the World Trade Center on September 11, 2001. Initially, it
    was my job to establish a staging area for first responders at
    Shea Stadium. Having nothing on hand, we borrowed supplies that
    we could from the NYPD detail at the stadium.
        As hundreds of firefighters began assembling at the
    stadium, we recorded their names and then dispatched them to
    the World Trade Center on buses provided by the Department.
        I assigned other officers to my duties, and I made my way
    to Ground Zero. I arrived shortly after the second tower fell.
    The scene was pure chaos. Everywhere I turned I saw
    firefighters with debris, our radios were screeching with
    urgent calls and May Days, an operations command post had not
    been set up, and I was immediately assigned to find and rescue
    the men of Ladder Company 6. The men of Ladder Company 6,
    including one of my best friends, had been on the fourth floor
    of Tower 2 when it collapsed.
        I pulled together people I knew personally, and we began
    the search. Somehow, I was able to quiet the chatter on the
    radio long enough to contact the missing company, and
    amazingly, I received an answer.
        Thinking they had only experienced a localized stairwell
    collapse, and not realizing that the entire building had
    crumbled down upon them, the captain asked that someone respond
    to a May Day that had been received from firefighters on the 12
    floor. I couldn't bring myself to tell them that there was no
    longer a 12th floor.
        As we conducted a futile search for the stairwell, which no
    longer existed, the men of Ladder 6, who were miraculously able
    to dig themselves out of rubble, I can only imagine what they
    felt when they realized the full extent of what had happened.
    That was first and last miracle I experienced that day.
        As we continued to search for victims and survivors, a
    firefighter, who is just off to my side, spotted some well-
    shined shoes in the debris. This discovery led to the removal
    of the body of the Chief of the department, Peter Ganci. Almost
    at the same time, the search for another pile of debris
    uncovered the body of William Feehan, the First Deputy Fire
    Commissioner. Two of the highest members of the fire department
    were found no more than 25 feet apart.
        For the rest of the day and into the night, my team and I
    searched for victims, hindered by the chaos and the complete
    lack of unit integrity. We had nothing to work with. We had no
    water, no trucks, no stretchers or body bags in which to place
    the victims we expected to find.
        We also expected to find survivors. Sadly, there were none.
    Only on the following day was a woman rescued from what was
    left of the north tower, and, to the best of my knowledge, she
    was the last.
        At about 11:00, I took my first break. I found the phone to
    call my wife and family to tell them that I was okay. Then I
    went back to the pile. For 3 days I did little else,
    occasionally catching a couple of hours of sleep at a firehouse
    before returning.
        On that day we lost 343 brother firefighters. As hard as it
    is to acknowledge, I know that illness and disease from
    hazardous exposures to Ground Zero will take yet more from us.
    It is from the perspective of one man who responded to that
    awful day that I wish to address the health and safety risks
    faced by first responders during major disasters.
        On September 11, there was nothing we could have done to
    have saved the towers from falling, but we could have and
    should have saved 121 firefighters who couldn't hear evacuation
    orders because their radios weren't working.
        We could have and should have provided responders with
    proper respiratory gear. We could have and should have an
    operated under a unified command system that effectively used
    well--trained and well-prepared emergency response
    professionals.
        The failure of the New York Fire Department to provide its
    firefighters with radios that worked in that environment is the
    greatest. The study of the FDNY response to the 1993 World
    Trade Center bombing included several recommendations, but none
    more important than replacing the antiquated radios we were
    using.
        Eight years later, we were using the exact same radios.
    Four years later our responders and the citizens of the gulf
    coast suffered many of the same problems during the response to
    the Katrina. There is, unfortunately, no quick fix. If Congress
    wishes national safety to be a national priority, it will
    require a concerted, long-term effort to ensure responders
    health and safety before, during and after a disaster.
        The best way to ensure responders' health and safety during
    a disaster is to ensure that they have the right personnel,
    tools and training they need before the response even begins.
        Unfortunately, far too many fire departments lack
    sufficient personnel to perform their duties safely, and far
    too many firefighters lack the training, equipment and
    preparation they need to safely participate in large-scale
    response. The Federal Government must provide both financial
    and programmatic support to address these shortcomings. Grant
    programs that provide resources to our fire departments must be
    fully funded. Research to improve personal protective gear and
    equipment, such as the work currently under way at the NIOSH
    lab must be expanded, and we must assure that the
    communications failures we witness on September 11 and during
    Katrina never happen again.
        The Federal Government also has an important role to play
    in assuring the health and safety of responders during the
    response. The National Incident Management System reflects a
    fundamental understanding by establishing a common framework to
    enable all government private sector and nongovernmental
    organizations to work together during disasters. In order for
    NIMS to work effectively, all firefighters must have certain
    minimum levels of training and capabilities. Just because
    someone calls himself a firefighter does not mean he or she is
    capable of doing what a firefighter should be able to do.
        In New York, we already have mandated minimum standards for
    mutual aid responses, and we believe this concept should be
    implemented nationwide. We therefore urge prompt and full
    implementation of the NIMS Integration Center National
    Credentialing System.
        Lastly, we must insure that on scene emergency commanders
    have the training and that they comply with standard operating
    procedures. There is no excuse for firefighters to operate in
    an unsafe manner when we know how to keep them safe. Every
    firefighter knows that the work of first responders does not
    end when the fire is out.
        Recovery after the fact is just as important as preparation
    and response. This is especially true in major disasters such
    as 9/11 and Katrina where the health needs of responders
    continue to be far beyond the initial response and illustrate
    the importance of management of disasters' aftermath. Medical
    monitoring and treatment programs addressing both the physical
    and mental health needs of the responders must be implemented
    following any large-scale event.
        In conclusion, I want to thank you for the opportunity to
    share a firefighter's perspective on protecting the health and
    safety of individuals who respond to major disasters. The
    issues and recommendations outlined in my testimony today only
    skim the surface of the matter at hand.
        Ensuring the health and safety of our first responders will
    require a comprehensive, long-term effort to align our Nation's
    policies and priorities with this goal.
        I want to thank the chairman once again and the committee
    for its attention. I would be happy to answer any questions.
        [The statement of Mr. Visconti follows:]

                    Prepared Statement of Nicholas Visconti

        Thank you Chairman Thompson, Ranking Member King, and distinguished
    members of the Committee for the opportunity to testify before you
    today. My name is Nick Visconti, and I currently serve as Deputy Chief
    of the New York City Fire Department. I am pleased to appear before you
    today on behalf of the International Association of Fire Fighters
    (IAFF) and the more than quarter million full-time emergency response
    personnel who comprise our organization.
        Whenever and wherever disaster strikes, America's professional fire
    fighters and emergency medical personnel are on the front lines working
    tirelessly and heroically to save lives and protect the public safety.
    As we have witnessed, whether responding to a bomb in Oklahoma City, an
    earthquake in San Francisco, massive flooding in the Gulf Coast or
    terrorist attacks on the World Trade Center, the men and women of the
    IAFF are the first to arrive on the scene and the last to leave.
        Like virtually every other member of the New York City Fire
    Department, I responded to the World Trade Center on September 11,
    2001. Although I was not scheduled to be on-duty that day, when the
    planes hit, every New York City fire fighter was mobilized. Initially,
    it was my job to establish a staging area for first responders at Shea
    Stadium. When I arrived, we had no equipment or material to set up a
    staging area. We rushed to collect needed supplies, record the names
    and units of the Fire Officers and fire fighters who responded, and
    began to delegate responsibilities. Having nothing on hand, we borrowed
    what we could from the NYPD detail at the stadium. As hundreds of fire
    fighters began assembling at the stadium and after five bus loads were
    dispatched to the World Trade Center, I assigned my duties to a
    Battalion Chief and made my way to Ground Zero.
        I arrived somewhere around thirty minutes after the second Tower
    fell. The scene was pure chaos. Everywhere I turned, I saw fire
    fighters covered with debris. Our radios were screeching with urgent
    calls and ``May-Days.'' An Operations Command Post had been set up, and
    I was immediately assigned to find the members of Ladder 6. The men of
    Ladder 6, including one of my best friends, had been on the fourth
    floor of Tower Two when it collapsed.
        We began to assemble our own search and rescue teams. At that time
    there were no ``units'' available. There were only groups of Fire
    Officers and fire fighters from different units and different areas of
    the City. I pulled together people I knew personally--people I knew how
    to work with--and began my search. Somehow, I was able to quiet the
    chatter on the radio long enough to contact the missing company--
    amazingly--I received an answer. They didn't know the entire building
    had crumbled around them. Thinking that they had only experienced a
    localized stairwell collapse, they asked that someone respond to a
    mayday they had received from fire fighters on the twelfth floor. I
    couldn't bring myself to tell them that there was no twelfth floor--
    there was only the mound that was once the North Tower. As we conducted
    a futile search for a stairwell which no longer existed, the men of
    Ladder 6 were miraculously able to dig themselves out from the rubble.
    I can only imagine what they felt when they realized what had happened.
        That was the first and last miracle I experienced that day.
        During this time fire officers were establishing command posts
    around the perimeter of the pile, but it was difficult to keep track of
    all personnel on scene. I must repeat that there was little to no unit
    integrity. The mainstay of Fire Department operations is organization.
    People know who is in command; they know their immediate supervisor and
    they know their role in the work at hand. Fire Department radio
    communications, despite the fact that the Towers had collapsed, were
    intermittent and jammed with individual messages. Furthermore, we
    lacked even the most basic of necessities. There was no water. There
    was no hose, there were no trucks. There were no stretchers or body
    bags in which to place the bodies we expected to find. We also expected
    to find survivors. Sadly, there were none. Only on the following day
    was a women rescued from what was left of the North Tower. To the best
    of my knowledge she was the last.
        I was assigned to set up an operations post on the south side of
    the collapsed North Pedestrian Walkway. We accessed the collapse field
    through a window of a World Financial Center building. The first
    priority was to organize the group and the others flowing into the
    debris field. Everyone was trying to do something; to accomplish
    anything we had to work together. As my group and I made our way around
    our assigned area, I looked down and found myself walking on the roof
    of a fire engine. When we searched the remains of that Engine we found
    the bodies of two members of the FDNY. A short time later, as the group
    that I commanded searched the debris field, a fire fighter, who was
    just off to my side, yelled out that he had spotted some well-shined
    shoes in the debris. This discovery led to the removal of the body of
    Chief of Department Peter Ganci. Almost at the same time the search of
    another pile of debris uncovered the body of William Feehan, the First
    Deputy Fire Commissioner. The two highest ranking members of the Fire
    Department were found no more than twenty-five feet apart.
        And so it went for the next several hours: digging through debris,
    trying to bring some order to unimaginable chaos, finding the bodies of
    not only our friends, our brothers, but also the civilian victims of
    the attack. I'd like to add that when a body was discovered and
    removed, it was done with the utmost respect and care, regardless of
    the identity or affiliation of the individual. At no time were we only
    seeking our Brothers; we wanted to find each and every victim.
        At about 4:30 PM the Operations Chief notified all Sector
    Commanders to evacuate the entire area of the debris field. The Chief
    had enough evidence to suspect that WTC 7 would collapse. Under normal
    circumstances, an evacuation order would have been transmitted over the
    handheld radios that are carried by officers and fire fighters. At this
    horrific landscape, successful radio communications were intermittent,
    most fire personnel did not have radios, we had no radio communication
    with other agencies that were working in the debris field, and there
    were many construction workers and others with whom we had no
    communications at all. To evacuate the area as rapidly as possible, the
    order to evacuate was transmitted repeatedly; Fire Department members
    were ordered to evacuate and to notify anyone with whom they had
    contact to leave the area. It was necessary to send individual
    ``runners'' to groups of people working throughout the area who did not
    receive the order. WTC 7 collapsed around 5:30 PM without further
    injury or death.
        At 11:00 PM I took my first break of the day. I found a phone and
    called my wife and family to tell them that I was OK. Then I went back
    to the pile. For three days, I did little else, occasionally catching a
    couple of hours of sleep at a firehouse before returning to the
    nightmare of that pile.
        On that darkest day, we lost 343 brother fire fighters. And as hard
    as it is to acknowledge, I know that illness and disease from hazardous
    exposures at Ground Zero will take yet more from us.
        It is from this perspective, the perspective of one man who
    responded on that awful day, that I wish to address the health and
    safety risks faced by first responders during major disasters.
        The terrorist attacks of September 11 and the devastation wrought
    by Hurricane Katrina fundamentally changed the way our nation views
    emergency response. Prior to these seminal events, public safety was
    viewed almost exclusively as a local government function. No more.
    Americans now fully understand that homeland security is a vital
    federal government responsibility, and Congress has rightly acted to
    improve the manner by which our nation responds to major disasters. But
    while the federal government has focused on how to better protect our
    nation's communities, citizens, and property, we have yet to focus on
    how to better protect the individuals who respond to major disasters in
    any comprehensive way.
        The fact of the matter is that, in today's post-9/11 world, local
    first responders play the most significant role in the federal response
    to large-scale disasters. As the federal government continues to ask
    more of its first responders, we owe it to them to ensure that our
    nation's policies and priorities enable their safe and effective
    response.

        The Response to the World Trade Center and Hurricane Katrina:
    Lessons Learned
        On September 11, there was nothing we could have done to have saved
    the Towers from falling, or to have saved the lives of those on the
    Towers' highest floors. But we could have, and we should have, saved
    121 fire fighters who couldn't hear evacuation orders because their
    radios weren't working. We could have, and should have, lessened the
    health impact on responders by providing them with proper respirators
    and protective gear from day one. We could have, and should have,
    operated under a unified command system staffed by well-trained and
    well-prepared emergency response professionals.
        The tragic reality is that these failures were avoidable. Workers
    were allowed on the pile without respirators, even though the air had
    not yet been determined safe to breathe. The City's command center,
    whose staff had never prepared for a high-rise fire, much less a major
    incident at the World Trade Center, collapsed at 7 World Trade Center,
    while fire fighters struggled to keep order on the ground.
        Perhaps most egregious was the failure of the New York Fire
    Department to provide its fire fighters with radios that worked in that
    environment. The exhaustive study of the FDNY response to the 1993
    World Trade Center bombing included several recommendations, but none
    more important than replacing the antiquated radios we were using. Yet,
    eight years later we were using the exact same radios.
        Following the cataclysmic events of 9/11, our nation rightly
    decided it needed a better way to respond to major disasters. Congress
    and the Administration moved quickly and forcefully to develop new
    systems so that we would be better prepared for the next disaster. We
    created the Department of Homeland Security, the largest reorganization
    of the federal government in half a century. The President of the
    United States issued a series of Directives that were meant to change
    not only procedures, but the way in which we thought about emergency
    response, leading to the creation of the National Incident Management
    System (NIMS) and the National Response Plan (NRP). Money flowed to
    establish interoperable communications systems.
        Yet, four years, billions of dollars, and countless man-hours
    later, our nation's new preparedness and response system failed the
    citizens of the Gulf Coast, and our responders, yet again. The response
    to Hurricane Katrina was plagued by the delayed deployment of people
    and resources, a lack of basic supplies, and a failed communications
    system.
        There is, unfortunately, no quick fix to safeguard those who put
    their lives on the line to protect the public. If Congress wishes first
    responder safety to be a national priority, it will require a
    concerted, long-term effort to ensure responders' health and safety
    before, during, and after a disaster.

        Before a Disaster: Preparation
        The very best way to ensure responders' health and safety during a
    disaster is to ensure you have the right personnel, tools, and training
    you need before the response even begins. Every Boy Scout knows the
    mantra ``Be Prepared.'' Yet, far too often, we as a nation forget that
    simple lesson from our childhood. Unfortunately, far too many fire
    fighters today lack the training, equipment and preparation they need
    to safely participate in a large-scale response.
        The single most effective thing the federal government can do to
    protect fire fighter safety is assure that every fire department in the
    nation has a sufficient number of adequately trained and equipped fire
    fighters. Currently, two-thirds of all fire departments are
    understaffed and operating below safe minimum staffing guidelines
    issued by the National Fire Protection Association (NFPA). The results
    are tragic and harrowing.
        Since 1998, the National Institute for Occupational Safety and
    Health (NIOSH) has investigated every fire fighter line of duty
    fatality. From January 1, 1998 through 2005, there were 174 fatalities
    from trauma, such as burns, crushing, falls and inhalation of toxic
    gases, at a fire scene. In almost all of these incidents, NIOSH found a
    lack of incident command, accountability, and most importantly,
    staffing as a primary cause of these line of duty deaths.
        That said, having sufficient personnel on the ground would make
    little difference if they are not properly equipped or properly trained
    for the job at hand. New resources must be dedicated to develop and
    test new protective gear and equipment. Currently, NIOSH's National
    Personal Protective Technology Laboratory is developing new
    technologies to better protect fire fighters from all hazards,
    including a terrorist attack using deadly chemicals or biological
    agents.
        Based on the innovations that emerged from NIOSH's lab and other
    research centers, all fire fighter respirators now protect fire
    fighters against chemical, biological, radiological and nuclear (CBRN)
    agents. And NIOSH is continuing its efforts to improve turnout gear and
    other personal protective gear to protect fire fighters against the
    dangers of the 21st Century.
        Training levels must also ensure fire fighters are able to function
    in even the most hazardous scenarios. NFPA has recently revised its
    standard for hazmat training to fully incorporate response to weapons
    of mass destruction. We believe it should be a minimal requirement for
    all fire fighters to receive this hazmat/WMD training as a matter of
    course.
        As the failures on September 11 and during the response to Katrina
    illustrate, emergency communications challenges during major disasters
    continue to endanger first responders. However, despite the common
    belief that communications issues on 9/11 and on the Gulf Coast were
    failures of interoperability, they were, in actuality, failures of
    basic operability. The fact of the matter is that, before emergency
    response departments can grapple with the issue of interoperability,
    they must ensure that basic communications needs are fulfilled. Too
    many emergency departments lack effective and reliable communications
    equipment. Additionally, in a major disaster basic communications
    systems may be destroyed.
        Once departments overcome any weaknesses in their own internal
    communications systems, they may then face additional technical and
    operational challenges in achieving interoperability. Equipment
    purchases alone will not ensure interoperable communications.
    Communities must also ensure appropriate planning, design, exercises,
    modeling and training.
        The Office of Management and Budget conservatively estimates that
    $15 billion is needed to address communications interoperability issues
    in the United States. Billions more will also be needed to assist local
    emergency response agencies meet their own communications needs.
    Congress should take steps to provide additional funds for emergency
    responder operability and interoperability needs as expeditiously as
    possible, and ensure that interoperability grants are made available
    for a wide variety of activities.
        Equally as important as ensuring that personnel have proper
    equipment and training is ensuring that such personnel are physically
    fit to carry out their duties. To this end, all fire fighters should be
    required to undergo an annual physical evaluation to identify and
    address any health issues a responder might have. Furthermore, fitness
    facilities should be made readily available, and incentives should be
    provided for fire fighters to undertake regular fitness programs.
        The IAFF has made achieving and maintaining fire fighter wellness
    and fitness one of its top priorities. Working in conjunction with the
    International Association of Fire Chiefs, the IAFF has developed a
    Wellness-Fitness Initiative designed to help maintain fire fighters'
    physical and mental capabilities throughout their careers. One way to
    better protect fire fighters in responding to major disasters would be
    to implement this initiative in every fire department in America.

        During a Disaster: On-the-Scene
        The federal government also has an important role to play in
    assuring the health and safety of responders during an actual response.
    As I mentioned previously, the mainstay of fire department operations
    is organization. The National Incident Management System (NIMS)
    reflects this fundamental understanding by establishing a common
    framework to enable all government, private-sector, and nongovernmental
    organizations to work together during disasters. By establishing a
    common language, a unified approach, and standard command structures,
    NIMS enables first responders and those with whom they work to operate
    more efficiently, and thus, more safely. As the federal government
    continues to update and refine NIMS, it must ensure continued
    compliance with its principles among all levels of government, and
    proactively provide continuing educational opportunities to first
    responders and government officials to achieve such compliance.
        Additionally, the safety of responders and citizens during a major
    disaster, as well as mission effectiveness, can be greatly increased by
    the efficient and appropriate management of response personnel.
    Although their impact on disaster response has always been
    overwhelmingly positive, the arrival of fire fighters on the scene has
    often been chaotic and less than 100% effective. There are several
    reasons for this.
        First and foremost, too many well-meaning fire fighters self-
    dispatch rather than waiting to be officially mobilized. Second, the
    qualifications of fire fighters currently vary across and within
    departments. Just because someone calls himself a fire fighter does not
    mean he is capable of doing what a fire fighter should be able to do.
    Current difficulties tracking on-scene personnel and their capabilities
    prevents on-scene commanders from making the best use of their most
    valuable resources. This was certainly my experience on 9/11.
        The NIMS Integration Center (NIC) within the Department of Homeland
    Security is currently developing a national credentialing system to
    help verify the identity and qualifications of emergency personnel
    responding to a major disaster. The System, requiring minimum national
    qualifications for specific emergency response functions, will help on-
    scene commanders identify who is on-scene and make the best possible
    use of their capabilities. Had such a system been in place on 9/11, the
    issues we experienced tracking and utilizing personnel may have been
    avoided. Congress should do all it can to ensure that States and
    localities only credential personnel who fully comply with the minimum
    national standards established by the NIC, and that the National
    Credentialing System is quickly and thoroughly implemented.
        Lastly, we must ensure that on-scene commanders fully comply with
    standard operating procedures. Unfortunately, far too often, fire
    fighter deaths and injuries result not from failures of equipment or
    unexpected dangers, but from a failure to comply with widely accepted
    rules and procedures for operating safely. This is completely
    unacceptable; there is no excuse for fire fighters to operate in an
    unsafe manner when we know how to keep them safe on-scene.

        After a Disaster: Follow-Up and Follow-Through
        Every fire fighter knows that the work of first responders does not
    end when the fire is out. Recovery after the fact is just as important
    as preparation and response. This is especially true in major disasters
    such as 9/11 and Katrina. In these two cases, the health needs of
    responders, in particular, have continued far beyond the initial
    response and provided an illustration of the importance of managing a
    disaster's aftermath.
        Because any major disaster is bound to pose significant physical
    dangers and mental health challenges, the establishment of a
    comprehensive health monitoring program is essential. Following the 9/
    11 response, the New York Fire Department established a medical
    monitoring program to identify and treat any new health problems in
    responders. The situation facing responders and their physicians was
    extremely serious. The Ground Zero dust cloud was the largest acute
    exposure to high-volume particulate matter in a modern urban
    environment--ever. Within the first week following 9/11, the FDNY found
    that 99% of exposed New York City fire fighters reported at least one
    new respiratory symptom while working at Ground Zero. Fortunately,
    FDNY's annual physical requirement established a baseline medical
    picture from which monitoring physicians could judge a fire fighter's
    relative health.
        The Department also provided mental health treatment through its
    Counseling Service Unit, providing treatment for post traumatic stress
    disorder, substance abuse counseling and grief counseling. Due in large
    part to the program, FDNY experienced only one post-9/11 suicide.
        There is no doubt in my mind that hundreds of additional fire
    fighters would have experienced serious physical and mental health
    issues were it not for the FDNY programs. Their success makes them an
    excellent model for comprehensive physical and mental health monitoring
    programs established in the wake of future disasters.
        We must also ensure that lessons learned from future response
    efforts are retained and applied in preparation for the next
    catastrophe. The 9/11 Commission report and the Katrina report enabled
    organizations and persons at all levels of society to identify and
    remedy broken response components and missed opportunities. In response
    to these reports, Congress, for example, established the Department of
    Homeland Security, provided homeland security funding to the states and
    passed a comprehensive FEMA reform bill. After-action reports such as
    these should be de rigueur for any major disaster so that lessons
    learned can be incorporated into our future training, exercises, and
    response plans.
        Lastly, it should go without saying that when the public safety
    department of a community is completely devastated by a disaster, the
    federal government should step up to the plate and help that community
    rebuild that department. On 9/11, FDNY lost 343 fire fighters, and 100
    pieces of apparatus--equivalent to losing an entire fire department the
    size of San Diego. Similarly, when Katrina hit the Gulf Coast, New
    Orleans lost two-thirds of their fire stations, while the St. Bernard
    Parish Fire Department lost five of six stations. When a community
    takes such a devastating blow, the federal government must intervene to
    protect the safety of the homeland as well as its citizens. And it
    should do so without adding the burden of dealing with red tape and
    bureaucracy on a community already facing an overwhelming burden.

        Progress Made: Recent Congressional Action
        While there is still much work do be done to align our nation's
    policies and priorities with the goal of protecting the protectors, I
    am encouraged by the spotlight this Committee and the Congress has
    shone on the issue as of late. I would be remiss if I did not mention a
    number of recent reforms instituted by the Congress which I believe
    will help better ensure the health and safety of fire fighters and
    others who respond to future disasters.
        One of the most important recent reforms implemented by the
    Congress was the enactment of the Emergency Management Reform Act of
    2007, popularly known as the FEMA reform bill. The leadership of this
    Committee was early to recognize many of the problems facing FEMA, and
    actively engaged the IAFF as you crafted your bill, which we were proud
    to support.
        Many of the provisions included in the FEMA reform bill will
    significantly contribute to assuring the health and safety of
    responders in an emergency. By reuniting emergency preparedness with
    emergency response under FEMA, the bill will help ensure that
    tomorrow's emergency response efforts are in sync with today's
    preparedness efforts. Authorizing the National Integration Center to
    promote compliance with the National Incident Management System (NIMS)
    and the National Response Framework (NRF) will help assure that
    responders are operating under common procedures. And involving first
    responder organizations through the National Advisory Council will
    ensure that the plans made by governmental officials make real-world
    sense to those who must carry them out.
        Congress has also consistently supported grant programs to ensure
    that fire departments nationwide are safely staffed by properly
    equipped and trained personnel. This year, the House of Representatives
    has provided $235 million for the SAFER grant program as well as $570
    million for the FIRE grant programs. Although these funds will provide
    a down-payment on fire fighter safety, I urge the Congress to fully
    fund these vital and life-saving grant programs so that they may
    achieve their full potential.
        I am also appreciative of legislation passed by the Congress and
    signed into law authorizing the President to establish medical
    monitoring programs following disasters. We at FDNY benefited from a
    truly comprehensive monitoring and treatment program that, I have no
    doubt, saved countless lives. Likewise, future monitoring programs will
    permit the treatment of potential diseases and other health conditions
    in responders that might not otherwise be detected.
        I am also pleased that Congress has made significant strides to
    improve emergency communications during disasters. By doubling the
    current spectrum available to public safety and establishing two new
    grant programs to help public safety agencies achieve interoperability
    as well as basic communications operability, you have made great
    strides towards ensuring that the communications failures of 9/11 and
    Katrina are not repeated.
        Furthermore, provisions in the recently enacted 9/11 Commission Act
    help ensure that federal homeland security assistance be distributed to
    state and local governments based on risk and vulnerability. A key
    recommendation of the 9/11 Commission, this reform will help ensure
    that the lion's share of resources are used to provide equipment and
    training to protect those responders at highest risk for disaster,
    whether natural or man-made.

        Conclusion
        On behalf of myself and the IAFF, I appreciate the opportunity to
    offer our perspective on protecting the health and safety of
    individuals who respond to major disasters. But the reality is that the
    issues and recommendations outlined in my testimony today only manage
    to skim the surface of the matter at hand. Ensuring the health and
    safety of our first responders will require the dogged will of
    legislators, such as yourselves, to undertake a comprehensive, long-
    term effort to align our nation's policies and priorities with this
    goal. We look forward to working and partnering with your committee to
    this end, so that we may better safeguard our first responders as they
    put their lives on the line every day to protect our communities and
    their citizens from emergency situations both large and small.
        Again, I would like to thank the Committee for its attention and I
    would be happy to answer any questions you may have.

        Ms. Clarke. [Presiding] Thank you for your testimony.
        I now recognize Dr. Mike McDaniel to summarize his
    statement for 5 minutes.

    STATEMENT OF MIKE MCDANIEL, SECRETARY, LOUISIANA DEPARTMENT OF
                         ENVIRONMENTAL QUALITY

        Mr. McDaniel. Thank you, Representative Clark, the
    committee members.
        I am Mike McDaniel of the Louisiana Department of
    Environmental Quality.
        My testimony will address DQ's response to Hurricanes
    Katrina and Rita. LDEQ's responsibility under Louisiana's
    emergency operating plan are limited primarily to environmental
    support function 10, and that is oil spill, hazardous materials
    and radiation.
        However, as detailed in my written testimony, the
    Department conducted many activities that yielded critical
    information to assist and protect first responders. This
    information was provided through the unified command center.
    These activities included search and rescue, reconnaissance,
    damage and environmental threats assessment, environmental
    sampling and assessment and hazardous radioactive materials
    management.
        In the area of search and rescue, teaming with the
    Louisiana Sheriff's Association, the LDEQ employees aided in
    the rescue of approximately 480 people from the area impacted
    by Hurricane Katrina.
        In the area of reconnaissance damage and environmental
    threats assessment, our immediate concerns relevant to
    responders included industrial sites, oil spills, waste water
    treatment plants, rail cars, barges, radioactive material
    locations, drinking water sources and intakes, underground
    storage tanks, ruptured pipelines, Superfund tanks and then
    access routes and photo documentation.
        Air reconnaissance was used to provide an initial
    evaluation of status of these sites of concern. In addition to
    high resolution aerial photography and satellite imagery, also
    utilized were the EPA ASPECT aircraft, the Department of
    Energy's airborne radiation detectors, the EPA's mobile air
    monitoring units and a helicopter-mounted HAWK camera.
        The EPA ASPECT aircraft has capabilities for air quality
    and radiation monitoring, as well as aerial photography. The
    HAWK camera is an infrared gas-imaging technology that captures
    images of volatile gases that are visible to the naked eye.
    This information obtained during these assessments was shared
    with the unified command center, including assisting first
    responders.
        In addition, hazards such as oil spills, gas releases were
    photo documented, and potential access routes were evaluated to
    assist first responders and for followup ground assessments. As
    facilities and sites became assessable, ground assessments were
    made of all potential sources and all potential releases of
    hazardous materials.
        Drinking water sources were evaluated for contamination,
    and operational status of water and waste water treatment
    plants were determined. In many cases, multiple visits were
    made to sites in order to ascertain that potential hazards had
    been secured. For example, 383 visits were made to 258
    radiation source licensees in order to verify that all
    radiation sources had been secured.
        In the area of environmental sampling and assessment, with
    EPA and other partners, thousands of environmental samples were
    collected, including floodwaters, waters of Lake Pontchartrain,
    adjacent coastal areas in the Mississippi River, sediment and
    soils, seafood and air quality. These efforts are detailed in
    our written testimony.
        In all over 1 million individual analyses were performed,
    and data and health risk assessments were presented to the
    public and LDEQ and EPA Web sites, through press releases,
    press conferences, presentations, media interviews and calls to
    live radio.
        Effectively communicating the environmental sampling
    results to first responders and the public was recognized as
    critical, and great effort was extended in this area. The
    various means of communicating and environmental results to the
    first responders and the public, along with some examples, are
    described in our written testimony.
        In the area of hazardous and radioactive materials
    management, with valuable assistance and resources provided by
    EPA, over 22.4 million pounds of hazardous material were
    collected and removed from waste streams for proper treatment
    and disposal. Over 1 million white goods such as refrigerators,
    956,000 electronic goods and 250,000 small engines were
    collected and sent to be recycled.
        Over 4 million orphan containers, many containing hazardous
    materials were collected and reprocessed for recycling
    disposal. Over 110 school laboratories were cleared of
    hazardous material. Our radiological response efforts included
    issues relating to the security of the State's nuclear facility
    and radioactive materials held by our licensees.
        In the area of protecting our first responders, throughout
    our emergency response efforts, great care was taken to protect
    all first responders working from our unified command center.
    The LDEQ attended many briefings on a daily basis to share
    information from its assessments and other activities that was
    used to assist and protect first responders.
        Specifically, environmental conditions, as well as health
    and safety procedures were discussed and briefings held every
    morning before our field crews left for their various
    responsibilities. An example of the types of communication and
    information provided to the responders are provided in our
    written testimony.
        In closing, I would like to note that at the request of the
    Senate Committee on the Environment and Public Works, the LDEQ
    put together a report entitled Some Observations and
    Recommendations for those Planning for or Responding to
    Environmental Challenges presented by Major Disasters. This
    report addresses issues relevant to this hearing and can be
    found on LDEQ's Web site.
        That concludes my statement. I would be happy to take any
    questions at this time.\1\
    ---------------------------------------------------------------------------
        \1\ All exhibits referenced in this written testimony may be found
    at www.deg.louisiana.gov.

        Ms. Clarke. I thank all of the witnesses for their
    testimony. I will remind each member that he or she will have 5
    minutes to question the panel.
        I will now recognize myself for questions.
        Let me start by just thanking Chief Visconti for coming and
    testifying today, for his service to our Nation, the State of
    New York, the City of New York, for the past 39 years. You must
    have started when you were about 8, right, chief?
        Deputy Chief Visconti. Five.
        Ms. Clarke. Five. But you raised some very important
    questions, just based on your personal experience and through
    the wealth of knowledge that you have gained throughout your
    career as a firefighter and as a ranking member of the FDNY.
        Chief Visconti, having interoperability with
    communications, proper staffing levels, solid leadership and
    proper personnel protective equipment are critical health and
    safety issues.
        You stated in your testimony that you felt that we weren't,
    or the City of New York and Nation was not equipped on
    September 11.
        Do you feel that the New York City fire department have all
    these things currently and what would you recommend to make
    sure that fire departments around this Nation are prepared for
    emergency events such as a terrorist attack or a natural
    disaster?
        Deputy Chief Visconti. Well, I will begin with
    interoperability. I don't believe that the city is up and
    running yet with the interoperability portion of
    communications. I know they are working very hard, and there is
    a center that is being created. They are spending a lot of man-
    hours and money into getting that up and running.
        But the bedrock of communications, of any emergency scene,
    is that if each agency can talk to themselves. That was the
    problem at the World Trade Center.
        At the World Trade Center, we couldn't communicate
    effectively with our own people. Even after the towers were
    down, and there was no line-of-sight problems, we could not
    talk to somebody 60 yards away when somebody 100 yards away
    could hear them from a different location. The communications
    were really terrible.
        If we had been able to communicate with our people
    effectively, we could have probably lost fewer people in Tower
    2. Tower 1 collapsed without anybody realizing that it was
    going to collapse. But Tower 2, when Chief Cowan gave the order
    to evacuate, the vast majority of people in that tower did not
    receive the message.
        Going up one level, if the fire department had been aware
    that a police officer in a helicopter saw signs or suspected
    that Tower 1 was going to collapse, we certainly could have
    notified some people in Tower 1 and obviously in Tower 2. So
    that is an issue that starts at the bedrock of communications
    within your own agency, and then communicating with other
    agencies will definitely be of benefit to us.
        Staffing, I really can't argue with the staffing of the New
    York City Fire Department. We have the best staffing in the
    entire country, from what I understand. We have also at a
    minimum, four firefighters on every engine and also a minimum
    of five firefighters on every ladder. That is excellent
    staffing.
        The third issue that you mentioned?
        Ms. Clarke. Is personal protective equipment.
        Deputy Chief Visconti. On September 11, I don't know where
    they came from, but ultimately we would see people walking
    around with filter masks. Now filter masks were inappropriate
    for that atmosphere. Everybody was talking around covered in
    dust. Firefighters, when they arrived at the scene, had the
    self-contained breathing apparatus, but that is a 1-hour
    bottle. You work with a face piece.
        In that environment, especially after the air cleared,
    nobody was aware that they would need respiratory protection.
    But the first that I can recall, and it is a pretty hazy period
    of time, the best that I can recall is that about a week later,
    a concerted effort was made to provide everybody with HEPA
    masks, dual-canister respirators. Before that, it was
    disjointed. People would have filter masks, people would have
    other protection. Firefighters did not walk around after the
    collapses the next days with their masks on, because it didn't
    appear that we needed any.
        Ms. Clarke. Why didn't it appear so? Was there something
    that indicated was their message or, you know, we are all aware
    of what the EPA said, but what do you think precipitated that?
        Deputy Chief Visconti. Well, I am not sure what
    precipitated that, but I know that after the collapses, and the
    dust cloud moved away, and all that was left was the smoking
    debris, that most people felt confident that they were
    breathing clean air.
        It was only once the fire department actually established a
    second fire department just to deal with the World Trade
    Center, that every single individual down there was mandated to
    wear the HEPA dual-canister mask. If you didn't have it on, you
    were removed from the site. We had site safety people walking
    around making sure you had that respirator on. But that was not
    until sometime later.
        Ms. Clarke. The gentlelady from New York, Mrs. Lowey.
        Mrs. Lowey. I thank the distinguished Chair, a fellow New
    Yorker, and I am very pleased to welcome the panel, Dr.
    Landrigan, Chief Visconti, and the gentleman from Louisiana,
    who I haven't had the pleasure of meeting. Thank you very much
    for being with us today.
        Since September 11, the issue of first responder health has
    been one of my top priorities. As someone who had hundreds of
    first responders from my district were the pilots, and really
    tragic seeing the health problems faced by many of our heroes.
        While New Yorkers faced the biggest impact, the issue
    certainly goes beyond New York. The World Trade Center health
    registry has collected information from 71,400 out of the
    410,000 individuals who were exposed to serious health hazards.
    Those exposed, many of whom are first responders, as we know
    too well, who worked the pile, came from every congressional
    district in the country.
        For instance, 57 of the registry's participants are from
    the chairman's State of Mississippi, and we should keep in mind
    that the registry has only collected information of one-sixth
    of the total number of individuals who are likely exposed. So I
    encourage everyone who is here before and now to support the
    efforts that are being led by the New York delegation to ensure
    that everyone exposed to Ground Zero toxins is medically
    monitored and treated.
        I have several questions, but, Chief, I just want to
    respond to something that you just said. No one was aware that
    they needed a mask.
        Now, there has been a lot of discussion about this, from
    the mayor, from the former head of the EPA, if you could
    elaborate on that, you said about a week later?
        Deputy Chief Visconti. Yes.
        Mrs. Lowey. The masks were delivered.
        Deputy Chief Visconti. Yes to the best of my recollection.
    The first few days on the pile, seeing somebody with a filter
    mask on was not uncommon, but it wasn't widespread. I saw
    several people, firefighters, police officers and construction
    workers with the little filter masks on. Where they got them,
    how they got them, what made them think about getting them, I
    don't know.
        But then it was later on, after that first week, that the
    HEPA masks were brought in. Now, initially, it was just handed
    it out, and then it was realized that they must be fitted. You
    had to have a fit test. Otherwise, you would do more damage by
    using the mask than not using it. So then they got into the
    program of you had to have one of those masks, you had to be
    fitted for it and you had to use it.
        Mrs. Lowey. After the first week.
        Deputy Chief Visconti. I am guessing, I am going to say the
    first 4 days, I don't think anybody had the capability of
    realizing or capability of gathering enough respiratory
    protection to bring it into the site.
        Mrs. Lowey. Dr. Landrigan, nice to see you again. We know
    sustained Federal funding is critical to continue to provide
    monitoring and treatment to 9/11 workers who are ill, and I was
    pleased that the supplemental funding bill enacted earlier this
    year in the fiscal year 2008 House Labor-HHS appropriations
    bill, each contained $50 million for health monitoring and
    treatment. As you know, many of us worked hard to get that.
        Unfortunately, estimates for the 9/11 health problems would
    be as high as $393 million per year. The Federal Government
    just has to be prepared to invest significantly more funds. The
    annual figure is substantially more than the $227 million total
    figure that has gone to 9/11 health programs.
        If funding was not an issue, Dr. Landrigan, how would you
    expand the program at Mount Sinai. How much would it cost to do
    this, and how does a lack of adequate funding impair your
    ability to provide the services and care that these individuals
    need?
        Dr. Landrigan. Thank you for that question, Mrs. Lowey, and
    thank you for being with us throughout this issue. There have
    been two issues about the funding that have been problematic.
    One is that it has been limited over the past 6 years, and the
    second is that the flow has been intermittent. There hasn't
    been the assurance from one year to the next that there would
    be funding, nor has there been any assurance as to the level of
    funding from one year to the next, which has made the planning
    very difficult, the space, personnel, and the rest of it.
        If funding were not an issue, then we would continue to
    work in two areas, and we would expand both of them.
        First of all, we would continue the aggressive monitoring
    that we are doing. We have now seen more than 22,000 of the
    responders who were down there, and our colleagues at FDNY have
    seen another about 15 or 16,000 or so between us. We have seen
    36--or 37,000, but we know that there were somewhere between
    40,000 and 90,000 responders down on the pile.
        Therefore, we still have many tens of thousands that we
    haven't seen, and we would, if we had full funding, we would
    reach out even more aggressively than we are already reaching.
        The second issue is treatment. Federal funding for
    treatment began only 1 year ago in September of 2006. Prior to
    that time, all of our treatment activities were funded solely
    by philanthropy, by local foundations, plus the American Red
    Cross. It is clear that we are only scratching the surface on
    treatment. There are lots of persistent respiratory diseases, I
    mentioned in my testimony, there are mental health problems,
    and there is the possibility, it is not a certainty, but there
    is the possibility that we will see additional disease in the
    year ahead, and some well locked-in funding for medical
    treatment that extended over the years would be a great source
    of security for the responders themselves, as well as for those
    of us who are providing their care.
        Mrs. Lowey. Thank you very much. Madam Chairman, do you
    want to ask a question, and then we can just go back and forth,
    since it is the two of us.
        Ms. Clarke. Very well.
        Mrs. Lowey. We have another guest.
        Ms. Clarke. We have Mr. Etheridge joining us from North
    Carolina. The gentleman from North Carolina has 5 minutes to
    ask his questions.
        Mr. Etheridge. Thank you, Madam Chairman. I apologize for
    having to duck out. I am involved in two hearings this morning,
    and both of them at the same time.
        You probably heard me earlier raise the question with our
    previous panel about the number of firefighters who lose their
    lives of a heart attack or stroke.
        But let me, Chief, ask you a question, if I may, and thank
    you for your service and all of you folks for what you are
    doing.
        Prior to the 9/11 attack, the Fire Department of New York
    had systematically collected and updated, really had developed
    a baseline of medical data for all of your firemen, which had
    to have a significant impact on assisting the clinical ability
    to detect the subsequent health problems that came as a result
    of the World Trade Center.
        My question is to what extent can professional responder
    groups, not just firefighters but all the responders that we
    with call, upon benefit from that? What would you share with
    this committee that we ought to be doing at the Federal level,
    if anything, as I raised the issue a while ago? What can we do.
        Deputy Chief Visconti. In The New York Fire Department,
    there are physical standards to become a firefighter as in
    every other fire department. The New York City Fire Department
    has kept a record. I know I can do go down and find x-rays from
    when I was appointed to the Department in 1968. They keep their
    records.
        They maintain a baseline on you. The Department, after 9/
    11, Dr. Kelly and Dr. Prezant, instituted a program of giving a
    World Trade Center physical to each and every member of the
    department. That data is now available for the yearly checkup
    that each firefighter or fire officer gets. They are able to
    determine if there are some changes going on. They are able to
    see whatever and what other illnesses are becoming apparent.
        I don't think that in this day and age that any department
    or any agency should be without that capability. It is
    essential to have that so that in the future, in a situation
    like this, we have some place to start.
        Mr. Etheridge. Let me follow up with you, because just in
    conversation, I like to have, I realize the system is as large
    as New York, and maybe Washington alone, but I guess I want to
    probe it just a little farther because across the country we
    have a lot of first responders who are volunteers, probably, 70
    or 80 percent I would have to check that, and I don't know how
    many of them do what you are talking about. Now, the
    probability is less, but I do know in a number of instances
    across, even in rural departments now, we have had firemen, by
    and large firemen, police officers too, for that matter.
        Some EMS have responded to meth labs not recognizing houses
    on fire, they go in not recognizing what they have had, and all
    of a sudden you have a problem. I know of one situation where
    we had a volunteer who lost his life, did not know what it was
    till it was over.
        I would be interested in your thoughts, and either of the
    medical officers, how we can encourage that, because I think
    there is a whole group of first responders out there, that we
    don't have that data on and are responding.
        Deputy Chief Visconti. I don't know what the requirement
    would be. I don't know who would institute it. But in 2007,
    that would not be--that would be an excellent goal to achieve,
    that every member of that volunteer fire department has the
    training he needs to recognize hazards and to deal with
    hazards, but also to make sure they are able to physically able
    to do the job.
        I don't see how you can get around that. If an entrance
    physical and a medical examination is required, and this doctor
    said this person is capable, you have right there and then as
    soon as they enter the department a baseline on the physical
    condition when they entered. As far as the training goes, it is
    absolutely essential to have the training.
        Mr. Etheridge. Yes, that is required, I think, in most
    jurisdictions.
        Deputy Chief Visconti. But I don't know what the standard
    is across the country.
        Mr. Etheridge. Sure.
        Deputy Chief Visconti. All I know is the volunteers of my
    town, because I live outside of New York, they train, they have
    New York City fire officers who are members of their volunteer
    fire company. I give them classes on commander control and
    other things. I know they are interested in training, not only
    in what comes out of books but hands-on training. I know they
    are well prepared. I don't know if there is a standard of level
    of training across the country for that expertise.
        Mr. Etheridge. Madam Chairman, I know my time has expired.
    I do from State to State you do have this. I think it would be
    a great issue that ought to be developed simply because of the
    mobility of people today, the movement of transportation, the
    hazardous things that move across our borders and the
    interstates and the probability that it could happen today.
        Thank you, Madam Chairman, I yield back.
        Ms. Clarke. Dr. McDaniel, I understand that the Louisiana
    Department of Environmental Quality, LDEQ, started gathering
    data, monitoring the environment and putting out information to
    everyone in Louisiana very soon after Hurricane Katrina made
    landfall.
        What challenges did you face in obtaining this data,
    getting lab analysis done and et cetera?
        Mr. McDaniel. I would say the greatest challenge and the
    thing that we are working on with EPA is getting the samples
    taken, the analysis time and turning the information around to
    the public as rapidly as possible. Sometime there is a delay of
    the time you take the sample, you deliver it to the lab and get
    the analysis.
        So emphasis should be placed, and we are looking at this,
    on instrumentation in the field that gives you quick, at least
    surrogate information that helps in protecting first
    responders. We got better and better as time went, but having
    prepositioned assets for remote sensing, for taking samples,
    whatever media it might come from, to be able to provide that
    information as rapidly as possible.
        Ms. Clarke. What additional support would you have liked to
    have seen from your Federal partners in the aftermath of
    Hurricane Katrina, acknowledging that there was some support
    provided by the National Center For Environmental Health and
    the EPA and others?
        Mr. McDaniel. I would say that we enjoyed a pretty good
    working relationship, particularly with EPA region 6, and they
    were actually housed in our conference room in a unified
    command center, so we had a very close working relationship. I
    think that was very helpful to have that communication up
    front, very efficient, effective in responding.
        I would say, again, going back to my first point, having
    them have the equipment or the assets, preposition or readily
    available that give us quick turn around on information on
    environmental sampling would be very helpful in any instance,
    of course.
        We had the advantage of having a little time. Knowing that
    a problem was approaching, you don't always have that luxury.
        Ms. Clarke. In the aftermath of this storm, were there
    predictions about the types of toxins that would hit the area
    and how to mitigate that, and were you able to follow through
    on that?
        Mr. McDaniel. Yes. One of the problems we had, quite
    frankly, was a lot of false information that was being put out.
    We were collecting information, you probably saw some of the
    press releases on toxic soup, toxic sludge, toxic air killing
    lake Lake Pontchartain and on and on. We spent a lot of time
    trying to get information out, trying to quell the anxiety that
    was out there.
        We found the floodwaters certainly were unsanitary. There
    was some fuel components in it. But this information was
    provided to the responders. We have a very good preventive
    program and training and briefings every morning so they know
    how to deal with those kinds of conditions when they get to the
    field.
        Ms. Clarke. Thank you very much, Doctor.
        I want to turn to you, Dr. Landrigan. I understand that
    approximately 1,000 folks sign up every week for the Mount
    Sinai World Trade Center screening program. How has the
    screening program expanded since its inception, and are there
    issues that are not being addressed due to research or funding
    limitations?
        Dr. Landrigan. Yes, madam, the number of new responders who
    are coming in for the first time, even now 6 years and some
    after the attacks, fluctuates between 400 and 500 a month, new
    people, multiply that by 12, that is about close to 5,000 new
    people every year at the current rate. That has been holding
    steady for the last year and a half, 2 years.
        At the present time, we are funded in the monitoring
    program through 2009, and it is moving along well. We have a
    very efficient system. The wait time for new visits for
    somebody who comes along is just a few weeks. We are in the
    process of attempting to set up a satellite out in Staten
    Island to take care of people in that borough and in areas of
    New Jersey.
        Of course, we continue to work closely with Belleview
    Hospital, Queens College, UMDNJ and State University of New
    York at Stony Brook. So I would say the monitoring program is
    doing well, but I am still saddened, as I said to Mrs. Lowey
    several moments ago, that there are probably 35--, 40,000
    people who even now we have not yet now seen. We will continue
    to hope that they will come forward.
        Ms. Clarke. You didn't speak to any funding limitations or
    research challenges. Could you just give us a sense of the
    status of that?
        Dr. Landrigan. Well, clearly we will need continued
    funding. The funding sunsets in 2009. Indeed, we may run out
    sooner if the number of patients continues to come in at the
    rate they are coming, 4 to 500 a month. We will continue to
    keep you informed as to the status of that. Anything that you
    can and Congress can do to extend the funding beyond 2009 will
    be critically important.
        Ms. Clarke. The gentlelady from New York.
        Mrs. Lowey. Thank you, Madam Chair.
        I wanted to follow up on one of my good friend from New
    York's questions concerning the equipment.
        Chief Visconti, is the Federal Government doing enough to
    test equipment to ensure that it is truly safe? If you can
    comment on that.
        Deputy Chief Visconti. Mrs. Lowey, you are referring to the
    personal protective equipment, the bunker gear that we are
    talking about?
        Mrs. Lowey. In other words, are there a lot of salespeople
    coming around trying to sell equipment, and do you feel that
    the Federal Government is taking response--I see people
    smiling. Maybe they are the salespeople in back of you.
        Do you feel the Federal Government is testing the equipment
    to ensure that it is safe? Those of us who sit on
    appropriations as well work very hard to get the money for
    first responders and equipment. I just want to get a handle on
    whether it is being tested adequately.
        Deputy Chief Visconti. I know for a fact that the National
    Fire Protection Association has standards for firefighter gear.
    I know that the Federal Government has standards for the gear.
        The vendors, when they come in, no matter what the
    organization, they have to comply with an RFP. We have it
    tested. We run pilot programs which may appear, in some cases,
    to be too extensive, but we want to make sure that the
    equipment is good.
        The equipment, bunker gear that firefighters have now is
    being constantly upgraded to include levels of protection from
    different contaminants, and not only from fire. These are not
    garments--they are meant to protect you for a limited amount of
    time, but they are putting barriers in them, which does create
    problems because of heat and exhaustion. But they are putting
    barriers in the garments so you can be protected from heat and
    elements.
        Mrs. Lowey. Thank you. I will have to come back to you for
    another question. I am sorry, Dr. McDaniel.
        We all agree that those who are made ill deserve special
    care and attention. However, there are some people who disagree
    that care needs to be provided by Mount Sinai and other centers
    of excellence and Federal resources. I strongly disagree.
        I am pleased you are here to make the case that there needs
    to be more Federal support and some more medical monitoring and
    treatment.
        If you could explain to us, number one, why isn't it
    sufficient for many of these individuals to obtain care from
    their primary care physicians?
        And, what do you know, what do we know about the long-term
    health consequences of exposure to toxins at Ground Zero?
        And what would happen if the funding for the centers did
    not continue, how important is it to have experience with a
    knowledge of World Trade Center-related illnesses, and truly
    helping these individuals obtain the diagnoses and care that
    they need? Tell us how important it is.
        Dr. Landrigan. Thank you, Mrs. Lowey. There are several
    reasons why these centers of excellence are critically
    important. First of all, lies in the high quality of the
    medical care that they can provide.
        The people that went through 9/11, and I suspect in the
    future, people that might go through any future disaster that
    befalls this country, suffered a complex mix of exposures,
    cement, shards of glass, a unique soup of toxic chemicals. It
    is only at a major medical center that has experience in
    occupational medicine, as we do at Sinai and as our colleagues
    in the other institutions that I mentioned in the greater New
    York area--it is only--you need to have that expertise, you
    knew he had to be able to combine that expertise in
    occupational medicine with expertise in pulmonary medicine,
    gastroenterology, psychiatry, very important. Many of those
    folks have multisystem problems.
        If they were to go to a general practitioner in a town or a
    suburb who was not in a position to call upon these other
    medical disciplines, then the care of the responder who put his
    or her life on the line is going to be compromised, possibly
    seriously compromised.
        The second advantage of centers of excellence is that after
    a time of disaster, we gain experience. We have seen in the
    neighborhood of 22,000 patients. That is a great deal of
    experience. Out of that experience we have distilled
    recommendations for the provisions of optimal care. We worked
    with the New York City Department of Health to issue guidelines
    for the care of people.
        If the care of these 22,000 people were scattered out among
    15,000 practitioners who saw a few responders each, there would
    be no opportunity to accumulate that body of experience.
        Thirdly and finally, an enormously important advantage that
    results from the existence of these centers of excellence is
    that we are in a position to keep records, track patterns of
    disease, recognize new diseases as they emerge. In the absence
    of some kind of centralized recordkeeping, that sort of medical
    surveillance would not be possible.
        You ask, what does if future hold for these people? I don't
    know. None of us do.
        But what I do know is that we will be able to spot the
    future as it begins to arrive if we have these centralized
    record systems in hand that serve as what used to be called a
    distant early warning system.
        Mrs. Lowey. Thank you very much. Thank you, Madam Chairman.
    Thank you, Chair of the full committee. Thank you, Dr.
    Landrigan, Chief Visconti, Dr. McDaniel. Thank you very much.
        Ms. Clarke. I now call on our chairman, the gentleman from
    Mississippi.
        Chairman Thompson. Thank you very much, Madam Chairman. I
    appreciate you stepping in while I stepped away for a few
    minutes.
        Let me thank the panel.
        A couple of questions come to mind.
        Dr. Landrigan, to what extent do you, with the Mount Sinai
    project, relate to the Federal partners are you exchanging
    data? Explain a little bit of the relationship?
        Dr. Landrigan. First of all, we have a very close
    relationship with the other programs in New York City. Our
    group of firefighters, the FDNY, have aligned our medical
    programs very closely. We use pretty much the same protocols
    for doing the examinations on the two groupers of workers and
    recording the data. We also stay in very close touch with the
    health department and their registry that now encompasses
    71,000 people.
        With regard to the Federal partners, we work very closely.
    We are probably on our phone to our funding principal agency,
    NIOSH, at, least twice a day. It is almost constant
    communication. Folks from NIOSH are up to visit us, I would say
    on average, every 2 or 3 weeks. We exchange a great deal of
    information with them.
        The other thing we do with their encouragement and support
    is we take the scientific analyses that we have conducted,
    based on our medical findings, and we write these up. We
    publish them in the peer-reviewed medical journals. We have
    done it several times in the past already. One of those
    articles is appended to my testimony.
        The reason that we disseminate this information out in the
    peer-reviewed medical literature is to alert doctors across the
    country about our findings so that they will be educated, and
    they will be intellectually prepared in the future should there
    be further disasters.
        Chairman Thompson. Thank you very much. One of my reasons
    for asking is, from a lessons-learned standpoint, the previous
    panel kind of said, well, it is our overall responsibility, but
    we haven't quite done it. So if that happened in Detroit or
    Chicago, would we have the 9/11 experience there starting, or
    have we put together a system that can now be incorporated into
    the broader picture?
        I guess I am saying that what we are grappling with is
    based on the testimony of the last panel, we have not gotten to
    that point. I hope we have your participation in moving that
    part of the response puzzle, so that we follow people from the
    incident forward, and not have to pick it up along the way, and
    then try to catch up.
        We feel that the Katrina situation is equally as troubling
    because when people come to help, there is very little regard
    for personal safety.
        I think what we have to do, as Members of Congress,
    anticipate that certain things will happen when people offer
    themselves for help, whether they have Federal, State, locals
    or just volunteers. But we want the system to work as fast as
    it can and not play catch up. So we are going to have to
    identify the people through some system, and that is a real
    challenge.
        Chief, I hope over time we can provide the departments with
    the necessary equipment. People ought to be able to communicate
    with each other.
        In most instances, the public already thinks that everybody
    can talk to each other any way, but that is not the case.
        So that is a real issue for us. We are trying to get
    through the bureaucracies. You heard GAO say that those
    agencies who are responsible for it, we put the money there,
    but they can't work out the logistics of coordinating and
    cooperating with each other. So that remains a real challenge
    for us.
        Let me thank you for your testimony. It is absolutely
    essential to helping us define legislatively what we can do.
    But it is people like you who are on the front line who
    ultimately have responsibility for not only carrying it out but
    helping us get it right.
        So I appreciate you in that respect, as well as your
    service to your city or State and the Nation.
        I yield back.
        Ms. Clarke. Mr. Chairman, you took my closing.
        I thank the witnesses for their valuable testimony, and the
    Members for their questions.
        The Members of the committee may have additional questions
    for the witnesses, and we ask that you respond expeditiously in
    writing to those questions.
        Hearing no further business, the committee stands
    adjourned.
        [Whereupon, at 1:20 p.m., the committee was adjourned.]

                       Appendix:  Questions and Responses

                                  ----------

    Questions From the Honorable Bennie G. Thompson, Chairman, Committee on
                               Homeland Security

                         Responses From John Howard, MD

        Question 1.: As the Federal Coordinator for World Trade Center
    (WTC) Health Issues, can you please describe for the Committee how you
    coordinate the activities among the various Federal agencies and non-
    governmental organizations involved in this effort and what challenges
    you have faced in coordination these different efforts?
            (a) What research and health monitoring is the Federal
            government undertaking Gulf Coast?
            (b) In your opinion, are first responders who were in the Gulf
            in the aftermath of Hurricane Katrina at risk for developing
            health problems?
        As the WTC Coordinator for the U.S. Department of Health and
    Services (HHS), I coordinate existing HHS programs addressing WTC
    health effects. These programs include the WTC Responder Health Program
    (New York City Fire Department and Mt. Sinai School of Medicine), the
    WTC Federal Responder Screening Program, the Police Organization
    Providing Peer Assistance (POPPA), Project COPE, and the WTC Health
    Registry. I coordinate these programs by meeting regularly with the
    leadership of each to discuss program status and ongoing activities. I
    also host WTC Programs Coordination meetings to bring together program
    leadership and key representatives from federal, state and city
    government, community and labor organizations to share program updates
    and explore opportunities for collaboration to better serve the
    affected population.
        The National Institute for Occupational Safety and Health (NIOSH),
    in consultation with the Occupational Safety and Administration (OSHA),
    developed and broadly guidance for pre-and post-exposure medical
    screening programs for workers in hurricane disaster recovery areas
    soon after Hurricane These recommendations are available at: http://
    www.cdc.gov/niosh/topics/flood/preexposure.html; http://www.cdc.gov/
    niosh/topics/flood/MedScreenWork.html.
        NIOSH has also conducted research to assess potential health
    effects associated Hurricane Katrina response effort. is currently
    funding a study at University to examine exposure to post-Katrina flood
    cleanup and restoration work and the risk of respiratory illness,
    symptoms, and decline in lung function in workers. Study participants
    (approximately 1,000 New Orleans area workers performing demolition
    work, trash and debris removal and disposal, sewerage and water line
    repair, construction work. tree cutting, and landscape restoration)
    will complete questionnaires and undergo standardized clinical testing
    annually over a five year period. The findings this study will provide
    valuable information on the respiratory impact of exposures, including
    the level or respiratory protection required in similar flood recovery
    operations.
        As requested by the New Orleans Fire Department (NOFD), in October
    2005 NIOSH conducted a health hazard evaluation of the NOFD. NIOSH
    investigators conducted a survey to evaluate physical and psychological
    consequences in NOFD personnel following work after Hurricane Katrina.
    The results showed that fire fighters who reported floodwater contact
    for longer than a few hours reported significantly more upper
    respiratory systems than those who reported no contact with the
    floodwater. Fire fighters experiencing these physical symptoms, as well
    as those involved in gun shot incidents and body retrieval more often
    reported systems consistent with depression and post traumatic stress
    disorder (PTSD). NIOSH recommended that New Orleans Fire Department
    management provide clinical follow-up of affected fire fighters for
    physical and psychological conditions should be implemented. Results of
    this and NIOSH recommendations were distributed widely through the
    International Association of Fire Fighters (IAFF) and through
    scientific publications. The full report is available at: http://
    www.cdc.gov/niosh/hhe/reports/pdfs/2006-0023-3003.pdf
        Also in October 2005, NIOSI-I conducted a similar study at the New
    Orleans Police Department (NOPD) to assess the impact of the Hurricane
    Katrina disaster on employee physical and mental health. NIOSH
    conducted a survey and found that NOPD personnel frequently reported
    experiencing head and sinus congestion, nose and throat irritation, as
    well as symptoms consistent with PTSD and depression. Factors including
    contact with floodwater and isolation from family were associated with
    the physical and mental outcomes. NIOSH made a number of
    recommendations, such as suggesting NOPD management encourage personnel
    to seek follow up care for clinical and mental health symptoms, develop
    a disaster preparedness plan, and improve the incident reporting
    system. As a result the NOPD has implemented a disaster preparedness
    that has a contingency plan for evacuation and relief of personnel
    during disaster events. The NOPD continues to explore programs that
    provide guidance for crisis management and debriefing, to further to
    support officers. The results of this evaluation and subsequent
    recommendations will have implications for all police officers involved
    in disaster response. The full report is available at: http://
    www.cdc.gov/niosh/hhe/reports/pdfs/2006-0027-3001.pdf
        Other important health and safety research conducted the Gulf Coast
    involved the use of respirators by the public in post-Katrina New
    Orleans, where respirators were recommended for mold remediation. This
    research indicated that only 24% of participants donned respirators
    properly. The resulting publication has received much attention because
    of its implications for use of respirators by the public in settings,
    such as during an outbreak of pandemic influenza. [Cummings KJ, Cox-
    Ganser J, Riggs MA, Edwards N, Kreiss K. Respirator donning in post-
    hurricane New Orleans. Emerg Infect Dis. 2007 May; 13(5):700-7. http://
    www.cdc.gov/eid/content/13/5/7000.htm]
        In the aftermath of Hurricane Katrina, thousands of responders
    worked in a complex, uncontrolled environment; one that involved mixed
    chemical exposures, hazardous substances, microbial agents, and
    psychological stress. Most of the hazards have poorly characterized due
    to the changing nature of the site and the receding waters. Given the
    complexity of the Gulf Coast response, uncertainty regarding the extent
    of exposure, lack of regarding the use of personal protective equipment
    and follow-up treatment, it is not possible to generalize the risk of
    health effects to all Hurricane Katrina responders. However, based on
    available evidence, such as the NOPD and NOFD studies discussed above,
    some responders worked in environments with exposures that may have
    resulted in short--or longer-term health effects, including eye and
    respiratory respiratory illness, hearing loss and psychological stress.

        Question 2.: Section 709 of the Safe Port Act of 2006 refers to
    research and a report to be conducted by the National Academies of
    Science on Disaster Area Health.
            (a) What is the status of this research?
        I am not aware of any research or reports being developed in
    response to the Safe Port Act of 2006. Section 709 of the statute has
    never received congressional funding and, therefore: has not been
    implemented.

    Questions from the Honorable Bennie G. Thompson, Chairman, Committee on
                               Homeland Security

                       Responses from Jon R. Krohmer, MD

        Question 1: What are we doing to help local first responders that
    respond to emergencies at federal sites? They do not necessarily have
    all of the information regarding what is in those locations (e.g.
    locations of hazardous materials, military weapons caches, and
    scientific research on dangerous organisms).
        Response: The universe of first responders includes law
    enforcement, fire, emergency medical services, and other public safety
    officials. Each facility and agency is responsible for identifying and
    marking potentially hazardous or dangerous situations, developing
    emergency action plans, coordinating those plans with local resources,
    and briefing any responders on current conditions when they arrive at
    any federally managed site. The Office of Health Affairs will work in
    the near future through the Federal Interagency Committee on Emergency
    Medical Services (FICEMS) to bring forward the issue of identification
    of best practices for addressing hazardous materials and other unique
    situations at federal sites for communication with local medical
    responders during an event, and when applicable, before an event. This
    type of initiative will also require coordination across interagency
    partners that work directly with other first responder groups. As
    funding and staff enable our office to establish our planned outreach
    program to state, local and regional partners, we will work with our
    partners to develop a model for identifying specific needs of local
    responders.

        Question 2.: Has the OSHA role been modified in the National
    Response Framework versus the National Response Plan?
        Response: The Department of Labor/Occupational Safety and Health
    Administration (OSHA) has been, and continues to be, a vital partner in
    Federal response activities under the National Response Framework
    (NRF). OSHA's primary intended purpose under the NRF is to provide
    resources, policies, and structures (e.g. technical assistance, safety
    monitoring, etc.) to other Federal agencies, States or other
    jurisdictions and entities during response and recovery activities of
    major incidents.
        OSHA's key role as the coordinating agency for the Worker Safety
    and Health Support Annex remains unchanged from the National Response
    Plan (NRP) to the NRF. The purpose of the Worker Safety and Health
    Support Annex is to coordinate the management of worker safety and
    health among all responders (Federal, state, local, private sector,
    etc.) and provide worker safety and health resources to response
    organizations that are overwhelmed by the incident.
        In addition to its role as coordinating agency for the Worker
    Safety and Health Support Annex, OSHA continues to serve as a support
    agency to various Emergency Support Functions and as a cooperating
    agency to certain Support Annexes and Incident Annexes. In addition to
    roles carried forward from the NRP, OSHA has been added as a
    cooperating agency to the new Critical Infrastructure/Key Resources
    Support Annex to the NRF.

        Question 3.: What is the status of the Component Services
    Directorate of the Department of Homeland Security Office of Health
    Affairs? When was this Directorate established? How does it interact
    specifically with relevant entities in the Department's Management
    Directorate?
        How is the Component Services Directorate ensuring the Department's
    ``early responder'' workforce is provided with scientifically-based and
    regulatory-compliant occupational health and safety standards and
    practices?
        As part of its goal to create a culture of wellness throughout the
    Department, what work has the Components Services Directorate done in
    the way of developing policies, standards, requirements and metrics for
    fitness-for-duty, drug testing, health screening and monitoring, health
    promotion and management, pre-placement evaluations, and immunizations
    and deployment physicals--especially for the Departments ``early
    responders?''
        Response: The Office of Component Services within OHA was
    established concurrently with the Office of Health Affairs in April of
    this year. Until this month, the office has been staffed by one full-
    time detailee, one detailee divided between Component Services and
    pandemic influenza planning, and one part-time contractor focused on
    workforce protection issues related to pandemic influenza (which is
    being extended to ``all hazards'' workforce education to the extent
    possible). Funding, including any funding for personnel, was not
    available until a reprogramming was authorized late this summer.
    Consequently, the efforts to this point have focused on strategic
    planning and hiring actions for the initial staff to carry out the
    important functions of the office. The initial hiring actions are
    underway currently, with the first new staff member scheduled to report
    this month.
        Having said that, the Associate Chief Medical Officer for Component
    Services has been extremely active in supporting specific incidents /
    activities--including the incorporation of the Division of Immigration
    Health Services into DHS/ICE; the DHS response to the Speaker TB
    incident and supporting the FEMA investigation into the trailer
    formaldehyde issues.
        From the outset, a major philosophy in the operation of the Office
    of Component Services has been to establish a close working
    relationship between the Occupational Safety and Environmental Programs
    (OSEP) within the Office of the Under Secretary for Management and the
    Office of Health Affairs (OHA). DHS Management Directive 5200.2, which
    is currently in final vetting, provides that ``It is DHS Policy to
    establish and maintain an effective and comprehensive safety and
    occupational health program which is consistent with the standards
    promulgated under the Occupational Safety and Health Act of 1970, E.O.
    12196, and 29 CFR Part 1960.'' Under this Directive, the role of the
    Assistant Secretary for Health Affairs is to serve as the primary
    policy advisor to the Secretary, Under Secretary for Management, and
    the Designated Agency Safety and Health Official (DASHO) on
    occupational medicine aspects of the safety and occupational health
    program. Backed by the seniority of an Assistant Secretary and with the
    subject matter expertise of physician staff, including an Occupational
    Medicine physician, the Office of Component Services will be well
    positioned to establish scientifically and medically valid policy,
    requirements, standards, and metrics that will serve to drive
    synchronization, standardization, and unification of occupational
    safety and health (OSH) policies and regulations across the department.
    Over the next fiscal year, we will catalog existing OSH programs within
    the Department and benchmark these against best practices in industry.
    Our goal is to complete this process over the fiscal year and, in
    conjunction with OSEP, reach 50% development of unified DHS OSH
    policies and regulations this year, laying the ground work for a
    complete program by the conclusion of the next fiscal year. The major
    challenge in accomplishing this goal will be the varied missions of the
    Department's Components. This will require establishing a firm
    scientific and ``best practices'' basis in order to allow Component
    leadership to adopt common policies and procedures except in those
    areas where mission dictates unique approaches.
        Specifically in regard to support for DHS employees during response
    to disasters, there are three major Components that OHA, specifically
    the Office of Component Services, will address: Ensuring medical
    readiness for response duties, ensuring availability of medical
    response for DHS employees during contingency missions, and minimizing
    safety risks during those missions.
        OHA has a significant role, in conjunction with OSEP and the
    Components' safety offices for the first two portions of this, while
    OSEP has the lead for the third. A significant role of the Office of
    Component Services within OHA is establishment of an emergency medical
    services (EMS) section with 2 primary roles: medical supervision of EMS
    services provided by or on behalf of the Department in support of its
    own deployed personnel, and establishment of policies, requirements,
    standards and metrics for EMS support of DHS operations. The EMS
    section will work closely with the Department of Health and Human
    Services (HHS) regarding those aspects of EMS that fall within HHS's
    purview. Hiring of staff was started in late fiscal year 07 with the
    first personnel arriving in October 2007. In the interim, we are
    coordinating with the Components to catalog existing services and map
    gaps in medical supervisory support for EMS. The first employee, who is
    reporting later this month as noted above, is an EMS coordinator and
    OHA is in the process of hiring an EMS Physician Medical Director.
    Their role will be to ensure that appropriate emergency response
    systems, either directly provided or established through local
    services, are in place and that they have the required medical
    supervisory structures, including protocols and back-up, to enable
    their efficient operation during both day-to-day and contingency
    operations.
        In addition, with the availability of funds, the Office of
    Component Services has converted the part-time detailee noted
    previously, into a full-time Director of Force Health Protection and
    Wellness, and is in the hiring process for a Director of Occupational
    Medicine. Their closely linked roles will be to coordinate with the
    Components to ensure that occupational health principles are
    incorporated into the job ``life-cycle'' of all appropriate DHS
    personnel, especially responders, to ensure coordinated policies and
    standards for issues such as duty-based physical standards, pre-
    placement physical evaluations, periodic physical evaluations, pre-
    response medical preparation, etc.
        Finally, OSEP has the lead for all safety programs, including those
    related to response operations. Through an MOA with OSEP, OHA will
    function as a major partner in these safety operations through adding
    medical/scientific basis to recommendations and providing a senior-
    level, ``third party'' voice for safety controls in operational
    environments.

        Question 4.: What is the Medical Readiness Directorate of the
    Office of Health Affairs doing specifically to coordinate medical
    readiness of first responders?
        Response: The Office of Medical Readiness is currently in the
    process of hiring a Medical First Responder Coordinator, based on
    funding that has recently become available through a reprogramming that
    was authorized late this summer. This position will be responsible for
    serving as the DHS point of contact for all medical first responders.
    Even though this personnel action is currently pending, the Office is
    actively engaged with the medical first responder community through
    representation on the Federal Interagency Committee on Emergency
    Medical Services (FICEMS), and through growing coordination of
    activities, including grants, with DHS and DHHS. It is the goal of the
    Office to better incorporate issues related to medical first responders
    into initiatives related to planning, training, exercises, and funding
    throughout relevant parts of the federal government and to ensure that
    medical first responders are more fully integrated into local emergency
    management communities through the country.

        Question 5.: We understand that federal first responders were
    turned away from screening programs offered to non-federal first
    responders, and that many have a cap on how much mental health
    counseling their health insurance will pay for, before they have to pay
    for these services out of their own pockets.
        Since we know that post-traumatic stress disorder and other
    responses to these sorts of incidents can go on for decades, affecting
    productivity now and in the future. How will the Office of Health
    Affairs address these sorts of mental health issues for the Federal
    ``early responders'' working in the Department?
        Response: The Office of Health Affairs has worked closely with our
    occupational safety and health colleagues on issues related to World
    Trade Center response issues, and recognize that there are problems
    with ensuring all employees have taken advantage of resources that are
    available to them. Because every agency determines independently how it
    will comply with Federal Occupational Safety and Health Guidelines (as
    required by Executive Order 12196, ``Occupational Safety and Health
    Programs for Federal Employees'' and 29 CFR Part 1960, ``Basic Program
    Elements for Federal Employee Occupational Safety and Health Programs
    and Related Matters'') and because agencies use various occupational
    health services providers, there is no consistent occupational
    screening program across the government. Therefore, even for our
    federal responders, there is no structured mechanism, at present, to
    get good information beyond the voluntary enrollment mechanisms.
        Current Federal workers, who were exposed to environmental hazards
    at the World Trade Center site and choose to register for tracking, are
    screened through Federal Occupational Health (FOH) clinics and other
    clinics that have contracts with FOH throughout the country. Retired
    Federal workers and intermittent Federal employees hired during the
    post-9/11 period to work in Manhattan have access to screening through
    the NIOSH Medical Monitoring program. Because these programs are
    voluntary they will not provide useful epidemiologic data, but they
    will ensure that Federal Employees have a safety net to see that their
    needs are addressed.
        The exposures to environmental hazards in the aftermath of
    Hurricane Katrina were much less homogenous and also spread across many
    more agencies. This would likely contribute to an inability for some
    federal employees to access common support for post event screening and
    care. We appreciate the Committee alerting us to this issue and will
    actively engage with the components to provide assistance and guidance
    in ensuring all DHS employees have appropriate access to screening and
    treatment.

        Question 5.: We understand that a decision was made we understand
    that the Office of Health Affairs recently declined to include the
    CONTOMs program (Counter Narcotics and Terrorism Operational Medical
    Support Program) in the Office of Health Affairs. The program is
    expressly designed to ``protect the protectors,'' by providing advanced
    training (beyond EMT-B) to medics who's job it is to provide emergency
    medicine under difficult conditions to our tactical first and early
    responders. It is the only program of its kind for which faculty are
    both sworn law enforcement officers and medical practitioners, with
    extremely current real-world experience (such as with the shootings at
    Virginia Tech, combat operations in Iraq, Ruby Ridge, Waco, and
    Hurricane Katrina). Participation in this specific program has been
    mandated by state and local tactical and special operations law
    enforcement units (such as SWAT) throughout the country, and that
    requirement continues today.
        How did the Office of Health Affairs arrive at this decision?
        How will the Office of Health Affairs ensure that this training
    will be provided to the component agencies within the Department that
    need and would clearly benefit from this training, without contracting
    out to academic programs at greater cost to the government?
        How will the Office of Health Affairs ensure that this training is
    obtained by those state and local units that have mandated its
    completion, without increasing the costs at the state and local level?
        What does the Office of Health Affairs believe should be offered in
    its stead?
        Response: The Office of Health Affairs shares the Committee's
    concerns regarding the medical support of tactical law enforcement
    officers and all early responders. The DHS Office of Health Affairs
    agrees that the Counter-Narcotics/Terrorism Operational Medical Support
    (``CONTOMS'') has been a valuable contributor to the development and
    ongoing support of the field of tactical medicine. The decision of the
    Office of Health Affairs not to absorb the existing program from
    Immigration and Customs Enforcement (ICE) is in no way abandonment of
    the principles embodied in CONTOMS, but a recognition that the
    ``playing field'' has changed in the nearly 20 years since CONTOMS was
    established. OHA believes that the approach we are taking, based on
    establishment of requirements, policies, protocols, standards, and
    metrics, enhances DHS support of tactical medicine throughout the
    country.
        As you are aware, ICE's Federal Protective Service (FPS), of which
    the Protective Medical Branch is a component, recently completed a
    restructuring in order to more efficiently ensure the protection of
    Federal offices throughout the country. As part of this restructuring,
    the Protective Medical Branch was discontinued in order to better focus
    available FPS resources on facility protection.
        Recognizing the importance of federal leadership in tactical
    medicine programs, OHA has established, within the Office of Component
    Services, an Operational Medical Services branch. The focus of this
    branch is to ensure that operational personnel of DHS, many, but not
    all of whom would be considered ``tactical law enforcement'' personnel,
    have appropriate medical support in whatever environment to which they
    are assigned. In accomplishing this function, it is important to note
    that OHA was not established to be an operational component of DHS.
    While OHA may in the future develop very limited operational medical
    capabilities for support of DHS personnel and missions , OHA's primary
    focus is and will be to provide operational components with medical
    guidance (requirements, policies, protocols, standards, and metrics, as
    noted previously), to include the medical supervisory chain to Chief
    Medical Officer. As a part of this medical guidance OHA will continue
    research into tactical medicine and support of tactical medicine
    protocols and training which will be of significant benefit not only to
    the Department, but to law enforcement officers throughout the country.
    In fact, by shifting tactical medicine issues from an operational
    branch of a small segment (FPS) in one of the Department's operating
    components (ICE), to an office only one level removed from the
    Assistant Secretary for Health Affairs and Chief Medical Officer, these
    issues will get the attention and resourcing they deserve. It should
    also be noted that the Deputy Assistant Secretary / Deputy Chief
    Medical Officer is extremely supportive of tactical medical activities,
    having served for over 10 years as a tactical physician and the medical
    director for several TEMS programs.
        Additionally, in the 18 years since CONTOMS was initiated at the
    Uniformed Services University of the Health Sciences, a number of
    similar programs focused on tactical emergency medical support have
    developed throughout the country. Chairman Thompson's home state of
    Mississippi is home to one of oldest such organizations in the country,
    the Tactical Medical Operators Group (TMOG) of Mississippi
    (www.tmog.org), which is dedicated to training, support, and medical
    direction to tactical medics and SWAT operators within the state of
    Mississippi. OHA management approach to this issue is to focus on the
    internal DHS requirements, while using our own needs to act as a
    catalyst to effectively synchronize activities and findings of groups
    like TMOG. Consequently, the role of DHS will not primarily be as a
    service provider, as was the focus of CONTOMS and PMB, but as a
    scientifically-based standards-setting organization (in conjunction
    with national groups such as such as the National Tactical Officers
    Association, the Tactical Emergency Medical Services Association, the
    American College of Emergency Physicians, the National Association of
    EMS Physicians, the National Association of EMS Directors, and the
    National Registry of Emergency Medical Technicians). It is also
    important to note that there are, in fact, several TEMS training
    programs throughout the country in which faculty are both sworn law
    enforcement officers and medical practitioners.
        The initial funding for the OHA mission is part of the pending
    fiscal year 2008 DHS appropriation. In the interim, available funds
    have been used to hire the first member of the operational services
    staff who will be the coordinator for programs and protocols for the
    office. Over the next several weeks, OHA will be hiring the first OHA
    Director of Emergency Medical Services who will head that branch within
    the Office of Component Services.

    Questions from the Honorable Bennie G. Thompson, Chairman, Committee on
                               Homeland Security

                  Responses from Philip J. Landrigan, MD, MSc

        I would like to thank you and the Committee on Homeland Security
    for your continuing vigorous investigation into the question of how
    this nation can best protect the health and safety of our first
    responders in the aftermath of catastrophic disasters.
        To assist you in this important work, my colleagues and I are
    pleased to share with you the lessons that we have learned through the
    World Trade Center Monitoring and Treatment Program that is supported
    at the Mount Sinai School of Medicine in New York City by the National
    Institute for Occupational Safety and Health (NIOSH), and to respond to
    the questions that you have asked in follow-up to your recent hearing:

        Question 1.: We understand that 1,000 approximately sign up every
    week for the Mt. Sinai World Trade Center Screening Program.
        a. How has the screening program expanded since its inception?
        The World Trade Center Medical Monitoring and Treatment Program at
    Mount Sinai has received federal funding from since April 2002. The
    focus of the program from its inception has been on workers and
    volunteers who served at Ground Zero, at the Staten Island landfill,
    and at other locations where there was potential for occupational
    exposure to World Trade Center dust. The program has expanded and
    transformed several times since 2002.
        Initially, the program was called the World Trade Center Worker and
    Volunteer Medical Screening Program. At that time, it was funded to see
    9,000 responders for a single medical screening examination for the
    purpose of assessing health problems post 911 the target number was
    expanded a few months later to 12,000. It was intended initially that
    the program would continue only until spring 2004.
        By 2004, however, it was becoming clear that there were substantial
    continuing health problems in responders and that a larger number of
    responders than anticipated had become ill as a consequence their work.
    Also by 2002, we had identified groups of workers not previously
    included in the initial criteria for eligibility. These included
    mechanics who had worked on vehicles contaminated by debris as well as
    PATH (Port Authority Trans-Hudson) workers who labored in WTC-dust-
    contaminated PATH tunnels. Initially, eligibility covered only a narrow
    geographic area, as the program wanted to make sure people who were
    exposed came in for an examination. Once the capacity of the program
    was established and we had demonstrated our capacity to reach this
    initial population, the program was able to expand parameters for
    eligibility. To date, there have been 7--8 alterations/expansions to
    the eligibility criteria. With the identification of new groups,
    eligibility criteria also, expanded geographically.
        In July 2004 the program was reconstructed and renamed the World
    Trade Center Medical Monitoring Program. This change in name reflected
    the fact that the program was now expected to see workers and
    volunteers periodically--every 12 to 18 months--rather than merely once
    for screening. To date, the program has performed 22,224 initial
    examinations, has seen approximately 8,000 of these workers and
    volunteers for a second examination, and approximately 1200 for a third
    examination. All data from all examinations are stored in a
    computerized database.
        A further major transformation of the program occurred in the fall
    of 2006. At that time, treatment for covered World Trade Center
    conditions began to be provided with federal support and at no cost to
    WTC responders who were enrolled in the Screening or Monitoring
    Program. Provision of treatment without charge was necessary because
    many responders had little or no health insurance before 911 or
    subsequently lost their insurance as a consequence of their work-
    related illness.
        Many new responders still continue to contact the program for
    initial examinations at this time--six years the attacks of September
    11, 2001. These are persons whom we have never previously seen. Some
    come to our program because they have symptoms, while others are free
    of symptoms, but have come to appreciate the wisdom of obtaining a
    baseline examination. Thus approximately 500--600 new eligible
    participants have registered with our program each month over the past
    two years.
        Three major lessons that we have learned from this experience are:
        (1) It is important to anticipate that the number of first
    responders who will become ill as a consequence of their heroic work
    will be large;
        (2) It is important to anticipate that illnesses in at least some
    responders will be severe and persistent; and
        (3) It is important to anticipate that treatment as well as
    diagnostic services will be needed for responders
        b. Are there issues that are not being addressed due to research or
    funding limitations?
        An impediment to the World Trade Center Medical Monitoring and
    Treatment Program is that the program has received no funding for
    research. This has hindered our ability to conduct detailed
    investigation into causes of illnesses in responders and into
    treatments. Despite this limitation, we have collected data on over
    22,000 individuals who have received over 31,000 cumulative
    standardized examinations and we have published descriptions of our
    findings.
        Research funding would provide a vitally needed opportunity to
    further explore these findings in greater depth so that physicians who
    will care for future responders will better understand the full
    spectrum of World Trade Center related health effects. Such research
    could be instrumental in identifying new treatment modalities.
        The lesson here is that provision funding for research into health
    effects in responders should be an integral component of planning for
    future disaster response.
        An additional impediment is that funding for the Medical Monitoring
    Program was allocated for only four and one-half years, According to
    this timetable, examinations will cease in FY 09. We see this as a
    major unresolved problem, because illnesses in many responders and
    their prognosisis is unclear. Funding for the treatment program is also
    time-limited and will soon end if not renewed. If the program ceases,
    we will not be able to answer questions related to the long-term
    implications of exposures sustained at the WTC site. This is very
    important since many diseases related to dust exposure may take years
    to manifest. Similarly, we will not be able to answer questions about
    the possible persistence of disease. A further consequence of program
    cessation will be that the collective expertise of the WTC Centers of
    Excellence, particularly in terms of the care of the WTC responders,
    will be lost.
        The less for the future here is that there must be established a
    stable, multi-year source of funding to sustain the provision of
    medical care of first responders.

        Question 2.: What does the data generated by Mt Sinai indicate
    about the impact of the World Trade Center events on the ability of
    first responders to breathe?
        Of 9,442 responders examined between July 2002 and April 2004, 69%
    reported new or worsened respiratory symptoms while performing WTC
    work. Of these, 46% had lower respiratory symptoms, and 62% had upper
    respiratory symptoms. Symptoms persisted to the time of examination in
    59% of these workers.
        On pulmonary function testing, 28% had abnormal spirometry forced
    vital capacity (FVC) was low in 21%; and obstruction was present in 5%.
    Among nonsmokers, 27% had abnormal spirometry compared with 13% in the
    general population. Prevalence of low FVC among nonsmokers was 5-fold
    greater than in the population (20% vs. 4%). Respiratory symptoms and
    spirometry abnormalities were significantly associated with early
    arrival at the site.
        2.1. Would you recommend additional research to improve personal
    protective equipment, including respirators?
        Many of the respirators available to responders were unsuitable,
    and responders did not receive adequate training in their use.
    Additional research to develop better respirators is certainly
    warranted.
        The failure of federal Occupational Safety and Health
    Administration (OSHA) to require respirator use at Ground Zero was in
    my opinion a serious dereliction of duty. OSHA's failure to act is not
    justified by the fact that average levels of exposure to dust were
    below OSHA's standards, because OSHA's reliance on average levels of
    exposure fails to protect workers against the intermittent high-dose
    exposure to toxic substances that are common in urban demolition work.
    OSHA's failure to act to require respirators at Ground Zero contrasts
    painfully with their aggressive insistence on the use of respirators at
    Staten Island landfill and at the Pentagon.
        The lesson here is that insistence on proper personal gear is
    essential for the protection of worker health, OSHA must enforce the
    law.
        My colleagues and I deeply appreciate your continued support and
    work on behalf of those heroic responders whose health was affected by
    the World Trade Disaster. We agree with you that it is essential to
    extract all possible lessons from this tragedy so that responders to
    future disasters may be optimally protected.
        Please do not hesitate to contact me with any additional questions.

    Attachment 2--Title 33 Environmental Quality Part V.\1\
    Attachment 3--Hazardous Materials and Hazardous Waste Reporting
    Requirements under Emergency Conditions \1\
    ---------------------------------------------------------------------------
        \1\ See committee file.