[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:]

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    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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