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

     H.R. 6594, THE JAMES ZADROGA 9/11 HEALTH AND COMPENSATION ACT OF 2008

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

                                    HEARING

                                   BEFORE THE

                             SUBCOMMITTEE ON HEALTH

                                     OF THE

                        COMMITTEE ON ENERGY AND COMMERCE
                            HOUSE OF REPRESENTATIVES

                           ONE HUNDRED TENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                 JULY 31, 2008

                                   __________

                               Serial No. 110-143

          Printed for the use of the Committee on Energy and Commerce

                            energycommerce.house.gov

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                        COMMITTEE ON ENERGY AND COMMERCE

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

                               Professional Staff

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

                                      (ii)

                             Subcommittee on Health

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

                                 C O N T E N T S

                                  ----------
                                                                       Page
    Hon. Frank Pallone, Jr., a Representative in Congress from the
      State of New Jersey, opening statement.........................     1
    Hon. Nathan Deal, a Representative in Congress from the State of
      Georgia, opening statement.....................................     3
    Hon. Gene Green, a Representative in Congress from the State of
      Texas, opening statement.......................................     4
    Hon. Lois Capps, a Representative in Congress from the State of
      California, opening statement..................................     5
    Hon. Anthony D. Wiener, a Representative in Congress from the
      State of New York, opening statement...........................     5
    Hon. Hilda L. Solis, a Representative in Congress from the State
      of California, opening statement...............................     7
    Hon. Edolphus Towns, a Representative in Congress from the State
      of New York, opening statement.................................     8
    Hon. Eliot L. Engel, a Representative in Congress from the State
      of New York, opening statement.................................     8
    Hon. Vito Fossella, a Representative in Congress from the State
      of New York, opening statement.................................    19
    Hon. Joe Barton, a Representative in Congress from the State of
      Texas, opening statement.......................................    38
    Hon. Michael C. Burgess, a Representative in Congress from the
      State of Texas, opening statement..............................    40

                                   Witnesses

    Hon. Jerrold Nadler, a Representative in Congress from the State
      of New York....................................................    41
        Prepared statement...........................................    45
    Hon. Peter King, a Representative in Congress from the State of
      New York.......................................................    49
        Prepared statement...........................................    50
    Michael Bloomberg, Mayor, City of New York.......................    51
        Prepared statement...........................................    53
    Julie Gerberding, M.D., M.P.H., Director, Centers for Disease
      Control and Prevention.........................................    56
        Prepared statement...........................................    58
    Margaret Seminario, Director, Safety and Health, AFL-CIO.........    78
        Prepared statement...........................................    80
    Jacqueline Moline, M.D., M.Sc., Vice Chair and Associate
      Professor, Department of Community and Preventive Medicine,
      Mount Sinai School of Medicine.................................    85
        Prepared statement...........................................    80
    Caswell F. Holloway, Chief of Staff to the Deputy Mayor for
      Operations Counsel, Special Advisor to Mayor Bloomberg.........    97
        Prepared statement...........................................   100

                               Submitted Material

    Prepared statement of John Reibman, M.D., Associate Professor of
      Medicine and Environmental Medicine Director NYU/Bellevue
      Asthma Center; Director of Health and Hospitals Corporation WTC
      Environmental Health Center....................................    10
    Prepared statement of David Prezant, M.D., Chief Medical Officer,
      Office of Medical Affairs; Co-Director WTC Medical Monitoring &
      Treatment Programs, New York City Fire Department..............    21
    Prepared statement of Hon. Carolyn Maloney, a Representative in
      Congress from the State of New York............................    32
    ``A Pointless Departure,'' New York Times, editorial, July 31,
      2008...........................................................   120
    H.R. 6594........................................................   121
    .................................................................

     H.R. 6594, THE JAMES ZADROGA 9/11 HEALTH AND COMPENSATION ACT OF 2008

                                  ----------

                            THURSDAY, JULY 31, 2008

                      House of Representatives,
                                Subcommittee on Health,
                              Committee on Energy and Commerce,
                                                        Washington, DC.
        The subcommittee met, pursuant to call, at 10:10 a.m., in
    room 2322 of the Rayburn House Office Building, Hon. Frank
    Pallone, Jr. (chairman) presiding.
        Members present: Representatives Pallone, Towns, Green,
    Capps, Engel, Solis, Weiner, Deal, Burgess, Barton (ex
    officio), and Fossella.
        Staff present: Jack Maniho, Brin Frazier, Lauren Bloomberg,
    Melissa Sidman, Chad Grant, and Aarti Shah.

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

        Mr. Pallone. The meeting of the subcommittee is called to
    order. And today we are having a hearing on the James Zadroga
    9/11 Health and Compensation Act of 2008. And the Chair now
    recognizes himself for an opening statement.
        The bill, as you know, has been introduced by Ms. Maloney,
    Mr. Nadler, Mr. King, and Mr. Fossella on a bipartisan basis
    and I want to thank all of you for your hard work on this
    legislation. I know how hard all of you have been working, not
    only in the last few weeks, in particular, but also in the last
    few years.
        Last year the subcommittee held a hearing to examine the
    ongoing medical monitoring and treatment programs related to 9/
    11 health defects and I am proud to be able to hold the second
    hearing today on legislation designed to bolster current
    efforts and provide adequate monitoring and treatment services.
        I have to say, none of us will ever forget the horrible
    events of 9/11, and 7 years later, we simply cannot forget
    about the thousands of people who helped at Ground Zero in the
    days and months afterwards. I remember, in particular, coming
    there a few days later when the President visited the Ground
    Zero and I also remember going with Mr. Nadler to, I guess, the
    Federal Court or the Federal building where we had a hearing--
    field hearing, specifically, on the health effects. I don't
    remember when that was, Jerry, a couple weeks or a couple
    months later, but I remember you, in particular, very concerned
    about the health effects at a time when many of the--those in
    Washington, including then--or former Governor Whitman, who
    were sort of downplaying the impact of it and saying that it
    really wasn't a problem. But we have to do everything in our
    power to protect the responders, the clean-up crews, the
    volunteers, and the victims of the World Trade Center attacks.
        Thousands of first-responders, rescue workers, and local
    residents now suffer from chronic medical conditions that are
    directly related to the tons of dust, glass fragments and other
    toxins that were released into the air in lower Manhattan when
    the Twin Towers collapsed. Studies have shown that nearly 70
    percent of the rescue workers currently suffer from complex
    respiratory conditions that were caused or worsened by the
    September 11 terrorist attacks. One-third have abnormal
    pulmonary function tests and one in every eight responders has
    experienced symptoms of post-traumatic stress disorder.
        Studies have also examined the effects on local residents,
    showing a three-fold increase in lower respiratory diseases, as
    compared to controlled populations, low pregnancy rates and an
    increase in the variety of mental health disorders.
        OK. Is that better? OK. I will put it back on you. All
    right.
        And these brave men and women who were present during one
    of our Nation's darkest hours are in need of our help. In my
    district alone, there are 1400 known individuals who were
    exposed to the toxins released by the 9/11 attacks. It is now
    our turn to step up to the plate and help ensure that they can
    access the medical care they need and deserve.
        The James Zadroga 9/11 Health and Compensation Act is an
    important step in this direction. The bill is named for James
    Zadroga, who I should mention was a New Jersey hero who
    responded on 9/11 and spent hundreds of hours digging through
    the World Trade Center debris. Mr. Zadroga died in 2006 from
    pulmonary disease and respiratory failure after his exposure to
    toxic dust at the World Trade Center.
        The bill would establish a permanent program to monitor and
    screen eligible residents and responders and provide medical
    treatment to those who are suffering from World Trade Center-
    related diseases. It would direct the Department of Health and
    Human Services to conduct and support research into new
    conditions that may be related to the attacks and to evaluate
    different and emerging methods of diagnosis and treatment for
    these conditions. And it would build upon the expertise of the
    Centers for Excellence, which are currently providing high
    quality care to thousands of responders and insuring ongoing
    data collections and analysis to evaluate health risks.
        Now, one of these centers, as Jerry knows, is located in my
    district and is headed by Dr. Iris Udasin. That program is a
    joint institute of Rutgers and the UMDNJ-Robert Wood Johnson
    Medical School, serves over one thousand rescue and recovery
    workers. Last year, I had the opportunity to visit that
    program, at Rutgers, to see how it provides the opportunity for
    early detection and intervention to lessen the severity of the
    illnesses that many rescue and recovery workers are
    experiencing.
        We are really faced with a large undertaking. But it is
    crucial that we step up and share these costs. The responders,
    volunteers, workers, and community members should not be left
    to bear the burden of their health care costs after risking
    their lives to come to our Nation's rescues. And I will also
    say to the Mayor, I don't think that New York should have to
    bear as much of the costs as they have. The Federal Government
    has the overwhelming responsibility.
        Again, I want to thank all the sponsors of this bill, but I
    do want to voice my displeasure that Dr. Howard, the former
    Director of the NIOSH, is not present today to testify. While I
    greatly appreciate Dr. Gerberding being here today to testify
    and recognize her accomplishments as Director of the CDC, Dr.
    Howard has been the one overseeing the World Trade Center
    Medical Monitoring and Treatment Program since its inception.
    And I believe he is by far the most informed person in this
    administration to speak on these programs, and it is
    unfortunate that the Bush Administration refused to allow Dr.
    Howard to testify this morning.
        I am also dismayed by the Administration's decision to not
    reappoint Dr. Howard for another term. Dr. Howard has done an
    exceptional job and has earned the respect and praise from
    industry and labor alike for his commitment to this cause. So,
    his expertise will be greatly missed. But, again, thank all of
    you and I now would recognize our ranking member, Mr. Deal.

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

        Mr. Deal. Thank you Mr. Chairman for holding this hearing
    on this important issue to discuss H.R. 6594 and the health
    concerns associated with the terrorist attacks of September the
    11th. I want to thank our distinguished witnesses who have
    agreed to share their insight and perspective on this issue,
    which of course is of great importance to our entire country.
        We can certainly all agree that men and women who first
    responded to the call for help are true heroes. Thousands of
    fire fighters, police officers, emergency medical service
    personnel and other government and private sector workers
    heroically responded to the call of duty, not only on September
    the 11th, but for many weeks and months to follow as the
    recovery efforts and cleanup continued to persist.
        In the midst of a Nation rocked by the attacks, which left
    thousands of innocent people dead and many more seriously
    injured, these brave men and women came from across the Nation
    to lend their hands to a unified recovery effort. As we are all
    aware, those involved in these efforts and the residents of New
    York City were unavoidably exposed to toxic mixtures of dust,
    smoke, and various chemicals. Many of these individuals
    continue to experience persisting health issues as a result.
        This legislative hearing today, of course, is to focus on
    H.R. 6594, The James Zadroga 9/11 Health and Compensation Act
    and the assessment of current monitoring and treatment efforts
    being provided to the affected individuals. I look forward to
    continuing to work with the committee as we work on this issue
    and address it. And I, especially, appreciate the input of the
    panelists that we will hear from today. Thank you Mr. Chairman
    for holding the hearing and I would yield back my time.
        Mr. Pallone. Thank you, Mr. Deal. Next for an opening
    statement is Mr. Green, the gentleman from Texas.

       OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN
                    CONGRESS FROM THE STATE OF TEXAS

        Mr. Green. Thank you, Mr. Chairman, for calling this
    hearing on H.R. 6594, The James Zadroga 9/11 Health and
    Compensation Act. As a member of Congress from Houston and very
    close to my first responders, both firefighters and police
    officers, that tragic event on September the 11th, claiming
    2,974 lives, hit everyone. In New York City, the attack on the
    World Trade Center, claiming nearly 2700 lives on September 11,
    but these individuals and their family were not the only people
    impacted by the terrorist attack.
        In the weeks and months following the attacks, 40,000
    responders from Federal, State, and private organizations,
    other volunteers came to the World Trade Center site to aid
    with recovery and cleanup. We usually think of the victims of
    the 9/11 attacks as those who lost their lives on that terrible
    day, but in reality, many of these victims are still among us,
    suffering from the attacks.
        When the World Trade Center collapsed, asbestos, smoke, and
    other potential hazardous material was released into the air.
    As a result of the release of asbestos and smoke, the cleanup
    in general went first responders, area workers, students,
    residents, office workers have suffered physical ailments such
    as sinus asthma and The World Trade Center Cough. These
    individuals are also suffering from mental ailments, including
    post-traumatic stress disorder and increased alcohol use.
        The brave men and women who worked on the cleanup and
    recovery were not just from the New York area and those who
    were in New York at the time, many no longer live there. It is
    safe to say that individuals from all 50 States are suffering
    from adverse health effects related to the September 11
    attacks. It is clear we need to establish a permanent program
    to provide medical monitoring for the responders and
    individuals in the community who were exposed to toxins
    released by the collapse of the World Trade Center. We also
    need to reopen the 9/11 Victim Compensation Fund and allow
    those who wish to seek compensation for their economic losses
    and harm.
        Currently, these individuals have to go to the court system
    for compensation even though they may have been eligible for
    the 9/11 Compensation Fund or would now be considered eligible.
    H.R. 6594 addresses these issues by establishing World Trade
    health center program and it provides a medical monitoring
    treatment program for responders and community members in the
    direct area of the attacks in New York and the United States.
        The bill reopens the 9/11 Victims Compensation Fund,
    establishes a research program, through HHS, to evaluate the
    World Trade Center conditions. The bill would help those
    individuals. I am proud to be a co-sponsor of this bill and,
    again, Mr. Chairman I am glad you called the hearing. On and on
    I thank our New York members for making sure those of us
    understand that we all share in this. And, coming from Houston,
    we will have a hurricane some time and I appreciate everyone
    considering our situation, just like we are doing this, so
    thank you.
        Mr. Pallone. Thank you, Mr. Green. Next for an opening
    statement, the gentlewoman from California, Ms. Capps.

       OPENING STATEMENT OF HON. LOIS CAPPS, A REPRESENTATIVE IN
                 CONGRESS FROM THE STATE OF CALIFORNIA

        Ms. Capps. Thank you, Chairman Pallone, for holding this
    hearing. I thank my colleagues for testifying and also to the
    Honorable Mayor of New York. I thank all of the witnesses who
    will be testifying today. Quite frankly, though, I wish the
    testimonies that we will hear today would paint a rosier
    picture. A picture of us having risen above and beyond to
    ensure that every individual whose health was adversely
    affected by the attacks on 9/11 and subsequent cleanup has had
    access to any and all necessary medical treatment, one where we
    had done a better job of assessing the environmental impact of
    the attacks, the rescue missions and the cleanup.
        Unfortunately, we find ourselves, today, 7 years later with
    so much work still to do, to ensure that victims, heroes, and
    neighbors of the World Trade Center are being properly cared
    for. Though I don't represent New York City, I do represent
    many Californians who volunteered themselves quickly to assist
    and come to the site, and to assist in the aftermath of that
    horrific day, and they are also having a difficult time
    assessing the care they also, rightly, deserve.
        I am afraid this is largely due to a very weakened
    Environmental Protection Agency and OSHA under the current
    administration, but it is not too late to take the right steps
    now to correct what has gone wrong. I am proud to co-sponsor
    the legislation introduced by our colleagues Congressmen
    Nadler, Fossella, King, and Congresswoman Maloney that will
    take the positive steps to treat all affected individuals.
        We have a lot to learn from the experience, even including
    today, as we prepare for future scenarios that present public
    health emergencies. Failing to learn from past experiences and
    taking steps to prevent problems in the future is unacceptable
    to our way of life. I am confident that my colleagues and I
    share a commitment to better prepare ourselves in the future.
    For today, though, we must be strong in our resolve to care for
    every individual who is still suffering physically or
    psychologically as a result of 9/11.
        And I, particularly, welcome the opportunity to hear
    directly from the witnesses who were there that day, who have a
    great deal to tell us about how we can, in fact, help them. I
    yield back.
        Mr. Pallone. Thank you Ms. Capps, and next for an opening
    statement, the gentleman from New York, Mr. Weiner.

     OPENING STATEMENT OF HON. ANTHONY D. WEINER, A REPRESENTATIVE
                 IN CONGRESS FROM THE STATE OF NEW YORK

        Mr. Weiner. Thank you Mr. Chairman and I want to thank you
    and Ranking Member Deal for taking this issue so seriously.
    Congressman Nadler, Congressman King, Congresswoman Maloney,
    who have, just about, in every opportunity when there was a
    chance to talk to our colleagues about this issue, have done
    it. I also want to take a moment to pay tribute to Congressman
    Fossella, who championed this program for so long, almost from
    the moment it was conceived, was looking to expand it, has
    really moved this committee towards a place where we are now,
    hopefully, on the final steps on passing this legislation. I
    wanted to thank him for his service to this Congress and also
    for his sponsorship of this legislation.
        But, while we are going to have this hearing it is very
    important, to some degree, the major, the macro issues that we
    are going to discuss here have been discussed and, frankly,
    ruled upon by this Congress and by the American people. Shortly
    after September 11 everyone agreed the responsibility for the
    heroes that walked into those buildings, ran into those
    buildings to save so many people in the largest civil
    evacuation in American history, no one disputed this was the
    responsibility of the Federal Government to pay tribute to
    them, to take care of them, to take care of their families.
        This Congress decided, in an overwhelming fashion, when we
    created the Victims Compensation Fund. Never once was it
    uttered here in Congress or around the country that, ``ah, that
    is New York's problem, let them worry about it.'' Even in the
    context of a partisan country and a partisan Congress, everyone
    came together and realized this was the responsibility of the
    Federal Government to help the people of the city of New York.
        When Mayor Giuliani and Mayor Bloomberg called upon the
    resources of the city and contractors and volunteers and
    everyone to come down to Ground Zero and help us with the
    process of rebuilding and restoring and healing our city,
    nobody for a moment thought that was the responsibility of the
    city or those individual contractors. Everyone understood this
    was the responsibility of the Federal Government, as part of
    the obligation of the Federal Government to respond when we
    were attacked as a country and New York City just happened to
    be the point of that attack.
        So, to a large degree, the only question is how we decide
    who it is that we are going to be compensating and taking care
    of. Frankly, if we in this House knew that years and years
    after September 11 there would be people dying by degrees,
    dying day by day because of the impact of the attack, we would
    have written the original laws to take into the account the
    idea that this might be a process that should go on for 10, 12
    years.
        So the only issue we have today, I think, is the details.
    How we make sure the city is compensated, how we make sure the
    contractors are compensated and how we make sure individuals
    are made whole to the greatest extent possible. And I should
    make it very clear, Mr. Chairman, New York is not being asked
    to be repaired. We can never be repaired. The attack that was
    suffered by so many--has left a scar on so many. All we are
    asking is for a natural continuation of the discussion that we
    had in a bipartisan fashion shortly after September 11 when we
    said, ``you know what, we are all going pitch in.''
        The Victims Compensation Fund, only by oversight, only for
    lack of a clause that said ``for those who have passed away or
    those who, as a result of this, are sick, injured or dying by
    degrees.'' If it were not for that language, the addition of
    that language, we would have no real dispute here today.
        And I want to thank you, Mr. Pallone and thank the
    witnesses and thank Mayor Bloomberg for reminding us every day
    of the responsibility that we have. If we get this wrong, I say
    to my colleagues, here is the scenario that we face. We face
    the possibility, the very real possibility, in any number of
    cities, in any town, or in any part of this country being
    attacked and people say, ``you know what, I don't want to be
    involved because the Federal Government, while encouraging us
    to do so is not taking care of us once we do.''
        This Congress is not going to let that happen and if we
    hearken back to the substance of that debate, let us hearken
    back to one other thing. This was a bipartisan agreement. We
    had all decided we were going to come together as part of a
    package of restoring our country. We were going to restore New
    York City. We were going to help to pave the way for New York
    City to get back on its feet. Today, in living rooms and dining
    rooms and in hospital rooms, frankly, all around the New York
    City area are people who are dying because of September 11.
    This legislation honors them, it does our best to make it whole
    and it lives up to the commitment we made after September 11,
    and I thank you Mr. Chairman for holding this hearing.
        Mr. Pallone. Thank you Mr. Weiner. Next is the gentlewoman
    from California, Ms. Solis.

     OPENING STATEMENT OF HON. HILDA L. SOLIS, A REPRESENTATIVE IN
                 CONGRESS FROM THE STATE OF CALIFORNIA

        Ms. Solis. Thank you, Mr. Chairman, and I also want to
    welcome our witnesses, our colleagues, as well as the Mayor
    from New York, Mr. Bloomberg. It is an honor to have you here.
    I will be brief. I just want to say that I have often wondered
    why our government takes so long to address catastrophes like
    this. And we know that as a result of the toxins and the
    exposure, we see higher rates of asthma now in individuals that
    were around the World Trade Center and especially among our
    first-responders. California, as was noted, did send a number
    of our emergency responders to help out in that situation, and
    I believe that we have a responsibility to help provide the
    best healthcare assessments and access that they need in their
    recovery. In addition to asthma rates going up, care for post-
    traumatic stress and mental health assistance needs to be
    provided as well. So I agree, in part, with all that has been
    said by my colleagues. This is a bipartisan issue, one that all
    of us would never want to have placed upon us at any time in
    our lives. And there is an urgency for us to help people, and
    not just the first-responders, but anyone that was affected by
    the fallout of the hazardous material that spread throughout
    that city in that particular time. So, with that, I yield back
    the balance of my time.
        Mr. Pallone. Thank you. The gentleman from New York, Mr.
    Towns, is recognized for an opening statement.

     OPENING STATEMENT OF HON. EDOLPHUS TOWNS, A REPRESENTATIVE IN
                  CONGRESS FROM THE STATE OF NEW YORK

        Mr. Towns. Thank you very much Mr. Chairman, and of course
    thank you Ranking Member Deal, for convening this important
    hearing. This bill recognizes and addresses the rising health
    problems among the brave citizens who were exposed to unknown
    health risks as a result of the terrorist attack of 9/11. I
    would also like to thank the author of the bill, my friend and
    colleague from New York, Carolyn Maloney, in her diligence and
    leadership on this issue, and other members of our New York
    delegation who have really been very involved in pushing this
    bill forward: Congressmen Weiner, Engel, Fossella, Nadler, and
    King. And I would especially like to thank the Honorable Mayor
    of the city of New York for joining us this morning to offer
    his testimony. I would also like to thank the New York State
    Department of Labor Commissioner, Patricia Smith, for joining
    us.
        As we approach the seventh anniversary of the 9/11 attacks,
    I hope we can work together to bring effective medical
    treatment and financial assistance to those affected on that
    fateful day. I have held several 9/11 hearings in my Government
    Reform Subcommittee and this has been a long and painstaking
    process. But I look forward to a successful passing of this
    legislation before us today and moving toward a solution we can
    all be proud of. Now, we need to encourage people to be
    supportive of each other. We need to encourage people to, in
    times of crisis, that if you respond and go beyond the call of
    duty, we will be there for you. I think the Federal Government
    has that responsibility. So I come today to say that I hope
    that we will assume that responsibility to respond in a
    positive way. Again, I thank the Chairman and the Ranking
    Member for holding this hearing. I look forward to the
    testimony, and on that note I yield back.
        Mr. Pallone. Thank you Mr. Towns. Next, another gentleman
    from New York, Mr. Engel recognized for an opening statement.

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

        Mr. Engel. Thank you very much Mr. Chairman. I appreciate
    it and we--those of us who are New Yorkers appreciate this
    hearing. It is one of the reasons why I am proud to serve on
    the Energy and Commerce Committee and on the Health
    Subcommittee. I can think of nothing more topical and more
    important to New Yorkers than this hearing and to try to help,
    based on the tragedy of 9/11. I would like to welcome our
    witnesses here today, including our Mayor Michael Bloomberg, my
    colleagues Jerry Nadler and Pete King and I would also like to
    welcome the New York State Commissioner of Labor, Patricia
    Smith and the New York State AFL-CIO representative Suzy
    Ballentine, who are with us in the audience today.
        As devastating as September 11 was, there are few days I
    have been more proud to be an American than on 9/11. Within
    minutes of crashes into the Twin Towers New York's first
    responders mobilized to save those trapped within the World
    Trade Center, putting themselves in unspeakable danger and too
    many lost their life that day, including many of my
    constituents. Within days over 40,000 responders from across
    the Nation descended upon Ground Zero to do anything possible
    to help with the rescue, recovery, and cleanup.
        I remember those bittersweet days. I was there in New York
    City where I was born and bred and remember seeing Americans
    lined up around blocks to donate blood. I remember the chaos as
    we didn't know quite what to do. People knew they had to do
    something, anything to help our Nation rise up from the assault
    by the terrorists.
        The past 6 years have not been kind to so many of the first
    responders who put themselves in harm's way. It is estimated
    that up to 400,000 people in the World Trade Center area on 9/
    11 were exposed to extremely toxic environmental hazards,
    including asbestos, particulate matter, and smoke. Years later
    this exposure has left a significant number of first responders
    with severe respiratory ailments, including asthma, at a rate
    that is 12 times the normal rate of adult onset asthma.
        Also common are mental health problems, including PTSD and
    depression. This has all been well documented in the scientific
    peer-reviewed published work regarding the long-term health
    effects of 9/11 by Mount Sinai, the Fire Department of the city
    of New York, and the World Trade Center Health Registry.
        While these illnesses should sadden all of us, what is more
    outrageous is that our Nation has failed to provide the first
    responders with anything more than a fragmented and unreliable
    health care monitoring and treatment program that forces those
    who fearlessly volunteered for our country to fight within a
    myriad of bureaucracy to receive care that should be given, and
    yet in a struggle.
        It is outrageous that officials like Christine Todd-Whitman
    told us that the air was fine and we should go about our
    business and we should just continue to do what ever is
    necessary when that was not the case. And there are many people
    in the area, not only first responders who were exposed to
    these deadly toxins--and I know my colleague, Jerry Nadler, in
    whose district the World Trade Center is, is making a very
    forceful case that we ought to not only help first responders,
    but we ought to help the communities around and people who were
    exposed to that. And I am very sympathetic to what Jerry Nadler
    has said in that regard.
        So I am proud to join with my New York colleagues, led by
    Representatives Maloney, Nadler, Fossella, and King and Ed
    Towns and Tony Weiner, as well, in introducing the revised 9/11
    Health and Compensation Act.
        This comprehensive bill would ensure that first responders
    and community residents exposed to the Ground Zero toxins have
    a right to be medically monitored and all that are sick have a
    right to treatment.
        It would also rightfully provide compensation for loss by
    reopening the 9/11 Compensation Fund. No more fragmented
    healthcare. No more excuses. We must and shall do what is
    right.
        In this vein, it is troubling to me that just before the
    July 4 holiday CDC Director, Julie Gerberding informed Dr. John
    Howard, Director of The National Institute for Occupational
    Safety and Health, that he would not be reappointed to a second
    term, even though he had asked to be reappointed. This
    effective termination came despite universal praise regarding
    Dr. Howard's service of protecting American workers, accolades
    for his outstanding work on behalf of the heroes of 9/11 in his
    capacity as 9/11 Health Coordinator and strong support from
    Labor Employers, the public health community, and Congress for
    his reappointment. I would like to enter into the record an
    editorial from the New York Times criticizing the
    administration for this action.
        I still feel great sorrow in our remembrance of the tragedy
    of 9/11. We will never forget what happened that day, but we
    must look forward and right the wrongs that our Nation has
    perpetrated against our own heroes and provide them with the
    care and compensation they so desperately deserve.
        Mr. Chairman, I urge all Americans to pause and reflect on
    this tremendous loss of life that day and how so many
    sacrificed so much for their fellow Americans and make sure
    that our future actions are driven by these memories and I
    again thank you for the hearing.
        Mr. Pallone. Thank you Mr. Engel. Now, you had a unanimous
    consent request there?
        Mr. Engel. Yes, Mr. Chairman.
        Mr. Pallone. All right, without objection, so ordered.
        Mr. Engel. Thank you.
        Mr. Pallone. You have your hand up, Mr. Towns.
        Mr. Towns. Yes, I also have one.
        Mr. Pallone. What is yours?
        Mr. Towns. I ask for unanimous consent to submit the
    testimony of Dr. Reibman, Associate Professor of Medicine and
    Environmental Medicine, Director of NYU Bellevue Asthma Center.
        Mr. Pallone. Without objection, so ordered.
        [The prepared statement of Dr. Reibman follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Pallone. And next for an opening statement, the
    gentleman--I was going to say New York, I will say Staten
    Island, because we think that Staten Island is closer to New
    Jersey, but thank you for all your efforts.

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

        Mr. Fossella. It is closer to New Jersey. And thank you,
    Chairman Pallone and Ranking Member Deal, thank you for
    extending me the courtesy of sitting on your subcommittee for
    today's hearing, and at the outset I ask unanimous consent to
    submit, for the record, the testimony of Representative Carolyn
    Maloney, and without her we wouldn't be here today. She has
    been the most tireless advocate, so I submit that. In addition,
    unanimous consent to submit the testimony of Dr. David Prezant,
    M.D., Chief Medical Officer, Office of Medical Affairs and the
    Co-Director of the World Trade Center Medical and Monitoring
    Treatment Programs of New York City Fire Department.
        Mr. Pallone. Without objection, so ordered.
        [The prepared statement of Ms. Maloney follows:]

                       Statement of Hon. Carolyn Maloney

        Chairman Pallone, Ranking Member Deal, members of the
    Health Subcommittee, I want to thank you for inviting me to
    testify here today on H.R. 6594, the James Zadroga 9/11 Health
    and Compensation Act, which I introduced with Representatives
    Nadler, Fossella, and King, with the support of the entire New
    York Delegation. I am pleased to be here with Mr. Nadler, Mr.
    King, and Mayor Bloomberg, and I am grateful that the Committee
    is taking up the important issue of health care for the heroes
    of 9/11--the World Trade Center rescue, recovery and clean up
    workers, residents, area workers, school children and others
    who have become sick because of exposures to the toxins of
    Ground Zero.
        On 9/11, our Nation was brutally attacked at the hands of
    terrorists. Nearly 3,000 people lost their lives that day. But
    as we now know, many more have lost their health.
        The James Zadroga 9/11 Health and Compensation Act would
    ensure that those brave Americans who have lost their health
    have a right to medical monitoring and treatment for their WTC-
    related illnesses and the opportunity to get compensation for
    economic loss and harm. We need to pass this bill because
    responders came to the aid of our nation after 9/11 and many
    are sick as a result. If we don't take care of them now, what
    will happen in the event of another disaster?
        Now, some here today might say that this is a very
    expensive endeavor and, truth be told, they would be right.
    Thousands of people from all 50 states were exposed to the
    toxins and many of them are sick. Monitoring, treating, and
    compensating all of them carries a hefty price tag. And it's a
    price tag that the Federal Government is going to have to pay.
        Because the truth is that this is a national problem that
    needs a federal solution. We all wish the terrorist attacks had
    never happened, we wish all those lives weren't needlessly
    lost, and we wish that there weren't so many people sick
    because of the air as caustic as Drano, but that won't change
    the facts. People are sick because our Nation was attacked. Not
    just New York City, not just New York State, but our Nation as
    a whole. In the aftermath of 9/11, Americans everywhere cried
    for our losses, prayed for our country, and found that
    patriotic spirit within. And people acted: first responders
    traveled from every single state in the Nation to help.
        Early on, some in Congress and in the Administration didn't
    think that 9/11 health issues were a real problem. They
    questioned the science. They questioned the need for funding.
    But hearing after hearing and GAO report after report made
    clear what we know today: that thousands of people are sick
    from 9/11 and they need and deserve our help.
        So we in Congress went to work to drum up the funding that
    was needed. Over 6 years, we have provided $335 million for
    screening, monitoring, and treatment for responders and
    community members. This funding allowed the Director of NIOSH,
    Dr. John Howard, to provide medical monitoring for 40,000
    Responders and treatment for 16,000 sick responders.
    Furthermore, NIOSH made arrangements for a national program for
    those who live outside the New York area, and has started the
    process toward helping non-responders who are sick and need
    treatment.
        And what happens in this Administration to an official who
    does what Congress directs and helps the heroes of 9/11?
    Unfortunately, he gets fired. That's right, although Dr. Howard
    asked to be reappointed as Director of NIOSH, Secretary Leavitt
    and CDC Director Gerberding refused to reappoint him to his
    post. There was absolutely no reason given for his dismissal.
    In fact, at a meeting just this morning with Secretary Leavitt
    and Dr. Gerberding, they refused to offer any grounds for
    terminating Dr. Howard.
        The program that Dr. Howard supervised, the WTC Medical
    Monitoring and Treatment Program, is playing a very important
    role in the lives of so many heroes of 9/11, and the facilities
    that are a part of this program are truly Centers of
    Excellence. The FDNY has a program of over 16,000 firefighters
    who are being monitored, and a Consortium of providers led by
    Mt. Sinai is monitoring about 24,000 other responders.
    Combined, the responder programs are treating about 16,000
    responders for WTC-related illnesses. For all the good work
    that the WTC Medical Monitoring and Treatment Program is doing,
    it constantly faces the challenge of uncertain funding, never
    knowing when they may need to close their doors or cut back on
    their medical personnel. Notably, year to year funding makes it
    very difficult to recruit and keep the high quality doctors and
    other care providers that make this Center of Excellence what
    it is.
        Today, residents, area workers, school children, and others
    are being screened and treated at a WTC Center of Excellence
    which receives no federal funding whatsoever. The City of New
    York is picking up the bill for the WTC Environmental Health
    Center at Bellevue Hospital, which has about 2,700 community
    members currently enrolled.
        H.R. 6594 will build on these current Centers of
    Excellence, expanding what's working and filling in the gaps
    left by what's missing. It will provide the steady funding that
    people need to know their care will continue and provide the
    funding to recruit and keep doctors who are experts in their
    field. It will make care for Responders and others mandatory.
    The care for sick heroes of 9/11 should not be left to the
    discretion of the year-to-year appropriations process.
        As I mentioned earlier, this is not an inexpensive
    proposition. Handling a big problem usually has a big cost.
    But, as some of you know, hand-in-hand with the City of New
    York and the AFL-CIO, we have sharpened the scope of our
    previous bill, H.R. 3543, allowing us to save billions of
    dollars in our newly introduced bill, H.R. 6594. We were able
    to do this because our original bill didn't match the problem
    it was trying to solve on the ground. It was too broad in its
    scope. In drafting H.R. 6594, we brought the bill in line with
    the real problem that needed to be solved: monitoring only
    those were exposed and treating only those who are sick.
        For example, H.R. 3543 included a radius of 2 to 5 miles
    within which community members would be covered. In the new
    bill, we create a smaller geographic area-south of Houston
    Street in Manhattan and up to a 1.5 mile radius in Brooklyn-
    which more closely mirrors where the dust cloud blew. Then, for
    anyone outside that smaller radius, we set up a capped
    contingency fund which could screen and treat only those
    community members who are determined to have WTC-related
    conditions. We made a number of changes like this so that the
    bill targeted the problem that needed solving and helped the
    people who need to be helped.
        This morning, I hope that my testimony has set the stage
    for you to hear more from the other panelists about H.R. 6594,
    the James Zadroga 9/11 Health and Compensation Act.
        In closing, I'm pleased to say to the Committee what I've
    told thousands of people before-I will not rest, we here at
    this table will not rest-until everyone at risk of illness from
    Ground Zero toxins is monitored and all those sick receive
    treatment for the WTC-related illnesses. This is the very least
    we can do, as a grateful nation.
                                  ----------

        [The prepared statement of Dr. Prezant follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Fossella. Another gentleman who has spent the last,
    almost, 7 years committed to helping those in need. And I
    highlight why we are here because of the many advocates who
    haven't given up, the Union officials, the FLC, I know has been
    mentioned, Susan and Dennis Hughes, the first responders, New
    York City Fire Department, Police Department, healthcare
    professionals, among them, Mount Sinai who just have not let us
    forget what happened, in particular, the witnesses, Congressman
    Nadler, Congressman King, I mentioned Congresswoman Maloney, my
    colleagues of the New York delegation, Mr. Towns, and one, in
    particular, Mr. Weiner who has been a vocal advocate to ensure
    that something get done. And above all is our Mayor from the
    great city of New York, Mike Bloomberg. He could have easily
    walked away from this issue, but there has been no one who has
    been more tireless and more vocal in support of those who
    suffered greatly on 9/11 and we couldn't have a better advocate
    in City Hall. So thank you, Mr. Mayor, for coming.
        And let me just also add something Mr. Green said earlier
    about if there is a hurricane in Houston, the Federal
    Government is there to help. Frankly, if there is a hurricane
    anywhere in this country or fire or flood, the Federal
    Government is there to help and that is what the American
    people do. They will respond through their Representatives,
    through their Congress to help. And, frankly, the people who
    responded in New York City and 9/11 still need help, and we
    haven't fulfilled the obligation to all of them. So we are here
    to talk about the legislation, which is a culmination of many
    long hours of work and even longer hours of compromise from the
    offices of Ms. Maloney, Mr. Nadler, Mr. King, and the Mayor's
    office.
        Their staffs have worked tirelessly to ensure that the bill
    we are set to discuss provides the best and most effective care
    to those still suffering. These individuals believe, as I do,
    that when we started working on this issue, it was for the
    right reasons and to help those still suffering. Those reasons
    remain the same today. We will continue pushing for the
    legislation till we finally see that all those who continue to
    suffer receive the treatment they deserve.
        It has been exactly 6 years, 10 months, and 20 days since
    the Nation suffered the horrible attacks. While much progress
    has been made to address the residual health effects, many of
    our Nation's citizens are still suffering and much is left to
    be done.
        The bill before us is our best chance to fulfill that
    obligation. Most of all, this bill represents our joint
    commitment to those who continue to suffer and deserve the
    monitoring treatment that has been deferred to them far too
    long.
        We cannot continue to stress enough the national health
    impact that these attacks have had. Currently, there are
    individuals from every congressional district in our country
    enrolled in the World Trade Center Health Registry. On this
    subcommittee alone, Democrats and Republicans combined
    represent roughly 10,000 individuals affected by these attacks.
        I, sadly, represent nearly 5,000 individuals enrolled in
    the registry. It is hard to imagine the public outrage we would
    see if there was an attack today on our country and the Federal
    Government did not provide adequately for those injured. Yet,
    this is exactly what we are experiencing today, as those who
    were exposed to these toxins from 9/11 continue to grow sick.
        The updated 9/11 Health and Compensation Act represents
    many significant changes from the original bill and much has
    been done to ensure that the best possible care is provided
    while minimizing the size of the program, specifically the
    geographic areas when patterned on the most likely affected
    population areas. Standards of association for those claiming
    health conditions related to 9/11 have a refined and cost-share
    with the city of New York for medical monitoring and treatment
    has been included. Our bill has been improved in ways unrelated
    to health.
        As much as possible, it makes whole the companies that
    brought the equipment and know-how to the rescue and recovery
    operation at the World Trade Center site. The Good Samaritan
    contractors and subcontractors performed a federal function by
    dealing with the aftermath of the attack. The bill indemnifies
    those companies so that they and others, who wish to help our
    Nation in a similar situation in the future, will do so without
    fear of losing everything. This is a significant improvement in
    our bill.
        This is a national health issue that needs to be addressed
    as such. Numerous studies have documented the illnesses of
    those exposed to the deadly ash and smoke mixtures from these
    terrorist attacks are at risk of developing. And many who
    suffer from these sicknesses face the added financial strain of
    no longer being able to work and having to bear the brunt of
    their medical costs without a federally funded national program
    to incur the costs.
        The Federal Government has an obligation to come to the aid
    of both the first responders who answered the call when their
    Nation needed them most and the innocents whose health continue
    to suffer from these devastating attacks. Any failure on our
    part to address this urgent issue now can have far reaching
    implications on our future response efforts.
        To those exposed to the sickening cloud of ashes and
    chemicals, the suffering continues long after the physical
    remains of the taxed have been addressed. I applaud the work of
    my colleagues in coming together to help those whose health at
    risk due to their exposure at Ground Zero on that fateful day,
    and we should pledge our support never to forget. Thank you Mr.
    Chairman.
        Mr. Pallone. Thank you. The ranking member, the gentleman
    from Texas, Mr. Barton, recognized for an opening statement.

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

        Mr. Barton. Thanks, Mr. Chairman. I am conflicted by this
    hearing. We all want to take care of the first-responders at
    the World Trade Center. We want to take care of the individuals
    who were in those buildings. We want to take care of the
    volunteers who risked their lives to try to help the
    professionals. And we also want to help our congressional
    friends from New York. I am glad to have the mayor here. It is
    a privilege to have you here, sir.
        It is good that we are having a hearing. I mean, I have
    spent a fair amount of time complaining to Mr. Pallone and Mr.
    Dingell that things that should go through the committee are
    taken to the floor on the suspension calendar so I can't
    complain that we are having a hearing. Having said that, this
    is a bill that was introduced, I think, last Thursday. We have
    tried to get a minority witness to appear but we haven't had
    time to make that happen.
        This bill is well-intended but it appears, on the surface,
    to be somewhat, to be as polite as I can about it, somewhat
    more comprehensive and beneficial than it really needs to be to
    solve the immediate problem. It is certainly something that
    needs to be addressed. I am told that there are several state
    and national initiatives trying to address it right now, Mr.
    Chairman, so I am a little bit perplexed that a bill that was
    introduced last Thursday, we are having a hearing on today.
        Again, I am glad that you have a lot of witnesses, that is
    a good thing, but if I had to vote on this legislation today, I
    would vote no. If we can narrow the legislation down, if we can
    target it to those that are most in need of help, there is
    certainly some gold in the legislation. But there are also, as
    it is currently drafted, some hidden costs that don't
    necessarily need to be borne, in my opinion, by the federal
    taxpayers. So, I have another hearing, as you know, going on
    downstairs. It is good that we are having the hearing. It is
    good that we need to address the problem.
        Again, Mr. Fossella has been an absolute champion on this
    issue for a number of years, and we know that he is sincere
    about it, and I can say the same thing for Mr. Nadler and Mrs.
    Maloney and Mr. King but sometimes haste does make waste and
    this particular bill may be an example of that. So with that,
    Mr. Chairman, I am going to be happy--if we can yield during an
    opening statement, I will be happy to yield. I am willing to,
    sure.
        Mr. Fossella. Only because you say you have to leave and
    thank you for yielding. I have the deepest respect for Mr.
    Barton and concluding with haste makes waste--almost 7 years,
    to me, is not haste. The fact is that we have tried,
    desperately, to have an adequate federal response and it has
    been lacking. And many people who have suffered, and their
    advocates, people who care deeply--I am not suggesting you
    don't--could have walked away and left the city of New York and
    the city taxpayers and the State taxpayers assume that burden,
    which has been tremendous. And we have tried desperately to get
    the Federal Government and its appropriate agencies to do what
    it should have done years ago. And I would just, respectfully,
    request that if anyone has anything to add, expeditiously, they
    should do so now.
        As you know, the congressional calendar is coming to a
    close, Congress is going on recess for the month of August. We
    come back for all of, probably, several weeks. In order to get
    something achieved this year, it will have to be done sooner
    rather than later and today is perhaps the last day we will
    have one of these hearings. So haste does not make waste in
    some respects. No, I should say--let me be clear--yes it does,
    but 7 years is far from haste, so I say that and if anyone has
    something to add that makes this program better and put in
    place now, I think we are all ears.
        Mr. Barton. Well, I don't know how much time I still have,
    Mr. Chairman. I have probably consumed it. But my concern, Mr.
    Chairman, and I am not going to belabor this because I know we
    need to get forward with the hearing, is that some of the
    eligibility requirements we are giving people, that
    apparently--and I say apparently--were not truly first
    responders. It appears to be drafted in such a way that
    somebody that just happened to be in the vicinity could be
    eligible and I think that we need to look at that.
        We are giving some folks that have signed waivers a second
    opportunity and I think that is where having a second look--I
    am not opposed to the concept. Don't misunderstand me. I just
    want to try to narrow the scope and make sure that we target
    the benefits to those that are truly needy and truly eligible.
    And that is not being Attila the Hun, that is just trying to be
    responsible, but with that, Mr. Chairman, it is good that you
    are holding a hearing on the subject.
        I have a number of bills I would like hearings held on too
    if you are in the market for bills. So, with that, we
    appreciate your concern and we know that the New York
    delegation is grateful that you are doing this.
        Mr. Pallone. Thank you, Mr. Barton. I see Mr. Burgess is
    sort of hesitating to sit down. Would you like to be recognized
    for an opening statement? I recognize the gentleman from Texas.

    OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE
                  IN CONGRESS FROM THE STATE OF TEXAS

        Mr. Burgess. Thank you, Mr. Chairman, for the recognition.
    I apologize for being late. I am trying to work between two
    hearings. I do believe this country has a solemn obligation to
    those who selflessly responded to the World Trade Center after
    the attacks on September 11, 2001. They didn't know the risks.
    These Americans went down to a site that, probably, more
    closely resembled Dante's inferno than any disaster site they
    had ever seen before. In lower Manhattan the fires went on for
    weeks. The plume of smoke and ash covered downtown and
    surrounding boroughs. We watched on the news, from down in
    Texas, hour after hour.
        Those working on the site were exposed to numerous toxins.
    Some may result in long-term medical conditions. The
    psychological impact of the event can't be overcalculated for
    those that will never recover the bodies of their comrades, for
    those that knew someone who may have been in the building that
    day or just affected by the sheer magnitude of this tragic act.
    Their mental health needs could persist for years to come.
        I appreciate the members of the New York delegation that
    are here today. Thanks to the Mayor for being in attendance. I
    hope as we move forward that this committee can work with you
    to improve H.R. 6594 and bring a bill to the floor. I think it
    would be a welcome commemoration and recognition for the
    sacrifice for those who responded to the worst terrorist attack
    ever to take place in the United States of America.
        We do need to be certain the program is a response to those
    who face an occupational illness because of their service. We
    need to ensure that past federal investments have been
    prioritized to then determine if improvements can be made and
    make them. This is a complicated issue. It is an emotional
    issue, but I commit to the Chairman that my staff and I are
    ready and willing to work with you to produce a bill, a better
    bill if one can be attained, but a bill nevertheless, one that
    we can all be proud of and one that will make people in this
    country proud of the sacrifice exhibited by all of those who
    answered the call to service on 9/11. I will yield back.
        Mr. Pallone. Thank you and I believe that concludes the
    opening statements by members of the subcommittee, so we will
    now turn to our witnesses in our first panel.
        Let me welcome all of you. Let me say to the Mayor, we are
    certainly honored that you are here with us today, not only
    because of what you have done on this issue, but also what you
    do for the great city of New York. I will note that Carolyn
    Maloney, who is the prime sponsor of legislation, wasn't able
    to be here because she has a mark-up on another bill in
    financial services. But I do want to welcome all of you.
        Let me say, well--nobody here needs any introduction, but I
    will do it anyway because that is what we normally do. First,
    we have the Honorable Jerry Nadler. I have to say, Mayor, and
    this is not in any way commenting on the Republican members,
    but I have never seen anybody work harder on an issue than I
    see in Jerry and Carolyn. They have been relentless. Not only
    from the very beginning, when you had that hearing and called
    attention to this issue Jerry and I came to the courthouse in
    Manhattan, but also in terms of you and Carolyn constantly
    coming to the floor and demanding that we move this bill and
    have hearings and try to come up with something that is
    workable with the leadership. So, I want to commend you for
    that. And we also have with us Peter King, also from New York,
    and of course the Mayor of New York, Michael Bloomberg. We will
    start with Congressman Nadler.

    STATEMENT OF HON. JERROLD NADLER, A REPRESENTATIVE IN CONGRESS
                       FROM THE STATE OF NEW YORK

        Mr. Nadler. Thank you very much. Let me begin by extending
    my thanks to Chairman Pallone, Ranking Member Deal, and the
    members of the subcommittee for convening this hearing and
    inviting my colleagues and me to testify here this morning. I
    want to thank Speaker Pelosi for her ongoing leadership and I
    also want to thank the chairmen of the Committees of
    Jurisdiction, the bipartisan members of the New York, New
    Jersey, and Connecticut congressional delegations, in
    particular Carolyn Maloney who is not here, about whom I will
    have more to say in a moment, and Vito Fossella and Peter King,
    the Mayor of the City of New York, and the Governor of New
    York, the AFL-CIO, numerous local community groups for working
    with us intensively over the past several weeks to sharpen the
    focus of the legislation before us today.
        As you know, Congresswoman Maloney and I, and let me say
    that, again, Carolyn has been working--we have been working
    together and she has been a leader on this since very early on
    and I am very sorry that she can't be here this morning because
    of the mark-up in the Financial Services Committee, but
    everyone who knows anything about this issue knows of her
    leadership role. And along with our colleagues Congressman King
    and Congressman Fossella have introduced H.R. 6594, the James
    Zadroga 9/11 Health and Compensation Act of 2008, which is not
    in one sense a brand new bill. It is a modification of a bill
    introduced a year ago, which in turn is a combination of
    several bills introduced over the years. We have bills going
    back 6 years on this topic and continually refining them on the
    basis of new knowledge and new experience.
        And the purpose of the bill is to ensure that the living
    victims of the September 11th terrorist attacks have a right to
    health care for their World Trade Center-related illnesses and
    a route to compensation for their economic losses. Although the
    Victims Compensation Fund part of the bill is not before this
    committee, today.
        We believe the current version of this bill represents our
    collective best efforts to provide that critical support for
    those affected by the attacks, our heroic first responders,
    area workers, resident, students or others--through a stable,
    long-term approach that builds on successful, existing
    programs. And it does all of this in a fiscally responsible
    manner. We are hopeful that today's hearing marks the beginning
    of the end of our collective 7-year struggle in pressing this
    case.
        Beginning shortly after 9/11 we were warned that the air
    wasn't safe and that our courageous first responders were not
    being afforded the proper protection from dangerous toxins as
    they worked on the rescue, recovery and cleanup operation. We
    spent years trying to convince public officials that the
    asbestos, fiberglass, and other toxins had traveled far and
    settled into the interiors of residences, workplaces and
    schools, and that a proper testing and cleanup program was
    required to eliminate the health risks to area residents,
    workers, and students. We asked that the government acknowledge
    the fact that thousands of our Nation's citizens were becoming
    sick from 9/11 and that many more could become sick in the
    future.
        We explained to whomever would listen that our 9/11 heroes
    were struggling to pay health care costs because they could no
    longer work and no longer had health insurance, or because they
    have had their workers' compensation claims controverted, and
    we argued vigorously that the federal response, to date, has
    been dangerously limited, piecemeal, and unstable.
        Thankfully, we believe that we have now finally achieved a
    much more widespread recognition of many of these problems, and
    nearly 7 years after the attacks, we believe and hope that
    Congress will do what is right for our heroes and our living
    victims, and pass H.R. 6594.
        Though the devastating 9/11 attacks on the World Trade
    Center occurred within my congressional district, we know that
    these were really attacks on our Nation as a whole--
    figuratively and literally. The President has repeatedly
    referred to them as such. The members of the New York
    delegation represent thousands of people who were exposed to
    contamination in lower Manhattan and then affected parts of
    Brooklyn. Indeed, every member in this room represents a state
    that has people suffering the health effects of 9/11.
        And as this is unquestionably a national problem, it has
    always required a national response. But despite our sustained
    efforts to get the administration to develop a comprehensive
    plan to deal with this growing public health problem the New
    York delegation has instead found itself, year after year,
    coming to Congress with its hat in hand to test its luck at the
    annual appropriations process.
        Thankfully, with growing bipartisan support for that
    funding, and with dedicated public servants like Dr. John
    Howard, we have had some key successes. But this is simply no
    longer a tenable course of action. Neither our heroes nor the
    excellent health care programs that are now in place to serve
    them should have to rely on such an unpredictable and
    unreliable funding source as annual appropriations.
        Passage of the James Zadroga 9/11 Health and Compensation
    Act would mark an end to this entire problematic approach and
    ensure that a consistent source of funding is available to
    monitor and treat the thousands of first-responders and
    community members who have been or will become ill because of
    World Trade Center related illnesses. And it would make sure
    that no matter where an affected individual were to live in the
    future, he or she could get care.
        The bill would also require substantial data collection
    regarding the nature and extent of World Trade Center
    illnesses, a critical step in learning more about these
    illnesses and then preparing for future natural or man-made
    disasters.
        And finally, as you know, this legislation would provide an
    opportunity for compensation for economic losses by reopening
    the 9/11 Victim Compensation Fund, and would indemnify the
    contractors who dropped everything and rushed to help the
    rescue and recovery operations.
        The needs here are abundantly clear. We now have 16,000
    first-responders being treated for World Trade Center related
    illnesses and another 40,000 being monitored through a
    consortium of providers led by Mount Sinai and by the Fire
    Department of New York. And we have nearly 3,000 sick community
    members being treated in an entirely city-funded program with
    countless others being treated elsewhere.
        But unfortunately these are just today's numbers. In a
    February 2007 report to Mayor Bloomberg, the City of New York
    estimated that there were nearly 90,000 first-responders and
    about 318,000 heavily exposed community members, who were
    living or working within an even more narrowly drawn radius
    than is used in this bill, an unknown number of whom may
    ultimately become sick as a result of the effects of the 9/11
    attacks.
        As you may know, the preliminary cost estimates of the
    original version of this bill, last year's version, were
    substantially higher than our expectation. Therefore, we have
    redesigned the bill in order to bring those costs down
    dramatically by many billions of dollars. We made many
    different cuts in the bill, and some of them were very
    difficult to swallow. With respect to the community program, a
    variety of cuts were required.
        First, this new bill dramatically shrinks the radius within
    which individuals who reside, go to school or work would be
    eligible for services.
        Mr. Pallone. Jerry, I apologize, but you are 2 minutes over
    so you need to wrap up a little.
        Mr. Nadler. OK, I will try to wrap it up quickly. Second,
    it caps the number of new treatment slots for the community
    members to 35,000. It places strict dollar limits on various
    contingency funds. Concerns have been raised that with these
    limits and caps some individuals who were or are still being
    exposed to 9/11 toxins and who may become sick in the future
    may be excluded from help. These fears arise because although
    we do not have--because we have a good deal of data about
    toxicity there has never been a systematic testing program to
    determine the geographic extent of indoor contamination, as was
    recommended by the EPA Inspector General.
        And individual cap levels in the bill were determined in
    part by looking to the current number of people being treated
    in each of the existing programs. And as has been previously
    noted, we know that the population in the community program at
    Bellevue under-represents the total population that is
    currently sick.
        Nonetheless, I am hopeful these fears are unfounded. Our
    goal has been to use the best available data and knowledge to
    estimate the number of people who could eventually get sick and
    craft a bill whose price tag allowed a real chance of passage.
    Our goal was not to deny any deserving individual care or
    compensation.
        Today we must decide if we are going to be a part of, in an
    effort to honor the heroes and victims of 9/11 and to provide
    for their health and for compensation for losses in a
    reasonable and responsible manner. I urge you to come to the
    aid by enacting this bill.
        You would not be alone. The broader, original, more
    expensive version of this bill had more than 100 bipartisan co-
    sponsors. It stands to reason that we will see even more
    support for this bill, which is strongly supported by the
    governor, the mayor, the national AFL-CIO, the contractors,
    numerous environmental and community advocacy groups and is
    essential if this Nation is going to redeem its honor and begin
    to behave properly toward the victims and the heroes of the 9/
    11 attacks on the United States.
        I urge you to give favorable consideration to this bill. I
    thank you for your attention and for your indulgence for the
    overtime statement.
        [The prepared statement of Mr. Nadler follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Pallone. Thank you. Congressman King.

    STATEMENT OF HON. PETER KING, A REPRESENTATIVE IN CONGRESS FROM
                         THE STATE OF NEW YORK

        Mr. King. Thank you, Mr. Chairman. Mr. Chairman, I would
    ask unanimous consent to have my prepared statement made part
    of the record.
        Mr. Pallone. Without objection, so ordered.
        Mr. King. Mr. Chairman, let me thank you and Ranking Member
    Deal for holding this hearing and let me commend Congresswoman
    Maloney and Congressman Nadler, who, as you rightly pointed
    out, have fought very hard on this issue very valiantly and, of
    course, Congressman Fossella who has been there from the start
    and that just works tirelessly on it. And, of course, Mayor
    Bloomberg whose--that he and his administration have dedicated
    themselves to addressing this issue. And it really is a human
    issue and it is not just a New York issue and I am glad that
    that has been pointed out by a number of people.
        Now Congressman Green mentioned the fact that if there is a
    hurricane in Houston, or it could also be a terrorist attack in
    Houston--in this year's Homeland Security Funding additional
    funds went to Houston because of its ports, there is a prime
    terrorist target, so there is virtually no--whether it is
    Houston or Los Angeles, whether it is New York, whether it is
    Boston, Chicago, the fact is there are any number of terrorist
    targets in this country--prime terrorist targets--Washington,
    DC--and we as a Nation have an obligation to come together and
    stand together as one.
        My own district, I had over 150 people killed, over 1,200
    first-responders. Congressman Fossella, I believe, had over 400
    people in his district killed. Congressman Nadler had, of
    course, thousands and thousands of residents who were affected
    by this, but as has been pointed out every--I think virtually
    every congressional district in this country sent volunteers to
    Ground Zero, so it truly is a national effort. And at the time,
    I believe that Congress and the administration, everyone did
    what they felt was the right thing to do.
        We did not anticipate that when we passed, for instance,
    the Victims Compensation Fund just a week after September 11,
    that the dust, debris, and the toxins would cause all of these
    terrible illnesses later on. And Dr. Burgess is the medical
    expert, but I can tell him there are constituents in my
    district, neighbors of mine, people in their 40s and 50s with
    very rare cancers, very unusually severe respiratory illnesses.
    And, again, it could be anecdotal. It could be coincidental,
    but you have such a large number of people who worked there
    coming down with these rare illnesses.
        To me, there is definitely a cause and effect. I think that
    that debate should almost be over, so we need a permanent
    monitoring system, a permanent system of treatment. We have to
    open up the Victims Compensation Fund and it has to be done for
    those who responded, those who came down, those who spent weeks
    and months, really going into the following year, working at
    Ground Zero.
        You have the contractors who showed up without signing any
    liability agreements, who really put their businesses on the
    line for this and they could be on the hook right now for many
    lawsuits and for many actions. So it is important that they be
    indemnified. And it is really vital we just set a tone and set
    a program in place, for if, God forbid, another attack does
    happen anywhere else in this country, we wont be going through
    this uncertainty for 6 or 7 years, not knowing exactly who to
    treat and how to treat them, how it is going to be paid, what
    the protocols are going to be.
        So, this is a bipartisan bill. It is a vital bill. It is
    one which we owe to those who responded. We owe it to those who
    did work there. I can remember Barton mentioning, he said
    people just happened to work there. Well, the fact is, downtown
    Manhattan was attacked because of the people that worked there.
    It was attacked because it is the financial center of the
    world. And so, to me those people just went to work, innocent
    people, on a Tuesday morning not knowing what is in store for
    them, but they were killed for a reason and those who were
    wounded and damaged and were suffering illnesses today, it is
    for a reason. They just didn't happen to be there, they worked
    in an area which is a prime target of Islamic terrorism.
        So we have an obligation to defend those who were attacked,
    to work with those to provide whatever health and medical care
    we can for them. So I thank the subcommittee for having this
    hearing. I certainly hope we can get this on the floor for a
    vote. It should not be caught up in partisan politics.
        I know those of us on the Republican side will do all we
    can to work with the Administration, to work with Republican
    leadership to ensure that this is not a New York bill, it is
    not a Democrat bill, it is not a Liberal bill, this is an
    American bill for real Americans who suffered, who died and,
    really, in memory of those who put their lives on the line and
    we should never ever forget them.
        So with that, I thank you for holding the hearing, I
    certainly urge the adoption of H.R. 6594 and, again, thank
    Congressman Nadler, Congresswoman Maloney, Vito Fossella, of
    course, and Mayor Bloomberg for being such a champion of this
    issue, and I yield back.
        [The prepared statement of Mr. King follows:]

                        Statement of Hon. Peter T. King

        Chairman Pallone, Ranking Member Deal, and members of the
    Subcommittee on Health, thank you for inviting me to speak on
    this important issue. I would like to thank my colleagues, Mrs.
    Maloney, Mr. Nadler, and Mr. Fossella, for their hard work and
    dedication to the James Zadroga 9/11 Health and Compensation
    Act, H.R. 6594, and am pleased to have the opportunity to
    explain why such legislation is so crucial.
        On September 11th, 2001, the Nation sustained the greatest
    attack on our homeland in history. I am sure that everyone in
    this room remembers the exact moment they found out about this
    tragedy and where they were as they watched the towers finally
    succumb and collapse. In New York City, as the towers burned
    and civilians were evacuating the buildings, brave men and
    women were rushing into the World Trade Center. These men and
    women, the members of the FDNY, NYPD, Port Authority, and other
    emergency services, gave their lives to save others. Moreover,
    in the weeks and months following the attack, after having
    already lost so many friends and colleagues, these same people
    worked diligently in the cleanup and recovery effort. Their
    work was an inspiration not only to me and my fellow New
    Yorkers, but to the nation as a whole. I am proud to say that
    over 1,200 of my constituents are among those that responded to
    the 9/11 attacks.
        However, the devastation of 9/11 did not end once the
    cleanup was complete. Those that responded are now becoming ill
    due to the dust, debris, and toxins they were exposed to on 9/
    11 and during the recovery effort. These individuals sustained
    not only serious physical harm, but also extreme emotional and
    mental trauma as a result of their work.
        As you heard from my colleagues, Congress has appropriated
    some funds for an ongoing medical monitoring and treatment
    program for 9/11 first responders. This program has resulted in
    a number of medical studies showing the detrimental effects
    that exposure to toxins at Ground Zero have had on first
    responders, volunteers, and area residents and workers. It is a
    scientific fact that those who worked in the recovery efforts
    have decreased pulmonary function, have developed adult onset
    of lower and upper respiratory conditions, and have experienced
    worsened symptoms of asthma and other conditions.
        With limited resources, the WTC Centers of Excellence in
    the New York metropolitan area have done an outstanding job of
    monitoring and caring for responders, but funding for this
    program should not be an annual battle. These men and women are
    very sick and they are so because they rose to the occasion and
    did the hard work that the Federal Government asked them to do.
    While I have been supportive of all current efforts, more must
    be done for the heroes of 9/11. We must come to the aid of
    those who selflessly responded to the 9/11 attacks by creating
    a permanent program of treatment and monitoring. The list of
    ailments currently being endured by those who had 9/11
    exposures may only grow longer as the years since the attacks
    pass. We must ensure that these individuals receive adequate
    preventive care in the present, but we must also create an
    infrastructure and be prepared to care for these individuals in
    the future.
        The program that would be established by H.R. 6594 would
    put in place a structure under which all those affected by 9/
    11, both responders and residents, can receive that healthcare.
    The cost of this program is a small price to pay given the
    sacrifice these courageous individuals have made.
        Furthermore, it was not only New Yorkers that responded to
    the attacks. Every district in this country has at least one
    responder that answered the call of duty on 9/11. H.R 6594
    would establish a national treatment and monitoring program so
    that those responders who either came from out-of-state to help
    New York in our time of need or who have since moved can
    receive quality medical treatment for their 9/11-related
    illnesses even if they do not live in the New York metropolitan
    area. I am extremely grateful to those that traveled from
    Texas, Florida, California, Pennsylvania, North Carolina, and
    across the country to help their fellow citizens in need. The
    national program established by H.R. 6594 would show that the
    Federal Government is also grateful for what these
    compassionate and patriotic individuals did.
        The reality is that the FDNY, NYPD, and others who
    responded to the attack on New York were on the front lines of
    the first battle in the War on Terror. Just as they were there
    for us when our country was challenged, these heroes now need
    our help. The Federal Government has the responsibility to care
    for all those who responded to the attack on the World Trade
    Center, just as those who responded at the Pentagon have been
    protected by the Federal Government. The men and women in New
    York--without question, without protest--worked tirelessly for
    months on the burning pile; the least we can do is to ensure
    they are receiving medical treatment for the ailments they have
    as a result of this work. This is truly a national problem and
    Congress must act now to help the heroes of 9/11.
                                  ----------

        Mr. Pallone. Thank you. Mayor Bloomberg.

        STATEMENT OF MICHAEL BLOOMBERG, MAYOR, CITY OF NEW YORK

        Mr. Bloomberg. Chairman Pallone, Ranking Member Deal,
    Congresswoman Solis and Congressmen Towns, Weiner, Burgess, I
    wanted to thank all of you and particularly the New York
    delegation, Vito Fossella, Carolyn Maloney, who couldn't be
    here, Congressman Nadler and King who have worked so hard on
    this. I understand that my presence on this panel, along with
    members of the Congress defies the normal procedures and I
    would like to thank Speaker Pelosi for her strong commitment to
    moving this bill forward. And I think it underscores the
    historic importance of this measure.
        Passing this bill would, at long last, fully engage the
    Federal Government in resolving the health challenges created
    by the attack on our entire Nation that took place on September
    11. The destruction of the World Trade Center was an act of war
    against the United States. Now people from every part of the
    country perished in the attack and people from 50 States took
    part in the subsequent relief and recovery efforts and I might
    point out that planes went into a field in Pennsylvania and
    into the Pentagon, right here in Washington.
        And that makes addressing the resulting and ongoing health
    effects of 9/11, I think, a national duty by any standard.
    Members of the committee, nearly 2 years ago on the fifth
    anniversary of 9/11, I directed New York City Deputy Mayors Ed
    Skyler and Linda Gibbs to work with the city health experts and
    agencies to make a thorough investigation of the health
    problems created by the terrorist attack. And their report,
    published 6 months later, established beyond question that many
    people suffered physical and mental health effects as a result
    of the World Trade Center attacks and its aftermath and they
    included fire fighters and police officers, community
    residents, school children, and owners and employees of
    neighborhood businesses. And also, and most importantly,
    construction workers and volunteers from across America that
    took part in the historic task of clearing the debris from the
    World Trade Center site.
        The report made clear that the ultimate scope of these
    health effects is still unknown. It also identified the two
    most important challenges presented by these health problems.
    And the great strength of this bill is that it addresses both
    of them. First, it would establish consistent federal support
    for monitoring, screening and treatment of health related
    problems among eligible 9/11 responders and community
    residents. It would also fund essential ongoing medical
    research so that we can better understand what the health
    impacts of 9/11 are and what the resources we need in order to
    address them. The Federal Government has provided ad hoc
    appropriations for monitoring treatment for first-responders
    and workers who answered the call on 9/11. As you know,
    Congress has also, in the past, appropriated funds for
    residents, area workers and other community members whose
    health was affected by the attack, but until last week the
    Federal Department of Health and Human Services had not
    released those funds and only now has issued a request for
    proposals.
        And now you should know that New York City has not waited
    for federal funds to address this unmet need. In fact the city
    has budgeted nearly $100 million for 9/11 health initiatives.
    About half of that will be used to treat residents, workers,
    and others at the World Trade Center and Environmental Health
    Centers in our Health and Hospitals Corporation.
        But providing long-term treatment to those who are sick or
    who could become sick because of 9/11, really, is a national
    responsibility. And to date, uncertain and insufficient federal
    support of treatment efforts has jeopardized the future of
    these programs and the passage of this bill would make those
    funds--that future secure.
        Similarly, the World Trade Center Health Registry that we
    created and that we maintain, in partnership with the Federal
    Government, is the most comprehensive nationwide database on 9/
    11 health related issues and consistent federal support for the
    registry, made possible by this bill, will guide essential
    research and treatment for Americans whose health was effected
    by 9/11.
        The bill also incorporates strict cost containment
    standards for spending on treatment. For example, it requires
    that New York City, itself, and its city taxpayers to pay five
    percent of the cost of treatment provided at our public
    hospitals and clinics. And we accept this obligation. It gives
    us a powerful incentive to work with federal health officials,
    to ensure that expensive and finite medical resources only go
    to those who truly need them.
        The second key element of this bill, and I will close in a
    minute, is that it would reopen the Victims Compensation Fund.
    This is an essential act of fairness for those whose 9/11
    related injuries or illnesses had not emerged before the fund
    was closed in December of '03, or who couldn't be compensated
    because of the overly narrow eligibility requirements in place
    at that time.
        It would also heal rifts that have needlessly emerged since
    9/11. Today, the Victims of 9/11, the city of New York and the
    construction companies that carried out the cleanup at the
    World Trade Center site are being forced into expensive legal
    procedures. This bill would stop those needless and costly
    court cases. It would allow the city to help, rather than
    litigate against those who are ill. It would end misplaced
    efforts to assign blame to the city and the companies who
    worked to bring New York back from 9/11 instead of to the
    terrorists who attacked our Nation. It would create a mechanism
    for converting $1 billion now available to the Captive
    Insurance Company for this purpose. It would indemnify the city
    and its contractors from future liabilities in such cases and
    it would send the clear message that if, God forbid, terrorists
    strike us again contractors and responders can meet the
    challenge urgently and unselfishly, knowing their government
    stands behind them.
        In summary, this bill directly addresses the current and
    the future health problems created by 9/11 and also provides
    important relief for past injuries and illnesses. Members of
    the committee, we will observe the anniversary of 9/11 just 6
    weeks from today, and let us work together to pass this bill
    and ensure that the brave men and women, who bravely answered
    the call of duty, when our Nation was attacked, receive the
    health care that they deserve. Thank you very much for having
    me.
        [The prepared statement of Mr. Bloomberg follows:]

                       Statement of Michael R. Bloomberg

        Chairman Pallone; Ranking Member Deal; Congressmen Towns,
    Engel, and Weiner; members of the subcommittee. I want to thank
    you for this extraordinary invitation to testify on this panel
    along with the bipartisan sponsors of the ``9/11 Health and
    Compensation Act.''
        I understand that my presence on this panel along with
    Members of Congress breaks with the normal procedures of
    Congress. And like Speaker Pelosi's strong commitment to moving
    forward on this bill, that strongly underscores the historic
    importance of this measure. Passing this bill would, at long
    last, fully engage the Federal Government in resolving the
    health challenges created by the attack on our entire nation
    that occurred on 9/11.
        The destruction of the World Trade Center was an act of war
    against the United States. People from every part of the
    country perished in the attack, and people from all 50 states
    took part in the subsequent relief and recovery efforts. And
    that makes addressing the resulting and ongoing health effects
    of 9/11 a national duty.
        Members of the Committee: Nearly 2 years ago, as the fifth
    anniversary of 9/11 approached, I directed Deputy Mayors Edward
    Skyler and Linda Gibbs to work with City health experts and
    agencies to make a thorough investigation of the health
    problems created by that terrorist attack. Their report,
    published 6 months later, established beyond question that many
    people suffered physical and mental health effects as a result
    of the World Trade Center attack and its aftermath. They
    include firefighters and police officers, community residents,
    schoolchildren, and owners and employees of neighborhood
    businesses, and also construction workers and volunteers from
    across America who took part in the heroic task of clearing the
    debris from the World Trade Center site.
        The report made clear that the ultimate scope of these
    health effects is still unknown. It also identified the two
    most important challenges presented by these health problems.
    The great strength of this bill is that it addresses them both.
        First, it would establish much-needed year-in, year-out
    Federal support for monitoring, screening, and treatment of
    health-related problems among eligible 9/11 responders and
    community residents. It would also fund essential ongoing
    medical research so that we can better understand what the
    health impacts of 9/11 are, and what resources we need in order
    to address them.
        To date, the Federal Government has provided ad hoc
    appropriations for monitoring and treatment for first
    responders and workers who answered the call on 9/11. Congress
    also appropriated funds for residents, area workers, and other
    community members whose health was affected by the attack. But
    until last week, the Federal Department of Health and Human
    Services had not released those funds, and only now has issued
    a request for proposals.
        New York City has long recognized this unmet need; we have
    not waited for Federal funds to address it. In fact, the City
    has budgeted nearly $100 million for 9/11 health initiatives.
    About half that will be used to treat residents, workers, and
    others at the WTC Environmental Health Center in our Health and
    Hospitals Corporation. But providing long-term treatment to
    those who are sick, or who could become sick, because of 9/11
    is rightly a national responsibility.
        And while Federal funds have supported important research
    and treatment efforts, the uncertain and insufficient nature of
    that support has needlessly jeopardized the future of these
    programs. Passage of this bill would make that future secure.
        Similarly, the World Trade Center Health Registry that we
    created and that we maintain in partnership with the Federal
    Government is the most comprehensive nationwide database on 9/
    11 health-related issues. Consistent Federal support for the
    Registry will guide essential research and treatment for
    Americans affected by 9/11-related health problems--who live in
    all but four of the nation's 435 congressional districts--for
    years to come.
        The bill also incorporates strict cost-containment
    standards for spending on treatment. For example, it requires
    the City of New York to pay 5% of the cost of treatment
    provided at our public hospitals and clinics. We accept this
    obligation. It will give us a powerful incentive to work with
    Federal health officials to ensure that expensive and finite
    medical resources only go to those who truly need them.
        The second key element of this bill is that it would re-
    open the Victim Compensation Fund. This is an essential act of
    fairness for those whose 9/11-related injuries or illnesses had
    not emerged before the fund was closed in December 2003, or who
    couldn't be compensated because of the overly narrow
    eligibility requirements in place at that time. It also would
    heal rifts that have needlessly emerged since 9/11.
        Today, the victims of 9/11, the City of New York and the
    construction companies that carried out the clean-up at the
    World Trade Center are being forced into expensive legal
    proceedings. This bill would stop these needless and costly
    court cases. It would allow the City to help, rather than
    litigate against, those who are ill. It would end misplaced
    efforts to assign blame to the City and the companies who
    worked to bring New York back from 9/11, instead of to the
    terrorists who attacked our Nation.
        It would also create a mechanism for converting $1 billion
    now available to the Captive Insurance Company for this
    purpose. And it would indemnify the City and its contractors
    from future liability in such cases.
        And it would send the clear message that if--God forbid--
    terrorists strike us again, contractors and responders can meet
    the challenge urgently and unselfishly, knowing that their
    government stands behind them.
        In summary: This bill directly addresses the current and
    future health problems created by 9/11, and also provides
    important relief for past injuries and illnesses.
        Members of the committee: We will observe the anniversary
    of 9/11 just 6 weeks from today.
        Let's work together to pass this bill and ensure that men
    and women who bravely answered the call of duty when our nation
    was attacked receive the health care that they deserve.
                                  ----------

        Mr. Pallone. Thank you, Mayor. It is the tradition not to
    ask questions of the members panel and unless someone has a
    problem with that, I am going to release you and thank you very
    much for being here, and have you know that, as I have
    mentioned to Jerry and Carolyn, that it is not our intention to
    just have a hearing. We do want to move a bill and we are very
    much cognitive of the fact that----
        Mr. Bloomberg. Mr. Chairman, can I say one more thing? I am
    sorry Congressmen Green and Barton aren't here, but Congressman
    Burgess from Texas is. Texas, in particular, of all the States
    in this country, is a state that should know just how much of a
    burden it is to come to the relief of other parts of our
    country. I have always had great admiration for the city of
    Houston and its people and its Mayor, Bill White, who had came
    to the aid of the terrible--the people who were involved in the
    terrible tragedy of Katrina. I was in New Orleans last week.
    Their population has gone from 500,000 to 250,000; 150,000 of
    those went to the city of Houston, that continues to try to
    provide jobs and education and healthcare and housing to them.
    So it is a State that really does understand that we all have
    an obligation to help each other. It is a State that also could
    use some help from other States who--which should be a part of
    that, and if you would express my views to your associates in
    Texas and particularly the Mayor of Houston, who I have great
    admiration for.
        Mr. Burgess. Thank you. We will have that hearing when----
        Mr. Pallone. I didn't commit anything.
        Mr. Bloomberg. What is fair is fair.
        Mr. Pallone. I am not committing anything, but we do want
    to move the bill that is before us. Let me tell you that, and
    again thank you very much. Thank you all. I would ask the
    second panel--I guess it is just one person, the panelist to
    come forward.
        OK, on our second panel, we have but one witness, and I
    want to welcome Dr. Gerberding. Is that the correct spelling,
    what we have there on your--G-e-r-e-b-e-r--no. OK, it is G-e-r-
    b-e-r-d-i-n-g. All right, thank you. Well, welcome. Thank you
    for being with us today. Dr. Julie L. Gerberding is Director of
    the Centers for Disease Control in Atlanta. You know we have 5-
    minute opening statements that become part of the record, and
    each witness, in the discretion of the committee, may submit
    additional brief and pertinent statements in writing. So we
    may, depending on the questions, ask you to submit additional
    material. I thank you for being here and I now recognize you.

    STATEMENT OF JULIE GERBERDING, M.D., M.P.H., DIRECTOR, CENTERS
                   FOR DISEASE CONTROL AND PREVENTION

        Dr. Gerberding. Thank you. I appreciate the opportunity to
    provide information for the committee, relevant to CDC and
    NIOSH's activities related to the World Trade Center
    catastrophe. I was thinking this morning, probably every
    American knows exactly where they were the morning of 9/11, and
    I know when I saw the plane hit the tower, my first thought
    wasn't ``oh, we are under a terrorism attack.'' It was
    basically ``where is my daughter?'' because our stepdaughter
    was working in Manhattan at that time, and as the events
    unfolded many CDC workers were there, in the pit at Ground
    Zero, helping with a variety of different issues and the safety
    for those people that I care for and those people that I am
    responsible for at CDC was something that has been on my mind
    ever since the attacks occurred. So, what I thought I would try
    to do in my remarks this morning was to just give you, kind of,
    an umbrella picture of what we see the health concerns are and
    what we see the likelihood of ongoing need for monitoring and
    treatment of these individuals, maybe both the responder
    community as well as those in the community that were adjacent
    to the Trade Centers when they collapsed.
        The first thing is to recognize that there is a lot of
    uncertainty about this. We have never experienced any kind of
    an event of this nature or this scale. But when we think about
    what was the nature of the work that people were doing with
    such passion and such dedication, what was the nature of the
    exposure that they may have received in this environment and
    what are the long-term health effects. There is no precedent.
    We know something about the dust. We know something about the
    combustibles. We can predict what kinds of toxins and chemicals
    were inhaled. We know that there is likely to be variability in
    the dose that people receive, both because of the time that
    they were first exposed and the duration of their exposure, and
    perhaps the respiratory protection that they used. But
    nevertheless, there is a great deal of uncertainty.
        What we can say, right now, thanks to the New York Fire
    Department and their annual screening effort where about 14,500
    fire workers are undergoing monitoring and evaluation, is that
    a significant proportion of those responders did experience
    respiratory symptoms following the collapse of the Towers and a
    significant proportion of them are continuing to experience
    respiratory symptoms and signs out of proportion with what we
    would expect for a comparable cohort of people of the same age
    or the same smoking history or their overall similar health
    histories.
        Of the people who have conditions, the majority of them are
    experiencing what we would call aerodigestive disorders or
    respiratory problems. Another significant proportion are
    reporting chronic mental health related issues along the lines
    of post-traumatic stress disorder. The people who have
    respiratory complications have been assessed and have had data
    published in several publications, which I can submit for the
    record, but which are also available on the CDC Web site.
        About one-third of people get better over time. About one-
    third of people are staying the same, and about one-third of
    people are getting worse. So when we have the challenge of
    assuring that people receive the appropriate monitoring care
    and treatment that they deserve and need we have very little
    background data to go on, in terms of assessing costs or
    requirements.
        We have to admit that we are learning as we go here. We
    have made good faith estimates. Health and Human Services has
    allocated about $925 million so far for the support of
    responders, and more recently non-responders, in the community.
    We think we have done a pretty good job of accurately assessing
    what the projections are, but we could be wrong and if we need
    more than what we are prepared to invest right now, we will
    tell you because we all want the same thing. We want the best
    possible treatment, a fair deal for the people who gave so much
    to really help America during that very challenging time.
        I think we also need to know more about these health
    effects. One of the things we have been very careful about is
    to not use the appropriation that Congress has provided us for
    research of activities that weren't directly linked to the
    support and treatment of the people who were affected. But now
    that we have some information, we are now raising questions and
    there is a need to know more to do some science work in the
    laboratory, to do some work in cohorts of people and to really
    get as much information as we can. Not just for the sake of the
    people who were affected in the New York environment, but for
    people who, sometime in the future, may find themselves in a
    similar situation.
        We have learned a lot of lessons about worker protection. I
    think we have learned a lot of lessons about what communities
    are going to need and we need to make sure that we have the
    science and the evidence to apply those lessons to protect
    people in a more proactive manner in the future than we have
    been able to do this time out.
        So we are committed. We want to do the very best we can and
    we will continue to try to do our job in supporting the
    responders and the non-responders who were affected. Thank you.
        [The prepared statement of Dr. Gerberding follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Pallone. Thank you Doctor, and we will have some
    questions now, and I will begin by recognizing myself for some
    questions. Mr. Barton, of course, mentioned that this bill was
    just introduced, I guess, about a week ago. But we have had
    other legislation that this was based on around for some time.
    I know that you state in your written statement that you are
    not ready to comment on the bill before us, but my problem, of
    course, is the session is running out. We have a month between
    now and when we come back, I guess, on September 8 and then 3
    weeks. And we would like to move to mark-up the legislation, so
    I am hoping that we can get your feedback within the next few
    weeks or so, so that we could have it to look at over the
    August recess. What is your time table for giving us feedback
    on the bill? One week, 2 weeks, hopefully not much longer.
        Dr. Gerberding. I don't know how big the bill is or
    everything that is in it, but obviously we want to be able to
    express our perspectives and our voice and we will do
    everything we can to respect your timetable, so we will make it
    a priority.
        Mr. Pallone. Let me just say that we do intend, over the
    August recess, to look this over, to talk, both Democrats and
    Republicans, and see if we can come up with a consensus so we
    really would like to have input from you within the next couple
    weeks if possible. We are not going to wait until we come back.
        Dr. Gerberding. I understand.
        Mr. Pallone. Thank you. At the last hearing that we had on
    the larger issue, including some of the precursor legislation
    to this, there was a lot of criticism of the administration,
    either because not enough money had been expended for these
    centers, or because the administration, frankly, hadn't come up
    with its own legislative initiative or long-term solution, if
    you will, regardless of whether it was legislative or not, to
    deal with the problem. In other words, the sense was that we
    are operating on an ad hoc basis, we are operating on
    contingency funding and that we need to do something permanent,
    which is why this bill is before us. So what is the reason why
    the Administration hasn't submitted its own long-term proposal,
    if you will?
        Dr. Gerberding. I can't really comment on the broader
    administrative perspective, but what I can say is that, as a
    doctor, what I am seeing--and I have read the literature in
    detail. I am seeing what is going to be an ongoing need. How
    long, how bad, I don't think we know, but we need to prepare
    for a sustainable----
        Mr. Pallone. But what I am saying, and you understand I am
    not trying to be difficult, is that what this bill tries to do
    is to not just look at this ad hoc, the way we have, but say OK
    this--we are going to set up a federal program that is long-
    term and that deals with this problem. Is there any talk with
    the administration of doing that, or even at least supporting
    such a long-term solution whether or not it is this bill?
        Dr. Gerberding. I am hesitant to speak for the broader
    administration, but from the standpoint of NIOSH and CDC we
    know that a long-term broad program is needed and I think we
    would welcome authorization that moves us out of the
    appropriations process and into something that creates some
    consistency. I am, as an agency head, very well aware of the
    congressional intent around making sure that there was a care
    and treatment program for these individuals. That has not been
    part of CDC, NIOSH's traditional mission, so part of the reason
    this has been difficult for us is because we don't really
    provide insurance or provide care and treatment. We are a
    research agency, in this sense, and so this has been something
    that, again, we would look forward, during the authorization
    process, to really look at who should be doing what and how can
    we assure that the research needs are met as well as the care
    and treatment needs.
        Mr. Pallone. OK. Now, the other aspect, of course, is that
    the criticism which again we had at the previous hearing about
    the funding not being forthcoming, not that Congress wasn't
    appropriating it, but that it wasn't forthcoming, even though
    it had been appropriated. And my understanding is that the
    money that was appropriated for this fiscal year, which I guess
    began last October, but I don't know exactly when it was
    finalized, probably a few months after that, was just released
    last week. I mean, can you explain why the CDC would delay
    taking action until this past week and what are the
    administrations plans to make sure that this $108 million
    appropriated for the fiscal year is utilized?
        Dr. Gerberding. If you ask me how would we go about
    spending x amount of money to build the gulf standard
    surveillance system----
        Mr. Pallone. No. I am just trying to find out why it took
    so long. I mean, it is July, and this money was available as
    early as January, February, as far as I remember.
        Dr. Gerberding. The challenge that we were facing is how do
    we provide a program for non-responders. Is that everyone who
    lives in Manhattan? Is that a few thousand people who are right
    next to the pit. I mean, with tremendous variability in who
    should be included and how we would go about planning for a
    medical program for an----
        Mr. Pallone. Do you know, Doctor, and I know I am
    interrupting you. My time has run out, but when I go to the
    center at Rutgers, which is the one that I am familiar with in
    my district, and--she is not here today, Dr. Udasin, because
    she wasn't able to be here, who is in charge or it. All they
    did was tell me how they needed more money for this, they
    needed more money for that, they have all these people that
    they want to do things for and they can't because of limited
    resources, so there doesn't seem to be any reason to wait 6
    months to release funding that we have already appropriated.
    That is all I am asking. Why 6 months and how do we make sure
    this money gets out there? I mean, we appropriate it, but it
    doesn't seem to get out there.
        Dr. Gerberding. I think we have mechanisms to cover all the
    groups that were included in the congressional intent, right
    now. But I got to tell you, it is hard and that is why I
    brought up the issue that this is not something we do at CDC,
    we are starting from scratch here, to try to figure out how do
    we build a care and treatment program for non-responders when
    we have never done anything even close to this before, so it
    took us longer than you would have liked. And believe me, I
    wish we had done it faster because it would have satisfied your
    constituents, but also because we would have less question
    about what our intent really was. We are committed. I think the
    mechanisms are there. These are long standing opportunities,
    now, to renew and continue funding. And I think you will see a
    better time line in the future.
        Mr. Pallone. All right, thank you. Mr. Deal.
        Mr. Deal. Before I ask Dr. Gerberding the questions, Mr.
    Chairman, I would like to ask you in response to your statement
    that you have intentions of moving a bill on this. Could you
    give us some idea of the timeline that you have in mind?
        Mr. Pallone. Mr. Deal, I don't have a timeline. I am hoping
    that you and I and Mr. Barton and Mr. Dingell and our staff can
    spend some time over the August recess so that when we come
    back we have a consensus. Obviously, since we are going to only
    be here, probably a short time in September--I don't even know
    if we go into October. We would have to do something in
    September, but I think what I would ask is that we spend the
    time during the August recess, get the Administration's input,
    meet on a bipartisan basis with the staff and try to see if we
    can come to a consensus by the time we come back.
        Mr. Deal. Welcome to the committee. I think I understand
    the concern that you have about being asked to do something
    that is not traditionally within the role of CDC, and I can
    understand that haste, in that regard, would probably result in
    a lot of criticism for money that might be misspent, and so I
    appreciate the complexity that you have outlined that you are
    facing. And that is one of the concerns that all of us, I
    think, should share. We know that there have been fraudulent
    claims submitted under the Victims Compensation Fund and so
    there are those who wish to take advantage of this catastrophe
    for purposes that are not intended by either Congress or anyone
    else, to be reimbursed for those kinds of things. So I commend
    caution and I think that is what you have done.
        As I understand your written testimony, there is about $138
    million that still is appropriated that is available for
    healthcare monitoring, et cetera. Is that about correct?
        Dr. Gerberding. This is a moving target so my testimony was
    reflecting on what we understood in April when we submitted a
    report to Congress, but obviously people have been treated and
    seen and costs are accumulating and money has been spent since
    that time so I would have to give you a refreshed understanding
    of where we actually are with the spending right now.
        Mr. Deal. OK. Obviously, you have learned a lot in terms of
    trying to administer the funds that have, currently, been
    appropriated. Will you, as an agency, be in a better position
    now to administer any future appropriations for programs such
    as the one outlined in this bill than you were initially?
        Dr. Gerberding. Yes, I am not sure what is outlined in the
    bill, but if it is expectation of continuing what we are doing
    right now, I mean, I think we are on a good track. We are still
    challenged and that is one of the areas, I think, we would like
    to consult and confer both within the department, but also with
    the committee because we might not be the best place to do all
    of the things that the bill is asking us to do. And we feel
    strongly that there are some things that only we should be
    doing and we would like to make sure that we are playing to
    everybody's strengths. But the really important thing is, we
    want to make sure that there is a care and treatment program
    for both the responders and the affected non-responders.
        Mr. Deal. Because traditionally, CDC has not been the
    agency that supervises what is really a large entitlement
    program for healthcare.
        Dr. Gerberding. Exactly.
        Mr. Deal. That is not your traditional role.
        Dr. Gerberding. That is our challenge.
        Mr. Deal. And I think that is a legitimate concern as to
    where, if we are going to do this, where is the appropriate
    place for that kind of oversight and administration to take
    place. Would you give us a brief idea, though--I know you
    summarized rather quickly, but could you give us a brief idea
    how the CDC and NIOSH have been working with the city of New
    York to deal with this issue?
        Dr. Gerberding. There have been several activities within
    the department and specifically within CDC and NIOSH. One is
    the registry program where people who believe that they were
    exposed or affected are welcome to register so that we can
    monitor and track them over time. Right now, there are about
    75,000 people, mainly from the metropolitan New York area, who
    are included in that registry.
        We have also funded quite a few of the hospital--well, we
    funded all the hospital facilities that are seeing patients
    through these Centers of Excellence concept, and the Mount
    Sinai consortium. About 24,000 visits have occurred for the
    first visit and about 13,000 follow-up visits have occurred. In
    the national program, there are about 4,000 people who are
    being followed that are not in New York. They are--this is
    happening around the country. And the fire department is
    following about 14,800 people and has done more than 20,000
    follow-up visits. So there have been a lot of base line and
    follow-up visits and that is where we are beginning to get the
    accumulated knowledge that this problem is not going to go
    away, that people have been affected and there will be ongoing
    health issues for those, particularly, who were exposed early
    or exposed for a long period of time, at Ground Zero.
        We also believe there are going to be some health effects
    in the people who surrounded that area, but we know a little
    bit less about the long-term durability of those. And when you
    look at this dust, this material and you think about how deep
    it was and how dark it was when it was contaminating the air,
    you just have to appreciate that peoples lungs have been
    affected by their exposure to these materials that may include
    chemical and metal toxins, but also just particulates including
    asbestos.
        So there is a legitimate concern here and I am emphasizing
    that because sometimes I have--not here, but in other
    environments, I have seen a tendency for some people to be
    dismissive about the long-term seriousness of these effects and
    I wanted to be very clear and on the record as a physician and
    as a CDC Director that this is very credible evidence to me
    that this requires a long-term health monitoring program.
        Mr. Deal. Thank you Dr. Gerberding.
        Mr. Pallone. Thank you, Mr. Deal. Ms. Capps.
        Ms. Capps. Thank you, Mr. Chairman, and thank you Dr.
    Gerberding for your testimony today and for taking questions.
    One issue of worker safety that has come up is that workers at
    Ground Zero were not required to wear fit-tested respirators
    during clean-up. As a public health nurse, I know it is well
    documented that the tested respirators are an effective tool to
    reduce inhalation of asbestos and hazardous materials, as well
    as to prevent the transmission of disease.
        I find it no surprise that workers at the Pentagon site,
    who were required to wear them, have experienced fewer negative
    health effects. In fact, I understand that even some of the
    workers at Ground Zero itself, who wore respirators, have not
    suffered as much as those who did not. I don't know if this is
    scientifically demonstrated, but there has been some
    documentation. So without going back to revisit what happened
    that day, what steps are the CDC and other federal agencies
    that you are associated with, taking to ensure greater usage or
    mandatory usage of fit-tested respirators and any other
    protective equipment for future emergencies. In other words, as
    you prepare pre-mitigation planning, including the possibility
    of Avian Flu or other pandemic?
        Dr. Gerberding. I wanted to address two points very
    quickly. One is there is a big difference between what happened
    in New York and what happened at the Pentagon in terms of the
    kinds of exposures and so forth, so it is not just a matter of
    respiratory protection, but that is likely. I mean, it is
    common sense that it would make a difference, so I agree with
    your overall principle.
        NIOSH has published, now, four volumes of guidance based on
    the lessons that we have learned from these experiences for
    protecting responders in situations of various kinds of
    emergencies, including an emergency such as an implosion or an
    explosion of a building, and it certainly does emphasize the
    importance of respiratory fitting and required use.
        We are also initiating a process of going State by State
    and examining the statutes and regulations on a State basis to
    assure that it isn't just a matter of guidance that we are
    supporting that with effective regulatory and statutory
    language where that is required at a state level because not
    all states function the same way. So we think this is very
    important and we are doing everything that we can, as a
    government agency, to support that.
        Ms. Capps. So if there was an emergency, God forbid, in the
    next few days, would there be more of these fit-tested
    respirators----
        Dr. Gerberding. Absolutely.
        Ms. Capps [continuing]. Available and would they be
    deployed? I mean, nothing can happen 100 percent overnight,
    but----
        Dr. Gerberding. There are several issues here. One is
    availability, absolutely availability and access to testing.
    Those things can and will be done effectively. But there is a
    practical aspect of wearing one of these masks. I mean, what I
    remember in those early days is the fire personnel were there
    searching for their colleagues that were missing. And they were
    not thinking about themselves. They were thinking about
    rescuing people that they cared about. In that environment it
    is hard to breathe in a mask when you are working that hard and
    exerting that much, these masks get very--the work of breathing
    goes up. You get exhausted and they take the mask off, so there
    is a practical issue as well as a kind of infrastructure issue.
        Ms. Capps. And as we all do here, there is drilling and
    preparation so that instinctively you know, just like on a
    plane, you put your own oxygen mask on before you assist----
        Dr. Gerberding. And the supervisors in the field have to
    plan on the fact that people will get tired of breathing with
    these masks on and work out schedules and rests and other
    administrative procedures to assure that workers can continue
    to work and wear their masks. I have many poignant photographs
    of masks hanging on pieces of concrete or beams, not because
    they weren't there, but because people, just simply, couldn't
    tolerate using them for as long as they were working.
        Ms. Capps. Thank you. If I have time, I want to address
    another issue. I am a member of Congress from California and I
    am disturbed to learn that there are only a small number of
    clinics in a very few States nationwide that are equipped to
    respond--provide screening and monitoring services for World
    Trade Center responders. Can you tell me where some of these
    are located? I represent the Central Coast of California and
    know personally and was so proud to say that a group of very
    brave talented, specially trained, first-responders responded
    very quickly to the call for help and now they are not sure
    where they can go for assessment and so forth. And shortly
    after we had Katrina, and so we know now that an event of that
    magnitude that happened on 9/11 is going to bring people from
    all over the country.
        Dr. Gerberding. Some weeks ago we announced an award to an
    organization that operates national occupational health
    clinics, and they will assume the responsibility for providing
    care to the people who are outside the areas of New York and
    New Jersey where the Centers of Excellence are currently
    operational. So this award has been made. These clinics are
    scaling up. They want to be able to create a continuity of care
    so that there isn't, ``you had everything here and now you got
    to start all over.'' So there is a transition period.
        Ms. Capps. Right.
        Dr. Gerberding. But I think you are going to see, over the
    next year, a significant improvement in access.
        Ms. Capps. And this is now just beginning?
        Dr. Gerberding. Several weeks ago the award was----
        Ms. Capps. But all these years have gone by.
        Dr. Gerberding. But we awarded the money the year we got
    it, so it is--we could have----
        Ms. Capps. Used it earlier.
        Dr. Gerberding. I have heard we should have been faster
    based on people's need, but we did make that award available,
    and I think it is an expansion of what we were doing before and
    a broadening of the scale and scope of the reach. I hope it
    will be successful. We will have to monitor carefully to make
    sure that we are not missing people that need to be treated in
    that program.
        Ms. Capps. Thank you.
        Mr. Pallone. Thank you. Mr. Weiner.
        Mr. Weiner. Thank you, Doctor, appreciate your testimony.
    Can you help us clear up a couple of concerns that some of our
    colleagues have had about the bill. You have spent some time in
    your testimony and response to questions to Mr. Pallone talking
    about why it has taken so long to, kind of, come up with a
    foundational system to, kind of, deal with this problem. That
    is in stark contrast to what the ranking member, Mr. Barton,
    said earlier about us being hasty. In your view, have we been
    hasty in providing services to those in need?
        Dr. Gerberding. I don't think anyone would characterize our
    response as hasty.
        Mr. Weiner. Can I ask? You have been very frank about the
    long-term need for monitoring and the complexities of what is
    in peoples bodies at this point. Is there any question, in your
    mind, that the affliction that these people have is a direct
    result of 9/11?
        Dr. Gerberding. On any given individual basis, I think that
    is always going to be impossible to say for sure, if a person
    has a problem was it attributed to the exposure or not
    attributed to the exposure, but the scientific information,
    looking at the population of exposed people, suggests that
    there is a significant attributable impact from the exposures
    at Ground Zero.
        And two lines of evidence support that. One is the
    proportion of people with respiratory and mental health issues
    is much greater than it was before 9/11, especially among the
    people who were enrolled in annual screening. But, in addition,
    compared to controls in the community who weren't exposed that
    have higher rates and then finally, to the best of peoples
    ability to estimate dose of exposure. There is a dose response,
    so the earlier you were in, the longer you were there, the more
    likely you are to have significant symptoms and that has been
    documented with pulmonary function tests, independent of
    whether people also use tobacco products or not.
        Mr. Weiner. Right, but if--I mean, not expecting you to
    drill down to metaphysical certitude. As a medical
    professional, is there any doubt in your mind that the attack
    of September 11 and exposure to the after effects of that
    attack has led to the debilitating illness, in many cases, of
    thousands of people?
        Dr. Gerberding. That is what the scientist says is the
    truth.
        Mr. Weiner. Well, I appreciate that. Can I also ask you
    this question, there is this question about how it is you
    define the universe of who we are going to cover, and you have
    touched on, in your testimony--I mean, I am concerned we must
    not let the perfect be the enemy of the necessary. We might
    never know with absolute precision every single human being and
    be able to issue them a card, you are affected, and then they
    come in and flash it.
        But, all that being said, there are some indicators that
    physicians can see and say, ``you know what, this isn't someone
    who just got off the bus from Kansas City trying to fill the
    gaps in their health insurance plan, and are trying to get into
    this.'' This notion that we are creating, that there is a
    danger of creating this wide open system--there are markers
    that doctors can see. There is a way to separate, at least in
    the broadest sense, the wheat from the chaff.
        I think that what is truly mysterious is there is some
    opposition to saying, ``Oh, you don't want to create this open-
    ended health care plan.''
        By the way, that should be the worst thing we ever do, Mr.
    Chairman, is create an open-ended health care plan where people
    can get healthcare. That should be--like people say that what a
    crime that would be to create healthcare for Americans.
        But there is this idea that, oh, we are going to create
    this process that the port authority and JFK and La Guardia are
    going to be filled up with people, I want to get a piece of
    this program. There are ways that physicians would some--we can
    acknowledge whether someone is showing the signs of the
    elements of asbestos, the elements of the dust, the elements of
    precedent that has been set from people who have been
    monitored. I can't imagine that this is a process that needs to
    go on another 2, 3, 4, 7 years. I mean, there has got to be
    some, not universal consensus, but some sense of physicians who
    have been down there, have been taking a look at the files of
    people affected to be able to say, ``you know what? This is
    clearly a case. Let us get on with providing the care.'' Isn't
    that the case?
        Dr. Gerberding. Well, I have not personally been involved
    in the care of any of these people, so I can't answer you from
    my own personal perspective, but obviously for some people it
    is easy. It is a no-brainer. They were there. They have the
    classic presentation that we were describing in this literature
    and it is very clear, but I think what we are trying to do here
    is balance the importance of being inclusive and acknowledging
    our uncertainty that we have got a lot to learn.
        There may be other things that emerge that we haven't
    predicted or haven't thought of yet, so you can't exclude
    something because you haven't seen it yet. At the same time we
    have to be accountable for the investment that we are making
    and that is an important part of this too.
        Mr. Weiner. Well, I think that is right, and my time is up,
    but I think that the most important part of your testimony is
    the notion that we need to be inclusive. We need to make sure
    that if we are going to create a program, it includes people in
    the community, it includes, I mean--the much more desirable
    mistake to make is to include two larger universes of people
    than it is to draw a line that includes too few people. And I
    think that that needs to be the defining ethos of people who
    take a look at this bill. We can always take an imaginary line
    and constrict it and make it smaller if it turns out OK.
        But I have to tell you something, I was standing on the
    deck of my office on Emmons Avenue in Sheepshead Bay, not
    exactly in the neighborhood. And we literally had dust and
    ember falling there--pieces of paper falling there. I can
    imagine how much fine and particulate matter that wasn't
    written on a piece of paper I couldn't see, how far that was
    going. I would encourage your office--we will try to deal with
    the fiscal constraints that we are handed, but your job as a
    medical professional is to think of the most expansive universe
    that we can and then, as we get through time, as you learn a
    little bit more, maybe you do draw the lines in.
        But that last thing we should do is draw such a tiny bubble
    then say, well, this is the only absolute certitude that we
    know and we wind up excluding thousands or tens of thousands of
    people who really do need this care simply because of our
    desire to find the perfect line. We are not going to find that.
    I acknowledge that, but right now, inertia is the enemy because
    there are people, right now, that need care and people, right
    now, tragically, as you know, are dying because of the effects
    of 9/11 air.
        Dr. Gerberding. And I think that the--at least our
    understanding of the congressional intent and the appropriation
    that was made was to be inclusive of the various groups. And
    we, as I admit, we were not as fast as you would like us to
    have been, but we have made a good faith effort to be inclusive
    of both the responders and now the community. And yes, there is
    uncertainty over what we will ultimately need to be doing, but
    we intend to reflect your intent.
        Mr. Weiner. Well, I thank you. You are the living,
    breathing speaking rebuttal to Mr. Barton's notion that we are
    being hasty. And I have to tell you, if there is any benefit
    from your not being so quick, it is clear that Mr. Barton's----
        Mr. Pallone. We have to move on, but thank you, Mr. Weiner.
    And, oh, Mr. Engel is here, so we have Mr.--the gentleman from
    New York is recognized.
        Mr. Engel. Thank you, Mr. Chairman. Doctor, I said in my
    opening statement that I was disappointed with your not
    reappointing Dr. Howard, and I would like to ask you if you
    could tell us why not, why you did not choose to reappoint him.
    I don't agree that 12 years is too long. I don't think that is
    an acceptable answer. There were others, Donald Miller, who
    served for 12 years, from '81 to '93. Linda Rosenstock was
    reappointed and served eight years. I know you have said it is
    a personal issue and you don't want to discuss it. That is not
    acceptable.
        CRS tells us that there is no legal reason for you not to
    answer to Congress about a secretary level appointment. You
    have said you have given him a job in Atlanta to finish out his
    time before retirement. I don't find that acceptable. It is not
    about finishing his tenure, it is about the great work he has
    done that you are putting an end to and you have said he had a
    problem with horizontal management. I don't find that
    acceptable. I don't know what it means. And does it mean that
    he was doing what Congress told him to do and not allowing
    things to be dissolved into CDC.
        And let me just say, if you won't reappoint Dr. Howard to
    another 6-year term, I believe that you should keep him on as
    acting director through the end of the year or extend his term
    for a period of 1 year to provide continuity and give the new
    administration time to determine the appropriate leadership, as
    Chairman Obey, Chairman Harkin and ranking member Specter have
    called on you to do. And at a minimum, I think Dr. Howard
    should be retained as an advisor to Secretary Leavitt and the
    Office of the Secretary to oversee, and be a liaison on the
    World Trade Center Health Program. So I would like to ask you
    those things.
        I have put the New York Times editorial ``A Pointless
    Departure'' into the record. There are quotes praising Dr.
    Howard's work from so many different organizations, including
    the Chamber of Commerce, the AFL, CIO and the American
    Industrial Hygiene Association, so obviously I am quite worked
    up about this and I would like to ask you to comment.
        Dr. Gerberding. Thank you. It has been heartening, I think,
    to understand and respect how much Dr. Howard's work on the
    World Trade Center has been to the New York delegation and to
    those who are concerned about the overall situation with care
    and treatment for the responders and the non-responders who
    were affected.
        And I also think I need to be very clear that we appreciate
    Dr. Howard's service. Dr. Howard has accepted a new position at
    CDC where he is actually going to be involved in working on
    issues related to worker protection around emergency response
    in our public health law program where his law degree will be
    serving him well, I think. As I mentioned to the Congresswoman,
    we are interested in making sure that we have statutes and
    regulations that protect workers generically on these kinds of
    disasters and that is going to be the focus of his ongoing
    work. And he has committed to making himself available to me
    and to his successor, Dr. Christine Branch, who is here in the
    room today. The deputy that he selected a year, or so, ago who
    has been also working on these issues and is a credible and
    credential scientist in her own right.
        We are taking away from this an acknowledgement of your
    expectation that you want a comparable level of support and
    service from CDC and NIOSH that you have come to enjoy with Dr.
    Howard. And so, I take it as a personal challenge to assure
    that we continue to focus on the World Trade Center efforts,
    that we make ourselves available, that we are responsive.
        I, this morning, had a chance to meet with some members of
    the delegation and gave them my personal cell number and my
    card and if there is ever an issue that you feel that CDC,
    NIOSH, HHS, or the administration are not responsive, I want
    you to please contact me directly because that is not my
    intent. I hope you would support us meeting in New York, having
    stakeholder conversations and really building on Dr. Howard's
    successful engagement on the World Trade Center as we go
    forward.
        Mr. Engel. Well, let me just say, and this is nothing
    against the current deputy who I am sure is doing a fine job
    and will do a fine job, but it is very aggravating that you
    have been adamant in, just, not listening to all of us who feel
    so strongly in the New York region about what has happened.
    There is no reason whatsoever for Dr. Howard not to be
    reappointed, and this is not just my opinion. It is my strong
    opinion, but it is the opinion of the vast overwhelming
    majority of those of us and I--it is very disheartening that
    our wishes were not respected. It is just very, very
    disheartening. Let me ask you one other question.
        Mr. Pallone. Time is expired. I will allow one more because
    I have let other people go over, but let us have the one and
    that is it.
        Mr. Engel. OK, thank you, Mr. Chairman. I am forever in----
        Mr. Pallone. You don't have to be. Go ahead.
        Mr. Engel. Thank you. Why was Mount Sinai Hospital, the
    largest clinical center of the New York/New Jersey consortium,
    not allocated the original budget request and will additional
    funds be available to provide necessary services to this
    population of heroes? Why was it allocated $1 million dollars
    less than what they actually spent last year when they had
    expected growth in treatment from 5,000 to 6,000 patients?
        They were awarded $24 million and can't under the grant
    update that they got last night, can submit a supplement for up
    to $6.4 million, which is still considerably less than they
    feel they will spend based on cohort size and continued growth
    and treatment and monitoring, plus inflation. So I wonder if
    you could explain this because even if awarded the supplemental
    later in the year, it still wont get them to what they expect
    will be the cost of $32 million plus.
        Dr. Gerberding. My understanding from the NIOSH team and
    conversations that I had, both with Dr. Howard as well as his
    deputy for management, is that the Mr. Sinai request, as it
    originally came in, was for $32 million and the senior grant
    managers in both sides of that equation looked at some of the
    projections and the estimates and said, ``no, 30 was the more
    appropriate request amount.'' So there was already a
    negotiation that $30 million dollars was what they were
    projecting they would need.
        We have looked at last year's resource utilization. We have
    looked at money that has not been obligated and that is carried
    over as of April. Significant dollars had not yet been spent.
    It is impossible to say exactly what they are going to need.
    And I acknowledge a great deal of uncertainty, so we made sure
    that--we knew they would need at least $24 million, let us get
    that out. If there is evidence through our better monitoring
    programs, now, that the spend rate is going to continue to go
    up, as I wont be surprised if it does, we will need to make
    sure that they have the additional resources and if that
    doesn't cover it or we don't have what we need, we are going to
    have to come back and tell you we need more.
        So I am prepared to update these investments if the
    information and the experience suggests that there is a greater
    requirement than we are projecting today. But I am also clear
    that there is a lot of uncertainty here and we have never done
    this before and we don't really know what people are going to
    need and we just have to make sure that you know that we will
    come back and ask if we need it and that our goal here is not
    to attenuate needed services, it is to try to support them, but
    also in an accountable and cost effective way that--we don't
    want to end up in a situation where we have not been fiscally
    accountable and then we would have to come back to this
    committee and explain why we hadn't been managing the money
    effectively. So we want them to get what they need.
        Mr. Pallone. All right. Thank you very much, and thank you
    Eliot. And we appreciate your testimony. It has been very
    helpful. Thanks again, and I will ask the third panel to come
    forward.
        OK, welcome to the third panel, today. Let me introduce
    you. Starting on my left is Ms. Margaret Seminario, who is
    Director of Safety and Health for the AFL-CIO. Then we have Dr.
    Jacqueline Moline, who is Vice Chair and Associate Professor of
    the Department of Community and Preventive Medicine at Mount
    Sinai School of Medicine, in New York City. And, finally, Mr.
    Cas Holloway, who is Chief of Staff to the Deputy Mayor for
    Operations Counsel and Special Advisor to Mayor Bloomberg.
        And I will just say, I think you know the drill. We have 5-
    minute opening statements that become part of the record, and
    each witness may, in the discretion of the committee, submit
    additional brief and pertinent statements in writing. We may
    ask you additional questions in writing, and we will start
    with--from my left, with Ms. Seminario.

     STATEMENT OF MARGARET SEMINARIO, DIRECTOR, SAFETY AND HEALTH,
                                AFL-CIO

        Ms. Seminario. Thank you very much, Chairman Pallone and
    ranking member Deal and members of the committee. I appreciate
    the opportunity to testify today to express the AFL-CIO's
    strong support for the 9/11 Health and Compensation Act of
    2008. This legislation will provide much needed and long
    overdue help to thousands of brave responders, recovery and
    clean-up workers and residents who are now sick as a result of
    exposures to toxins and other hazards that resulted from the
    attacks on the World Trade Center in 2001.
        We have already had a lot of testimony this morning
    reviewing what has happened and what we know. we know, with
    respect to the 9/11 attacks and the resulting collapse of the
    Trade Center, that we had, really, a level of unprecedented
    exposures to very large numbers of individuals, both on the day
    of the attack with the collapse of the towers and in the days
    and months that followed with the fires that burned and the
    dust exposures that continued.
        We also know that these exposures were made much worse by
    the fact that EPA pronounced that the air was safe and that for
    10 months on the clean-up of that site that the Occupational
    Safety and Health Administration did not enforce the law. As
    the committee has heard, last September and today, there is
    wide spread disease that has occurred as a result of these
    exposures and that we have thousands of workers who are now
    sick. Many of these people are disabled and they can no longer
    work, and a number of individuals have died.
        We have also heard that these problems, indeed, are serious
    and they are persistent. They are long term. And we have also
    heard that despite the fact that we have known about these
    serious health problems for some time, that still we have no
    action by the Bush Administration to put in place a
    comprehensive plan or a comprehensive response to what is a
    very, very large public health catastrophe.
        So today we are here to talk about H.R. 6594, a legislation
    that has been introduced that would establish such a
    comprehensive program and plan. This legislation has been under
    development for some time. A bill was introduced last September
    that actually formed the basis for this legislation. The new
    bill is a refinement on that piece of legislation. So we have
    not moved hastily on this at all. In fact, we in the labor
    movement, and others with the involvement, obviously, in
    leadership of Congresswoman Maloney, Congressman Nadler,
    Congressman Fossella, and the city of New York, we have been
    working on this for a very, very long time. First, with respect
    to putting in place the programs that are in place, as a result
    of funding that has been appropriated, but also tried to come
    up with a long-term legislative solution. And we think that
    H.R. 6594 is a very responsible measure, a much needed measure
    to address the problems that have been identified.
        Let me just briefly review what the bill would do and what
    has been done to try and address some of the concerns about the
    cost of this program. The legislation attempts to build on the
    successful existing programs, so it builds on the Centers of
    Excellence at the Fire Department of New York and at the Mount
    Sinai Medical Consortium, because those programs have been
    successful and have been working. So that is the basis for this
    legislation. It also would establish a community program to
    finally provide, in an ongoing basis, the services, the medical
    treatment to those in the community who have been affected. It
    would provide monitoring to those who are eligible and it would
    provide medical care and medical treatment to those who have
    been determined to have a World Trade Center related condition.
        We have now refined the bill to include provisions to
    address the concerns that many have expressed about cost. But
    let me just state, because the problems are extensive, we have
    18,000 responders who we know are sick, who have been in
    medical treatment. Because the problems are extensive and
    serious, the cost will be large. There is no getting around
    that. What has been done to try to address these costs in the
    bill are a number of things.
        First of all, the program is based at these Centers of
    Excellence and designated providers by including and limiting
    the care to these particular centers, it will both provide the
    high quality care, but it will also constrain cost by having
    people seen by individuals who know these conditions and can
    diagnose them and treat them effectively.
        The legislation also now includes particular provisions
    that raise the standard of proof and causality that is required
    for these to be considered World Trade Center related diseases.
    There are offsets included in the bill where workers
    compensation payments are made and those claims are accepted,
    the workers' comp reimbursement cost will be reimbursed and
    offset to the program.
        For individuals who don't have a work related problem,
    health care will be the primary payer with the federal program
    being the secondary payer. And New York City has also, in the
    bill, been designated to be responsible for a five percent cost
    share on the community program.
        And to deal with the questions of uncertainty, the bill now
    includes a cap on the number of participants in the program,
    that being set at 35 additional responders and 35 additional
    individuals in the community program. And so we think these
    measures are sound, they are responsible and that they have
    addressed the concerns that have been raised by individuals and
    Members of Congress about the potential large cost of this
    program.
        In conclusion, let me just say that on September 11, 2001
    and the days that followed, tens of thousands of brave
    firefighters, police, emergency workers, and construction
    workers answered the call when the Nation was attacked. They
    toiled for days, weeks, and months trying to save lives,
    recover victims and repair a broken city, and now thousands of
    these workers and others are now sick. Some are disabled and
    many have died. These brave responders have received the
    Nation's gratitude, but now they need the Nation's help. The
    September 11 attacks were an attack on the Nation and the
    Federal Government has a moral obligation to assist those who
    responded just as it would assist others who have defended our
    country.
        And now 7 years after the September 11 attacks, it is time
    for the Congress to make a commitment and establish a long-term
    permanent program to provide these responders and all who are
    sick the ongoing medical care and compensation they need and
    deserve. The AFL-CIO urges the Committee to move with all speed
    to support and favorably report the 9/11 Health and
    Compensation Act of 2008 so that this long overdue measure can
    be enacted into law. Thank you.
        [The prepared statement of Ms. Seminario follows:]

                        Statement of Margaret Seminario

        Chairman Pallone, Ranking Member Deal and Members of the
    Committee, I appreciate the opportunity to testify today to
    express the AFL-CIO's strong support for the James Zadroga 9/11
    Health and Compensation Act of 2008 (H.R. 6594). This
    legislation will provide much needed and long overdue help to
    the thousands of brave responders, recovery and clean-up
    workers and residents who are now sick as a result of exposures
    to toxins and other hazards that resulted from the attacks on
    the World Trade Center in 2001.
        Nearly 7 years ago, the September 11, 2001, terrorist
    attacks claimed the lives of 3,000 individuals, injured
    thousands more and brought unparalleled grief and anguish to
    the nation. But soon after the 9/11 attacks it became clear
    that those who died and were injured on that day were not the
    only victims. Tens of thousands rescue and recovery workers--
    including firefighters, police, emergency medical technicians,
    workers in the building and construction trades, transit
    workers and others--and hundreds of thousands of other workers
    and residents near Ground Zero were exposed to a toxic mix of
    dust and fumes from the collapse of the World Trade Center. The
    scale and scope of these exposures was massive and
    extraordinary, with tons of glass, pulverized concrete,
    asbestos, lead, and burning jet fuel forming a dust and smoke
    cloud that engulfed the WTC site and lower Manhattan and spread
    throughout the area. The exposures continued for months as the
    fires at the WTC burned, rescue, recovery, and clean-up
    operations ensued, and toxic dust contaminated the area. The
    exposures were made much worse by EPA's pronouncements that the
    environment was safe and OSHA's failure to enforce workplace
    safety and health requirements during the entire 10-month
    period of rescue, recovery, and clean-up operations at the WTC
    site.
        As this committee heard at a hearing last September, the
    exposures resulting from the attacks on the World Trade Center
    and its aftermath have caused significant and widespread health
    problems among rescue, recovery, and clean-up workers,
    residents, and others who were exposed. Peer reviewed studies
    by the New York City Fire Department (FDNY) show that 90
    percent of FDNY rescue workers suffered new respiratory
    problems, experiencing an average loss of 12 years of lung
    capacity. A study of Ground Zero responders, recovery and
    clean-up workers conducted by the Mount Sinai Medical Center
    found that 69 percent had new or worsened upper or lower
    respiratory symptoms and one-third had abnormal pulmonary
    function tests. Similar findings have been reported by
    researchers from the Penn State University College of Medicine
    and Johns Hopkins in studies of police and other recovery and
    clean-up workers. These and other studies have also documented
    a high incidence of gastrointenstinal and mental health
    problems.
        While those who responded on September 11 and the days that
    followed had the highest exposures, other groups of workers and
    residents were exposed to the toxic dusts and also suffer
    similar health problems. A study of clean-up workers conducted
    by researchers from the Johns Hopkins University found that
    workers who started working at the WTC site after January 2002
    also experienced significant respiratory health problems. And
    studies and surveys of residents and area workers conducted by
    the New York City Department of Health World Trade Center
    Registry have found similar patterns of reported respiratory
    and mental health problems in these populations.
        Despite the fact that serious health problems among World
    Trade Center responders have been documented and recognized for
    several years, it has been a struggle to get these brave
    workers and others affected the help and the care they need
    Since September 11, 2001, the Bush Administration has failed to
    provide leadership or take action. The administration has
    opposed reprogramming already appropriated funds for medical
    treatment, and dragged its feet on funding and establishing
    monitoring and treatment programs for responders outside the NY
    area, for federal workers, and for residents and area workers.
    Repeatedly, the administration has failed to request the level
    of funding needed to support these programs. And most recently,
    the administration failed to reappoint Dr. John Howard as
    Director of NIOSH, also terminating his appointment as Director
    of the World Trade Center Health Program, despite widespread
    universal support from labor, industry, and the occupational
    health community and bipartisan support from Members of
    Congress.
        Largely at the initiative of Congress, in 2002, a federally
    funded screening program for firefighters, police, rescue and
    clean-up workers was established which identified serious
    health problems among these workers. This screening program was
    conducted by the FDNY and a consortium of medical centers with
    expertise in occupational health coordinated by the Mt. Sinai
    Medical Center. In 2004 this program was expanded to provide
    more comprehensive medical monitoring, which confirmed
    significant respiratory and gastrointestinal problems as a
    result of exposure to the toxic dust and fumes. But the
    workers' compensation claims of many workers who were sick and
    disabled were contested by the city of New York and private
    contractors, leaving them nowhere to turn for medical
    treatment. Due to their health conditions, many of these sick
    responders are unable to work and have lost their health
    insurance. And even for those who have insurance, health
    insurance policies generally do not cover work-related
    conditions since they are supposed to be covered by workers'
    compensation. None of these insurance policies provide coverage
    for ongoing medical monitoring for individuals who have been
    exposed and are at risk of developing disease.
        In FY 2006, through the efforts of the New York delegation
    and the unions, the Congress appropriated $75 million to
    further support these programs and to provide medical treatment
    to workers sick as a result from their exposures from the World
    Trade Center attacks and its aftermath. This medical treatment
    was provided through the same medical centers that had
    conducted the earlier screening and monitoring and had first
    identified and documented the health problems in responders,
    recovery and clean-up workers. In FY 2007, $50 million for
    medical treatment was included in a supplemental spending
    measure, and in FY 2008 a total of $158 million was
    appropriated. The National Institute for Occupational Safety
    and Health (NIOSH) has coordinated and overseen these
    monitoring and treatment initiatives through the WTC Medical
    Monitoring and Treatment Program, which until recently was
    headed by NIOSH Director Dr. John Howard.
        In 2006, the city of New York announced and established the
    WTC Environmental Health Center at Bellevue Hospital to provide
    medical treatment to residents, clean-up workers and area
    workers who were not covered by the federally funded treatment
    programs. In the FY 2008 Consolidated Appropriations Act,
    Congress designated that some of the appropriated funds should
    be used to fund medical treatment for residents, students and
    area workers with World Trade Center Health problems. But HHS
    has yet to distribute these funds for this purpose.
        As of December 2007, 39,368 responders had received at
    least one examination in the FDNY or Mt. Sinai Consortium
    programs, according to the April 2008 Department of Human
    Services ``Report to Congress: Providing Monitoring and
    Treatment Services for those Experiencing Injuries or Illnesses
    as a Result of the World Trade Center Exposures.'' The FDNY
    conducted 14,620 of these initial exams and the Mt. Sinai
    consortium conducted 22,748 initial exams. HHS reports that of
    among the responders and recovery workers examined, 9,744
    received medical treatment for a combination of respiratory and
    gastrointestinal conditions such as asthma, interstitial lung
    disease, chronic cough, and gastroesophageal reflux disease
    (GERD), and 5,674 received treatment for mental health
    conditions such as post-traumatic stress disorder (PTSD).
    According to FDNY and Mt. Sinai between 40 to 45 percent of the
    responders in the monitoring program have been treated for WTC-
    related health conditions, with some individuals being treated
    for both physical and mental health problems.
        The number of individuals in monitoring and treatment
    continues to grow as more responders have enrolled in the
    program, many of whom are sick as a result of their WTC
    exposures. It should be noted that these numbers do not include
    approximately 4,000 responders who live outside of the NY-NJ
    area who have also received screening or monitoring or the
    approximately 2,700 residents, area and clean-up workers who
    have received medical treatment for WTC-related health
    conditions through the WTC Environmental Health Center at the
    Bellevue Hospital. Nor do they include individuals who are not
    enrolled in existing programs or receiving treatment from other
    health care providers.
        In November 2007, in a Congressional briefing on the WTC
    responder monitoring and treatment program, NIOSH estimated the
    cost of the responder medical monitoring and treatment program
    at approximately $218 million for FY 2008. Of this amount, the
    estimated cost of treatment is $149 million, the cost of
    monitoring is $37.5 million, and the cost of program
    coordination, data collection and other support is $32 million.
        As more responders become sick, as is still the case, these
    costs will likely increase. Since many of the WTC-related
    health problems are chronic conditions, these individuals will
    need medical treatment for years to come. Moreover, due to the
    massive and complex exposures that occurred, there is concern
    that new conditions with longer latencies, including cancer,
    fibrosis, and auto-immune diseases will also emerge.
        The medical monitoring and treatment programs that have
    been established at the FDNY, Mt. Sinai Consortium, and
    Bellevue Hospital have been vital for the thousands of workers
    and others who are now sick as a result of their exposures. But
    nearly seven years after the collapse of the World Trade Center
    towers, these efforts are still temporary and piecemeal; and
    there is no comprehensive permanent program to provide ongoing
    guaranteed medical monitoring to those who were exposed and
    medical treatment to responders, recovery and clean-up workers
    and members of the community who are suffering from WTC-related
    health problems.

     The James Zadroga 9/11 Health and Compensation Act of 2008 (H.R. 6594)

        The 9/11 Health and Compensation Act of 2008 (H.R. 6594)
    would establish a comprehensive program to provide medical
    monitoring to those who have been exposed to WTC toxins and
    medical treatment and compensation to those who are sick. It
    would also fund ongoing research on WTC-related health
    conditions and reopen the Victim Compensation Fund (VCF) to
    provide compensation to those who have been harmed or suffered
    economic loss.
        Specifically H.R. 6594 would amend the Public Health
    Service Act to establish the World Trade Center Health Program
    within the National Institute for Occupational Safety and
    Health, to be administered by the NIOSH director or his or her
    designee.
        The legislation would establish a monitoring and treatment
    program for responders, a program for the community and a
    national program for those eligible individuals who reside
    outside the NY Metropolitan area.
        The legislation builds on the successful monitoring and
    treatment programs that have been providing services to these
    populations. The responder program would be delivered through
    Clinical Centers of Excellence at the FDNY and the Mt. Sinai
    coordinated consortium, in which five medical institutions
    currently participate. The community program would be delivered
    through Clinical Centers of Excellence at the Bellevue
    Hospital. This delivery system will ensure that workers and
    community members are evaluated and treated by physicians who
    have expertise in diagnosing and treating World Trade Center
    related conditions, and will receive high quality care.
    Additional clinical centers and providers may be designated by
    the program administrator, providing they have the necessary
    expertise and meet other program requirements.
        Steering committees of providers and representatives of the
    affected populations would be established to help guide and
    coordinate the responder and community programs.
        Coordination of these clinical center programs is to be
    overseen by Coordinating Centers of Excellence at the FDNY, Mt.
    Sinai and Bellevue Hospital which will collect and analyze
    uniform data, develop medical monitoring and treatment
    protocols, coordinate outreach and oversee the steering
    committees for the responder and community health programs.
        The bill sets forth eligibility criteria for inclusion in
    the program, which are based upon exposure to World Trade
    Center toxins and hazards, and are defined in geographic and
    temporal terms. For the responder program, the eligibility
    criteria are based upon work at the World Trade Center site and
    related disposal and support facilities. These criteria are
    based on those that have been utilized in the existing WTC
    Medical Monitoring and Treatment Program for responders and
    have been approved by NIOSH. Responders who meet the
    eligibility criteria qualify for the medical monitoring
    program. As stated earlier, approximately 40,000 responders
    have received monitoring exams in the current program.
    Estimates of the total population of responders who may qualify
    range from 50,000 to 100,000 individuals.
        Responders who are in the monitoring program are eligible
    for medical treatment, if an examining physician at a clinical
    center of excellence diagnoses a condition that is on the list
    of identified WTC-related health conditions included in the
    bill, and the physician determines that exposure to WTC toxins
    or hazards is substantially likely to be a significant factor
    in causing the condition. The list of conditions included in
    the bill is the same list utilized in the current responder
    monitoring and treatment program that has been approved by
    NIOSH.
        Under the bill, the NIOSH Administrator is responsible for
    making final eligibility determinations and certifying
    individuals for participation in the monitoring program and
    their eligibility for medical treatment.
        Recognizing that the scientific and medical evidence on
    WTC-related health problems continues to evolve, the bill
    provides for the addition of conditions to the list of
    identified WTC-related conditions, with the review and input of
    a Scientific and Technical Advisory Committee. It also provides
    for special independent expert medical review procedures for
    the consideration of medical treatment claims of individuals
    diagnosed with WTC-related conditions that are not yet on the
    list.
        While we do not know the full extent of WTC-related disease
    among responders, we do know that in the current program
    approximately 40 0945 % of those in the monitoring program have
    been treated for a WTC-related health condition, and the number
    of sick responders continues to increase.
        For the community program, the bill also sets forth
    geographic and exposure criteria for defining the potential
    population that may be eligible for the program. The bill
    designates the geographic area covered by the bill as lower
    Manhattan South of Houston Street and the area in Brooklyn
    within a 1.5 mile radius of the World Trade Center site, and
    sets various time limits for residing, working, or being
    present in the designated area. In addition the bill requires
    the WTC Program Administrator to develop and adopt more refined
    eligibility criteria within 90 days taking into account the
    period and intensity of exposures, based upon the best
    available evidence, in consultation with the Bellevue Hospital,
    the Community Steering Committee and affected populations.
        For the community program, the bill includes provisions for
    making determinations of eligibility for medical treatment
    similar to those as for the responder program. The major
    difference in the programs is the expectation that the
    community program will not provide a comprehensive monitoring
    program but rather will focus on more limited screening and
    treatment of individuals with World Trade Center-related health
    conditions.
        For those eligible responders, residents or non-responders
    who reside outside the NY metropolitan area, the bill directs
    the WTC Program Administrator to establish a national program
    with services to be provided by health care providers
    designated and approved by the administrator. These providers
    must have expertise and experience in treating the type of
    medical conditions included on the list of identified WTC-
    related conditions and agree to follow the established medical
    treatment and data collection protocols set forth in the bill.

                      Provisions To Address Program Costs

        The AFL-CIO recognizes that many in Congress are concerned
    about the costs associated with this legislation, particularly
    since the bill is structured as an entitlement to ensure
    ongoing funding for medical treatment for those who are sick as
    a result of World Trade Center exposures. Unfortunately, due to
    the massive exposures that occurred and the failure to protect
    workers and residents, the health problems that have resulted
    are serious, persistent and extensive.
        While we do not know the full extent of the health problems
    that have resulted or will result from WTC exposures, nearly
    seven years after the September 11 attacks, we do have
    substantial knowledge and experience, particularly concerning
    responder health problems and related treatment costs. As
    stated earlier, there are approximately 40,000 responders who
    have received monitoring and 18,000 individuals who have
    received medical treatment for WTC-related physical and/or
    mental health conditions. According to NIOSH, the current cost
    of WTC Responder Monitoring and Treatment Program is
    approximately $218 million a year.
        For the community program, there is less experience and
    less information since the WTC Environmental Health Program at
    the Bellevue Hospital was just initiated in 2006. To date,
    approximately 2,700 individuals have received medical treatment
    for World Trade Center-related health problems similar to those
    seen in the responder population. While the exposures of most
    residents and area and clean-up workers were not as great as
    responders who worked at the WTC site, many of these
    individuals had significant exposures and are suffering from
    serious health problems. Moreover, the number of individuals
    seen in the Bellevue program does not represent the full
    populations of those who are eligible or sick with WTC-related
    health conditions. In a September 2007 report, ``Addressing the
    Health Impacts of 9-11: Report and Recommendations to Mayor R.
    Bloomberg,'' an expert panel of New York City officials
    estimated the potential costs of treatment for residents and
    area workers for 9/11 conditions at approximately $200 million
    a year.
        While the costs of WTC-related health problems will be
    large, the legislation includes a number of provisions to
    constrain these costs. First the program is limited to the
    Centers of Excellence or providers designated by the
    administrator who have experience with WTC-related health
    conditions. Eligible individuals must receive monitoring or
    treatment through these designated providers.
        Evaluations of exposures and health conditions are to be
    made utilizing standardized questionnaires approved by NIOSH,
    and treatment provided according to medical protocols
    established by the program.
        For conditions that are work-related, the medical treatment
    costs are offset by any workers' compensation payments and the
    Centers of Excellence are required to assist eligible
    individuals to file for these and other available benefits.
    Unfortunately, since the city of New York and other employers
    continue to contest these claims, to date the workers'
    compensation benefits for these conditions have been limited
    and delayed.
        For those conditions that are not work-related and are
    covered by existing health insurance, the legislation
    designates the WTC treatment program as the secondary payor,
    with private or public insurance having the primary obligation
    to pay for treatment.
        In addition, for individuals receiving treatment in the
    community program at Bellevue Hospital or other facilities of
    the Health and Hospitals Corporation, the city of New York is
    responsible for a 5 percent cost share of treatment costs.
        But because the numbers of individuals who may be affected
    is indeed uncertain, the legislation imposes a mandatory cap on
    participation. For the responder program this cap is set at
    35,000 additional responders to the number currently enrolled
    in the monitoring program, bringing the total program
    participation to approximately 75,000 responders. For
    responders this cap applies to the number of responders in
    monitoring, of which, based on current experience,
    approximately 40 0945% or 30,000 to 34,000 individuals can be
    expected to require some type and level of medical treatment.
        For the community program, the cap is also set at 35,000
    participants in addition to the approximately 2,700 individuals
    who are currently enrolled in the Bellevue program. Because of
    the design of the Bellevue program, which only enrolls those
    with diagnosed WTC-related conditions, all of those certified
    as eligible for the community program are expected to receive
    medical treatment.
        Because the geographic area for the community program has
    been limited and due to the uncertainty about the extent of
    exposures and disease, the bill provides for a contingent fund
    of $20 million a year to provide medical treatment to residents
    and non-responders who are diagnosed with WTC-related
    conditions, but fall outside the scope of the bill's exposure
    and geographic eligibility criteria. For example, this
    contingent fund would be available to pay the cost of medical
    treatment for individuals diagnosed with WTC related conditions
    in New Jersey, Staten Island and other locations in the NY
    metropolitan area who were exposed outside the geographical
    boundries set in the bill.
        In order to track the program's progress and experience,
    the legislation requires the WTC Program Administrator to
    provide an annual report to Congress setting forth the
    experience with claims, the nature of the diseases treated, the
    results of new research, program costs and other information.
    In addition, if and when 80 percent of the cap in either the
    responder or community program is reached, the administrator is
    required to notify Congress, so a determination can be made if
    further congressional action should be taken.

      The Congress Should Act Now To Provide Ongoing Medical Treatment to
     Responders, Residents and Others who are Sick from World Trade Center
    Exposures and Enact the 9/11 Health and Compensation Act of 2008 (H.R.
                                     6594)

        On September 11, 2001 and the days that followed tens of
    thousands of brave firefighters, police, emergency workers, and
    construction workers answered the call when the nation was
    attacked. They toiled for days, weeks and months trying to save
    lives, recover victims and repair a broken city.
        Now thousands of these workers and others are sick as a
    result of World Trade Center exposures, many are disabled and
    some have died. For the past several years, the Federal
    Government has provided monitoring and medical treatment for
    responders who are ill through a series of temporary short term
    funding measures. But many more who are ill have yet to receive
    the care they need, and there is no long term plan or funding
    to ensure that medical treatment will continue.
        These brave responders have received the nation's gratitude
    but now they need the nation's help. The September 11 attacks
    were an attack on the nation and the Federal Government has a
    moral obligation to assist those who responded just as it would
    assist others who have defended our country.
        Seven years after the September 11 attacks it is time for
    the Congress to provide these responders and all who are sick
    as a result of the World Trade Center attacks the ongoing
    medical care and compensation they need and deserve. The AFL-
    CIO urges the Committee to move will all speed to support and
    favorably report the James Zadroga 9/11 Health and Compensation
    Act of 2008 (H.R. 6594) so that this long overdue measure can
    be enacted into law.
        Thank you.
                                  ----------

        Mr. Pallone. Thank you. Dr. Moline.

      STATEMENT OF JACQUELINE MOLINE, M.D., M.SC., VICE CHAIR AND
      ASSOCIATE PROFESSOR, DEPARTMENT OF COMMUNITY AND PREVENTIVE
                MEDICINE, MOUNT SINAI SCHOOL OF MEDICINE

        Dr. Moline. Good afternoon. I am a board certified
    specialist in Occupational Medicine and in Internal Medicine
    and I am the Director of the Mount Sinai Clinical Center for
    the World Trade Center Medical Monitoring and Treatment
    Program. Our center is the flagship of a regional and national
    consortium that has been supported by NIOSH, and since July
    2002 has seen over 25,000 responders in the New York
    metropolitan area and across the United States.
        In the days, weeks, and months that followed September 11,
    an estimated 50,000 to 100,000 people from across the country
    responded selflessly without concern for their own lives or
    well-being when our Nation needed them. Workers and volunteers,
    traditional first-responders, firefighters, police officers,
    paramedics, the National Guard, and the not so traditional--a
    diverse force of operating engineers, laborers, iron workers,
    telecommunication workers, transit workers, sanitation workers,
    building cleaners and many more. They came from across America,
    tens of thousands from the metropolitan New York area, but from
    every state in the Nation. They toiled for days, weeks, and
    months in and around Ground Zero, at the Staten Island
    landfill, engaged in rescue and recovery work, the restoration
    of critical services, debris removal, and clean-up. Their hard
    work and bravery got New York back on its feet and we owe them
    tremendous gratitude.
        While they were there, they were exposed to a complex and
    unprecedented mix of toxic chemicals. Ninety thousand liters of
    jet fuel created a dense plume of black smoke with volatile
    compounds in it, such as benzene, metals, and polycyclic
    aromatic hydrocarbons. The collapse of the Twin Towers, and
    later that day a third tower, World Trade Center seven,
    produced an enormous dust cloud filled with pulverized cement
    that was 60 to 65 percent of that dust mass. Trillions of
    microscopic glass particles and fibers, asbestos, lead,
    hydrochloric acid, PCBs, pesticides, furans, and dioxins were
    in the air. Levels of airborne dust, estimated by the U.S.
    Environmental Protection Agency, range from--up to 100,000
    micrograms per cubic meter creating a thick airborne soup that
    turned a bright sunny day into night. The high content of
    pulverized cement made the dust extremely caustic with a pH
    similar to lye. Fires burned both above and below ground until
    December. Rubble removal operations continued until May,
    continuously re-exposing individuals to this dust.
        In addition to the physical exposures there were extreme
    psychological stressors. Responders lost friends and family and
    during the desperate search and rescue operations; thousands of
    them came upon human remains. Stress was compounded by fatigue
    as these dedicated workers remained at the site working for
    hour on hour. Among those most affected are the non-traditional
    responders, those not trained for any emergency, but who
    responded when our Nation needed them.
        Mount Sinai, through its Center for Occupational and
    Environmental Medicine has taken a leading role in treating
    these workers. This work began days after the attack, many
    months before any Federal program was in place. We designed and
    developed what stands as the Federal Government's health
    response to 9/11, a model based on experience and expertise of
    academic physicians who are trained in Occupational Medicine,
    surrounded by specialists in Pulmonary Medicine, Psychiatry,
    Rehab Medicine, and other healthcare workers.
        We have been proud to work as a partner with all of you,
    legislators, agencies, and the stakeholders, to represent them
    to provide a program that brings experience and excellence. We
    have a regional consortium that you have heard of earlier
    today: Mount Sinai, SUNY Stony Brook, University of Medicine
    and Dentistry of New Jersey, in your region Chairman, the
    Queens College Center for Biology of Natural Systems and
    Bellevue. Together with the national program that we, until
    recently, coordinated has provided, as of the end of May,
    nearly 40,000 examinations to over 25,000 responders from all
    50 states.
        In that time, we have also provided 70,000 treatment
    services in our consortium. At Mount Sinai alone we have
    provided over 53,000 treatment services and over 24,000 of
    those services have been since federal funding was in place.
    Earlier we had philanthropy that covered many of the costs.
        Much of what we know about the health effects has been
    learned through our program and our sister program at the Fire
    Department of New York. Our physicians have diagnosed and
    carefully documented diseases and responders and linked these
    conditions to the exposures at the World Trade Center. We have
    provided expert medical, mental health and social work
    treatment, as is needed, to all who come in our doors. We
    remain constantly vigilant for newly emerging diseases and
    trends in the 9/11 population. People are still coming in. In
    the past year, almost seven years after September 11, an
    average of over 160 new, eligible responders come in every
    month.
        Adverse health effects are suffered by a large percentage
    of our responders. There have been social and financial impacts
    which have added to the problems they face. Respiratory
    conditions have been well documented in peer reviewed
    literature. In 2006 we published a paper that showed that among
    monitoring responders new or worsened respiratory symptoms were
    experienced by 63 percent; lower respiratory symptoms, such as
    asthma, COPD in 47 percent. One quarter had objective measures
    of decreased pulmonary function and rates were higher, five
    times higher, in some tests than in comparably non-smoking,
    non-exposed Americans.
        Mental health consequences also afflict a large percentage
    of 9/11 responders. We recently published a paper that shows
    that PTSD, or post-traumatic stress disorder, rates are at
    rates similar to returning veterans from Afghanistan, with 11
    percent.
        Mr. Pallone. I am sorry, but I just wanted you to know you
    are a minute-and-a-half over, so you have to wrap up.
        Dr. Moline. Oh my goodness, I will talk faster.
        Mr. Pallone. Right, or summarize.
        Dr. Moline. I will summarize. We continue to see health
    effects, gastrointestinal problems in the folks we treat. Four
    thousand people in the past 6 months have been treated. Mental
    health problems in one-third, lower respiratory conditions in
    nearly half, 25 percent of our folks are on disability and out
    of work as a result of their health problems, and over 60
    percent have multiple World Trade Center conditions.
        The medical literature from all the programs, whether it is
    the Mount Sinai consortium, the Fire Department, Bellevue's
    Environmental Health Clinic, we have all published. We have all
    found the same percentages of illnesses. These illnesses are
    real. They are persistent and we need a long-term stream of
    funding in order to ensure that people can get adequate
    healthcare going forward, without concerns about interruption
    in the care so that we can learn and be prepared for diseases
    that may come in the future. We know there are carcinogens and
    other health hazards that will manifest in the future and we
    need to be prepared through our Centers of Excellence to be
    able to cover these.
        [The prepared statement of Dr. Moline follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Pallone. Thank you, and your full statement will be put
    in the record too. Thank you, Doctor. Mr. Holloway.

      STATEMENT OF CASWELL HOLLOWAY, CHIEF OF STAFF TO THE DEPUTY
        MAYOR FOR OPERATIONS COUNSEL, SPECIAL ADVISOR TO MAYOR
                               BLOOMBERG

        Mr. Holloway. Thank you very much, Mr. Chairman. Can you
    hear me? Thank you very much.
        Mr. Pallone. Maybe bring it closer.
        Mr. Holloway. There we go. Sorry about that.
        Mr. Pallone. That is good.
        Mr. Holloway. Thank you, Chairman Pallone and the members
    of the committee who were here. I want to reiterate Mayor
    Bloomberg's thanks to Speaker Nancy Pelosi, to the New York
    delegation, particularly Representatives Nadler, King, and
    Fossella for making this legislation a priority. My name is Cas
    Holloway and I am Chief of Staff to New York City's Deputy
    Mayor for Operations, Edward Skyler and a Special Advisor to
    Mayor Bloomberg. Along with my colleague, Rima Cohen, who is
    also here behind me today, I served as Executive Director of
    the Panel convened by Mayor Bloomberg at the fifth anniversary
    of the attacks to assess the health impacts of 9/11 and what
    needed to be done to ensure that those who are sick or could
    become sick get the treatment that they need.
        I also want to acknowledge Dr. Joan Reibman and Dr. David
    Prezant, who are also sitting behind me as back-up. Dr. Reibman
    runs the Bellevue Center, which is the only center open to
    residents and community members and is currently treating 2,700
    patients. And, of course, Dr. Prezant, who I think is known to
    everybody involved with this issue, who runs the Fire
    Department's program. Both of these doctors have submitted
    testimony to the committee, which details the same effects and
    treatment information. For example, in the community program
    they are fielding 100 calls a week and admitting as many as 25
    patients a week over the last 6 months, so the need is clearly
    there.
        And as the Mayor said when he testified, just a short while
    ago, this bill establishes two critical things. It provides the
    long-term funding that we need to meet the health needs. It
    also reopens the Victim Compensation Fund.
        I don't want to go back over all of that. What I would like
    to do though is focus on some of the controls that are in the
    bill, some of the changes that have been made over time, that
    working with the people sitting with me here, we think, will do
    a lot to control the costs and make sure everybody who needs
    care gets care, because we recognize that these are public
    dollars and Mayor Bloomberg is as committed to fiscal
    responsibility as anybody on the committee.
        First, the bill defines specific groups, for example,
    firefighters and recovery workers and specific geographic areas
    the people must have been in or on or within a defined period
    after 9/11 to be eligible for treatment. Now, there is a
    defined specific contingency fund for people who would be
    outside that area because, the fact is, we don't know the full
    extent of the problem and the goal of this bill is to cover
    anybody who could be sick.
        Second, although people who meet these criteria are
    eligible for treatment under the bill, to actually get
    treatment a doctor with experience treating WTC related
    conditions must determine, based on medical examination, that
    the exposure was caused or exacerbated by 9/11. That assessment
    has to be based, in part, on standardized questionnaires. And
    even after a condition is deemed to be WTC-related, it is
    subject to review and certification by the World Trade Center
    administrator under the bill.
        Now, these are tough standards, and they are based to a
    large extent on protocols already in place at the Environmental
    Health Center at Bellevue at HHC, and I know that there are
    lengthy questionnaires that are used for the responder
    programs.
        The bill also caps the number of responders and community
    members who can get monitoring and treatment. These limitations
    are based on the best available information. And to make sure
    that we don't get it wrong, there is a provision in the bill to
    notify Congress if those caps are reached, which is critical to
    making sure, again, that anybody who is ill gets covered.
        In addition to these controls, which apply to every
    potential patient, the bill mandates the establishment of
    quality assurance and fraud prevention programs that act as
    further safeguards against the misuse of these funds for any
    purpose other than to monitor and treat those who were affected
    by the 9/11 terrorist attacks.
        The bill also ensures important provisions to contain costs
    and make sure that federal dollars are used wisely. As Peg
    Seminario mentioned, there is an offset for workers'
    compensation if it has been paid. The program acts as the last
    payer if there is health insurance that covers the conditions
    that people present for.
        And finally, as Mayor Bloomberg pointed out, under the
    bill, the City is responsible for paying 5 percent of treating
    anyone treated at a Center of Excellence that is within the
    Health and Hospitals Corporation. Currently, by the way, that
    is everybody in the community program because it is only an HHC
    program that is open to community members. We accept this
    responsibility because Mayor Bloomberg thinks that it is
    critical for the city to have an investment in making sure that
    these dollars are spent wisely and that that is fully
    consistent with this being a national obligation.
        I do want to mention one issue that we would like addressed
    as the bill moves forward. The bill establishes steering
    committees for both the responder and the community programs
    and we would like to make sure that there are representatives
    from the Police Department and another responder agency on the
    responder committee and that the Department of Health is
    represented on both of the committees because we think that is
    important institutionally, as we move forward. We are actually
    working together to resolve those issues, but I wanted to just
    mention it.
        The bill also ensures that critical 9/11 related research
    is expanded and existing efforts like the World Trade Center
    Health Registry are continued because long-term research is the
    only way that we are going to be able to develop a full
    understanding of the health impacts of 9/11.
        And finally, this bill fulfills another core recommendation
    of Mayor Bloomberg's World Trade Center Health Panel, the
    urgent need for Congress to reopen the VCF. The VCF was fair
    and efficient and it provided a means of relief for the victims
    of the attacks and their families. It is imperative that the
    fund be reauthorized to take care of those who were not
    eligible to benefit before it closed in December of 2003. The
    fact that their injuries were slower to emerge or that the
    initial criteria were too narrow should not disqualify them
    from getting the help they need.
        The reason we need this is that the city and the
    contractors need the indemnity that the bill also provides, is
    to ensure that, God forbid another attack like this is to
    happen again, the private sector and the public sector would
    respond knowing that they had the full backing of the Federal
    Government. And, in addition, the way the bill is structured
    once these things are in place, the one billion dollars that is
    currently available in the Captive Insurance Company would be
    made available to pay out claims under the VCF.
        So, in sum, this bill achieves two critically important
    things to help complete the recovery from 9/11, the health
    funding and reopening the VCF. That is why it has gained such
    strong support in the New York delegation and that is why Mayor
    Bloomberg has come down here many times and was down here
    today, in support of the bill. We are pledged to working with
    you to do everything in our power to make sure that it moves
    forward and is ultimately enacted. Thank you.
        [The prepared statement of Mr. Holloway follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Pallone. Thank you and thank you to all of you. I am
    going to recognize myself for questions. Initially, I am trying
    to get one in for each of you in my time, so let me start with
    Ms. Seminario, and I understand you were actively involved in
    the drafting of this new version of the bill and I am going to
    be very parochial on this one.
        I am curious about how the changes from the first bill to
    this one might affect my constituents and the citizens of New
    Jersey. I mean, I am sure you are aware that many New Jerseyans
    were affected by the attacks. Most of the people who live in
    the--and who worked on one of the top floors from--what was it
    Cantor, they mostly were--most of those people that died were
    in my district, actually.
        So, specifically, the way that you did this with the radius
    so that it is south of Houston and within one-and-a-half miles
    of Brooklyn, would the previous bill, in terms of--not first-
    responders, but the people that actually lived or worked
    there--would the previous bill have included parts of New
    Jersey that would not be included the way it has been struck
    now. I mean, I know now it wouldn't include Staten Island or
    New Jersey because you have to be Manhattan or Brooklyn. I
    mean, is there a reason for that and is it because the cloud
    didn't go over New Jersey or Staten Island? That would be my
    first question.
        And then, with regard to the Centers for Excellence,
    obviously the site in New Jersey has been very important for
    the State. Is there any way that the legislation guarantees
    that we continue to have the site in New Jersey? I am being
    very parochial here, as you can see. And I also assume that
    Staten Island is part of New Jersey too, but go ahead.
        Ms. Seminario. That is fine. Let me address the first
    question with respect to the coverage under the bill. From the
    initial bill, 3543 to this bill, the criteria, essentially for
    the responders, remained the same, so that didn't change at
    all, but what did change were some of the criteria with respect
    to the residents and area workers, those who would be affected
    by the community program.
        The original bill, essentially, set a 2-mile radius from
    the World Trade Center site as the area in which those who were
    residents, working and meeting certain criteria would be
    potentially eligible. It, then, left it to the World Trade
    Center administrator, working with Bellevue and others in the
    community to tighten up those criteria to try to determine who,
    exactly----
        Mr. Pallone. Well, was the 2 miles--would that have
    included, say, New Jersey and Staten Island?
        Ms. Seminario. It would have included Staten Island,
    definitely, and I believe from my recollection looking at the
    map, it would have included parts of New Jersey. As far as the
    present bill, the geographic criteria were changed to make is
    south of Houston, within lower Manhattan, and a radius of 1-
    and-a-half miles into Manhattan. That population----
        Mr. Pallone. No, from Brooklyn, I thought.
        Ms. Seminario. I am sorry, Brooklyn, correct.
        Mr. Pallone. So what is the justification for that other
    than the money?
        Ms. Seminario. The money was the driver on this because in
    looking at the bill, it starts with a pool of potentially
    eligible people from where they live or where they work and
    with that number being pretty large--Manhattan and the New York
    area is a very densely populated area. There were a very, very
    large number of people who it potentially affected. In
    structuring the bill as an entitlement, that meant that anybody
    who was in that area, that presented with possibly a World
    Trade Center related----
        Mr. Pallone. But what I am asking you is, was there some
    reason to believe that the people in Brooklyn, for example,
    were affected greatly and those in Staten Island, New Jersey
    were not?
        Ms. Seminario. Yes, in terms of where the cloud went.
        Mr. Pallone. Yes, I mean, that is what I want to know.
        Ms. Seminario. We really tried to look at where the
    greatest exposure was and put those individuals in the area
    that were in the potentially eligible pool. But we also did--
    recognizing that there may be other individuals because we
    don't know who were exposed but aren't in that defined area. We
    created a contingent fund, and essentially what the bill does
    is it allows those people to come forward just like anybody
    else. Come forward and to be evaluated and for a determination
    made that they have a World Trade Center related condition. The
    only difference is, essentially, which pocket it gets paid out
    of. One would be an entitlement. The other is, essentially, a
    contingent fund that would provide payment for those
    individuals.
        Mr. Pallone. What I would ask you to do, if you could get
    back to us and explain this phenomenon of the cloud and how----
        Ms. Seminario. Sure.
        Mr. Pallone. It is true that if you are in Brooklyn or
    Manhattan, you are much more likely to be exposed than somebody
    that might have been to the west or to the--I don't know, sand
    house to the south and west, I guess. New Jersey's to the west.
        Ms. Seminario. Right, but let me just make----
        Mr. Pallone. If you could get back to us with that.
        Ms. Seminario. Be happy. One point, though, as far as the
    individuals. If they worked in Manhattan, if they worked in
    that area, they are covered.
        Mr. Pallone. Right, no I----
        Ms. Seminario. The only people who aren't are the people
    who, essentially, were residing outside of that area.
        Mr. Pallone. Right.
        Ms. Seminario. They would not----
        Mr. Pallone. Well, you have to give us some information on
    that.
        Ms. Seminario. We would be happy to, and then the next
    question you asked, just very quickly.
        Mr. Pallone. The center.
        Ms. Seminario. The center, yes. The center is specifically
    covered in the bill as one of the Centers of Excellence. It is
    established, as a matter of statute, as one of the ongoing
    Centers of Excellence to provide treatment and care for these
    individuals.
        Mr. Pallone. The one in New Jersey?
        Ms. Seminario. That is correct.
        Mr. Pallone. OK. We will come back. Let me yield to the
    gentleman from New York. Well, I have more, but we can go back
    and forth--
        Mr. Holloway. Chairman, do you mind if I just add one or
    two points on the----
        Mr. Pallone. On that? Sure.
        Mr. Holloway. The radius, as Peg first pointed out, there
    are categories of people in the bill, including for responders
    and non-responders, where if you were downtown working in
    Manhattan, if you worked on the pile. If you are in those
    groups, you are covered.
        Mr. Pallone. Right.
        Mr. Holloway. The radius really covers--we were looking at
    this more from the community perspective and working with Dr.
    Reibman and HHC we said, OK we have 2,700 people in our program
    now. Based on who we have seen, where are they falling, what is
    the scatter plot? What is the reasonable line drawing we can do
    based on what we know now, recognizing that it is so difficult
    to draw lines in this context, period. But it is important to
    note, I think, that those--so that was part of the calculus
    here. In terms of the cloud, we also, if you look there has
    been some research done on this.
        Mr. Pallone. Well, I will ask any of you to get back to me
    in writing on--to respond to that. It may very well be that the
    literature out there shows that it is primarily people or even
    exclusively people who were in Manhattan south of Houston and
    in that radius around Brooklyn, but I just would like to have
    whatever you have on that to get back to us, and I will yield
    to the gentleman from New York.
        Mr. Fossella. Well, thank you, and I am sorry I missed your
    testimony, but thank you again for appearing, in particular Mr.
    Holloway for representing the Mayor's office. Obviously, you
    heard today, still some skepticism and perhaps some education
    that still needs to take place regarding what happened on that
    day and what we need to do to respond.
        Evidently, at the core, I think we can easily talk away the
    money, but clearly, impediment, to getting this legislation
    passed to date has been the cost. So, to follow up on the
    Chairman's point, if I am not mistaken it is the research and
    the science and other, sort of critical, elements that have
    minimized the scope of this initial area as opposed to, if you
    will, the broad brush of the first go around--the first
    iteration of this legislation, is that correct?
        And in part, while you still may become eligible, in part
    it was to move this process forward, given the potential cost,
    which was clearly an obstacle to getting it beyond where we
    currently are. Is that a fair point? We have had to strike a
    compromise, if you will.
        Mr. Holloway. Yes.
        Ms. Seminario. Yes. That is absolutely correct and we tried
    to do that based upon the evidence, based upon the information,
    based upon what we know.
        Mr. Fossella. Right.
        Ms. Seminario. We don't know everything, but based upon
    what we do know, that is how we have tried to structure this
    bill and come up with something that we think is--it will cover
    people, but also is reasonable and responsible.
        Mr. Fossella. And Dr. Moline, there are people out there
    who question whether people are really sick because of the
    Ground Zero toxins. In short and in plain English, what do you
    say to those who are skeptical?
        Dr. Moline. I say, come to our clinical center or any of
    our clinical Centers of Excellence. Come talk to an iron worker
    who used to climb up 20, 30 flights of stairs, who can barely
    climb up one. Come meet someone who used to run marathons that
    can't walk a mile. Come look at someone who used to work two
    jobs and now has to rely on others. Come see the people that
    are sick. We have people that have upper and lower respiratory
    problems, they have gastro esophageal reflux disease. Those are
    the three main physical categories of diseases, and we have
    people who have post-traumatic stress disorder and depression.
        We have people at Mount Sinai and the Mount Sinai
    consortium, the Fire Department at Bellevue's program. We have
    all published and we all have the same numbers, the same
    diseases, independently arrived at it, everyone has the same
    types of disorders, and remarkably consistent numbers. The
    police department did a study. They found 28 percent have
    abnormal pulmonary function tests. We did a study, exact same
    number in a much larger group of individuals. The numbers are
    out there. The diseases are consistent. It is in the medical
    literature, but they should look at the human faces. They
    should come meet these responders.
        These are people--the average age of our population is
    about 42, people in the prime of their earning lives. These are
    people who are in physically demanding jobs who were well on
    September 10. From September 11 on, they were no longer able to
    do what they used to do. They were in physically demanding
    jobs. They were the healthy workers, and now they are ill. They
    have respiratory problems. They have gastrointestinal problems
    and they have mental health conditions, and they are suffering,
    and they continue to suffer.
        We have moved into a chronic phase, now. We see people--
    some have gotten better, some were able to maintain on a
    variety of medications, the cost of which can be astronomical
    for many of these folks. Some have not gotten better and some
    are getting worse and we are also concerned that others will
    continue to get worse in the future or new diseases.
        Mr. Fossella. Let me just thank you for that, and Mr.
    Holloway, you get the sense of the opposition to this and some
    of it is, I think, maybe you still need to educate more. For
    example, the questions come, well, of first-responders--
    responded, aren't they taken care of? Well, we know by now that
    it wasn't just--there weren't just first-responders who
    responded and suffered. The whole group of people, construction
    workers, iron workers, carpenters, residents, who don't fit the
    technical definition of a first-responder, who should be
    treated equally. So you sort of get that issue of, evidently,
    we still need to educate those who don't seem up to speed on
    what happened.
        But having said that, there is another--the tact is well,
    why should we do it, I mean the Federal Government? Why should
    the Federal Government assume this? Aren't there existing
    programs in place? Aren't there existing compensation programs
    in place? Isn't there the family doctor that one can see? Why
    is it our responsibility, meaning the Federal Government? Mr.
    Holloway, how would you best address that?
        Mr. Holloway. Well, first I think--and as Mayor Bloomberg
    testified earlier we think it is beyond doubt and I think
    Congress' reaction immediately after the attacks, reinforces
    this in the strongest way possible that 9/11 was an attack on
    the Nation, that people came from all 50 states. If you look at
    the registry, which only has 71,000 of the estimated more than
    400,000 people who were the most heavily affected by the
    attacks, but that is still a huge number. They come from every
    congressional district in the country but four.
        The response was immediate and the response was national.
    The attack was against the Nation and to say that one
    particular locality should bear the cost, happening to have
    been the unlucky target of that attack simply is just not--it
    doesn't make sense.
        And so, in terms of conceptualizing it as being a national
    issue, this includes responders and non-responders, then that
    means the community, the residents, the schoolchildren, the
    office workers, the people who were doing what they do in lower
    Manhattan on 9/11 and after. And those are also the people who,
    whether they were volunteers or doing other things, who helped
    to bring the city back and finish the work on the recovery
    which was historically quick and unprecedented in its nature
    that way.
        And what you see when we have looked at the data is that
    for those most heavily exposed, that includes about, up to
    100,000 or some say even more responders, people who were there
    doing the work. That includes contractors. But then about
    320,000 residents, office workers, community members, that is
    just within the narrow area of the most heavily exposed in the
    registry. If you look at the area under the bill, you are
    talking about approximately 630,000 people and, you know, for
    the city, and I think really based on the fact that the bill is
    out and how Congress has acted in the past, there is just no
    question that this is a national problem.
        And the city, though, recognizing that these are--dollars
    are scarce today in the current economic environment, but this
    is really a program for over the long run, so it is not a
    short-term question, but the city is putting in 5 percent of
    the cost to cover for those treated at HHC. That will cover
    responders and non-responders because the city recognizes we
    needed incentives to make sure that these dollars are spent
    wisely.
        Let us just talk about the third thing that you mentioned.
    What are the other mechanisms? Well, I guess you could describe
    those as, kind of--you could have health insurance. You could
    have workers compensation, and the first thing to recognize,
    and this was not in the earlier version of the bill, is that
    for workers compensation that has been paid, that is an offset
    of what would be paid under the bill.
        For health insurance, the program acts as the payer of last
    resort, if a person has health insurance for an injury that is
    not work related, and so that coverage would cover first. So
    those mechanisms, to the extent that they will cover, are
    actually being brought to bear under the bill.
        I should note, though, that a lot of people don't have
    health insurance. The community members at Bellevue--50 percent
    and up to 60--50 percent or more of people don't have health
    insurance or they are under insured. Their co-pays and
    deductibles and what we are trying to do here is make sure that
    where those gaps exist, we fill them so that people who are
    injured, because of these attacks on the country, that those
    gaps are filled. And I think that this bill does that in a
    responsible way, plus the city has skin in the game, so to
    speak. The city is on the hook.
        Ms. Seminario. Could I----
        Mr. Pallone. Thank you. Sure, go ahead.
        Ms. Seminario. I wanted to add to that. I think it is
    important. We have tried with this revised version, to call
    upon the other resources that might be available to bear some
    of the cost.
        But that being said, we also think it is really important
    to structure this program so that first and foremost it is
    designed in a way that people get the quality care they need,
    and that is why we developed it and delivered these services
    through the Centers of Excellence. So there will be an attempt
    to recoup money. We think it is really important that Dr.
    Moline and Dr. Reibman and Dr. Prezant have the ability and the
    program is structured in a way that first and foremost they are
    able to develop and deliver the services for these people in a
    timely way and not have to wait for the comp claim to be
    resolved three years later for that individual or to fight it
    out with the insurance companies necessarily.
        And I just wanted to make that very, very clear and that is
    why we think it doesn't make sense just to turn this into a
    health insurance program that people go off to their own doctor
    who don't have the qualifications and have to fight with them
    about getting coverage. So it is a hybrid but it is put
    together that way for a very important reason and that is to
    take care of those who are sick.
        Mr. Pallone. Dr. Moline.
        Dr. Moline. And just why shouldn't someone go to their
    family doctor rather than a center of excellence? I can't tell
    you how many patients I saw who were treated with antibiotics
    in the fall of 2001 for a cough, who didn't have a cough that
    was related to an infection. They had the World Trade Center
    cough. That was due to inflammation, and if they had gotten
    appropriate treatment earlier, perhaps they wouldn't have long-
    term health consequences.
        If people are--if their care is fractionated and they are
    not going to centers, one other critical element will be lost,
    which is we will never know what exactly has happened to the
    group of responders who worked at the World Trade Center site
    because we will never know who got sick where. We won't have a
    systematic way of collecting it and reporting after our
    colleagues to better prepare us in the future.
        We also are the ones--the centers have seen collectively,
    literally, 50,000 individuals with World Trade Center
    exposures. We can treat them. We do a good job. We talk to each
    other. If someone has seen an unusual condition, we say ``hey,
    have you seen any of these?'' Just last month on a conference
    call that we have we were talking about a potential new
    condition. That is going to be lost and people won't recognize
    and know to look for new diseases unless there are centers
    where this care can be delivered.
        Mr. Pallone. Thank you. Mr. Engel.
        Mr. Engel. Thank you, Mr. Chairman. Let me start with Dr.
    Moline. Since you are at Mount Sinai, and I am sure you were
    here before when I questioned Dr. Gerberding on the fact that
    Mount Sinai is the largest clinical center in the New York/New
    Jersey consortium and it was not allocated the original budget
    request. I am wondering if you would care to comment on that.
        Dr. Moline. Well, every year we have put in budget requests
    and we have been able to refine our requests as we have had
    more experience and we know what our expenses have been for the
    past time intervals and our budget request that we put in for
    the fifth year, which we got notice of just yesterday, for a
    budget year that started July 15, was for about $8\1/2\ million
    less than we asked with the ability to supplement it up by
    about 25 percent. It wont make us up to the exact amount we
    asked, but the--we have spent all the money we have been
    provided and then some. We have to ask for supplemental funds.
    We have to ask for them every year to cover the costs as the
    treatment expenses come in.
        I would like to be spending a lot more time dealing with
    the medical aspects rather than the budgetary aspects. We do
    have an absolute fiduciary responsibility to make sure that we
    are spending this money wisely, we are spending it on the
    responders, but it is frustrating to be asked to put in a
    budget that is based on real numbers and your best estimates
    and then be given a number that is significantly less with the
    expectation, come back and ask us if you need more. Well, our
    track record is such that we know we are going to need more. So
    it is just a matter of coming in with a budget now that is for
    one third less than we asked and then having to supplement it
    when we will need it and it is a matter of, just, which month
    we will need it in.
        Mr. Engel. I couldn't agree with you more, and I think we
    need to keep pushing that point. Let me ask you a question--
    your take on why it is necessary to make the World Trade Center
    Medical Monitoring and Treatment Program into a long-term
    entitlement program rather than just funding it year to year as
    Congress has done over the past few years. Give us your take on
    that.
        Dr. Moline. There are a variety of reasons why long-term
    funding would be beneficial. Some of the toxins that I was
    mentioning earlier in my testimony--many of the diseases that
    may occur are going to take years to manifest so we need a
    long-term program to ensure monitoring to look for the health
    effects that may develop so that we can diagnose diseases early
    and treat them. That is the ultimate goal.
        Year to year funding--we never know if we are going to have
    to send that letter out saying, ``I don't have any more money,
    I am going to have to try to provide you with another physician
    or another critical center or if I am going to have enough
    money to treat you.'' The year to year funding, while we have
    been absolutely appreciative of all that we have been given, it
    makes it difficult to run a stable program. People don't
    necessarily want to come to a place where they might only have
    a job for a year. Getting a physician credentialed takes a
    minimum of 3 months. The turn over, the expertise that we have
    amassed, you don't want to lose that by having people worried
    are they going to have a job in 9 months, do I have to start
    looking for a new position?
        But we want to make sure the resources are available, going
    forward, to take care of all who need the help. We know that
    these conditions are going to last. People are going to
    continue to need that medication for asthma or for reflux or
    their PTSD meds and we don't want to have to worry about, is
    there going to be enough to cover this med this year and that
    med that year.
        Long-term funding, as an entitlement, would allow people to
    get the care they need without concern about interruptions and
    allow the centers to be able to provide that care without
    worries that we are not going to be able to deliver it in a
    manner in which the responders deserve.
        Mr. Engel. Let me ask Ms. Seminario, why does--any relation
    to Tony Seminario, by the way?
        Ms. Seminario. I have been told that he is a distant
    cousin.
        Mr. Engel. OK. I served with him in the New York State
    Assembly many years ago. Why does this bill task NIOSH with the
    administration of a WTC health program? Isn't that outside the
    scope of what NIOSH usually does? And let me also ask you if
    you could explain why there are so many different committees
    created in this bill.
        Ms. Seminario. NIOSH is tasked because they are the agency
    that stepped up to the plate and actually has the experience in
    dealing with these problems and so they have been the lead
    agency. This program started, initially, as a screening program
    and a monitoring program. And that is exactly what is NIOSH's
    responsibility under the OSHA law and what they have done under
    the Mine Safety Law, so they have a long experience in
    conducting and overseeing monitoring and screening programs.
        Those screening programs and monitoring programs found that
    people were sick, and so they needed to be treated. So now we
    are in a position where we need programs to provide medical
    treatment, so NIOSH is tasked with this because they have the
    expertise in dealing with occupational health problems and that
    they have been overseeing it, but I think it is important to
    understand that there is the expectation and it is in the bill
    itself that NIOSH will work with other agencies and other
    entities to provide and administer this program. It is provided
    for in the bill that NIOSH can enter into contracts and
    arrangements with other agencies, for example, to provide
    reimbursement for the health costs. And so they could look to a
    private insurer. They could look to CMS. They could look to the
    Department of Labor, FICA, workers' comp program that routinely
    process claims and provide reimbursement for these kind of
    services.
        So that is actually envisioned in the bill, but we want a
    lead agency that has expertise in the issue and not just an
    administrative agency that, essentially, is cutting checks for
    medical care.
        With respect to the committees in the bill, there are three
    committees that are set up under the bill. One is a scientific
    technical advisory committee to the program administrator that
    is tasked at looking at the scientific data to make
    determinations, first of all, if there should be additional
    diseases added to the list of what are identified World Trade
    Center related conditions, and also tasked with looking at the
    scientific data to see if the eligibility criteria in
    populations that are covered under the bill should be modified
    or changed. And so that is a technical committee.
        Then there are two committees set up, one for the responder
    program and one for the community program that, essentially,
    are advisory committees comprised of providers and the affected
    communities to help coordinate and oversee the program. The
    program delivered through the Mount Sinai consortium and the
    FDNY, the responder program and similar for the community
    program. There is already an existing committee and the bill
    builds upon it.
        We think it is really, really important that there be
    mechanisms for those who are affected to have a role and
    participate in input into the programs that are affecting them,
    and so these are committees built on, again, the existing
    model, which are comprised of the providers and those who are
    affected to look at what is happening, try to coordinate the
    care and improve it so that those who are affected can get
    better services.
        Mr. Pallone. Mr. Engel, I am going to--I hesitate to say
    this but I am actually going to have a second round because I--
    so, if you want to wait, we will just do a second round. All
    right. And I don't want to keep people too long, but I have to
    ask these two additional questions so I am going to recognize
    myself and then we will go back to the other two members. I
    will try to put them together, although not related. What I
    wanted to ask Dr. Moline is if you just tell us a little more
    about why these Centers of Excellence are so important as
    opposed--I know you got into it a little, in responding to
    Congressman Fossella's question about why not just go to your
    family practitioner--why the expertise and the knowledge is so
    important.
        And then, I wanted to ask Mr. Holloway, after that, I still
    don't understand how people are treated if they are first-
    responders versus if they are people that happen to be working
    there or living in the area. Is there a difference in
    treatment? Is there a difference in where they go? Because,
    again, in terms of this being more narrowly focused in the new
    bill, there may be some--there obviously are going to be more
    limitations on the people who are not first-responders.
        So let me start with you, and you don't have to go on too
    long, but I just think that we need to have a little more on
    the record about why these centers are crucial.
        Dr. Moline. The centers have been in existence since 2002
    monitoring the healthcare. We have seen between the Fire
    Department Center and Mount Sinai Center, and I am speaking for
    the responder consortium, we have seen 40,000 individuals and
    monitored their health. About 40 percent of those are in
    treatment at our centers.
        Individuals have complex medical conditions. They have a
    constellation of findings that we are seeing and also are
    beginning--we are concerned that there may be new conditions
    emerging. We have developed the expertise in dealing with the
    complex physical and mental health conditions that the
    responders have. They have them together, often. Sixty percent
    of our folks have more than one World Trade Center related
    condition and they are getting comprehensive care for all of
    these conditions at one center that has seen thousands of other
    cases similar to this and knows how to develop best practices,
    find the most cost effective delivery of care and provide the
    best care possible.
        Another critical reason for these Centers of Excellence is
    the data coordination. We are able to collect the data through
    these Centers of Excellence using standardized instruments so
    that we can report out to the public, the medical community and
    the public at large what we have been able to find. We also can
    put into place quality assurance programs to make sure that the
    care is most effective and is most appropriate and also is
    elastic enough to move to meet the needs as they change over
    time. And also, through these centers, this is the way we are
    going to find out what new diseases might be emerging. Without
    those centers, you are going to lose that ability. You are
    going to lose the ability to tell whether rates of diseases are
    increased over the general population.
        Mr. Pallone. All right, that is fine. Thank you, and either
    Mr. Holloway or Ms. Seminario, you know you have these two
    defined universes, I guess. One is the first-responders that
    can be anybody who came there and then the second is, this now
    more narrowly defined radius or whatever of people who work
    there, lived in the area, whatever. Is there a difference in
    terms of where they go or how they are treated now and under
    the bill? Or they are all treated the same, to where they can
    go to the same places, they can go to the centers or----
        Mr. Holloway. Well, under the bill they can go to the
    centers that exist, and by the way the bill also sets criteria
    to establish additional centers that the point is to make sure
    that you have the expertise at treating WTC related conditions
    and the city has actually expanded its program from Bellevue to
    other HHC facilities, Elmhurst and Gouverneur.
        I think it is important to note before drawing distinctions
    between the programs that there is a lot about them that are
    the same and everybody works in collaboration to see what are
    we seeing. Bellevue and the Mount Sinai program and the FDNY
    work together to develop treatment protocols. They meet all of
    the time. People who come in, once you are determined to be
    eligible for the program, you go through and you receive a
    detailed medical workup and then you are treated and a lot of
    the conditions that are being seen, there are some variations
    which is really important and interesting for learning, what
    are the effects of the attacks, but the respiratory ailments,
    lower intestinal GERD--I am not a doctor so I am not going to
    go too deeply into that except to say that a lot of the things
    that are seen are the same.
        In terms of the mechanics of the programs, there are some
    differences right now. The Mount Sinai FDNY programs--first if
    you are in the FDNY you are eligible for the program. About 95
    percent, or more, of FDNY active members who and retired
    members, who came and worked on the site, are now in that
    program. They have had an incredible rate of retention for both
    monitoring and treatment, so they are monitored on a cyclical
    basis.
        For the community program the standards are a little
    different in terms of getting in. You present with a symptom
    and then once you are in, you are monitored periodically and
    then you are treated. And what they have found is about one-
    third get well, about one-third will probably be there for the
    long-term and then one-third will be there over some medium
    period, but Dr. Reibman is also here.
        Mr. Pallone. What I guess I am trying to say--maybe I
    should ask you. Let me give you an example, I live in my
    hometown, Long Branch, New Jersey, OK. I may have been working
    in the World Trade Center on the day, on 9/11, or I may have
    left the Fire Department at Long Branch and went up there to
    help for a week or two. In either case, under this legislation,
    can I go to the place at Rutgers and be treated or what if I am
    in San Francisco and I am in one or two of those categories,
    where do I go?
        Ms. Seminario. That is a very good question. The way the
    program is structured right now is it builds on what exists,
    and so for the responders, what that means is the program at
    FDNY in the Mount Sinai consortium is the base program, all
    right? For the community, for people who are not in the
    responder population, the base program is the World Trade
    Center Environmental Health Center at Bellevue. But what the
    program--and then also there is provisions in the bill to have
    a program of national providers for those individuals who are
    outside the New York/New Jersey area where the program
    administrator essentially designates and finds providers that
    have the qualifications, who have expertise in these kinds of
    diseases and they become designated providers that participate
    in the program.
        The bill also provides for the program administrator to add
    additional clinical Centers of Excellences to these base
    programs. So, in moving forward, the bill provides for the head
    of the program to say ``well we don't have enough capacity here
    at Bellevue because this program is growing and we have also
    got a number of individuals who are in this area who are, they
    are living in Staten Island, so we want to start a center
    there.'' And so, again, the bill uses the bases that are
    established but it doesn't limit it to this.
        Mr. Pallone. In other words, just to get going back to my
    example, if I am in Long Branch, New Jersey and I was working
    at the World Trade Center on 9/11 or I went there as a fireman
    for a week or two, I can definitely go to the Rutgers center,
    right, in either case?
        Ms. Seminario. Yes, right.
        Mr. Pallone. And if I am in San Francisco and I happen to
    have work there and move to San Francisco or first-responded
    and moved to San Francisco I could certainly travel back to the
    New York/New Jersey metropolitan area, but if I can't do that,
    you are going to have somebody in San Francisco that would be,
    hopefully, eligible to take me and attend to my concerns.
        Ms. Seminario. Yes, absolutely, and that was one of the
    questions that was raised by Representative Capps as a concern
    in California. One of the frustrations in the current system is
    that HHS has been very, very slow to get that national program
    up and going. There was a system of clinics that were in place,
    trying to provide some of these services, but it was recognized
    it needed to be more robust and wide spread and it is only in
    the last couple of weeks that, finally, a contract has been let
    to provide those services. So this is an area that really needs
    to be expanded under the legislation, and actually needs to be
    expanded under the current program, as well.
        Mr. Pallone. OK, thank you. Do you have any questions?
        Mr. Fossella. Yes, again, just to dispel the notion that it
    is concentrated exclusively in New York City, and or New
    Jersey, for example. And ironically, those who may be skeptical
    of the legislation are the ones whose constituents will
    probably suffer the most. By that I mean the reference to just
    go see a family doctor. If you are in the middle of California
    or in the middle of Texas and you went and responded and you
    are suffering just as someone else was suffering, say who lives
    in Staten Island, who has access to some of the programs that
    exist in New York City, or live in New Jersey and have access
    to Rutgers, but if you are in the middle of Texas, you are on
    your own, or more likely that you are on your own. You go to
    see a family doctor and they may treat you with antibiotics,
    not knowing the true harm that is being done to one's body.
        I would like you just to, for the record, let me know as a
    healthcare professional--anyone else? I know Cas, you are not,
    but--is that something that we should consider as this national
    scope as Ms. Capps pointed out earlier, and others who may be
    unaware of the implications of their own constituent's plight.
        Dr. Moline. Well I think one of the points you raise is
    that going to your family physician, if you are outside the New
    York area, they may not even know to ask. And that is something
    that we hope to do a better job of providing continuing
    education and actually have been asked by NIOSH to develop some
    medical education materials that we can provide throughout the
    country through various venues, so that providers throughout
    the country will have a better understanding of World Trade
    Center related health effects through our New York/New Jersey
    Education and Research Center, which we will be doing in the
    next several months to make sure that there is greater
    awareness of the healthcare problems.
        But we do need, for the national responders, those who
    aren't living in the metropolitan area, to have a place they
    can go to where they are, essentially, satellites of our
    Centers of Excellence. They are using similar diagnostic tools.
    They have ways of finding out what may--what to look for, and
    how they should be treated. What are the best practices? There
    has to be a robust program that isn't piecemeal, that isn't
    stopped and started, switched--you can go here, but wait you
    have to wait awhile to get in treatment. You responded, you
    came to New York City from, whether it was from a construction
    site on 23rd Street in Manhattan or from San Francisco as part
    of a USAR team. You came, you responded, everyone should be
    able to have access to the same type of healthcare regardless
    of their environment. And it is important that the national
    program--there is a national program that is tied in, very
    closely, to the metropolitan area program that provides the
    same level of care as those folks in New York are able to get.
        Ms. Seminario. Could I just add to that? I think over time
    this is going to become more important because as people age
    and these health problems continue and they retire and they
    move--I mean there is mobility in the population, and so
    insuring that there is a very high quality national program and
    that people know how to access it, that we don't keep it secret
    as to who these providers are, so that people have some
    knowledge and they also have some confidence that when they go
    to those providers, they are going to get care that is going to
    be part of the integrated care--an overall program is really,
    really critical and important, and that hasn't happened to
    date.
        Mr. Holloway. And to add an additional detail--I mean, we
    know from the Fire Department, the Police Department, the
    agencies that responded that those populations migrate toward
    retirement. A lot stay in the area, but as, I am sure you know,
    they move all over the place--down to Florida and other places
    and 15,000 people have retired in the Police Department who
    actually are in the World Trade Center database at the
    Department, of the 34,000 who participated in some way in the
    operations, so this is critically important for the city, as
    well.
        Mr. Pallone. Mr. Engel.
        Mr. Engel. Thank you, Mr. Chairman. I just have two
    questions. Let me start with Mr. Holloway. You heard Mr.
    Nadler's testimony and I said in my opening statement that I
    was persuaded that, while we need to, obviously, help the
    first-responders the greatest way we can, there are community
    people who were told, erroneously, that the air quality was
    fine after the days of 9/11 and stayed in the community and may
    not even know that they are going to get sick in the future.
        There is a cap of 35,000 people on the number of new
    community members who can come into the program. I am concerned
    about that. I would like your take on that. Do you think it is
    enough, not enough? How do you explain the number? I know we
    are all trying to keep costs down, but it just would seem to me
    if someone is legitimately sick, as a result of breathing in
    that air, why would we devise a program to deny them, at some
    point, if they get sick after the cap has--the number of
    people--the claims have happened.
        I mean, we really just don't know. Some people have gotten
    sick immediately. Some people have gotten sick many years later
    and we don't know, in years to come, if people will get sick
    and I am very troubled by formulas that keep people out of a
    system who are legitimately--who have legitimately gotten sick
    as a result of 9/11.
        Mr. Holloway. Let me start by saying, as I noted earlier,
    line drawing and making limitations in this context is clearly
    a very difficult thing to do. I think what the city tried to
    do, in working with people here and all of the people who have
    been working on this bill is to say, ``well what do we know now
    and can we reasonably make an estimation to set this kind of a
    limitation.'' And so, let me just talk a little bit about what
    we did.
        Building on a methodology we used in the Mayor's report,
    which--and I can--we did a full write up on this, which I will
    make sure I circulate so that the whole members of the
    committee can get it. We looked at----
        Mr. Pallone. If the gentleman would yield. I mean, I have
    to admit guilt or responsibility here because you should know
    that, the leadership of the committee, we obviously asked them
    to cut back on the cost, so you understand that they are trying
    to address this because we told them that they have to. I just
    want you to know that.
        Mr. Engel. No, I know and I am sympathetic if we are going
    to sell this program to the rest of the country and the rest of
    the Congress, we need to be mindful of trying to cut back on
    costs I certainly am, but my difficulty and my problem is that
    we are really going into uncharted waters here and we really
    just don't know how many people have gotten sick immediately
    and how many people have yet to get sick.
        And my concern is that there seems to be a lack of
    flexibility in terms of people who are legitimately sick as a
    result of 9/11, of being shut out of the process. I mean, I
    fully understand that we don't want to give help to everyone
    who may claim that they are ill as a result of 9/11, when,
    indeed, some people may not have been ill as a result of 9/11,
    but conversely we don't want to shut anybody out who may get
    sick years down the road, so that is the point I was----
        Mr. Pallone. No, I agree, and if the gentleman would yield.
    I mean, I want you to tell us how you figured this out, but I
    also think that in the same way that I asked you to give us
    some background on the radius and how you decided to make it
    Brooklyn and Manhattan that maybe you could give us some
    written information. Because the kinds of questions that Mr.
    Engel are asking are going to be asked by everybody as we move
    forward. How did we get to these caps? How did we limit the
    radius, but go ahead.
        Mr. Holloway. Absolutely, so I will be very brief, just a
    few sentences. We looked, and by we I mean Dr. Reibman, Dr.
    Prezant, health experts on the city side, looked at what are
    the rates that we are seeing for treatment in the--what do we
    know from the World Trade Center registry? What are the rates
    that we are seeing, in terms of in the underlying population,
    make some assumptions about how many of those people--how many
    of who are where the prevalence is there. How many of those
    people would actually present for treatment? And it is a
    methodology that, clearly, is based on a set of assumptions,
    and it is challenging to do, but I will send a full analysis of
    how we did it.
        There is a method to that number that we looked at the
    entire group of who would be eligible, potentially, under the
    New York City Disaster Area defined in the bill, and then walk
    through each of the conditions and made a series of
    assumptions. I will make sure you get that.
        I want to also note, importantly, though the overall goal
    is to make sure that nobody, whether you are inside those
    areas, because that is another problem--issue with the bill,
    not a problem with the bill. It is line drawing and what if you
    are outside? What if you are north of Houston Street? Is that--
    are you shut out? The short answer to that is, there is a
    mechanism for you if you have a WTC-related condition that you
    are diagnosed with, to get treated, there is this defined fund.
    So that is a safety valve in the bill, and then there are
    reporting requirements.
        We could be wrong, you know we made assumptions and came up
    with an estimate that is reflected in the bill, but there are
    also reporting requirements in the bill. There is an annual
    reporting requirement on the program, who is being treated, how
    many people. And then the administrator is required to report
    to Congress if we hit or exceed 80 percent of the caps in the
    bill and then we are going to need to address that because we
    could be off. There is no question about it.
        Mr. Engel. Thank you. Thank you, Mr. Chairman.
        Mr. Pallone. I just wanted to say, again, I know I am not--
    maybe I am prolonging this unnecessarily, but, obviously all of
    us who represent the New York metropolitan area, at some point,
    are going to have to agree on some kind of consensus as to the
    radius and the numbers. And that is not going to be an easy
    thing. I know it wasn't an easy thing for Carolyn and Jerry
    Nadler to agree on in presenting this bill. But this is part of
    the consensus that we are going to have to work on over the
    August recess. I would like to, if we can, come to a consensus
    that when we come back in September, we can all sign off and
    say, ``look, this is what we can live with, and this is what
    will sell, financially, as well as in terms of covering people
    the way they should be.''
        It is not an easy task and I appreciate the fact that all
    of you have been involved in this, and helped us get to where
    we are today. But it is important that we do this and come to a
    consensus that we can all agree on and that we do it as quickly
    as possible if we are going to move something before the
    session ends, so I just want to thank you all again. You have
    done a great job, you really have.
        We appreciate it and we have a process whereby we may
    submit additional questions to you. You should hear--if we have
    any you will probably get those within the next 10 days so that
    you can respond and the clerk would notify you of those
    procedures. But, again, thank you again and without objection,
    this meeting of the subcommittee is adjourned.
        [Whereupon, at 1:10 p.m., the subcommittee was adjourned.]
        [Material submitted for inclusion in the record follows:]

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