[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. 
    
    
                                 
