[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]


 
       THE JAMES ZADROGA 9/11 HEALTH AND COMPENSATION ACT OF 2009 

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                             APRIL 22, 2009

                               __________

                           Serial No. 111-30


      Printed for the use of the Committee on Energy and Commerce

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                    COMMITTEE ON ENERGY AND COMMERCE

                 HENRY A. WAXMAN, California, Chairman

JOHN D. DINGELL, Michigan            JOE BARTON, Texas
  Chairman Emeritus                    Ranking Member
EDWARD J. MARKEY, Massachusetts      RALPH M. HALL, Texas
RICK BOUCHER, Virginia               FRED UPTON, Michigan
FRANK PALLONE, Jr., New Jersey       CLIFF STEARNS, Florida
BART GORDON, Tennessee               NATHAN DEAL, Georgia
BOBBY L. RUSH, Illinois              ED WHITFIELD, Kentucky
ANNA G. ESHOO, California            JOHN SHIMKUS, Illinois
BART STUPAK, Michigan                JOHN B. SHADEGG, Arizona
ELIOT L. ENGEL, New York             ROY BLUNT, Missouri
GENE GREEN, Texas                    STEVE BUYER, Indiana
DIANA DeGETTE, Colorado              GEORGE RADANOVICH, California
  Vice Chairman                      JOSEPH R. PITTS, Pennsylvania
LOIS CAPPS, California               MARY BONO MACK, California
MICHAEL F. DOYLE, Pennsylvania       GREG WALDEN, Oregon
JANE HARMAN, California              LEE TERRY, Nebraska
TOM ALLEN, Maine                     MIKE ROGERS, Michigan
JAN SCHAKOWSKY, Illinois             SUE WILKINS MYRICK, North Carolina
HILDA L. SOLIS, California           JOHN SULLIVAN, Oklahoma
CHARLES A. GONZALEZ, Texas           TIM MURPHY, Pennsylvania
JAY INSLEE, Washington               MICHAEL C. BURGESS, Texas
TAMMY BALDWIN, Wisconsin             MARSHA BLACKBURN, Tennessee
MIKE ROSS, Arkansas                  PHIL GINGREY, Georgia
ANTHONY D. WEINER, New York          STEVE SCALISE, Louisiana
JIM MATHESON, Utah                   PARKER GRIFFITH, Alabama
G.K. BUTTERFIELD, North Carolina     ROBERT E. LATTA, Ohio
CHARLIE MELANCON, Louisiana
JOHN BARROW, Georgia
BARON P. HILL, Indiana
DORIS O. MATSUI, California
DONNA M. CHRISTENSEN, Virgin 
Islands
KATHY CASTOR, Florida
JOHN P. SARBANES, Maryland
CHRISTOPHER MURPHY, Connecticut
ZACHARY T. SPACE, Ohio
JERRY McNERNEY, California
BETTY SUTTON, Ohio
BRUCE L. BRALEY, Iowa
PETER WELCH, Vermont

                                  (ii)
                         Subcommittee on Health

                FRANK PALLONE, Jr., New Jersey, Chairman
JOHN D. DINGELL, Michigan            NATHAN DEAL, Georgia,
BART GORDON, Tennessee                   Ranking Member
ANNA G. ESHOO, California            RALPH M. HALL, Texas
ELIOT L. ENGEL, New York             BARBARA CUBIN, Wyoming
GENE GREEN, Texas                    HEATHER WILSON, New Mexico
DIANA DeGETTE, Colorado              JOHN B. SHADEGG, Arizona
LOIS CAPPS, California               STEVE BUYER, Indiana
JAN SCHAKOWSKY, Illinois             JOSEPH R. PITTS, Pennsylvania
TAMMY BALDWIN, Wisconsin             MARY BONO MACK, California
MIKE ROSS, Arkansas                  MIKE FERGUSON, New Jersey
ANTHONY D. WEINER, New York          MIKE ROGERS, Michigan
JIM MATHESON, Utah                   SUE WILKINS MYRICK, North Carolina
JANE HARMAN, California              JOHN SULLIVAN, Oklahoma
CHARLES A. GONZALEZ, Texas           TIM MURPHY, Pennsylvania
JOHN BARROW, Georgia                 MICHAEL C. BURGESS, Texas
DONNA M. CHRISTENSEN, Virgin 
    Islands
KATHY CASTOR, Florida
JOHN P. SARBANES, Maryland
CHRISTOPHER S. MURPHY, Connecticut
ZACHARY T. SPACE, Ohio
BETTY SUTTON, Ohio
BRUCE L. BRALEY, Iowa





























                             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.........................
Hon. Nathan Deal, a Representative in Congress from the State of 
  Georgia, opening statement.....................................
Hon. Eliot L. Engel, a Representative in Congress from the State 
  of New York, opening statement.................................
Hon. John D. Dingell, a Representative in Congress from the State 
  of Michigan, prepared statement................................
Hon. Edolphus Towns, a Representative in Congress from the State 
  of New York, prepared statement................................
Hon. Joe Barton, a Representative in Congress from the State of 
  Texas, prepared statement......................................
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, prepared statement.............................

                               Witnesses

Hon. Carolyn B. Maloney, a Representative in Congress from the 
  State of New York..............................................
    Prepared statement...........................................
Hon. Jerrold Nadler, a Representative in Congress from the State 
  of New York....................................................
    Prepared statement...........................................
Hon. Peter King, a Representative in Congress from the State of 
  New York.......................................................
    Prepared statement...........................................
Edwardo Torres, Resident of Jersey City, New Jersey..............
    Prepared statement...........................................
Jacqueline Moline, M.D., M.Sc., Vice Chair, Community and 
  Preventive Medicine, Director, WTC Medical Monitoring and 
  Treatment Program, Clinical Center at Mount Sinai, Director, 
  NY/NJ Education and Research Center, Mount Sinai School of 
  Medicine, New York.............................................
    Prepared statement...........................................
Joan 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, Bellevue Hospital, New York.....................
    Prepared statement...........................................
Jim Melius, Administrator, New York State Laborers' Tri-Funds, 
  Albany, New York...............................................
    Prepared statement...........................................
Caswell F. Holloway, Special Advisor to New York City Mayor 
  Michael R. Bloomberg, Chief of Staff to New York City Deputy 
  Mayor for Operations Edward Skyler.............................
    Prepared statement...........................................

                           Submitted Material

Hearing memorandum...............................................


       THE JAMES ZADROGA 9/11 HEALTH AND COMPENSATION ACT OF 2009

                              ----------                              


                        THURSDAY, APRIL 2, 2009

                  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, Engel, Weiner, 
Barrow, and Deal.
    Staff present: Andy Schneider, Chief Health Counsel; Sarah 
Depres, Counsel; Elana Leventhal, Counsel; Alvin Banks, Special 
Assistant; Alli Corr, Special Assistant; Miriam Edelman, 
Special Assistant; Lindsay Vidal, Special Assistant; Aarti 
Shah, Minority Counsel; Jerri Couri, Minority Professional 
Staff; Chad Grant, Minority Legislative Analyst.

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

    Mr. Pallone. The subcommittee hearing will be called to 
order, and today we are having a hearing on the James Zadroga 
9/11 Health and Compensation Act of 2009. First of all, let me 
say good morning to our colleagues who are at the desk there 
and to all of you who are here. I know how important an issue 
this is not only to the New York and New Jersey delegation, but 
I think also nationwide.
    The bill was introduced by Ms. Maloney, Mr. Nadler, and Mr. 
King. And again I want to thank you for all you have done on 
this legislation. I think actually in my opening remarks I 
mention the hearing that Jerry had, that Mr. Nadler within 
maybe a month or so of the World Trade Center attack, and I 
remember going to the Federal Building--I think it was at the 
Federal Building--in New York, and you were bringing up--you 
were sort of raising all the issues that, at the time, were 
being denied by the EPA, and it turned out to be true. So it is 
often the case with Mr. Nadler that he brings issue to the 
attention that agencies deny, and then it turns out that he was 
absolutely right from the beginning.
    Last year, the subcommittee had two hearings on this issue 
to examine medical monitoring and treatment programs for those 
affected by 9/11 diseases and a legislative hearing on a 
similar bill to the one before us today. Both of these hearings 
provided us with vital information on this issue.
    Eight years ago, as we all know, our country was struck by 
a horrible tragedy. People lost their lives, families were 
shattered, and our Nation responded. And individuals from all 
over the country rushed to the aid of those in need, not 
stopping to think about the effects on their health or lives. I 
know I will never forget those horrifying days. I was at the 
World Trade Center site with President Bush. I think the attack 
occurred on Tuesday, and we were there maybe Friday of that 
week. And, you know, I saw firsthand the dedication and 
determination of the rescue workers and the volunteers who 
pushed themselves to the brink of exhaustion and beyond.
    The singular memory that when we arrived, I was standing 
next to a, like a yellow fire truck that was from Hialeah, 
Florida. And I thought, you know, how did that truck get up 
here in such a short time? I mean I guess it is possible to do, 
but it was people literally from all over the country.
    In the month following the 9/11 attacks, I mentioned I 
attended a field hearing with Congressman Nadler in New York 
City to investigate the presence of hazardous waste and the 
health implications for those who were exposed. We did not know 
then if there would be any long-term effects or just how 
debilitating they would be. But we now have more in-depth 
understanding of how the dust, the glass fragments, and other 
toxins released into the air affected by responders and 
community residents. Studies have shown that individuals 
present during and immediately after the attack now suffer from 
new or worsened respiratory disease, gastroesophageal 
disorders, and mental health conditions including post-
traumatic stress disorder.
    We in Congress have an obligation to our Nation's heroes 
and to the victims of these attacks. It is our turn to step up 
to the plate and come to their aid, and the bill before us 
today is a vital step in that direction. H.R.847 would 
establish a permanent program to monitor and screen eligible 
residents and responders and provide medical treatment for 
those 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.
    The legislation would build upon the expertise of the 
Centers of Excellence, which are currently providing high 
quality care to thousands of responders and ensuring ongoing 
data collection and analysis to evaluate health risks.
    Now, one of these centers is, as you know, is located in my 
district on the Bush Campus of Rutgers University in Piscataway 
and is run by Dr. Iris Utasin. It is the UMDNJ World Trade 
Center Medical Monitoring and Treatment Program, which was 
established in January 2003 to study, interpret, and treat 
medical symptoms commonly occurring in responders and 
volunteers. The center currently--this is the New Jersey 
center--currently serves approximately 1,370 patients. I 
visited the center a few times and have seen the work that Dr. 
Utasin and her team are doing to help our Nation's heroes.
    I know she couldn't be here today. I think she is not in 
the country, so she wasn't able to come today. But at the 
center, the in-depth knowledge of these complex conditions is 
crucial to all the patients, and we must ensure that this 
program is permanently funded so that they can continue 
providing this excellent care.
    So I just want to thank all the sponsors again for your 
tireless efforts, and Mr. Deal and I know how tireless you are 
because oftentimes a week does not pass by without you 
mentioning this issue on the floor. We want to thank the 
witnesses, not only our two colleagues, but those who will be 
on the next panel, in particular Mr. Torres who is from New 
Jersey and who was one of the first responders to the 9/11 
attacks. We are going to be hearing his story today, and on 
behalf of everyone, I want to particularly thank you also for 
being here.
    And I will now recognize the 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. Thank you for holding 
the hearing and thanks to our two colleagues for being on the 
first panel. I think we all understand the significance of the 
events of 9/11 and as we explore this bill, H.R. 847, we 
understand the long-term consequences in terms of health to 
those who rushed to the aid of others and to the consequences 
that they have suffered as a result of it.
    My only regret is that, and I have to tell my colleagues as 
well as the other panel members, this just happens to be at the 
very same time that we are holding a full committee hearing on 
climate change of the Energy and Commerce Committee. And for 
those such as myself who are on the full committee but are not 
on the Energy Subcommittee, this is the only opportunity, this 
hearing that is going on right now, to participate in that 
particular important discussion. So I think that accounts for 
the fact that you probably will not have very many members here 
because of the full committee hearing on that important issue 
going on simultaneously. Wish it would have been otherwise, but 
we deal with the time constraints that we have.
    The hearing today, of course, is to assess the current 
monitoring and treatment efforts that have been provided to 
individuals who were involved in the 9/11 catastrophe and to 
those who were within proximity to the World Trade Center on 9/
11 and the weeks and months that followed. It is my 
understanding that to date, the federal government has 
allocated approximately $1 billion toward monitoring and 
treatment of first responders.
    Although this legislation has yet to be scored by the 
Congressional Budget Office, CBO estimated last year that the 
impact of similar legislation, which was H.R. 7174, upon which 
the subcommittee held a legislative hearing last summer, that 
it would cost taxpayers over $11 billion within a 10-year 
timeframe. If the majority intends to move this legislation out 
of the committee for a vote, I hope that members on both sides 
of the aisle will be given the opportunity to hold another 
legislative hearing to receive the expert input from CBO 
regarding the true cost of the legislation.
    I look forward to continuing to work with the members of 
the committee on this, and once again thank my colleagues for 
their interest and their attendance here today. I yield back.
    Mr. Pallone. Thank you, Mr. Deal. And let me reiterate with 
Mr. Deal said about conflicts today. Actually Lisa Jackson, I 
think, you know, was our--the Jersey commissioner now is the 
EPA administrators, I think, testifying this morning on, you 
know, on the global climate change in the full committee. So we 
are missing that, and I would appreciate the fact that Mr. 
Engel is here, but I--you are doing something with Hillary 
Clinton this morning, aren't you, in your other committee?
    Mr. Engel. Foreign Affairs Committee has a full hearing 
with the Secretary of State. First time she is appearing before 
any committee, either in the House or the Senate.
    Mr. Pallone. So there is a lot going on. So forgive us. But 
even with that, Mr. Engel is here. And I want to also 
acknowledge his significant involvement in this legislation as 
well. Thank you, Eliot.

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

    Mr. Engel. Well, thank you, Mr. Chairman, and I want to 
thank you for holding this hearing today because you and I have 
had many talks about the importance of the 9/11 Health and 
Compensation Act. And I appreciate your willingness to hold a 
hearing to--in the midst of all the committee's work on many 
things but particularly on health reform. So I am glad that you 
are chairing this important subcommittee, and thank you for 
doing this.
    I am also delighted to see my colleagues Jerry Nadler and 
Pete King, both of whom I have firsthand knowledge, being a 
colleague of theirs from New York, of the work that both of 
them have done in focusing on this very important issue of 9/11 
health care, the 9/11 Health and Compensation Act, and all the 
other things that relate to the devastating attack on September 
11, 2001, and particular, Mr. Nadler, the World Trade Center 
and the attacks are in his district, and he has played a front-
and-center role on all these issues, not just on the health 
issues, but on all the issues pertaining to the attacks. So I 
want to thank Mr. Nadler and Mr. King for being here this 
morning.
    You know, as devastating as that day was, there are few 
days I have been more proud to be an American than on September 
11. I said that in my first statement on the House floor a day 
or two after the attacks where I spoke from the heart, not by 
reading anything. 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 of course, too many lost their lives 
that day.
    Within days, over 40,000 responders from across the Nation 
descended upon Ground Zero to do anything possible to help with 
the rescue, recovery, clean up. I remember those bittersweet 
days. I was there in New York City, where I was born and bred. 
I was happy to be in New York City on September 11 and remember 
seeing Americans lined up around blocks to donate blood. The 
attack was on Tuesday. That Friday, the New York Delegation 
stood with President Bush at Ground Zero, that very famous 
picture of President Bush with the firemen and the bullhorn. We 
were all there right by his side. Particularly Mr. Nadler, I 
remember, flew in the helicopter that day. There were things we 
all remember.
    I remember the chaos as no one knew quite what to do, only 
that we had to do something, anything to help our Nation rise 
up from the assault by the terrorists. I was very, very proud 
to be in New York on that day.
    The past seven years though have not been 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.
    You know it is a funny thing. Those of us in the New York 
City delegation, we kept going back to the World Trade Center, 
the devastation while we saw people running around. And, you 
know, they gave us these little kind of helmets. None of us 
wore them, and we kept going back. We were assured at the time 
by Christy Todd Whitman that everything was fine. And so even 
those of us in Congress were exposed to these things. I am not 
saying that we were exposed the way the first responders were 
who were there every day. But we were there, you know, half a 
dozen times or more, and we were exposed to it as well.
    Years later the exposure though to the 400,000 people has 
left a significant number of first responders with severe 
respiratory ailments including an asthma rate that is 12 times 
the normal rate of adult onset asthma, lung disease, and 
persistent cough. Also common are PTSD and depression. This has 
all been well documented in a scientific, peer-reviewed 
published work regarding the long-term health effects of 9/11 
by Mt. Sinai Hospital, the fire department of the city of New 
York, and the World Trade Center health registry.
    We really don't know the long-term effects of exposure to 
the toxins from 9/11. Many of us fear that there may be 
significant late emergent diseases, both in our first 
responders and members of the community, such as cancer, that 
will require treatment for years to come.
    While these illnesses should sadden all of us, what pains 
me most is that our Nation has failed to provide our first 
responders and community members, Mr. Nadler's constituents, 
with a sustainable and reliable source of federal funding for a 
health care monitoring and treatment program. The GAO has 
documented the failure of HHS to provide consistent care in 
multiple reports. It certainly sends a chilling message to 
those who fearlessly volunteered for our country that nearly 
eight years later, they are still fighting for medical care 
that should just be a given.
    So I am proud to join with my New York colleagues, lead by 
Representatives Maloney, Nadler, and so many others in 
introducing the 9/11 Health and Compensation Act. This 
comprehensive bill would ensure that those 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 health 
care, no more excuses. We must and shall do what is right, and 
I thank you, Mr. Chairman, for bringing this to the floor, and 
I thank my colleagues, Mr. Nadler and Mr. King, for coming here 
today. I yield back.
    Mr. Pallone. Thank you, Mr. Engel. We are going to now turn 
to the first panel, and obviously I am very pleased that you 
are with us here today and all that you have done. I guess I 
should mention--I think we already mentioned it--that 
Representative Carol Maloney could not be here because she has 
a bill. I think one of her other bills is being marked up--
credit card bill, another important bill that is being marked 
up. But we have her statement, so without objection, I will ask 
unanimous consent to submit that for the record.
    [The prepared statement of Ms. Maloney 
follows:]*************** INSERT 7 ***************
    Mr. Deal. Mr. Chairman, I would ask unanimous consent that 
members of the committee be given five days in which to submit 
their statements for the record in this hearing.
    Mr. Pallone. Without objection, so ordered. We are going to 
start with the Congressman Nadler.

STATEMENTS OF HON. JERROLD NADLER, A REPRESENTATIVE IN CONGRESS 
      FROM THE STATE OF NEW YORK; AND HON. PETER KING, A 
     REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW YORK

                  STATEMENT OF JERROLD NADLER

    Mr. Nadler. Well, thank you, Mr. Chairman. Mr. Chairman, 
Ranking Member Deal, members of the subcommittee including my 
fellow New Yorker, Mr. Engel, thank you for convening this 
hearing and inviting my colleagues and me to testify before you 
this morning. I also want to thank everyone who has worked on 
this bill to help us achieve our long-standing goal of 
providing a stable, long-term program to help the responders, 
the residents, area workers, students, and others who were 
injured by the attack on our country on September 11.
    Representative Maloney and I along with Representatives 
King and McMahon have introduced H.R. 847, the 9/11 Health and 
Compensation Act of 2009 to ensure that the living victims of 
the September 11 terrorist attacks have a right to health care 
for their World Trade Center related illnesses and the root to 
compensation for economic losses.
    Now, as many of my colleagues know and as many of us 
sitting in this room know, today's panelists have come together 
many times since the towers fell almost eight years ago, 
holding press conferences, testifying at hearings, and 
releasing countless pages of information detailing the 
environmental impacts and health effects created by the attack 
on the United States.
    For eight years, those of us here today have testified 
about the toxins that were inhaled by those near Ground Zero in 
the days and weeks following the attacks. We warned then that 
the air wasn't safe and that our courageous first responders 
were not being afforded the proper protection from dangerous 
toxins as they were working on the pile.
    But the federal EPA kept assuring everyone wrongly that the 
air was safe. We spent years working to try to convince public 
officials that the asbestos, fiberglass, mercury, manganese, 
and other toxins that traveled far and settled into the 
interiors of residences, workplaces, and school and that a 
proper testing and clean-up program was required to eliminate 
the continuing health risks to area residents, workers and 
students.
    We demanded that the government acknowledge the fact, 
supported by a mountain of peer-reviewed research, that 
thousands of our Nation's citizens are today sick because of 9/
11 and that many more will likely become sick in the future.
    We explained to whoever would listen that our 9/11 heroes 
were struggling to pay health care costs because they could not 
longer work and had lost their health insurance or because they 
had had their worker's compensation claims contested. We have 
argued vigorously that the federal response to date has been 
dangerously limited, piecemeal, and unpredictable, both in 
terms of preventing further health impacts from potentially 
persistent indoor contamination, and most notably in terms of a 
lack of comprehensive long-term approach to providing health 
care and compensation for those already affected.
    Yet each time we presented our case for comprehensive 
solution, we were told better luck next year. Well, a new year 
has come, and we are here again on behalf of those who continue 
to suffer. Undaunted and due to considerable efforts by all of 
the stakeholders, we have modified the bill to achieve what 
have been our dual goals from the beginning. One, to establish 
a stable, long-term approach that builds on successful existing 
programs to provide much-needed care for those who were 
affected by the attacks, regardless of whether they are first 
responders or area workers, residents, students, or others. And 
two, doing this in a fiscally responsible manner.
    We are hopeful that today's hearing marks the beginning of 
the end of our collective eight-year struggle. We are hopeful 
that this is the first step in finally passing this critical 
legislation to give those men, women, and children who live 
with the daily reminders of that terrible day in 2001 the 
support and care they deserve.
    Although the devastating 9/11 attacks on the World Trade 
Center occurred within the bounds of my congressional district, 
it was our Nation as a whole that was attacked. And the 
ramifications stretch well beyond the bounds of my district or 
indeed of New York. Every member in New York's down state 
delegation represents hundreds if not thousands of people who 
live, work, attend school, or were otherwise present in lower 
Manhattan and the affected parts of Brooklyn and were exposed 
to the toxic brew in the air.
    But it doesn't end there. Because people from all across 
the country came to New York City to help, there are now 
citizens in every state, in fact, in 431 congressional 
districts that we know about--431 out of 435 who were exposed 
to the toxic fumes of 9/11 and were concerned enough about it 
to register with the World Trade Center health registry.
    So this is not just a problem for members from New York and 
New Jersey. This issue should concern every member of the 
House. Because this is unquestionably a national problem, it 
has always required a national response. Yet the previous 
administration declined to develop a comprehensive plan to deal 
with the growing public health problem, forcing the New York 
delegation year after year to come to Congress to test its luck 
during the annual appropriations process.
    Thankfully with growing bipartisan support for that 
funding, we have had some key successes. And with those funds, 
we have seen some critical first steps in federally funded 
health care programming, but quite simply this disjointed and 
unpredictable approach to securing critical funding is not a 
tenable course of action.
    Both our heroes and the excellent health care programs that 
are now in place to serve them deserve better. Passage of the 
9/11 Health and Compensation Act would mark an end to this 
problematic approach and ensure that a consistent source of 
funding is available to monitor and treat the thousands of 
first responders and community members already affected by 
World Trade Center related illnesses as well as those who 
illnesses may become apparent in the future.
    And it would ensure that no matter where an affected 
individual lives in the future, he or she could get care. 
Building on the expertise of the Centers of Excellence, the 
bill would fill gaps in how we are currently providing 
treatment and monitoring. The bill would also provide for 
substantial data collection regarding the nature and extent of 
related illnesses. This is a particularly critical provision as 
there is still much we have to learn about these illnesses and 
how they affect different exposure populations.
    And finally, as you know, this legislation would provide an 
opportunity for compensation for economic damages and losses by 
reopening the 9/11 Victims' Compensation Fund. As you will hear 
from the other panelists, the needs here are abundantly clear. 
About 16,000 first responders are currently being treated for 
illnesses, and about 40,000 more--and more than 40,000 are 
being monitored through a consortium of providers lead by Mt. 
Sinai Hospital and the New York City Fire Department.
    And we already have nearly 3,400 sick community members 
being treated by a program funded in part by the federal 
government, the World Trade Center Environmental Health Program 
at Bellevue Hospital. As you may know, the bill has been 
modified several times in order to ensure that those in need 
receive the care they deserve and that the cost is feasible and 
responsible.
    First, the bill limits the radius, the geographical radius 
within which individuals who reside go to school or work would 
be eligible for services. Second it caps the total number of 
new treatment slots to 35,000, which incidentally is the same 
level as the responder program. Finally, the bill creates 
contingency funds with strict dollar limits and caps other 
kinds of spending.
    Today every member of the subcommittee has an opportunity. 
You can decide that you are going to join with those of us in 
this room who have been fighting for this funding for eight 
long years, with those back in New York and throughout the 
country who continue to grapple with the consequences of the 9/
11 attacks.
    With your help, we can finally give the heroes and victims 
of 9/11 the peace of mind they deserve by providing for their 
health needs and other losses. I urge you to please join us in 
supporting the 9/11 Health and Compensation Act and helping us 
to move this important legislation forward so that it can 
finally be brought to the whole House for a vote.
    Thank you again, Mr. Chairman, and members of the 
subcommittee for holding this hearing, and I look forward to 
the testimony of my colleagues and other witnesses today. I 
yield back the balance of my time.
    [The prepared statement of Mr. Nadler 
follows:]*************** INSERT 6 ***************
    Mr. Pallone. Thank you, Congressman Nadler. And next is 
Congressman Peter King, and again thank you for your major 
efforts on this legislation. And of course you also make it 
bipartisan, which is very important. Thanks.

                    STATEMENT OF PETER KING

    Mr. King. Thank you, Mr. Chairman. I will thank you and the 
ranking member for holding this hearing today. Obviously I see 
Congressman Weiner is here, Congressman Engel, who know 
firsthand just how devastating this attack has been on New York 
and New Jersey, but as Congressman Nadler said, on the entire 
Nation.
    Also let me commend Jerry Nadler and Carolyn Maloney 
because they really have been there from the start. If I could 
just add one humorous note in a very serious issue, passage of 
this bill protects so many members in the House floor from 
being accosted by Jerry Nadler. After seven and a half years, 
if he spots anyone standing still, he comes up to them and 
urges the adoption of this bill. So there is a very selfish 
interest in passing this legislation.
    But seriously Congressman Nadler and others have worked so 
hard on this because it is such a vital issue. And it is really 
an issue whose time has come. It actually came many years ago, 
and there really is no excuse at all for going further with 
this. And on a bipartisan note, I am a Republican on this bill, 
but also Dr. Burgess on your committee has been very helpful. 
And I know he strongly supports this bill. I saw him this 
morning, and he asked me to point that out.
    What Congressman Nadler said about the thousands and 
thousands--also Congressman Engel--of first responders who went 
to the scene that day and stayed there for the next eight, 
nine, ten months, I mean day in and day out working in some 
cases almost around the clock at the time without real concern 
for their safety. They just wanted to get the job done, and 
when the time limit for the Victims' Compensation Fund expired, 
most of these people had no idea of the underlying illnesses 
that they had.
    But we have seen thousands coming forward. I mean so many 
firefighters know of serious pulmonary illnesses, men who were 
really in the prime of life, absolutely perfect physical 
condition. Now some of them can barely breathe, and you just 
see the impact it has had. And it has all come in the last two, 
three, four years.
    Just the other night--this is anecdotal, but I happened to 
be at an event. There were two police officers there, and they 
did not even work around the clock at the World Trade Center. 
They were there the day of the attack, and they were in charge 
of bringing dignitaries and government officials to the site 
over the next six or seven months. They both came down with the 
same type of serious sinus disorder, and, you know, the odds 
are--of that happening, of two people being struck with that 
type of--and it is a rare type of sinus disorder. So I just 
said anecdotally. And there are so many other stories like that 
we hear, and there is really no reason to delay this any 
further.
    We have an obligation to the country. We have an obligation 
to those who came forward. We have an obligation to the 
contractors who also put a lot on the line when they came down 
there. And, you know, it happened in New York now. It could 
happen in any other state in the country at any time. And I 
believe when a situation like this happens, it is imperative 
and it is incumbent upon the country to come together.
    And as Jerry said, 431 congressional districts in this 
country have been affected by this, and I would just hope that 
people not see this as a New York issue or a New Jersey or a 
Northeast issue. It really is an American issue. And also as 
Congressman Nadler said, this bill has been refined. It has 
been, I think, finely tuned. But if there is any specific 
objection that anyone has or question, I would just we resolve 
that and not put this on the back burner again and not come 
back to it next year or the year after.
    We are so close to the finish line right now, so close to 
getting this done, and we really--I think it would be 
outrageous and disgraceful not to complete the job and not to 
get it done. We owe it to those who were there that day. Jerry, 
of course, knows firsthand the people in his district who 
suffered. But as I said, in the entire region, in the entire 
country, so many others put their lives on the line and did it 
unquestioningly. They deserve this type of response.
    And we owe it also to future generations if, God forbid, 
something like this should ever happen again. So let people 
know that America does stand by those who respond to the call 
of duty.
    So with that, I thank you for holding this hearing today 
and really also thank, you know, the men and women who are here 
to testify, the men and women who have done so much, and the 
men and women who have really never stopped sacrificing for 
their country and unfortunately are still suffering because of 
that sacrifice. And with that, I yield back. Thank you, Mr. 
Chairman.
    [The prepared statement of Mr. King 
follows:]*************** COMMITTEE INSERT ***************
    Mr. Pallone. Thank you, Congressman King. Thank you both. 
We normally don't ask questions of our colleagues, so unless 
someone objects, I am going to move on. But thank you so much 
really. And you know we do intend to move the bill. I mean we 
are not just having a hearing as you know.
    Mr. Nadler. Thank you, Mr. Chairman.
    Mr. King. Thank you, Mr. Chairman.
    Mr. Pallone. Could the next panel come forward? We will get 
the nametags so you know where to sit, but I guess it doesn't 
matter. You can sit wherever you like. We are missing a chair? 
You have to come up. We will get you a chair. Yes, Mr. Torres, 
sorry. I don't know what happened to the nametags, but 
hopefully we will have some. There is a problem with the 
printer, so I think we are going to start without the nametags. 
Can we just--can we remove the ones that are there? He is going 
to do it, Charlie? Thank you. Thanks, Charlie. Thank you. All 
right, they may not be--here we go, oK.
    Now we will warn you that you are not sitting in the order 
that I have, so I am going to follow the order that I have in 
terms of your testimony. So let me introduce each of you, and 
the way I introduce you is the order that you are going to 
speak. OK, first is Mr. Edwardo Torres from Jersey City, who is 
over on my right. And then there is Dr. Jacqueline Moline, who 
is vice chair, Community and Preventative Medicine Director of 
the WTC Medical Monitoring and Treatment Program Clinical 
Center at Mt. Sinai and also director of the New York/New 
Jersey Education and Research Center at Mt. Sinai School of 
Medicine in the School of New York.
    Then we have Dr. Joan Reibman, who is associate professor 
of medicine and environmental medicine, director of the NYU 
Bellevue Asthma Center and director of Health and Hospitals 
Corporation for the World Trade Center Environmental Health 
Center at Bellevue Hospital in New York City. And then we have 
Dr. Jim Melius who is administrator for the New York State 
Laborers' Tri-Funds in Albany, New York. And finally is Caswell 
Holloway, who is special advisor to New York City Mayor Michael 
Bloomberg and chief of staff to New York City Deputy Mayor for 
Operations Edward Skyler. A long resume here for many of you.
    So I think you know it is five minutes opening statements. 
We are going to try to keep to that if possible. And if you 
want to submit, you know, testimony for the record, you know, 
we will do that as well. And then we will have questions after 
by members of the panel. And we will start with Mr. Torres. 
Thanks for being here. You need a mike. Just turn that that way 
and then just press the button until the light comes on there. 
That should do it. Maybe move it a little closer to him. It 
might be a little--yes.
    Mr. Torres. How is that? Can you hear me?
    Mr. Pallone. Yes, even a little closer.
    Mr. Torres. OK, how is that?
    Mr. Pallone. That is good.

  STATEMENTS OF EDWARDO TORRES, RESIDENT OF JERSEY CITY, NEW 
JERSEY; JACQUELINE MOLINE, M.D., MSC, VICE CHAIR, COMMUNITY AND 
   PREVENTIVE MEDICINE, DIRECTOR, WTC MEDICAL MONITORING AND 
 TREATMENT PROGRAM, CLINICAL CENTER AT MOUNT SINAI, DIRECTOR, 
  NY/NJ EDUCATION AND RESEARCH CENTER, MOUNT SINAI SCHOOL OF 
MEDICINE, NEW YORK; JOAN 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, BELLEVUE HOSPITAL, NEW YORK; 
JIM MELIUS, ADMINISTRATOR, NEW YORK STATE LABORERS' TRI-FUNDS, 
 ALBANY, NEW YORK; AND CASWELL F. HOLLOWAY, SPECIAL ADVISOR TO 
NEW YORK CITY MAYOR MICHAEL R. BLOOMBERG, CHIEF OF STAFF TO NEW 
      YORK CITY DEPUTY MAYOR FOR OPERATIONS EDWARD SKYLER.

                  STATEMENT OF EDWARDO TORRES

    Mr. Torres. Thank you, Mr. Chairman Pallone, members of the 
committee. Good morning and thank you for the opportunity to 
testify before you today. My name is Edwardo Torres. I am 47 
years old, and I am a resident of Jersey City. I am a 
construction worker and a trade member of the Plumbers Local 
Union 14 AFL/CIO based in Lodine, New Jersey. I am testifying 
before you today in support of the James Zadroga 9/11 Health 
Commission Compensation Act of 2009.
    I come before you this morning as a citizen wanting to do 
my part to assist the victims of 9/11 terrorist attack of the 
World Trade Center and assist their responders. But now I am 
suffering from serious health effects due to the exposure of 
Ground Zero toxins and the breathing of the toxins and the 
pulverized building materials.
    My story begins in September 2001. I arrived at Ground Zero 
from New Jersey at 11:00 a.m. Workers were being recruited from 
my job site and my local union to assist the rescue efforts. 
Upon the arriving to Manhattan from New Jersey, I immediately 
began to assist the police, firemen, and rescue attempts of 
possible survivors trapped in the ruble of the World Trade 
Center and to move debris from the pile.
    I was assigned to the bucket brigade, which slowly and 
painstakingly removed debris from certain areas via a long line 
of people passing one bucket after another. And I performed 
this task up to 8:00 p.m. that evening. I returned to the pile 
on September 13, 14, and 15, and over the course of those four 
days, I performed the same exact task for approximately 60 
hours.
    The first day on the pile, I wore a simple dust mask and a 
hard hat. The three following days, I wore a two-canister 
filter respirator and a hard hat. Through this time, we dug 
through the pile by hand because shovels simply didn't work 
well. The entire time I was filling up buckets and we were 
instructed to carefully sift through and review the material 
and attempt to identify remains.
    Although the environment I was working in was surreal, the 
weather was actually--couldn't have been nicer out. It was 
clear, sunny, and shiny. The first day, the level of dust that 
appeared to the naked eye had been reduced, although the smoke 
and the smell of the fumes were intense at times. There was a 
false sense of security and the frenzied dedication of the 
workers sometimes forced us to remove our respirators. We also 
removed them when we ate or drank water, both of which occurred 
right on the pile.
    I was completely unaware of the health hazards presented in 
the air, and although the dust appeared to be minimal, I would 
be reminded of the massive amount of dust in the air when I 
washed my face on an hourly basis. And when I would dry with a 
paper towel I would see heavy grey cover on it. I wiped massive 
amounts of soot from my face on a regular basis.
    When I went to Ground Zero on September 15, I was proud to 
volunteer every ounce of my energy over the last four days 
helping victims of the attacks. That day was the last day that 
I went to volunteer at Ground Zero.
    I returned to my home that Saturday, and I attempted to go 
back to the pile on September 16, but there was no longer 
running ferries from New Jersey and much of the workers and so 
less volunteers were being recruited. I returned to work on 
Monday, September 17.
    It is important to note I never had any health problems 
prior to 9/11. In fact, I considered myself to be in great 
shape. I jogged approximately three times a week, and I never 
had any problems breathing. For the first four months after 9/
11, I had no symptoms or health problems of any kind.
    That changed with what I would describe as an on-again-off-
again sore throat starting from February of 2002 in which I 
would lose my voice on occasion. 2002, I started having stomach 
pains, not comfortable but pains similar to a worse type of 
acid reflux or heartburn. And I had no stomach problems at all 
prior to 9/11.
    This persisted and got consistently worse in the course of 
the next three years. 2005, my throat, my stomach problems were 
consistently more problematic at the time of receiving a 
physical at March of 2005.
    The worst came in November of 2005, a period of time, I 
could no longer walk up more than one flight of stairs. Work 
was becoming much more difficult. The winter, I lost about six 
or seven days of work because it was too cold in the weather 
that simply I couldn't breathe. In fact, at one point during 
the dance performance, my chest pains and ability to breathe 
forced me to stop performing.
    There are days that I couldn't even run with my kids, 
participate in sports, and sleep cycles have been disturbed due 
to my respiratory problems. The only medicine I had at this 
time was acid reflux, but symptoms got worse. And at the time, 
I visited a lung specialist who performed a PET scan. On March 
2006 and October of 20006, I was diagnosed with having modules 
in my lungs resulting in lung opacity and lung scarring. The 
doctors however did not say it was a result of my exposure.
    After finding this problem and recognizing in my opinion 
that they were a result of my working at Ground Zero, I decided 
to attend Mt. Sinai Medical Monitoring Program for examination 
and was accepted into the program in May of 2006.
    At this time, I was diagnosed with two World Trade Center-
related conditions--gastro-esophageal reflux disorder (GERD) 
and chronic respiratory restriction. My treatment began at this 
time, and I was taking prescription medicine to treat the 
constant throat pain that I was suffering. Eventually I had 
surgery which was paid for by the Medical Monitoring Fund in 
October of 2006. And the surgery removed a mass or polyp on my 
throat. It was not cancerous. After the surgery, I was out for 
six weeks of work.
    I found the caregivers of the World Trade Center Monitoring 
Program very compassionate. Also, unlike my first doctor, they 
had a thorough understanding of the context in which the 
medical examinations and treatments were required. These 
caregivers understood the 9/11 association and how to treat 
these problems specifically.
    The program also performed an extensive breathing analysis, 
or a PFT test, pulmonary function test. Every 3 months I 
received a checkup and a CAT scan, and I met with doctors. 
Since May of 2006, I have been to the program 24 times. The 
program pays for the treatment and the monitoring. My insurance 
through my union pays for the CAT scans. I have never paid 
anything out of pocket with the exception of prescription drug 
co-payments. And they have a program in Piscataway, but prefer 
the one in New York City because it is a shorter drive for me.
    Under the James Zadroga 9/11 Health and Compensation Act of 
2009 legislation, I will continue to receive medical monitoring 
since both of my diagnosed conditions are on the list of 
identified World Trade Center conditions specifically in this 
bill.
    This would allow me to continue the course of the medical 
treatment paid for but would also assist other affected workers 
who are currently struggling. For workers like me and others 
participating in this program, the monitoring of treatment is 
essential. Furthermore, under this bill, we would be allowed to 
receive non-treatment core services such as education on my 
condition, counseling and advice on how to identify and obtain 
benefits if needed from workers' compensation, health 
insurance, disability insurance and public, private and social 
service agencies.
    In closing, I would like to repeat a question a nurse 
gathering research from me had asked at Mt. Sinai Hospital and 
ask you to put this in context as you deliberate this 
legislation. I was asked on August 2008 during a checkup at the 
monitoring program if I understood the health effects resulted 
from your Ground Zero volunteering, would you still have gone? 
And I responded yes before she could even have a chance of 
finishing the question. Despite all the pain that it has caused 
me, I would not have changed a day. Those people needed me. My 
country needed me. I had to do the right thing. And now 
respectfully I ask you to respond to the health needs by also 
saying yes when this bill comes up to vote. Thank you.
    [The prepared statement of Mr. Torres 
follows:]*************** INSERT 2 ***************
    Mr. Pallone. Thank you, Mr. Torres. Thank you for relating 
your story, which I am sure is very much like what a lot of 
other responders have been going through. Thank you. Dr. 
Moline?

                 STATEMENT OF JACQUELINE MOLINE

    Dr. Moline. Chairman Pallone and Ranking Member Deal and 
members of the committee, I would like to thank you for 
inviting me to present testimony today. My name is Dr. 
Jacqueline Moline. I am an occupational medicine specialist at 
Mt. Sinai School of Medicine in New York City, and I direct Mt. 
Sinai's Clinical Center of the World Trade Center Medical 
Monitoring and Treatment Program.
    We are the flagship of a regional and national consortium 
that is supported by NIOSH, the National Institute for 
Occupational Safety and Health through February 28, 2009 has 
diagnosed and treated nearly 27,000 World Trade Center 
responders throughout this country. I am here today to testify 
in support of H.R. 847, which in my view is the best vehicle to 
meet the need for continued medical care of the responders and 
ensure that the 9/11 responders receive the high quality 
medical care they rightfully deserve.
    On or after September 11, 2001, an estimated 60,000 to 
70,000 traditional first responders and not-so-traditional 
responders came from every state in the Nation, including tens 
of thousands from the New York metropolitan area, working for 
days, weeks, and months in and around Ground Zero. Their hard 
work and bravery got New York and our Nation back on its feet, 
and we owe them tremendous gratitude.
    They were exposed to a complex and unprecedented mixture of 
toxic chemicals including dust, glass shards, and carcinogens 
like benzene, asbestos, and dioxin. The collapse of the towers 
in the morning and then a third building in the afternoon 
created a dust cloud turning a bright sunny day into night. The 
pulverized cement had a pH equivalent to lye. Fires burned for 
three months. Rubble operations, removal operations lasted 
through May 2002, repeatedly exposing these workers to dust.
    In addition to the physical exposures, they had extreme 
psychological stress. They came upon human remains. Their 
stress was compounded by fatigue as they worked hour after 
hour, day after day. Among those most affected have been the 
non-traditional responders, those not trained for any 
emergency, let alone a disaster the scale posed by 9/11. Mt. 
Sinai, through its Center for Occupational and Environmental 
Medicine designed and developed what stands today as the 
federal government's health response to 9/11, a model based on 
experience and expertise of academic physicians with specialty 
training in occupational medicine, surrounded by specialists in 
various disciplines.
    Our regional consortium of clinical Centers of Excellence 
in New York and New Jersey, together with the national program 
that initially was coordinated by Mt. Sinai and is now 
coordinated by LHI has provided 46,858 monitoring exams to 
26,651 responders in all 50 states. Mt. Sinai alone has 
provided over 30,000 of these exams to over 17,350 responders.
    Since the New York and New Jersey Metropolitan Area 
Consortium treatment programs began, we have provided nearly 
90,000 physical, mental and social work services in our 
consortium. Even now, approximately 150 new eligible responders 
join our program every month. Many of these responders continue 
to suffer health effects with attendant social and financial 
effects. We have seen asthma, sinus problems, GERD. Breathing 
tests still are abnormal in 25 percent of our patients. Mental 
health consequences are at rates seen in our returning veterans 
from Afghanistan.
    If we look at six months of conditions in approximately 
4,400 patients undergoing treatment in our programs, we see 
GERD or reflux in 53 percent. 35 percent have mental health 
problems. Lower respiratory conditions in 46 percent, upper 
respiratory conditions in 69 percent, social disability, no 
health insurance in 22 percent, and 64 percent have multiple 
medical conditions. Some have responded, but thousands have 
received treatment and still require care.
    One of my patients, Mr. S, is a carpenter. He worked for a 
New York City agency and was in great health. Never had a 
health problem. Never had shortness of breath. He developed 
GERD, reactive airways, sinus problems, anxiety, couldn't work 
in a dusty environment and thus could no longer be a carpenter. 
He lost his health insurance, fell behind on his bills, 
couldn't obtain worker's compensation because it controverted 
his case. He couldn't afford medication, his necessary tests.
    Through this program, he is receiving the care he needs, 
and his health is stable. He is not back to normal. He can't 
work anymore, but at least he is able to care for himself and 
his family.
    We know that new conditions, things marked by longer 
latency, will emerge among 9/11 responders since they were 
exposed to carcinogens, neurotoxins, and other chemicals toxic 
to the respiratory track in concentrations and combinations 
never before encountered. The future health outlook for 
responders remains uncertain, and the long-term consequences of 
an unprecedented mixture of toxicants is not known. All of us 
must remain vigilant for these problems.
    Through the medical findings I have summarized this morning 
and the persistence of illness that we are seeing in a 
substantial number of responders, we must have stable, 
predictable federal funding for a medical program for the 
responders. We establish these programs. We have established 
ties with our patients, gained their trust in our care for 
them, and we hope to continue doing this without interruption 
of care.
    We are also coordinating data. This is the only way we are 
going to know what has happened to the 9/11 responders. We, in 
real time, collect data on the outcomes, looking for medical 
trends, patterns of disease. We can assess the efficacy of 
treatments. We can inform the medical community, the scientific 
community, and the legislative community of these findings. We 
disseminate these regularly in medical journals, and this will 
provide essential guidance in helping us in any future 
disasters.
    All of the good work is impossible without the Centers of 
Excellence. We are providing state-of-the-art medical care to 
men and women who risk everything for us in a time tantamount 
to war. Our goal in these programs is simple: we want to 
provide the best care possible to these men and women and not 
worry we won't be there if they need care for World Trade 
Center related diseases. Passage of H.R. 847 will ensure that 
the heroes of 9/11 are never forgotten. Thank you.
    [The prepared statement of Dr. Moline 
follows:]*************** INSERT 8 ***************
    Mr. Pallone. Thank you, Dr. Moline. Dr. Reibman is next.

                   STATEMENT OF JOAN REIBMAN

    Dr. Reibman. Good morning, Chairman Pallone, Ranking Member 
Deal, members of the committee. My name is Joan Reibman, and I 
am an associate professor of medicine and environmental 
medicine at New York University. And I am an attending 
physician at Bellevue Hospital, a public hospital on 27th 
Street in New York City.
    I am a specialist in pulmonary medicine, and for the past 
17, almost 18 years now, I have directed the NYU/Bellevue 
Asthma Center and am pleased to be able to testify on behalf of 
the local workers, the residents, and the students of downtown 
New York who are exposed to World Trade Center dust and fumes.
    I am very pleased to be here today to support H.R. 847, The 
James Zadroga 9/11 Health and Compensation Act which would 
provided needed long-term funding for the monitoring and 
treatment of those members of the community exposed to toxic 
substances as a result of 9/11. Many of these individuals 
unfortunately have become patients with long-term health needed 
related to respiratory as well as other physical and mental 
health illness.
    Let me talk a little bit about populations at risk. You 
have heard a lot about the heroes who helped in the recovery of 
our city and our country. I would like to tell you a little bit 
about the people that we serve, the local workers, residents, 
and the students exposed to the World Trade Center dust and 
fumes. On the morning of 9/11, about 300,000 individuals were 
at work in the area or in transit to their offices. Many were 
caught in the initial massive dust cloud as the buildings 
collapsed. We now call these people the dust cloud people. 
These are the thousands whom you saw in the videos and the 
still photographs coated in white running for their lives.
    In the great outpouring of pride and patriotism after 9/11, 
many local workers returned to work one week later. The massive 
World Trade Center cleanup and rescue operation still in full 
force and not all the buildings completely cleaned or 
decontaminated.
    As you also know, lower Manhattan is a dense residential 
community. Almost 60,000 people of diverse race and ethnic 
backgrounds live south of Canal Street. They are economically 
diverse, some living in large public housing complexes, others 
in new co-ops. Lower Manhattan is also an educational hub.
    There are almost 15,000 or more school children, large 
numbers of university and college students. Many of these 
students were locked in their building. Others were told to run 
for their lives. The dust of the towers settled on streets, 
playgrounds, cars, and buildings, entered apartments, schools, 
and office buildings through windows, building cracks and 
ventilation systems. The World Trade Center buildings burned 
through December. Each of these groups have potential for 
exposure to the dust, both indoors and outdoors, and to fumes 
from the fires that continued to burn.
    So what were the initial health effects in these 
populations? As pulmonologists in a public hospital, we sought 
to determine whether the collapse of the buildings posed a 
health hazard, and we worked to monitor the effect on the local 
residents in collaboration with the New York State Department 
of Health and with funds from the Centers for Disease Control 
and looked at the rate of new respiratory symptoms in the local 
residents after 9/11.
    This first study was completed just over a year after 9/11 
and has also been reported in three peer-reviewed publications. 
We were able to document that individuals who lived near the 
area compared to those who lived away from the area had a more 
than three times the number of reported incidents of eye 
irritation, nasal irritation, sinus congestion, nosebleeds, 
headaches, a threefold increase in lower respiratory symptoms 
including cough, shortness of breath, a six and a half fold 
increase in wheezing. These are people who were previously 
healthy, and this was also associated with an almost twofold 
increase in unplanned medical visits and use of medications 
prescribed for asthma.
    Residents reporting a longer duration of dust or odors or 
multiple sources of exposure had greater risk for symptoms 
compared to those reporting a shorter duration. Data from a New 
York City Department of Health and Mental Hygiene World Trade 
Center registry further documented adverse health effects in 
building evacuees, school children, and support our original 
findings.
    What do we now know about these populations and their 
illness? After 9/11, we began to treat residents who felt they 
had World Trade Center related illness in our Bellevue Hospital 
asthma clinic. We then developed a community collaboration and 
together began an unfounded program. We were subsequently 
awarded American Red Cross liberties disaster relief grant in 
2005 to set up a medical treatment program. And a year later, 
we received major funding from the city of New York.
    In the last year, we have just received our first federal 
funding support for five years for a treatment program from the 
National Institute for Occupational Safety and Health. I am 
sorry, providing three years of support. We know have an 
interdisciplinary medical and mental health program that has 
evaluated and is treating approximately 3,500 patients. We 
continue to receive inquiries each week. Most come from local 
people; however, we have received calls from individuals living 
in about 20 other states.
    To enter our program, one has to have a medical or now 
mental health complaint. We are not a screening program for 
asymptomatic individuals. To date, our patients are almost 
equally men and women of diverse race, ethnicity, and many, 
although not all, are uninsured. Some have never sought medical 
care. Some have been unable to seek care for lack of insurance. 
Others have been seeing doctors for years since 9/11 with 
recurrent bronchitis, pneumonia, sinusitis, or unexplained 
shortness of breath.
    As described in an article that we have just published, 
these individuals, residents, local workers, as well as cleanup 
workers and a few responders in our program have symptoms that 
include persistent rhino-sinusitis, asthma-like symptoms of 
cough, shortness of breath or wheeze, for which they continue 
to need care more than seven, almost eight years after 9/11.
    Thirty percent have shortness of breath that is at a level 
consistent with significant activity limitation. Ten percent 
have the highest score on a standardized scale of 
breathlessness used for disability assessment. These are people 
who report that they were previously working and functional. 
Many report that they had been highly physically active, some 
training even for marathons. Over 50 percent of our population 
continues to have persistent post-traumatic stress disorder.
    There are a lot of questions about this population. What 
respiratory disease are we treating? We now believe that the 
exposure resulted in several respiratory illnesses with varied 
patterns. Many of our patients have irritant-induced asthma. 
Although we can treat this, these individuals require prolonged 
courses of inhaled corticosteroids and bronchodilators, 
sometimes even oral steroids. Many will require these 
medications for years, if not for life.
    Others show a process in the lungs that may consist of a 
type of inflammation, a granulomatous process that is like an 
illness that is called sarcoid. Others have lung diseases that 
affect not only their airways or breathing tubes, but also the 
air sacs that allow for the exchange of oxygen and carbon 
dioxide. Some have pulmonary fibrosis, characterized as 
scarring or permanent damage in the lungs and are awaiting lung 
transplants.
    How do we know whether an illness is World Trade Center 
induced? We often hear that these diseases are common in the 
population anyway. How do we know that these people are sick 
from World Trade Center exposure?
    Mr. Pallone. Dr. Reibman, I hate to interrupt you, but you 
have basically used about as much as the others. But looking at 
your written statement, you are not even halfway through. So I 
don't know if you could summarize from now on.
    Dr. Reibman. I would be pleased to summarize.
    Mr. Pallone. Thank you.
    Dr. Reibman. I would just like to say that without these 
centers, we will not understand what we are treating, who we 
are treating, and how to treat. We would not understand why 
some people are sick and others aren't. We would not understand 
if there are going to be late emergent diseases not only in the 
responder population but also in the community population. And 
therefore we think it is very important, and we very strongly 
support this bill that provides support not only for the 
responders but also for the community. And I would like to 
thank you very much.
    [The prepared statement of Dr. Reibman 
follows:]*************** INSERT 5 ***************
    Mr. Pallone. Thank you, and I apologize. Your whole written 
testimony becomes part of the record in any case, but I am just 
trying to keep the time to a minimum if we can. Next is Dr. 
Melius.

                    STATEMENT OF JIM MELIUS

    Dr. Melius. Thank you, Chairman Pallone and Representative 
Weiner. I greatly appreciate the opportunity to appear before 
you at this hearing this morning. I am an occupational 
physician epidemiologist, currently work for the New York State 
Labor of Health and Safety Trust Fund in New York. And I also 
served the last several years as chair of the steering 
community for the medical monitoring and treatment program.
    I believe that Drs. Moline and Reibman have already 
presented a good description of some of the illnesses that 
people are suffering that were exposed to the World Trade 
Center. I don't want to repeat that information. Only indicate 
it is certainly remarkable how many of the people are. The 
numbers sometimes get lost when one thinks what a high 
percentage is, as both of them have presented here today.
    We have a lot of sick people, and there are many that are 
disabled and many that are continuing to need intensive medical 
care.
    I would like to focus briefly on why do we need the federal 
program and what are some of the features of this legislation 
that I think deserve support here in Congress. We need the 
federal funding for this program because other funding just is 
not available. Health insurance does not cover work-related 
health problems. So they automatically get turned down. That 
includes Medicare.
    Many of the people in the community don't lack health 
insurance. All the problems that, I think, actually this 
subcommittee may be dealing with in terms of health care 
reform. We have major problems there. So those two together, I 
think, make health insurance a very--you know, provides very 
limited help for these people.
    One would think that worker's compensation would be a 
logical place that would support these kinds of illnesses. To 
the extent that they are work-related, it certainly could be. 
The problem is that worker's compensation is not very good at 
handling new kinds of illnesses, new kinds of findings, and 
takes a long time. The average claim takes over three years to 
make it through the system. And then even then it can be 
contested for many more years. If there are changes in 
treatment, regimen, something, the insurer can also contest 
that. So it is not a system that provides for good medical care 
for the kind of intensive medical care that these people 
require, and one that is complicated, one that is constantly 
changing as the Centers of Excellence learn more about that.
    So I think, just to be clear, the legislation provide for 
some recovery of whatever funding might be available for health 
insurance or worker's compensation, but that will never be able 
to provide the kind of comprehensive funding that is needed for 
these medical programs.
    So what has been devised in H.R. 847, which I strongly 
support, is a mechanism that provides where the federal 
government would provide funding set up so it goes to Centers 
of Excellence. Well, why Centers of Excellence? Because we need 
centers such as the ones that Dr. Reibman and Dr. Moline run 
that have significant core of expertise and experience in 
dealing with World Trade Center medical problems.
    As we have heard Mr. Torres say, when he first went to Mt. 
Sinai, he finally found a medical care provider that understood 
his problems and was able and ready to provide the kind of care 
that he needed. And the Centers of Excellence can do that, that 
by seeing large numbers of people with these conditions, they 
can understand the problems, develop the appropriate treatment, 
appropriate ways of diagnosing these problems. And they can 
standardize the diagnosis and care of that.
    They can also collect the data that is needed to learn not 
only what is happening to these people and what the findings 
are, but also are new diseases going to emerge. The list of 
covered conditions currently in the bill cover those that we 
know about now, that have a sound scientific basis in the 
medical literature, the asthma, post-traumatic stress, and 
other diseases that have been mentioned here. But we may very 
well see other kinds of illnesses, cancer. We just don't know 
going forward.
    By having the data collection place, we will be able to 
recognize those as they appear. There are already studies 
underway looking at this, and there are mechanisms in the bill 
both on an individual basis and on a collective basis to be 
able to take care of people with health conditions that aren't 
yet recognized but may be. But those would only be triggered if 
there is significant scientific and medical evidence saying 
that those conditions should be covered.
    There are also provisions in the bill that provide for 
significant oversight by the federal government in all aspects 
of this program. Certification that people are eligible for 
program, certification that they are eligible for treatment, 
that they have a World Trade Center condition that should be 
treated.
    Oversight over the quality of the medical care, oversight 
over the reimbursement for that medical care and I think the 
mechanism that parallels other federal programs in terms of 
providing a good oversight of this program. So it is not 
something that, you know, where the money will be carelessly 
spent. It will be very carefully spent and very carefully 
monitored by the federal government.
    And finally it also sets up a mechanism for recovery from 
health insurance and from worker's compensation insurers where 
that is appropriate for medical care treatment costs. So if, 
for example, in worker's compensation. If there is a claim that 
has been recognized or if a claim that is in process eventually 
gets recognized in the system, there will be a program in place 
for the federal government to recover the reimbursement that 
was already spent, the medical care costs that the federal 
government has already spent.
    And I think that will make a significant difference in 
terms of, you know, a fair share from those sources of funding 
the same time without impeding or unnecessarily delaying the 
medical care for the responders or for the community residents 
that are in this program.
    I think this bill as it is presently developed here, the 
medical program is--it has the right safeguards. I think it 
will provide excellent medical care, a way for us to provide 
what these people deserve for the sacrifices they made to our 
country and one that without the federal assistance just would 
not be provided for them.
    It has already been going on eight years, and I think it 
is, you know, time we try to get this program in place on a 
more permanent basis and provide a good sound and excellent 
medical program for these people. Thank you, and I would be 
glad to answer any questions.
    [The prepared statement of Dr. Melius 
follows:]*************** INSERT 3 ***************
    Mr. Pallone. Thank you, Dr. Melius. Mr. Holloway.

                STATEMENT OF CASWELL F. HOLLOWAY

    Mr. Holloway. Thank you. Thank you, Chairman Pallone, 
Ranking Member Deal, Representative Weiner, for convening this 
hearing on this important bill, the H.R. 847, the 9/11 Health 
and Compensation Act. I also want to thank Speaker Nancy Pelosi 
and the New York delegation for making it a priority to enact 
legislation to establish a sustained, long-term 9/11 health 
program.
    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. I was also an executive 
director of a panel convened by Mayor Bloomberg at the fifth 
anniversary of the attacks to assess the health impacts of 9/
11.
    That report called for sustained, long-term program to 
provide monitoring and treatment to address the health impacts 
of 9/11 and for the reopening of the Victims' Compensation 
Fund. Since that time, Mayor Bloomberg, myself, and many others 
of the members of the mayor's administration have traveled here 
to Washington to make the case for sustained federal funding. 
In fact, as you may recall, last July, I testified before this 
subcommittee. And it is a privilege to appear before you again. 
It is also a privilege to appear here with Mr. Torres and these 
distinguished doctors who are involved in the treatment of 
these conditions.
    As members of this committee know, a tremendous amount has 
happened since I last appeared before you. In terms of this 
bill, the city has engaged in extensive discussions with 
stakeholders, including people at this table, and some of the 
issues that existed in the prior version of the bill have been 
addressed. In terms of the city's economic outlook, we are 
still in the throes of an economic crisis that has resulted in 
the highest unemployment rate in New York City since October 
2003 at a projected budget gap of $3.2 billion in fiscal year 
2011 that could grow to $4 billion and more in future years.
    Mayor Bloomberg has moved aggressively since well before 
the scope of this current crisis became apparent to save for 
tough times and cut costs. But even with these measures, the 
city will have to make deep cuts.
    I mention these statistics not merely because they are 
timely, but because the city's finances are severely strained. 
We must concentrate resources on providing the essential 
services New Yorkers and visitors to the city need and on 
getting the economy running again. With respect to H.R. 847, 
the version of the bill currently before this committee is an 
important step forward, and in its broad strokes achieves what 
the city has long been seeking: sustained funding to treat 
those who are sick or who could become sick because of 9/11, 
and it reopens the Victim Compensation Fund so that those who 
were harmed can be fairly compensated quickly and efficiently 
without having to prove that the city, its contractors, or 
anyone but the terrorists were at fault.
    But there are two important issues that, in the city's 
view, must be addressed. First, the bill requires the city to 
pay 10 percent of the entire treatment and monitoring costs for 
anyone eligible under the bill. Based on the best information 
we have to date, which Chairman Pallone mentioned from CBO--I 
am sorry, Ranking Member Deal--this translates into 
approximately $50 million per year and $500 million over 10 
years.
    And it is unfair for New Yorkers to bear so much of what we 
believe is clearly a national obligation. Moreover, 
particularly at a time when the city is being forced to make 
deep cuts including to essential services, this cost share is 
simply too high.
    Second, regardless of what the city's cost share ultimately 
turns out to be, the bill does not give the city adequate 
oversight of the programs it is expected to fund. This issue 
can be easily addressed by the inclusion of a right-to-audit or 
similar mechanism in the bill, and it should be included to 
make sure that we can oversee the program appropriately. We are 
confident that these issues can be addressed before this 
committee and in this legislative process, and the members of 
the committee have heard a lot of the detail about the scope 
and impacts of 9/11.
    So I won't repeat that except to say that what the mayor's 
report established when it came out in 2007, I think beyond 
question, was that this is a serious problem, that people are 
suffering serious mental and physical illnesses as a result of 
9/11, and that additional people continue to get sick, that it 
is imperative that those people get treated, that there 
continues to be research to fully understand the impacts, and 
that the funding be sustained. That is why we are here, and 
that is what we are seeking. And the research that has come out 
since the mayor's report, which Dr. Reibman, Dr. Moline and 
others have continued to produce, continues to validate these 
facts.
    I just want to mention quickly a couple of programs that 
haven't been mentioned here today. Most importantly the FDNY's 
program, which is also a Center of Excellence and has involved 
14,000 of the firefighters who are being monitored and several 
thousand who are being treated.
    In addition to that, with the federal government's 
assistance, we have also started back in 2003 the World Trade 
Center health registry which is without a doubt the best source 
of research that we are going to have in addition to the 
clinical research that we get out of the Centers of Excellence 
to ensure that we fully understand the impacts of 9/11.
    Now, the city hasn't waited for federal funding in order to 
address the needs that we found in our report. And in fact, the 
city is the primary funder of the Health and Hospitals 
Corporation Center of Excellence that Dr. Reibman runs. 
However, this program and many other programs are in jeopardy 
because the city took up the funding obligation to run these 
programs based on a need and also on an assumption that the 
federal government would ultimately come to the table and help 
us to get fully engaged and cover these costs. That is why is 
it so important that this bill be passed.
    As Dr. Melius explained, this bill provides long-term 
funding and has controls in it that we think are appropriate 
and ensure that money will only go to those who have actually 
been affected and are ill because of 9/11. So I won't repeat 
that.
    And I think to sum up, the--pardon me for one second. To 
sum up, the bill has important controls. It establishes the 
long-term funding that the city is seeking and is required to 
ensure that this problem, which we know is long term and we 
know can't be properly sustained by year-to-year ad hoc 
appropriations, can continue so that those who are injured as a 
result of 9/11, which was an attack on the Nation and not 
merely on New York City, can get the treatment they need.
    And it is important to note when we talk about the registry 
and as Representative Nadler and King mentioned in their 
testimony, this is not just a New York City problem. The World 
Trade Center health registry contains representatives for 
nearly every congressional district in the country. Ranking 
Member Deal, there are several hundred from Georgia who 
participated and a few from your district. And I am sure, as 
you know, Chairman Pallone, many thousands from the state of 
New Jersey and your district.
    As I mentioned at the outset of my testimony, there are the 
two issues that the city believes needs to be addressed and can 
be addressed in this legislative process. That is the cost 
share issue, and the issue of oversight if the city is going to 
be expected to fund programs that it doesn't control.
    And I do want to say importantly the city is not opposed to 
a cost share at all. In fact, Mayor Bloomberg fully embraced an 
earlier version of this bill in which the city was going to be 
required to pay a 5 percent share of the Centers of Excellence 
that are run by the city, which is the Health and Hospitals 
Corporation and the one treating community members. We think 
this is important because it gives the city the incentive that 
is needed to ensure that funds are spent carefully and wisely.
    However, the share that is in the bill, which could cost 
New York City taxpayers alone up to half a billion dollars is 
simply too high. However, we are hopeful that these issues will 
be addressed, that we can fully support a bill and that it will 
be presented for the President's signature before another 
anniversary of the attacks passes. Thank you very much, and I 
will be happy to answer any questions.
    [The prepared statement of Mr. Holloway 
follows:]*************** INSERT 4 ***************
    Mr. Pallone. Thank you, Mr. Holloway. Thank all of you. We 
now are going to have questions from the panel, and since there 
are only three of us, we may actually have two series of 
questions. We will see if anyone else joins us. You know I 
guess I am sort of following up on what Mr. Holloway said in 
the sense that, you know, if you wanted to be devil's advocate, 
and I guess I shouldn't be devil's advocate because I am from 
New Jersey and I would like, you know, this to be as robust as 
possible since so many of my New Jersey residents are impacted.
    But, you know, I guess one could argue, you know, the 
program exists. Obviously you have described how effective it 
is. To my knowledge, nobody is being turned away at this point. 
But we are really here with this legislation is making a 
permanent authorization for a program that basically does exist 
and has been funded for the last few years.
    And my questions are more along the lines of, you know, why 
do we need to make it permanent? And is this the time to do it? 
You know part of the problem that we have had with all of this 
is knowing how many people are going to be impacted, how many 
disorders are going to come forward. It does seem that as time 
goes on, there are more people that come forward and more 
people that are being seriously affected in terms of their 
health. And if that trend continues or accelerates, you know, 
we may have even more people that we anticipate because, you 
know, you have the caps right now in the program. I guess it is 
15,000 responders and 15,000 residents beyond those that are 
already in the program.
    So I guess I would start first with Dr. Melius or any of 
the doctors. You know you mentioned, I think, that there is a 
list of identified World Trade Center related health conditions 
in the bill. Do you expect that those additional diseases will 
emerge as the World Trade Center related, you know, conditions 
have more of an impact? And under the bill, how are additional 
conditions added to the list? Let us at least start with that.
    Dr. Melius. OK, I think we all would expect that there will 
be additional conditions added.
    Mr. Pallone. Right.
    Dr. Melius. There are a number under investigation already, 
and we know that people were exposed to carcinogens and a lot 
of toxic materials. And so I think looking forward, we would 
expect some. In the bill, I think, it was structured in a way 
that puts the caps in place so that that wouldn't get out of 
hand. And in terms of the list of covered conditions, we have 
to handle it without having to come back to Congress and say 
well, you know, this program is going to cover hundreds of 
thousands of people because they are sick, then we ought to 
rethink how we do this and so forth.
    In terms of the list of covered conditions, you know, the 
current list is based on one of clinical experience, Dr. 
Reibman and Dr. Moline and others, plus what has been found in 
the studies. It is a well-based risk, and in the current, you 
know, scientifically sound and reviewed multiple researchers 
that made these findings including some outside the program.
    So I think everyone is confident in what is on the list. 
Going forward, there is a mechanism to add specific covered 
conditions, say a type of cancer or something that is seen. 
One, there has to be some amount of scientific evidence 
available demonstrating that it should be covered.
    Secondly there is a process where the federal government, 
NIOSH, would promulgate a regulation to add that condition on 
the list of covered conditions. So they would be required, as 
with any regulation, to justify it, justify the cost, justify, 
more importantly, the science behind that. There is also 
provisions in there for a scientific advisory committee for the 
program to also review that information and be involved in 
making that recommendation.
    Mr. Pallone. Now, in terms of where we are, I mean you--I 
certainly get the impression from listening to you, and I know 
this may be difficult to answer. But I certainly get the 
impression that as time goes on, we are going to see more 
people that are affected and possibly worsening conditions. I 
mean is that just inevitable because as people age, you know, 
these symptoms and diseases get worse? Or is it possible, you 
know, that at some point, you know, that doesn't happen 
because, you know, time is somehow a healer? I mean I get the 
impression the opposite, that we should expect as times goes on 
that we are just going to have more people and worse 
conditions.
    Dr. Melius. I will let Dr. Moline and Dr. Reibman follow 
up, but I think it is a mix. There are people newly coming in 
that develop conditions, but there are also people getting 
better. In fact, one thing that has been observed in the 
responders program is that the treatment costs actually appear 
to be going down per patient on an annual basis because 
patients get stabilized in terms of treatment and so forth. A 
number of them do get better, are able to continue to work and 
so forth. Now, some don't. And so there is a balance there. So 
I don't think it is inevitable that these numbers will continue 
to get bigger and bigger because some people will recover.
    Mr. Pallone. But let me just ask----
    Dr. Melius. We just aren't able to predict accurately, I 
think.
    Mr. Pallone. Well, then I guess my third question would 
be--and if you want to ask Dr. Moline to answer it--the caps 
that are in place, I mean are they based on projections that, 
you know, you are seeing an acceleration of the numbers? I mean 
how is that derived at, or is it totally artificial?
    Dr. Melius. The caps are--on the responder program, the 
caps are based on an assessment of how many people we know that 
would be eligible for the responder program. We know how many 
people, you know, worked at the cite at least, you know, 
within, you know, several thousand. So we do that, and we have 
some, I think, pretty good idea of how many of those, you know, 
haven't come forward yet who are eligible and might come 
forward in the future. And then, you know, the assumption that 
they are not going to be any sicker than the people that are 
already in the program. In fact, there are probably going to be 
fewer that require treatment. So I think it is unlikely that 
that cap will be reached for the responder program.
    For the community program, I think we had less experience 
and maybe Dr. Reibman wants to comment, but it was trying to 
say that given the time when this legislation was being passed, 
given what was coming forward at that time, who we knew at that 
point that was coming forward that was ill that was eligible 
for the community program, you know, that that was a reasonable 
number that would fit in going forward and at least would for, 
you know, some significant period of time, 10 years or more, 
would, you know, be legitimately capping the program without 
denying large numbers of people care. It may need to be 
adjusted we don't know.
    Mr. Pallone. OK, gentlemen, I am being a little loose with 
the time here since there is only three of us. I am not going 
to clock any of us here. So if Dr. Reibman or anybody else 
wants to answer some of the questions.
    Dr. Reibman. I just want to reinforce what Dr. Melius just 
said which is for the community group, we have very little 
information to go on. We could only go by what we were seeing, 
data from the New York City Department of Health registry where 
we could sort of estimate a burden of illness and also 
understand that some people will be going to their own 
physicians. So it was really, with the information we had at 
hand, our best estimate.
    Mr. Pallone. OK, Dr. Moline?
    Dr. Moline. I think if we look at the responders who are 
coming in, about 150 are coming in consortium wide every month. 
This is down from the first two years of our program, beginning 
in 2002 to 2004, we have 12,000 responders.
    Mr. Pallone. So you are actually getting less per month 
instead of more?
    Dr. Moline. We are getting far fewer per month because----
    Mr. Pallone. Fewer.
    Dr. Moline. --most people are already in. I mean the 
question is why are some people coming in now.
    Mr. Pallone. Right.
    Dr. Moline. Where have they been? And there are a couple 
reasons. First and foremost, many people are very stoic. We 
also know that in a population that is overwhelmingly male, the 
responder population, they tend not to access health. They 
don't like doctors. I don't know why.
    Mr. Pallone. Stoic is the same as denial? Or that is a 
little different I guess?
    Dr. Moline. It is both.
    Mr. Pallone. Yes.
    Dr. Moline. It is a nice way of putting it sometimes, but 
some people--you know actually what I have often been amazed at 
is people feel they don't deserve to come in. Others are sicker 
than they are, and they reach a certain point. Or their wife 
says, you know, you have been coughing for seven years. Can you 
get it checked out finally? Or other health problems. Or their 
friend is getting care, and they say you know what, I am 
getting care. You were with me. Come in. So there are a variety 
of motivating factors, or they may just have had enough and 
that is why they are coming in. Some people actually haven't 
heard about the programs, which is surprising to us, but they 
may not know it is out there, and so they are coming in now for 
the first time.
    Mr. Pallone. OK, Mr. Deal.
    Mr. Deal. Well, first of all, thank you all for being here. 
We do have to ask the hard questions, and the first question 
that comes to mind, I think, from somebody who is not from the 
immediate area affected is that if we are asking the taxpayers 
of this country to pick up a tab that is estimated, from what 
we have up to this point, of at least a billion dollars a year 
additional federal expenditures for a restricted group of 
individuals, the first question I think that comes to mind is 
why do we have the stories such as Dr. Moline's illustration 
of, I believe, the carpenter who said that his worker's 
compensation claim was controverted and he was not being able 
to receive treatment based on the first line of providing 
treatment, which most people consider to be worker's 
compensation? Is the city of New York continuing, Mr. Holloway, 
to resist worker's compensation claims? And if you are and you 
are saying that the conditions on which you are being asked to 
compensate are not compensable, why should the federal taxpayer 
pick up something the city of New York is not wiling to pay 
for?
    Mr. Holloway. Well, the answer to that question has a 
couple of elements to it. First, when it comes down to 
individual worker's compensation claims, yes, there are cases 
that are 9/11 related that are controverted in the worker's 
compensation parlance by the city. But the reason for that is 
really--and Dr. Melius I think will jump in later.
    But the reason for that is that the worker's compensation 
system itself is not equipped to deal particularly well with 
these types of claims. The issues that we are dealing with with 
9/11 related illnesses at this point, they are late to arise. 
They are latent, and so important questions of causation and 
other issues arise in the context of these long tale claims 
that make it difficult to resolve one way or the other without 
an extended look at what is the medical evidence and so forth.
    And the reason for that is because the city does have an 
obligation through the worker's compensation system. You can't 
simply decide that it doesn't matter. You have to meet the 
standards in the statute. You have to--the city does have an 
obligation to, you know, protect the public. And so the way 
that the system is set up, it is poorly equipped to handle 
this.
    Now, New York State has made some changes in the worker's 
compensation law that address a few of these things, and one of 
those is an extended period to put in for a claim so that you 
don't have the two-year statute of limitations problem and some 
other things.
    But in the main, the system has some structural elements to 
it that make it difficult also. The system itself will 
compensate certain types of claims, but there are other people 
who are impacted. Uniform services actually get their 
compensation through--don't get their compensation through 
worker's compensation. It is a line-of-duty injury, but similar 
issues arise, and then community members, residents, and others 
who are impacted aren't eligible for worker's compensation.
    One other point is that the bill itself provides that in 
the event worker's compensation is recovered or it is deemed 
that it will be likely to be recovered, that goes first in 
terms of paying for the claims, which we fully support. So that 
is a long answer but----
    Mr. Deal. Dr. Melius?
    Dr. Melius. Can I just elaborate briefly? For the New York 
State worker's compensation systems required two, at least two 
pieces of legislation to amend that to make it possible that 
all the World Trade Center claims to be dealt with within that 
system and had a statute of limitations and just the nature of 
the injury coming out or illness coming out of their work. And 
that has helped somewhat.
    I recently served on a committee and then a task force for 
the state legislature to examine this whole issue. We are 
issuing a report, which I believe will become public tomorrow 
on this. Made a number of recommendations for actually 
requiring further legislative changes that we think that we 
will make this system work better.
    The city of New York has actually agreed with those changes 
even though it will, in some ways, you know, facilitate claims 
against the city of New York. So we are trying to work together 
to address that. It is just hard in a bureaucratic legalistic 
system like the state worker's compensation system.
    And even when it does, you know, for example, you would 
have a situation where someone is getting compensated for their 
asthma that may not provide help for their sinus condition or 
some other condition. It has to be, you know, a separate claim 
and follow through on. So it is complicated and difficult. All 
the clinics that are involved here, the Centers of Excellence, 
are also working very hard to assist people in filing claims. 
That was not--help was not available up until about two years 
ago. So there are efforts underway to try to improve that. And 
I think the city and others are supporting that. But it is 
still going to be difficult. It will never be, I think, an 
adequate for this particular situation.
    Mr. Deal. Dr. Moline?
    Dr. Moline. For this particular gentleman, his claim was 
controverted and eventually--it took about three or four 
years--it was judged in his favor. That is a typical delay. 
During that three or four-year period when he was no longer 
able to work and he lost his health insurance, he had no avenue 
to get health care. The program stepped in. We are now 
recouping the cost, and they will be offset as program income 
within the monies that we have received. So it allows to extend 
the care that we provide.
    But, you know, in his particular case, we tried to get 
diagnostic testing because he had such horrible reflux that he 
needed to have an endoscopy, a simple test where you look in 
and to make sure that he didn't have something more serious 
going on. And that particular test was denied by worker's 
compensation. Turned out that he had he test, and they found 
some abnormalities. That was paid for by the program. And it 
allowed us to give him the appropriate treatment to get him 
better.
    As a treating physician, this program has allowed us to 
provide the care for people to make sure that they get better. 
What we also do is we fill out the necessary paperwork to make 
sure that compensation, if it is there, everyone gets the 
appropriate medical documentation that they need to make sure 
these claims go forward as well.
    Mr. Deal. I think your statements have really illustrated 
the point that I am making is that somebody from the outside 
looking at this saying that if this kind of injury or problem 
resulting from exposure does not meet the definition of a work-
related condition under worker's compensation law for the state 
of New York or the city of New York City, then why should we 
have a broader, all-encompassing definition that the federal 
taxpayer is required to pick up?
    And that is just a problem, and I think trying to refine 
the statute to address that as best we can is very important 
because I think it is something that you have to convince other 
people that are you not just coordinating this big picnic 
basket that certain groups of individuals can come dip into the 
federal treasury through this mechanism.
    Let me ask one other practical thing, and that is I see the 
group that is here, and many of them have the New York Fire 
Department EMS shirts on. And one of the things that has been 
called to my attention is that apparently there is no provision 
for retirees or a retiree representative from that group to be 
on this advisory board that the statute creates. I would assume 
that you are going to have a large number of people who are in 
a retirement status that are going to be eligible on an ongoing 
basis for some of these benefits.
    Do any of you know why that retiree group would not have an 
advisor board member?
    Dr. Melius. Well, yes, let me answer that. I chair the 
steering committee that, I think, is being referred to here. 
The steering committee was set up with a specific number of 
labor union representatives beginning and along with 
representatives from all of the participating medical centers. 
Those representatives, the union's representatives, do 
represent retirees. The union I work with has at least three 
retiree organizations that are part of this program that are 
consulted. And we provide benefits to those retirees, health 
and pension. I believe all of the other unions involved do the 
same.
    There are many other union, other groups that potentially 
could be represented on the steering committee. There has to be 
some way of selecting those. The original selection was based 
on who was most involved in the program. It is certainly clear 
that the people in the retiree groups as time goes by and more 
of these people age and get old will be important in terms of 
representation. We need to work out a way for them to be 
involved in the program.
    There are other ways. Mt. Sinai has its own advisory 
committee. The fire department does. Some of the other clinics 
do. Dr. Reibman has a program. And we also--there are 
provisions in the legislation for additional people to be added 
to the steering committee, and so that will be worked out over 
time.
    But there are many groups to choose from so it is not like 
there is one umbrella retiree group that one could select. It 
has to be looked at. Some of those people with concerns I have 
met with and have offered to go out and meet with some more to 
talk. And we want to make sure that their concerns are 
addressed.
    Mr. Pallone. Thank you, Mr. Deal. Mr. Engel.
    Mr. Engel. Thank you, Mr. Chairman. You know I live about 
eight miles from the World Trade Center. My district begins 
about eight miles. And I remember about five days after 9/11, 
burnt pieces of paper falling from the sky into my district. 
With my own eyes, I remember seeing that. And that is eight 
miles away. So imagine the people who live right on top within 
a 1.5-mile radius. I understand the community program would 
help only the people with the 1.5-mile radius.
    I want to talk a little bit about the World Trade Center 
related illnesses experienced by people living in the disaster 
area. That hasn't received as much public attention as those of 
first responders, but in many cases, they are just as serious. 
And I don't take away anything from the first responders. I 
fight 100 percent for them, but there are also people in the 
area.
    This legislation provides medical monitoring and treatment 
services for community residents and workers affected by the 9/
11 attacks, not just the responders. So Dr. Reibman, can you 
tell us about the kinds of people that the community program 
treats and how they were exposed to the toxic dust from the 
World Trade Center collapse?
    Dr. Reibman. We have a variety of people, and we sort of 
group people by whether they were residents, whether they 
worked in the area, went to school in the area, or were there 
commuting, for example, people who were stuck in the tunnel at 
the time of the collapse.
    We also then look at people who were in the initial dust 
clouds of that day or people who came back a week later. And 
what we are finding is that there is a great variety and 
difference in how people's health responded to these exposures 
but that many people have many of the same illnesses that you 
are hearing described in the responders of chronic grinus 
sinusitis, that is sinus infections, nasal congestion, 
shortness of breath due to asthma or other lung diseases as 
well as gastroesophageal reflux disorders and clearly a lot of 
mental health issues.
    Mr. Engel. You talked a little bit about the kinds of 
illnesses these community members are suffering from as a 
result of their exposures. Can you tell me about the 
similarities similar to those of the responders? What I am 
trying to get at is that I believe that it is just as serious 
to help the people living in the immediate area as well. And do 
you find that the first responders and the people in the area 
have had similar difficulties?
    Dr. Reibman. What you are raising is a very important 
question, which is how do we know whether these illnesses are 
World Trade Center related or not. And we don't always know 
except by seeing many of the same symptoms over and over and 
over again in many of these people. The severity is clearly 
variable, and we have people who have very, very persistent 
sinus disease who have required surgery for their sinuses on 
repeated occasions.
    We have people who, for example, used to run a marathon who 
are now on chronic medications. We have people who can no 
longer--had to have their offices moved because their cough was 
so irritating that their workmates couldn't sit next to them. 
So that there is clearly a variety of severity in these people.
    We think that is due in part to degree of exposure. People 
who were in the dust cloud, for example, on the first day or 
people who had prolonged exposure as well as individual 
response to these exposures.
    Mr. Engel. Dr. Melius, can you explain what role provide 
health insurance would play in the community program under this 
legislation?
    Dr. Melius. Yes, under the current legislation, people that 
have coverage, there would be a billing mechanism set up for 
the government to be able to, through the clinics, the treating 
clinics, to recover the cost. So health insurance for those who 
have it, non-work-related health problem, health insurance 
would be essentially the first payer. And then what was not 
covered by health insurance would be covered through the 
federal program.
    Mr. Engel. Thank you. Can I ask you also, Dr. Melius, the 
legislation relies on Centers of Excellence for providing most 
of monitoring and medical care for the program. Responders and 
community residents who qualify for the program can only 
receive services at the program's expense through these Centers 
of Excellence.
    Now of course, the patients, the way I understand it, they 
continue to see their personal physicians. But if they want the 
monitoring and treatment services for the World Trade Center 
related conditions that the program offers them without charge, 
they will have to use the Centers of Excellence. Is that true? 
Am I right? And in your testimony, you defend the continued use 
of the Centers of Excellence. So why do you think that we 
should continue to rely on these centers rather than allow 
individuals to use their personal physicians?
    Dr. Melius. Yes, the reason for relying on the centers is 
because given all that we don't know about what is going to 
happen to these people medically and given the complications of 
diagnosing and treating them, we believe that a better quality 
overall medical care can be provided to them through these 
Centers of Excellence rather than trying to rely on providing 
that same experience and medical information to their personal 
physicians.
    Now, both Dr. Reibman and Dr. Moline would tell you that 
they coordinate with the personal physicians. So that--who may 
be treating the same person for some unrelated health 
condition, you know, heart disease or something that is not 
related to the World Trade Center. But I think it has been the 
experience of all the programs that it has not worked well for 
people to go to their personal physicians because they just 
don't have the experience in handling these types of 
conditions, and the quality of care is not as good.
    Now, there are also provisions in the legislation to allow 
for the expansion of the Centers of Excellence to bring in new 
centers and so forth. And I am sure, in fact, that the 
judiciary hearing on March 31, the police detective who had 
serious pulmonary disease and had developed before there was a 
treatment program, was being seen by another major medical 
center in New York City. And there is no reason that that 
medical center could not become part of this program, and there 
are a number that expressed interest.
    So I think we need to expand that out. It is also certainly 
true for the national program, people living in other parts of 
the country, that there be additional centers and additional 
physicians brought in. But it is trying to strike a balance 
between getting good care and ensuring that there is good 
follow up and at the same time, something that is convenient 
and practical for the patients.
    Mr. Engel. Dr. Moline, did you want to comment?
    Dr. Moline. I think Mr. Torres actually told us why a 
Center of Excellence can be essential in his care. He was going 
to a wonderful physician on the outside, but when he was able 
to come to a Center of Excellence, they were able to make a 
connection between his illnesses because we have seen thousands 
of people like Mr. Torres with the same constellation of 
symptoms and knew how to treat him in the same manner that we 
have treated thousands of others.
    One other issue related to not having Centers of Excellence 
is if we want to know what the ramifications were from a 
disaster, a manmade disaster, terrorist or otherwise, if the 
cure is fragmented, if it is in--if everyone is not receiving 
centralized care in a number of centers, then we will have no 
way of knowing the true scope of illnesses. There will be no 
way of being able to scientifically say that exposures to--of 
this sort can cause health problems. So that in 20 years when 
something else happens, we can say that every doctor is going 
to know because it will have been in the literature that these 
are the things you do first.
    And they are in this not only to treat people now, but to 
be able to inform the doctors and the people who might have 
ailments going forward.
    Mr. Engel. Mr. Torres, would you want to comment on that?
    Mr. Torres. Yes, just like the doctor said I already 
commented on my experience. I was going to my doctor almost a 
year, and I had a CAT scan done from my neck down, and they 
never found nothing wrong with my throat, but I was losing my 
voice. When I went to the monitoring program, when they were 
evaluating me, one of the doctors there said well, Mr. Torres, 
if you have GERD, acid reflux and you are having a breathing 
problem, a lot of people need to see an ENT doctor.
    So we are going to make an appointment for you, and they 
sent me to a throat doctor. And when they put the scope down, 
there was a polyp, a mass, in my throat, which wasn't picked up 
by a CAT scan, which wasn't picked up by my doctor, which--this 
might sound strange--was a very happy moment for me because I 
got an answer out of a year of no answers.
    And I am one of those males that don't like going to the 
doctors. I am one of those males that my wife had to force me 
to go to the doctor, and I was so happy to finally get an 
answer because I was tired of going to the doctor and coming 
back home and not knowing what was wrong. And I knew there was 
something wrong.
    Mr. Engel. Well, thank you. It is very good to hear 
firsthand experiences, Mr. Torres, Mr. Holloway. Let me ask one 
final question. How does the legislation--and perhaps Dr. 
Melius would be the best to answer this, but anybody else can. 
How does the legislation ensure that the care received through 
a Center of Excellence is coordinated with the care received by 
a responder or community resident from his or her personal 
physician? Mr. Torres talked about how he wasn't getting 
answers. But if someone has gone to a personal physician, how 
is it coordinated with the Center of Excellence? How does this 
legislation ensure that it is coordinated?
    Dr. Melius. I think there are no specific provisions in the 
legislation for that, but the normal way that--usual way that 
these physicians operated in these centers is they focus on 
World Trade Center related conditions. So they are focused on 
the sinus, on the lung disease and so forth.
    When there are other personal health problems that people 
may have, existing conditions or something else develops that 
is non World Trade Center related, then as any specialist 
would, they would refer back to the primary care physician. 
They would be building off what medical records, what medical 
information they would be in contact with that personal 
physician in terms of either doing referral or direct referral 
back for further care, and I think that is routine in the 
operation of the Sinai program and the Bellevue program.
    Mr. Engel. Right, but what about someone who gets care from 
a private physician and now is going to the Center of 
Excellence, as Mr. Torres said, went to a private physician 
first and a Center of Excellence? What is the coordination? 
Does the private physician reach out to the center? Would the 
center reach out to the physician? How would we know that it is 
not duplicative? That is the kind of question I am asking.
    Dr. Moline. There is a variety of ways at Mt. Sinai we do 
this. First of all, every patient who is in a monitoring 
program, whether it is the fire department's monitoring program 
or the consortium monitoring program, gets a results letter to 
bring with them to their doctor. And they get a copy of all of 
their test findings.
    We also ask if they would like copies sent to their doctor. 
If they give us authorization, then we send copies of all of 
this information to their doctor. All of our physicians reach 
out to these doctors to make sure that we aren't going at cross 
purposes, we are not both prescribing the same medications or 
medications that might counteract each other, that we are all 
on the same page in providing the best care.
    We are working in many ways as a consultant would to a 
primary care physician. We are providing care for a number of 
conditions. In addition to going to your family doctor for your 
routine checkup, you would be referred to--if you had a back 
problem, you would be referred to an orthopedic surgeon. The 
orthopedic surgeon would communicate back to the family doctor 
to say yes, this is what I saw. That is how we work with the 
private doctors.
    Mr. Engel. Well, thank you, Dr. Moline, and thank you for 
all the good work you do. And thank everyone. I want to thank 
everyone on the panel for the good work you do and for the 
people who have the courage to make their public struggles--
their personal struggles, to share them with us.
    It is very important that the country understands, as so 
many people have said, that this is a problem affecting all of 
us. And we need a federal response, and that is why we need 
this bill. New York happened to be the place where the 
terrorists attacked, but the terrorists attacked New York 
because of the symbol of New York and what it means.
    And therefore we have a tremendous responsibility. And 
those doctors who were on the front lines, you indeed are first 
responders because you are on the front lines. And those people 
with the courage to tell us their stories are really making 
such great progress.
    And finally, Mr. Chairman, I want to commend you because I 
am on this subcommittee, and there are so many related health 
concerns that we have in this country. And you and I have 
spoken many times about the need to have this hearing, and you 
have always been positive and helpful. And obviously this 
wouldn't have happened today without your leadership in this 
very, very important matter. And you and I have discussed this, 
and I am confident with you as chairman we are going to finally 
move forward and break through and pass this legislation, which 
is so desperately needed.
    So thank you again, Mr. Chairman. I want to state on the 
record how helpful you have been.
    Mr. Pallone. Well, thank you, and we do intend to move 
forward. Mr. Weiner.
    Mr. Weiner. Thank you, Mr. Pallone, and I want to echo the 
remarks of Mr. Engel. You and Mr. Deal have been very helpful 
in moving this forward, and it reminds us that when the first 
Victim Compensation Bill was passed, it was unanimous or nearly 
unanimous, the notion that people who perished in what was 
essentially an act of war deserve not only our gratitude. But 
they also deserve a quick dispensation of the needs of their 
surviving family members.
    And the universe of people that we talk about today, in 
fact many of them are people who are dying by degrees because 
of that day. And has been remarked in the past, if we knew then 
that people would be dying years later, there is no doubt in my 
mind that we would have, in a bipartisan fashion, changed the 
language of the bill to make sure that the Victim Compensation 
Fund took into account people like Mr. Torres.
    And Mr. Torres, who speaks for many people, some of whom 
are here, many of whom have gone on with their lives, some of 
whom unfortunately have perished, many of whom are sick. They 
responded that day because it was a combination of their job 
and their sense of their obligation to their neighbors. They 
went without being asked to sign forms. They didn't go with an 
instruction book. If anything, they advice they were getting 
from many officials, as we now know, was wrong.
    We had head of the EPA at the time saying the air was just 
fine. People were handing them equipment that you wouldn't use 
to paint your apartment, and they were being asked to wear it 
when they were dealing with the toxic soup that has been 
described here as unprecedented.
    But let me just ask a question that perhaps can refocus us 
on the broader question. The people with Drs. in front of your 
name, is there any doubt in your mind that people today are 
dying because of the attacks on September 11 and their 
proximity to that attack?
    Dr. Reibman. I think that people are very, very sick 
because of September 11 and their proximity at that time. We 
certainly hope we can prevent them from dying.
    Mr. Weiner. Dr. Melius, is there any doubt in your mind 
that are people who are dying by degrees because of that 
attack?
    Dr. Melius. Absolutely not.
    Mr. Weiner. Dr. Moline, any doubt in your mind that there 
are people who are dying by degrees because of that attack?
    Dr. Moline. Absolutely not.
    Mr. Weiner. And, Doctor, I want to take a moment to thank 
you. I have seen your work secondhand as folks who are close to 
me have turned to you for care and have received it. One of the 
questions that has come up is that whether or not in addition 
to us providing a service to the people who are sick, we also 
send a message to future generations of people like Mr. Torres 
that if they do run into the aftermath of these things and try 
to help out, that we are going to be there for them just as we 
would if they were soldiers.
    Mr. Torres, I know that you have said in a couple of places 
that you don't regret anything about the way you acted and your 
colleagues, the service that you provided. But certainly there 
must be a time in the still of the night where you think boy, 
was it worth it? Are you concerned that if someone--if you are 
seeing someone else and they say to you, you know it sounds 
like you got really sick from being there on the job and now 
the federal government isn't responding, that we might be in a 
circumstance in future attacks where people start to have 
second thoughts about whether or not they should go into that 
place when called by their neighbors?
    Do you think about that at all that, you know, that all 
that you have gone through--and you must have a lot of brothers 
and sisters who have situations that are like yours. They must 
sometimes say to themselves you know what? If I knew then what 
I know now, maybe I wouldn't have raced there to be of help.
    Mr. Torres. That conversation comes up a lot. At the 
workplace, it comes up. Just two days ago when I was telling my 
wife about this committee, she asked the same question. What 
will happen if they don't pass this bill? Will people go back 
out there and help again?
    I have a brother who is a fireman in Jersey City. He was 
out there too working. And we talk about it. He will go out 
there if he wasn't a fireman. I will go out there again. I will 
go out there. Hopefully, God willing, we never have to. But 
there is not a doubt in my mind even with the illness. I don't 
regret what I did. I did it because it was the right thing to 
do.
    And so to answer your question, most likely yes, some 
people do have that in their mind. But I think human beings in 
nature when something tragic happens, they respond.
    Mr. Weiner. Right.
    Mr. Torres. And we saw that at the World Trade Center 
because it wasn't firemen and policemen there alone. There was 
a lot of other people working, male, woman, old, young. Jersey 
City had a chain gang filling up tugboats from young people, 
high school, grammar school, anybody helping.
    I want to believe that they will come out again.
    Mr. Weiner. I believe they will, and we should be there for 
them now. Let me just conclude with just this one question. 
There was some opposition that has been voiced about the idea 
that we don't know for sure when someone comes in, whether they 
are afflicted by the effects of Ground Zero dust and their 
being in that environment or something else. You know someone 
comes in with a headache, it could be from anything.
    As you accumulate a larger database of information and see 
more clients and do more research, are you reaching the point 
where you can say, perhaps not with metaphysical certitude, but 
some certainty when you are dealing with someone who has come 
before you because of a 9/11 related thing?
    There have been some concerns raised well, it sounds like 
we have this catchall situation if anyone can show they were 
anywhere nearby at any time, they could come in. It might have 
nothing to do with the 9/11 dust. If we can just perhaps start 
with Dr. Moline, and then we will go down the line. Do you have 
some sense now that you have a sufficient body of knowledge, 
and as it grows, that you can allay the fears of some of my 
colleagues that this isn't entirely open-ended, that you can 
tell? We now have some foundation on which to draw a conclusion 
about who there by the effects of 9/11?
    Dr. Moline. Well, I think if you look at the medical 
studies that have come out, and studies come out from the fire 
department, from the police department, from the consortium 
that Mt. Sinai coordinates from Dr. Reibman's, everyone has the 
same numbers.
    You look at objection measures like pulmonary function 
tests. Twenty-eight percent have abnormal pulmonary function 
tests, whether it is police officers in a separate study, 
whether it is a group of 10,000 folks that we reported on. 
Whether it is folks from fire department or from Dr. Reibman. 
When you see this constellation of symptoms in thousands upon 
thousands of people, that I think there can be no doubt that 
these exposures were the cause of many of the ailments we are 
seeing, if not the specific ailments----
    Mr. Weiner. Yes, I am asking the inverse of that. I am 
asking we know about the population as a whole. The question is 
individual citizens that come in and say oK, I want to take 
advantage of the provisions of this bill. I am made sick by 9/
11. Do you have the ability to be able to allay the concerns of 
some of my colleagues that say you don't really know. It could 
have been from something, they could have had something 
predated that could have, you know, that you could be seeing.
    Are you at a point now that when you see someone, you look 
at the combination of where that person was, what kind of 
symptoms they have, their profile as, you know--are you at a 
pretty comfortable place that you can say yes, we are pretty 
sure. We don't know with absolute certainty, but we are pretty 
sure this is someone who was made sick by September 11.
    Dr. Moline. What you are describing is my specialty, which 
is occupational medicine, which is----
    Mr. Weiner. You should testify before a hearing or 
something. You would be perfect.
    Dr. Moline. Thank you. That is what we do. We say what do 
you do, where were you, what were you exposed to, and find out 
what was your health like before you had these things. And I do 
that every time I see a patient. I was going to be taking care 
of patients this afternoon, but I will be seeing them tomorrow 
morning. Those are the questions that all of them have been 
posed by me to find out on an individual basis. Sure we will 
publish on the aggregate, but on an individual basis, how were 
you on September 10? What was your medical history before that? 
And now when did you begin to have symptoms? What were you 
doing? Where were you? What other things have intervened in 
between? It might be something else. It might not be. How are 
all of these things affecting your health now?
    Mr. Weiner. And so you have some constant?
    Dr. Moline. We have constants.
    Mr. Weiner. And, Mr. Melius, you have a similar sense that 
you pretty much--you can now spot it when you see it and take a 
look at it?
    Dr. Melius. I don't provide the direct care, but I think 
what I would add to what Dr. Moline is said is remember that 
again why we have Centers of Excellence is to have standardized 
approaches for addressing and examining people. So they use the 
same questionnaires, the same types of testing. So that is 
standardized in everybody. And as I work with these physicians, 
they pick up on--they understand that issue, and they have 
developed so much experience that I am very confident in----
    Mr. Weiner. Thank you. Mr. Chairman, I have a vote in the 
other markup, and I want to thank the panel very much.
    Mr. Pallone. Thank you. We are about to conclude, but I do 
want to ask one or two more questions with the support here of 
my ranking member. I thought you said earlier--this is 
following up on what Mr. Weiner said. I thought you had said 
earlier, Dr. Melius, that you actually have a certification of 
some sort that a person had a World Trade Center disease or 
disorder? Did I misunderstood?
    Dr. Melius. No, right now the--what I was referring to 
earlier was in the legislation, there is now the requirement, 
which is not strictly in place now sort of administratively. 
But going forward that say Dr. Moline, Dr. Reibman would first, 
you know, they would say that when a person is eligible for the 
program, secondly that they have a World Trade Center related 
condition and so forth. They would do that.
    There would then be a certification by NIOSH or whoever is 
administering the federal agency that, you know, sort of 
reviewing that, making sure that it followed all the 
procedures, that it was correct.
    Mr. Pallone. So essentially--I mean maybe certification 
isn't the word. But essentially you would say this person has 
the disorder, and they are eligible for the program.
    Dr. Melius. Yes.
    Mr. Pallone. And if they weren't, if they didn't meet those 
criteria, you wouldn't treat them anymore in theory?
    Dr. Melius. Correct, and that is currently happening now in 
the program.
    Mr. Pallone. You do get people that come in that you decide 
don't have the disorder and then you turn them away 
essentially?
    Dr. Melius. Right, it is a limited number, but there are 
people. And we have actually worked out among all the 
participating Centers of Excellence a program to sort of make 
sure that in their process, as patients come in--because 
everyone is handled slightly differently--that they--if they 
are suspicious that someone is not really eligible or, you 
know, that they have a way of, you know, more intensively 
following up, you know, demanding that there be more 
documentation that they actually work there.
    And that process is working because I get calls from them, 
and we talk about at the steering committee meetings and so 
forth. And certainly, you know, with people coming in now, you 
know, seven years later, I think we have to be more careful 
about it. Though again it is not to say that the vast majority 
of the people coming in are----
    Mr. Pallone. I mean most people don't show up if they 
really don't have a problem.
    Dr. Melius. Exactly, yes.
    Mr. Pallone. All right, and my last question is this, and I 
kind of went back to the beginning. You know in terms of the 
need for a permanent program and authorization, which is what 
we are all about. And let me preface that by saying, you know, 
we are an authorizing committee, so we don't particularly like 
the fact that you operate without a permanent authorization 
because we don't like to do business that way. And certainly 
for us, that is not the way we do things. But the question 
really is without the permanent authorization, again sort of 
being the devil's advocate, I assume that you have had problems 
operating the way you are and that there is some inherent 
benefit in having a permanent authorization. If any of you 
would like to comment on that, I think that might be important.
    Dr. Moline. You know working in a clinical setting where 
there is uncertain funding year to year, I reach a certain 
point where I begin to draft the letter that is going to go out 
to say we can't provide the care that you have been receiving 
to all the patients. We can't guarantee that they will get the 
services that they need without having a permanent solution. We 
are intensely grateful, immeasurably grateful for the monies 
that have been appropriated for us, and it is year-to-year 
funding.
    I mean we have a staff that is--we are seeing thousands of 
patients a year at Mt. Sinai. We have an infrastructure that is 
developed. It is very hard when you don't know if you are able 
to sustain that every year, and you are worried is this going 
to be possible. Am I going to have to start from scratch again 
where I have this expertise that I have build up?
    And that has been one of the challenges in trying to make 
sure that we have the resources so that we know that if we do 
have to expand, if there are more people coming in or there are 
new illnesses, that we will be able to handle that.
    We are more worried about whether we are even going to have 
funding for the next year available.
    Mr. Pallone. Anyone else want to comment because I think 
that is kind of important here.
    Dr. Reibman. I would like to agree just to say that it is 
very important to be able to recruit people, to train people, 
to get people with experience so that they can answer just the 
questions you are asking. How do you know this is World Trade 
Center? Is this what we have seen before? How are we going to 
approach it? And to have--to not know whether you are going to 
be able to retain people, to have to retrain people all the 
time makes the program very difficult.
    Mr. Pallone. Mr. Holloway?
    Mr. Holloway. And just on--we are talking in part about 
programs that have appropriations, you have to come back and do 
it from year to year. There are also, from the city's 
perspective, a number of programs that are primarily funded by 
the city. And although we have gotten some of the--recently 
from NIOSH some money appropriated there, the HHC program right 
now is actually running at a deficit.
    One of the other programs that we didn't talk about in 
detail is a mental health program, which actually does 
reimbursement for mental health services that is funded in the 
bill, also operating at a deficit.
    So for some of these programs, you know, the city, as I 
said didn't wait for Congress to act for us to meet the needs 
that we found when we dug into this. But, you know, the program 
will be subject to the vagaries of the very, very difficult 
budget choices that the city has to make about all of the 
programs that it provides. And so, you know, this isn't just a 
matter of coming back and everybody testifying every year about 
an appropriation.
    You know we would really like to see this go past the point 
where it is a question whether these programs are going to run. 
And we do feel that it is important that, with the city 
contributing, it is a national responsibility.
    Mr. Pallone. OK, thank you.
    Dr. Melius. Can I just add I think it is also very 
important for the participants in the program, and one good 
recent example is one of the individuals, a firefighter, just 
recently underwent a lung transplant. And he and his family 
were asked well, do you want--who should cover this because it 
is covered out of this program, and it was World Trade Center 
related. Then what is going to happen in the future? Because 
that individual is going to be on, you know, significant 
medications for the rest of his life, which we hope is a long 
one. And who is going to be able to pay for that going forward?
    So knowing that this program had long-term funding would 
have made that decision much more easy for that individual and 
I think for everybody involved here. They often wonder what is 
going to happen with their health insurance. Who is going to 
take care of them in the future? It also has implications for 
the Victims Compensation Fund portion of this.
    Mr. Pallone. Sure. Mr. Deal.
    Mr. Deal. Well, my information is that CDC had, I think, 
$180 million carried over that was appropriated for fiscal year 
2009, and they have obligated just over $16 million through the 
end of March of '09. And my understanding is that based on 
those currently appropriated funds that there appears to be 
adequate funding through 2010. So that carryover money, I 
think, does make a difference.
    Mr. Pallone. I mean we obviously, you know, you still have 
to go through the appropriations process every year. But there 
is a big difference in terms of having something that is 
permanently authorized that you can count on as, you know, as 
being authorized versus having to, you know, come back every 
year for the money. We can't avoid that. That is just the 
annual process. Did you want to add anything? Otherwise we are 
going to conclude.
    Mr. Holloway. Just one thing to Congressman's point. There 
is money that carries over. It actually took NIOSH and CDC for 
whatever reason many, many months to actually get an RFP out on 
the street and create a vehicle to access that funding that had 
been appropriated. And in fact, after this hearing today, I 
will be going to NIOSH to talk about how we can do a better job 
ensuring that the money that has already been appropriated to 
deal with this is best used.
    So any help you can provide would be appreciated.
    Mr. Pallone. Sure. All right, well thank you very much. You 
may get additional questions within the next 10 days that 
members can submit for the record. And you would respond to us, 
and the clerk would notify you about that. But I just wanted to 
thank you. I thought this was a very good analysis. And as I 
said, we do intend to move forward with the legislation. So 
without objection, this meeting of the subcommittee is 
adjourned. Thank you.
    [Whereupon, at 12:20 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]

                                 
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