[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]


  EXAMINING H.R. 1786, THE JAMES ZADROGA 9/11 HEALTH AND COMPENSATION 
                          REAUTHORIZATION ACT

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             JUNE 11, 2015

                               __________

                           Serial No. 114-52
                           
                           
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                    COMMITTEE ON ENERGY AND COMMERCE

                          FRED UPTON, Michigan
                                 Chairman

JOE BARTON, Texas                    FRANK PALLONE, Jr., New Jersey
  Chairman Emeritus                    Ranking Member
ED WHITFIELD, Kentucky               BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois               ANNA G. ESHOO, California
JOSEPH R. PITTS, Pennsylvania        ELIOT L. ENGEL, New York
GREG WALDEN, Oregon                  GENE GREEN, Texas
TIM MURPHY, Pennsylvania             DIANA DeGETTE, Colorado
MICHAEL C. BURGESS, Texas            LOIS CAPPS, California
MARSHA BLACKBURN, Tennessee          MICHAEL F. DOYLE, Pennsylvania
  Vice Chairman                      JANICE D. SCHAKOWSKY, Illinois
STEVE SCALISE, Louisiana             G.K. BUTTERFIELD, North Carolina
ROBERT E. LATTA, Ohio                DORIS O. MATSUI, California
CATHY McMORRIS RODGERS, Washington   KATHY CASTOR, Florida
GREGG HARPER, Mississippi            JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey            JERRY McNERNEY, California
BRETT GUTHRIE, Kentucky              PETER WELCH, Vermont
PETE OLSON, Texas                    BEN RAY LUJAN, New Mexico
DAVID B. McKINLEY, West Virginia     PAUL TONKO, New York
MIKE POMPEO, Kansas                  JOHN A. YARMUTH, Kentucky
ADAM KINZINGER, Illinois             YVETTE D. CLARKE, New York
H. MORGAN GRIFFITH, Virginia         DAVID LOEBSACK, Iowa
GUS M. BILIRAKIS, Florida            KURT SCHRADER, Oregon
BILL JOHNSON, Ohio                   JOSEPH P. KENNEDY, III, 
BILLY LONG, Missouri                 Massachusetts
RENEE L. ELLMERS, North Carolina     TONY CARDENAS, California
LARRY BUCSHON, Indiana
BILL FLORES, Texas
SUSAN W. BROOKS, Indiana
MARKWAYNE MULLIN, Oklahoma
RICHARD HUDSON, North Carolina
CHRIS COLLINS, New York
KEVIN CRAMER, North Dakota

                         Subcommittee on Health

                     JOSEPH R. PITTS, Pennsylvania
                                 Chairman

BRETT GUTHRIE, Kentucky              GENE GREEN, Texas
  Vice Chairman                        Ranking Member
ED WHITFIELD, Kentucky               ELIOT L. ENGEL, New York
JOHN SHIMKUS, Illinois               LOIS CAPPS, California
TIM MURPHY, Pennsylvania             JANICE D. SCHAKOWSKY, Illinois
MICHAEL C. BURGESS, Texas            G.K. BUTTERFIELD, North Carolina
MARSHA BLACKBURN, Tennessee          KATHY CASTOR, Florida
CATHY McMORRIS RODGERS, Washington   JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey            DORIS O. MATSUI, California
H. MORGAN GRIFFITH, Virginia         BEN RAY LUJAN, New Mexico
GUS M. BILIRAKIS, Florida            KURT SCHRADER, Oregon
BILLY LONG, Missouri                 JOSEPH P. KENNEDY, III, 
RENEE L. ELLMERS, North Carolina     Massachusetts
LARRY BUCSHON, Indiana               TONY CARDENAS, California
SUSAN W. BROOKS, Indiana             FRANK PALLONE, Jr., New Jersey (ex 
CHRIS COLLINS, New York              officio)
JOE BARTON, Texas
FRED UPTON, Michigan (ex officio)

                                  (ii)
                             
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Joseph R. Pitts, a Representative in Congress from the 
  Commonwealth of Pennsylvania, opening statement................     1
    Prepared statement...........................................     2
Hon. Gene Green, a Representative in Congress from the State of 
  Texas, opening statement.......................................     4
    Prepared statement...........................................     5
Hon. Fred Upton, a Representative in Congress from the State of 
  Michigan, opening statement....................................     6
    Prepared statement...........................................     7
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     8
    Prepared statement...........................................    10

                               Witnesses

John Howard, M.D., Director, National Institute for Occupational 
  Safety and Health..............................................    11
    Prepared statement...........................................    13
    Answers to submitted questions \1\...........................   101
Iris G. Udasin, M.D., Director, Environmental and Occupational 
  Health Sciences Institute, Robert Wood Johnson Medical School..    39
    Prepared statement...........................................    42
David G. Howley, Retired Police Officer, New York City Police 
  Department.....................................................    48
    Prepared statement...........................................    49
Barbara Burnette, Former Detective, New York City Police 
  Department.....................................................    54
    Prepared statement...........................................    56

                           Submitted Material

H.R. 1786, the James Zadroga 9/11 Health and Compensation 
  Reauthorization Act, submitted by Mr. Pitts....................    68
Statement of Hon. Peter T. King, a Representative in Congress 
  from the State of New York, submitted by Mr. Pitts.............    79
Statement of Harold A. Schaitberger, General President, 
  InterNational Association of Fire Fighters, June 11, 2015, 
  submitted by Mr. Pitts.........................................    80
Statement of Ed Mullins, President, Sergeants Benevolent 
  Association of the New York City Police Department, June 11, 
  2015, submitted by Mr. Pitts...................................    82
Letter of June 9, 2015, from William J. Johnson, Executive 
  Director, National Association of Police Organizations, Inc., 
  to Mr. Pitts and Mr. Green, submitted by Mr. Pitts.............    91
Article, ``The Forgotten Victims,'' PBA Magazine, submitted by 
  Mr. Pitts......................................................    93
Statement of Hon. Daniel M. Donovan, Jr., a Representative in 
  Congress from the State of New York, submitted by Mr. Lance....    96
Letter of June 11, 2015, from Mr. Lance, et al., to House Speaker 
  John A. Boehner and Minority Leader Nancy Pelosi, submitted by 
  Mr. Lance......................................................    97

----------
\1\ Dr. Howard did not answer submitted questions for the record 
  by the time of printing.

 
  EXAMINING H.R. 1786, THE JAMES ZADROGA 9/11 HEALTH AND COMPENSATION 
                          REAUTHORIZATION ACT

                              ----------                              


                        THURSDAY, JUNE 11, 2015

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:17 a.m., in 
Room 2123 of the Rayburn House Office Building, Hon. Joseph R. 
Pitts (chairman of the subcommittee) presiding.
    Members present: Representatives Pitts, Guthrie, Whitfield, 
Shimkus, Burgess, Lance, Griffith, Bilirakis, Long, Ellmers, 
Bucshon, Brooks, Collins, Upton (ex officio), Green, Engel, 
Schakowsky, Castor, Sarbanes, Lujan, Schrader, Kennedy, 
Cardenas, and Pallone (ex officio).
    Also present: Representatives King, Maloney, Nadler, 
Donovan, and Clarke.
    Staff present: Clay Alspach, Chief Counsel, Health; Gary 
Andres, Staff Director; Leighton Brown, Press Assistant; Karen 
Christian, General Counsel; Noelle Clemente, Press Secretary; 
Paul Edattel, Professional Staff Member, Health; Carly 
McWilliams, Professional Staff Member, Health; Katie Noraria, 
Professional Staff Member, Health; Tim Pataki, Professional 
Staff Member; Graham Pittman, Legislative Clerk; Adrianna 
Simonelli, Legislative Associate, Health; Heidi Stirrup, Health 
Policy Coordinator; Greg Watson, Staff Assistant; Christine 
Brennan, Democratic Press Secretary; Jeff Carroll, Democratic 
Staff Director; Waverly Gordon, Democratic Professional Staff 
Member; Tiffany Guarascio, Democratic Deputy Staff Director and 
Chief Health Advisor; Ashley Jones, Democratic Director of 
Communications, Member Services and Outreach; Tim Robinson, 
Democratic Chief Counsel; and Samantha Satchell, Democratic 
Policy Analyst.
    Mr. Pitts. Ladies and gentlemen, if you will, if you will 
take your seats, we will begin. I would like to ask all of our 
guests today to please take their seats. The subcommittee will 
come to order. The Chair will recognize himself for an opening 
statement.

OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN 
         CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

    Today's Health Subcommittee hearing will examine the World 
Trade Center (WTC) Health Program that was created in the James 
Zadroga 9/11 Health and Compensation Act enacted in 2011. The 
Act allocated $4.2 billion to create the Health Program, which 
provides monitoring, testing, and treatment for people who 
worked in response and recovery operations, as well as for 
other survivors of the 9/11 attacks. The authorization of the 
Health Program ends on September 30, 2015. Another part of the 
law, the September 11th Victim Compensation Fund, is under the 
jurisdiction of the Judiciary Committee. It will continue to 
accept applications until October 3, 2016, over a year after 
the Health Program authorization ends.
    The WTC Health Program funds networks of specialized 
medical programs, and these programs are designed to monitor 
and treat those with 9/11-related conditions. For responders, 
The World Trade Center Medical Monitoring and Treatment 
Program; for survivors, the NYC Health and Hospitals 
Corporation WTC Environmental Health Center; for NYFD 
personnel, the Fire Department of New York Responder Health 
Program; the National Program, the WTC Health Program has a 
nationwide network of clinics with providers across the country 
for responders and survivors who live outside the New York City 
metropolitan area. These programs provide free medical services 
by health care professionals who specialize in 9/11-related 
conditions.
    Our colleagues, Representatives Carolyn Maloney, Peter 
King, and Jerrold Nadler, have jointly introduced legislation, 
H.R. 1786, the James Zadroga 9/11 Health and Compensation 
Reauthorization Act, which reauthorizes the Act. This 
legislation has begun an important conversation that will lead 
to a timely and fully offset reauthorization of the Health 
Program.
    Today's hearing will allow us to learn more about how the 
program is working and whether changes are needed. We will hear 
from the Director of the National Institute for Occupational 
Safety and Health, who is responsible for administering the 
program, as well as from the medical director of the Robert 
Wood Johnson Medical School, and 2 first responders who are 
enrolled in the World Trade Center Health Program.
    Mr. Pitts. I look forward to the testimony today.
    [The prepared statement of Mr. Pitts follows:]

               Prepared statement of Hon. Joseph R. Pitts

    Today's Health Subcommittee hearing will examine the World 
TradeCenter (WTC) Health Program that was created in the James 
Zadroga 9/11 Health and Compensation Act enacted in 2011.
    The Act allocated $4.2 billion to create the Health 
Program, which provides monitoring, testing, and treatment for 
people who worked in response and recovery operations as well 
as for other survivors of the 9/11 attacks. The authorization 
of the Health Program ends on September 30, 2015. Another part 
of the law, the September 11th Victim Compensation Fund, is 
under the jurisdiction of the Judiciary Committee. It will 
continue to accept applications until October 3, 2016, over a 
year after the Health Program authorization ends.
    The WTC Health Program funds networks of specialized 
medical programs. These programs are designed to monitor and 
treat those with 9/11-related conditions.
     For responders--The World Trade Center Medical 
Monitoring and Treatment Program;
     For survivors--NYC Health and Hospitals 
Corporation WTC Environmental Health Center;
     For NYFD Personnel--The Fire Department of New 
York (FDNY) Responder Health Program;
     The National Program--The WTC Health Program has a 
nationwide network of clinics with providers across the country 
for responders and survivors who live outside the New York City 
metropolitan area.
    These programs provide free medical services by health care 
professionals who specialize in 9/11-related conditions.
    Our colleagues, Reps. Carolyn Maloney (NY), Peter King (NY) 
and Jerrold Nadler (NY), have jointly introduced legislation, 
H.R. 1786--the ``James Zadroga 9/11 Health and Compensation 
Reauthorization Act''--which reauthorizes the Act. This 
legislation has begun an important conversation that will lead 
to a timely and fully offset reauthorization of the Health 
Program.
    Today's hearing will allow us to learn more about how the 
program is working and whether changes are needed. We will hear 
from the Director of the National Institute for Occupational 
Safety and Health who is responsible for administering the 
program, as well as from the medical director of the Robert 
Wood Johnson Medical School and two first responders who are 
enrolled in the World Trade Center Health Program.
    I look forward to the testimony today and yield the balance 
of my time to the gentleman from New Jersey, Rep. Leonard 
Lance.

    [Bill H.R. 1786 appears at the conclusion of the hearing.]
    Mr. Pitts. And I would like to yield the balance of my time 
to the gentleman from New Jersey, Representative Lance.
    Mr. Lance. Thank you, Mr. Chairman. It is my honor to 
welcome David Howley, a constituent of mine in New Jersey's 
seventh congressional district, to the committee this morning.
    David, thank you for making the trip from New Jersey to 
share your story, and advocate for those who cannot be with us 
today. We look forward to your testimony.
    I first met David several months ago when he came into my 
office in Westfield, New Jersey, to discuss the bill before us 
today. And this Reauthorization Act is, I think, critically 
important. David has been a tremendous advocate for the 
legislation because, as he will detail in his testimony, he 
knows firsthand the importance of these programs for him and 
his fellow first responders and survivors.
    David joined the New York Police Department in 1985, and 
served in various departments over his 21-year tenure. He is a 
third generation law enforcement official; following the 
tradition of his father and grandfather. He was serving in the 
NYPD Operations Division on September 11, 2001, and spent the 
next several months in the dust and rubble of Ground Zero.
    I am proud to have David here with us today, and I am proud 
to be a cosponsor of this critical legislation.
    It is my hope, Mr. Chairman, that we can work in a 
bipartisan fashion to move this legislation forward quickly, 
and I look forward to voting for it not only here and in full 
committee, but on the floor of the House of Representatives.
    Mr. Chairman, I yield back the balance of my time.
    Mr. Pitts. The Chair thanks the gentleman. And I also would 
note that some of our colleagues from the New York delegation 
who are not on the committee, but very concerned of this issue 
and sponsors of the legislation, have requested to sit on the 
dais, and we welcome them this morning.
    At this point, the Chair recognizes the ranking member of 
the subcommittee, Mr. Green, 5 minutes for an opening 
statement.

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

    Mr. Green. Thank you, Mr. Chairman, for holding the hearing 
on this important program. I thank the witnesses today, and for 
the first responders in the audience who--for their bravery and 
service both on and after the tragic day of 9/11. Thank you for 
coming today to share your personal experiences and shed light 
on the significance of the World Trade Center Health Programs.
    No one here can forget the horrific attacks perpetrated 
upon our country at the World Trade Center in New York, the 
Pentagon, and Washington, and at the field in Shanksville, 
Pennsylvania. During and after the attacks, tens of thousands 
of first responders, including police, firefighters, emergency 
medical workers, jumped into action to assist in rescue, 
recovery, and cleanup. As a result of their service, these 
responders were exposed to dust, smoke, toxins, such as 
pulverized concrete, fibrosis, glass, particulate matter, and 
asbestos. This exposure caused many of them to develop a 
spectrum of debilitating diseases, including respiratory 
disorders like asthma, skin, prostate, and lymphedema cancers. 
A GAO report on the 9/11 Health Program suggested that 
firefighters who responded to the attack ``experienced a 
decline in lung function equivalent to that of which produced 
by 12 years of aging.''
    In addition to the physical ailments these heroes now have, 
many have suffered post-traumatic stress syndrome, PTSD, 
depression, anxiety stemming from psychological trauma they 
experienced in the aftermath of the attack.
    Nearly 1 decade after the September 11 terrorist attacks, 
the James Zadroga 9/11 Health and Compensation Act was signed 
into law in 2010. The Zadroga Act created the World Trade 
Center Health Program within the Department of Health and Human 
Services. The program provided evaluation, monitoring, and 
medical necessary physical and mental health treatments to 
first responders and certified eligible survivors of the World 
Trade Center-related illnesses. It has also established a 
network of Clinical Centers of Excellence and data centers. For 
these responders and survivors who reside outside the New York 
area, the Act created a national network of health providers 
who provide the same types of services for World Trade Center-
related illnesses. While cancer was not originally listed among 
the statutory WTC-related health conditions, 60 types of cancer 
were added in 2012, after a petition by Members of Congress. As 
of May the 5th of this year, 37,000 members of the health 
program had cancer.
    The Act also established the Victim Compensation Fund that 
provides compensation for harm suffered as a result of debris 
removal. Without action by Congress, funding for the current 
Health Program will terminate on September of 2016. The James 
Zadroga 9/11 Health and Compensation Reauthorization will 
reauthorize the critical World Trade Center Health Program and 
the Victim Compensation Fund.
    As requires under the current program, New York City will 
continue to pay 10 percent of the total cost. It is important 
to note that WTC Health Program serves our heroes nationwide, 
and extends far beyond the New York area. Both these and 
currently enrolled and future enrollees live in all areas of 
the country. In fact, as of August 2014, 429 of the 435 
congressional districts were home to at least 1 9/11 responder 
or survivor.
    We must not abandon those who bravely sacrificed their own 
wellbeing on behalf of the country in the wake of terrible 
attacks. We have a duty to serve our first responders and 
survivors and heroes with complex healthcare from 9/11. It is 
critically important that we support the James Zadroga 9/11 
Health Compensation Reauthorization Act.
    I would like to thank the first responders for their 
gallant and selfless service on and after 9/11. I would also 
like to thank the doctors and administrators of the program for 
their efforts to treat the complex illnesses afflicted on our 
first responders, and continued research on the impact of 
exposure to toxins and psychological trauma.
    [The prepared statement of Mr. Green follows:]

                 Prepared statement of Hon. Gene Green

    Thank you, Mr. Chairman, for holding a hearing on this 
important program. I thank the witnesses today, and to the 
First Responders in the audience, for their bravery and 
service, both on and after, the tragic day of 9/11.
    Thank you for coming today to share your personal 
experiences with the committee and shed light on the 
significance of the World Trade Center Health Programs. No one 
here can forget the horrific attacks perpetrated upon our 
country at the World Trade Center in New York, the Pentagon in 
Washington, and at a field in Shanksville, Pennsylvania.
    During and after the attacks, tens of thousands of first 
responders--including police, firefighters, and emergency 
medical workers--jumped into action to assist in rescue, 
recovery, and clean up. As a result of their service, these 
responders were exposed to dust, smoke, and toxins, such as 
``pulverized concrete, fibrous glass, particulate matter, and 
asbestos.''
    This exposure caused many of them to develop a spectrum of 
debilitating diseases, including respiratory disorders like 
asthma, and skin, prostate. and lymphedema cancers.
    A GAO report on the 9/11 Health program suggested that 
firefighters who responded to the attack quote ``experienced a 
decline in lung function equivalent to that which would be 
produced by 12 years of aging.'' In addition to the physical 
ailments these heroes now have, many also suffer from Post-
Traumatic Stress Disorder or ``PTSD,'' depression, and anxiety 
stemming from the psychological trauma they experienced in the 
aftermath of the attack. Nearly one decade after the September 
11 terrorist attacks, the James Zadroga 9/11 Health and 
Compensation Act was signed into law in 2010. The Zadroga Act 
created the World Trade Center Health Program within the 
Department of Health & Human Services.
    The Program provides evaluation, monitoring, and medically 
necessary physical and mental healthtreatments to first 
responders and certified-eligible survivors for World Trade 
Center-related illnesses.
    It also established a network of Clinical Centers of 
Excellence and Data Centers. For those responders and survivors 
who reside outside the New York City area, the Act created a 
national network of health care providers, who provide the same 
types of services for World Trade Center-related illnesses. 
While cancer was not originally listed among the statutory WTC-
related health conditions, 60 types of cancer were added in 
2012 after a petition by members of Congress.
    As of May 5 of this year, 3,700 members of the Health 
Program had cancer. The Act also established the Victim 
Compensation Fund to provide compensation for harm suffered as 
a result of debris removal. Without action by Congress, funding 
for the current Health Program will terminate in September 
2016. The James Zadroga 9/11 Health and Compensation 
Reauthorization Act will reauthorize the critical WCT Health 
Program and VCF.
    As required under the current program, New York City would 
continue to pay for 10 percent of the total program costs.
    It is important to note that the WTC Health Program serves 
our heroes nationwide. It extends far beyond the New York area.
    Both those currently enrolled and future enrollees live in 
all areas of the country. In fact, as of August 2014, 429 of 
the 435 Congressional Districts were home to at least one 9/11 
responder or survivor. We must not abandon those who bravely 
sacrificed their own well-being on behalf of country in the 
wake of the terrible attacks.
    We have a duty to serve our first responders, survivors, 
and heroes with complex health needs from 9/11.
    It is critically important that we support the James 
Zadroga 9/11 Health and Compensation Reauthorization Act. I 
thank the first responders for their gallant and 
selflessservice on and after 9/11. I also want to thank the 
doctors and administrators of the program for their efforts to 
treat the complex illnesses afflicting our first responders, 
and continued research on the impact of exposure to toxins and 
psychological trauma.
    Thank you, Mr. Chairman. I yield back.

    Mr. Green. Mr. Chairman, if someone on our side of the 
aisle would like a minute, I would be glad to yield to them. I 
would like to yield to my colleague from New York.
    Ms. Clarke. I thank the ranking member of the subcommittee, 
as well as the chairman. And welcome our witnesses here today.
    While not a member of this subcommittee, I am a member of 
the full Committee on Energy and Commerce. I am Congresswoman 
Clarke of New York. And I wanted to thank Chairman Pitts and 
Ranking Member Green for holding this hearing, and allowing me 
to sit in this very important hearing. Also want to thank our 
panelists. It is a--good that you have shared your experiences 
and remind America of the importance of renewing this very 
important program. This is a great first step toward 
reauthorization, in a time when the American people are 
skeptical about the work of Congress, so I am happy that this 
committee is working in a bipartisan fashion to move 
expeditiously to renew these important health programs. 
Congress must move forward to ensure first responders and 
survivors of the 9/11 terrorist attacks on the World Trade 
Center, the Pentagon, and Shanksville, Pennsylvania, continue 
to receive the care they deserve and they so sorely need.
    With that, Mr. Chairman, Mr. Ranking Member, I yield back 
the time.
    Mr. Green. Mr. Chairman, I yield back.
    Mr. Pitts. The Chair thanks the gentleman.
    Now recognize the chair of the full committee, Mr. Upton, 5 
minutes for an opening statement.

   OPENING STATEMENT OF HON. FRED UPTON, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF MICHIGAN

    Mr. Upton. Well, thank you, Mr. Chairman.
    Now, back on September 11, '01, the world as we knew it was 
turned upside down by unthinkable acts of terrorism, which took 
the lives of nearly 3,000 individuals in New York, 
Pennsylvania, and Virginia, left a mark on every American. 
Every one of us was impacted. From the smoldering ruins of the 
Twin Towers and the Pentagon to the wreckage of United Airlines 
Flight 93, the painful images and heartbreaking personal 
stories of that day, every minute, will not be forgotten.
    We remember the thousands of innocent lives lost and the 
communities of loved ones they left behind, and many of us met 
with those. We also honor the countless acts of heroism and 
leadership shown by brave American men and women in those hours 
of pandemonium and in the days, weeks, months, and now years 
that have followed. Then, for me, as chair of the Telecom 
Subcommittee on this committee, I led a bipartisan delegation, 
both to New York and to the Pentagon, where we witnessed 
firsthand the valiant efforts of our first responders who were 
certainly exhausted, overwhelmed, but still working 24/7. First 
responders spent hours, days in air that was thick with dust 
and smoke, digging through the rubble, searching for survivors.
    When I visited Ground Zero, New York's finest were still 
working round the clock in impossible conditions for the 
recovery efforts. Their selfless work took a toll on their 
health. We know that. The Federal Government provided aid to 
those individuals who were injured and the families of those 
who were killed in the attacks through a discretionary grant 
program, as we should.
    In 2011, the Zadroga 9/11 Health and Compensation Act 
established the World Trade Center Health Program and the 
Victim Compensation Fund. Our ranking member, Frank Pallone, 
and our New York colleagues Representatives Carolyn Maloney, 
Peter King, and Jerry Nadler, have jointly introduced now H.R. 
1786, the James Zadroga 9/11 Health and Compensation 
Reauthorization Act, which would reauthorize both of these 
programs.
    At today's hearing, we are going to focus on the World 
Trade Center Health Program as it is the program that falls in 
this committee's jurisdiction. The authorization for the World 
Trade Center Health Program ends at the end of September, just 
a few months from now, while the Victim Compensation Fund 
remains open to applicants into October of 2016.
    The WTC Health Program funds networks of specialized 
medical programs designed to monitor and treat those with 9/11-
related conditions. The members enrolled in the program are not 
just from the greater New York area. In 2014, there were 71,942 
individuals in the World Trade Center Health Program from 429 
of the 435 congressional districts. In fact, there are 75 
Michigan residents currently enrolled in the WTC Health 
Program. Today's hearing is, yes, an important opportunity to 
learn more about how the World Trade Center Health Program has 
operated since its authorization in, and what is needed for it 
to successfully operate and meet the needs of its members in 
the future.
    I want to thank all of the witnesses today for taking the 
time to be here, especially thank Officer Howley and Detective 
Burnette for their service to our great country, and for 
sharing their personal stories and struggles with this 
subcommittee. The bill needs to be passed, and I will look to 
consider every effort to make sure that we get it to the House 
Floor prior to its--prior to the end of September so that we 
will have an opportunity to make sure that these victims are 
taken care of.
    And I yield back the balance of my time.
    [The prepared statement of Mr. Upton follows:]

                 Prepared statement of Hon. Fred Upton

    On September 11, 2001 the world as we know it was turned 
upside down by unthinkable acts of violent extremism, which 
took the lives of nearly 3,000 individuals in New York, 
Pennsylvania, and Virginia--leaving a mark on every American. 
From the smoldering ruins of the Twin Towers and the Pentagon 
to the wreckage of United Airlines Flight 93, the painful 
images and heartbreaking personal stories of that day will not 
be forgotten. We remember the thousands of innocent lives lost 
and the communities of loved ones they left behind. We also 
honor the countless acts of heroism and leadership shown by 
brave American men and women in those hours of pandemonium and 
in the days, weeks, and months that followed.
    First responders spent countless hours in air that was 
thick with dust and smoke digging through the rubble, and 
searching for survivors. The conditions were very difficult and 
took a toll on their health. Because of this the Federal 
Government provided aid to those individuals who were injured 
or killed in the attacks through a discretionary grant program. 
In 2010 the Zadroga 9/11 Health and Compensation Act was signed 
into law which established the World Trade Center Health 
Program (WTCHP) and the Victim Compensation Fund (VCF). Our New 
York colleagues Reps. Carolyn Maloney, Peter King, and Jerrold 
Nadler have jointly introduced H.R. 1786, the ``James Zadroga 
9/11 Health and Compensation Reauthorization Act'' which 
reauthorizes both of these programs.
    At today's hearing we will focus on the World Trade Center 
Health Program as it is the program that falls in our 
committee's jurisdiction. The WTC Health program funds networks 
of specialized medical programs that are designed to monitor 
and treat those with 9/11-related conditions. The members 
enrolled in the program are not only from the greater New York 
area, but in 2014 71,942 members enrolled in the World Trade 
Center Health Program from 429 out of 435 congressional 
districts.
    Today's hearing gives us an opportunity to learn more about 
how the WTC Health Program has operated since its authorization 
in 2010 and what is needed for it to successfully operate and 
meet the needs of its members in the future. I would like to 
thank all of the witnesses for taking the time to be here today 
to discuss the WTC Health Program and I would like to 
specifically thank Officer Howley and Detective Burnette for 
their service to our great country and for sharing their 
personal stories and struggles with the subcommittee.
    Thank you, Mr. Chairman, and I yield back the balance of my 
time.

    Mr. Pitts. The Chair thanks the gentleman.
    And now the Chair is pleased to recognize the ranking 
member of the full committee, a gentleman who has many 
constituents impacted by this issue, Mr. Pallone, 5 minutes for 
an opening statement.

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

    Mr. Pallone. Thank you, Chairman Pitts, and also Chairman 
Upton. And I particularly want to thank Chairman Upton for the 
comments he just made, you know, highlighting how we need to 
perceive this as a national program, and impacting people who 
came and helped out on 9/11 and the aftermath from all parts of 
the country.
    My staff probably is tired of my telling this story, but I 
remember within a few days after the attack, we went up to New 
York City with President Bush, and I was standing next to this 
big yellow fire engine that said Hialeah, Florida. And I said, 
what is this truck doing from Hialeah, because I think it was 
only 1 or 2 days after, and I wondered how it even got there so 
quickly. And I talked to the firemen from Hialeah, Florida, and 
they said, oh, we just--as soon as this happened, we just got 
in our fire truck and we drove up from Florida because we 
wanted to help. And it just struck me at the time about how so 
many people responded from all over the country, and so many 
people were injured because of the fact that they were there 
for a few days or a few weeks or a few months even.
    So this bill is a critical first step in ensuring that the 
9/11 Health Program is extended as soon as possible. As you 
both already know, this is one of my top priorities for 2015, 
and I am grateful for Chairman Pitts and Upton for your 
willingness to work with us to ensure the timely passage of 
this bill.
    I have to recognize all the first responders who are here, 
and to whom we owe a depth of gratitude. I also want to 
acknowledge Dr. Iris Udasin, who runs the New Jersey 9/11 
Health Clinic. Thank you for being here to share your expertise 
and experience with us today. And let me also mention all the 
New Yorkers, Representative Maloney, the sponsor of the bill. I 
don't know if Representative Nadler is here, but certainly he 
has been involved from the beginning. Representative King I 
see, who joined the committee today, as well as our 
representatives, Yvette Clarke, Eliot Engel, and also my 
colleague from New Jersey, Leonard Lance, who is the cosponsor. 
Since day 1, you have all fought tirelessly to ensure that our 
Nation's 9/11 responders and survivors are cared for, and I am 
proud to fight alongside you.
    Beyond the immediate loss of life of 9/11, we now know with 
great documentation that thousands of first responders and 
survivors of the attacks are now suffering debilitating 
illnesses from its aftermath, and in fact, more than 100 
firefighters and 50 law enforcement officers have reportedly 
lost their lives to WTC-related health conditions. 
Additionally, more than 1,500 active duty firefighters and EMS 
personnel, and over 550 law enforcement officers were forced to 
retire due to WTC-related health conditions.
    We now have a deep understanding of how the tons of dust, 
glass fragments, and other toxins released into the air 
affected both responders and survivors. Illnesses include 
respiratory diseases, gastroesophageal disorders, mental health 
conditions, and cancer. And that is why the James Zadroga 9/11 
Health and Compensation Act, signed into law in 2011, is so 
critical. It established a program to monitor and screen 
eligible responders and survivors, and provides medical 
treatment to those who are suffering from World Trade Center-
related diseases. But what is so important to note is that this 
program isn't there to provide health insurance. These are 
complicated conditions that are chronic in nature, and require 
special expertise to appropriately diagnose and treat. That is 
why the program includes a network of clinics and providers 
specifically trained to treat these diseases. It also ensures 
that providers and survivors bear no out-of-pocket costs 
associated with these particular health conditions.
    The WTC Health Program currently provides monitoring and 
treatment services for more than 71,000 responders and 
survivors. They reside in every State, and in 429 of the 435 
congressional districts. If some of you don't know, the law is 
named for James Zadroga, a New Jersey hero who responded on 9/
11 and spent hundreds of hours digging through World Trade 
Center debris. Mr. Zadroga died in 2006 from pulmonary disease 
and respiratory failure after his exposure to toxic dust at the 
World Trade Center site. Like him, thousands of people from all 
over this country came to the aid of our country, and helped 
others at Ground Zero. Those responders and survivors should 
not be abandoned, and I hope we can extend the health program 
without delay.
    [The prepared statement of Mr. Pallone follows:]

             Prepared statement of Hon. Frank Pallone, Jr.

    Thank you Chairmen Pitts and Upton for calling today's 
hearing. This is a critical first step in ensuring that the 9/
11 Health program is extended as soon as possible. As you both 
already know, this is one of my top priorities for 2015, and 
I'm grateful for your willingness to work with me to ensure its 
timely passage.
    Before I get started, I have to recognize all the first 
responders who are here and to whom we owe a debt of gratitude. 
I also want to acknowledge Dr. Iris Udasin, who I've known for 
many years, who runs New Jersey's 9/11 Health Clinic. Thank you 
for being here to share your expertise and experience with us 
today.
    Lastly, let me recognize Reps. Maloney, Nadler, and King 
from New York, who have joined the committee today, as well as 
our Members Reps. Engel and Clarke. Since day one you have all 
fought tirelessly to ensure that our Nation's 9/11 responders 
and survivors are cared for. I'm proud to fight alongside you.
    Beyond the immediate loss of life of 9/11, we now know, 
with great documentation, that thousands of first responders 
and survivors of the attacks are now suffering debilitating 
illnesses from its aftermath. In fact, more than 100 
firefighters and 50 law enforcement officers have reportedly 
lost their lives to WTC-related health conditions. 
Additionally, more than 1500 active duty firefighters and EMS 
personnel and over 550 law enforcement officers were forced to 
retire due to WTC-related health conditions.
    We now have a deep understanding of how the tons of dust, 
glass fragments and other toxins released into the air affected 
both responders and survivors. Illnesses include respiratory 
diseases, gastro-esophageal disorders, mental health 
conditions, and cancer.
    That is why the James Zadroga 9/11 Health and Compensation 
Act, signed into law in 2011, is so critical. It established a 
program to monitor and screen eligible responders and survivors 
and provides medical treatment to those who are suffering from 
World Trade Center related diseases.
    But what is so important to note, is that this program 
isn't there to provide health insurance. These are complicated 
conditions that are chronic in nature and require special 
expertise to appropriately diagnose and treat. That is why the 
program includes a network of clinics and providers specially 
trained to treat these diseases. It also ensures that providers 
and survivors bear no out of pocket costs associated with these 
particular health conditions.
    The WTC health program currently provides monitoring and 
treatment services for more than 71,000 responders and 
survivors. They reside in every State and in 429 of the 435 
Congressional Districts.
    If some of you don't know, the law is named for James 
Zadroga, a New Jersey hero who responded on 9/11 and spent 
hundreds of hours digging through World Trade Center debris. 
Mr. Zadroga died in 2006 from pulmonary disease and respiratory 
failure after his exposure to toxic dust at the World Trade 
Center site.
    Like him, thousands of people, from all across this 
country, came to the aid of our country and helped others at 
Ground Zero. Those responders and survivors should not be 
abandoned. I hope we can extend the WTC health program without 
delay.
    I yield the remainder of my time to Representative Engel.

    Mr. Pallone. I only have 30 seconds left for Mr. Engel, I 
apologize, but I yield to him.
    Mr. Engel. Well, thank you. I thank the gentleman for 
yielding. And let me agree with everything you said.
    In the aftermath of September 11, it is estimated that up 
to 400,000 Americans were exposed to copious amounts of smoke 
and toxic substances, such as asbestos, and as a result, many 
of our heroes now suffer from these debilitating conditions; 
acute respiratory disorders, cancer, depression, post-traumatic 
stress disorder, and it goes on and on. And it is heartbreaking 
that the 9/11 survivors and first responders who have already 
given so much must now carry the burdens of these lung 
ailments, brain, very least we can do in thanks is to help 
them.
    So I was proud to be an original cosponsor of the James 
Zadroga 9/11 Health and Compensation Act, and I am proud to be 
an original cosponsor of the reauthorization we are discussing 
today. A failure on Congress' part to pass this vital 
legislation would constitute an egregious affront to the 
Americans who gave so much on 9/11 in service to their country. 
And I specifically say Americans because the population of 
those who will benefit from this reauthorization spans the 
entire United States. It is 429 of the 435 congressional 
districts that benefit from these programs. So this is an issue 
of national performance. So the first responders who rely on 
the World Trade Center Health Program did not hesitate to risk 
their lives for fellow Americans on 9/11, and we should not 
hesitate to care for them now. So it is of critical importance 
that we permanently reauthorize the James Zadroga 9/11 Health 
and Compensation Act.
    Thank you, Mr. Pallone. Thank you, Mr. Chairman.
    Mr. Pitts. The Chair thanks the gentleman.
    And as usual, all members' written opening statements will 
be made part of the record.
    That concludes our time for opening statement. I have a 
unanimous consent request. I would like to submit the following 
documents for the record. Statements from Representative Peter 
King, New York, 2nd District, from the International 
Association of Firefighters, from the Sergeants Benevolent 
Association, from the National Association of Police 
Organizations, and an article from the New York City's 
Patrolman's Benevolent Association featuring Mr. David Howley.
    Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Pitts. We have 2 panels today. On our first panel we 
have Dr. John Howard, Director, National Institute for 
Occupational Safety and Health. Thank you very much for coming 
today, Dr. Howard. Your written statement will be made part of 
the record. You will be recognized for 5 minutes to make your 
opening statement. At this time, you are recognized. Welcome.

 STATEMENT OF JOHN HOWARD, M.D., DIRECTOR, NATIONAL INSTITUTE 
               FOR OCCUPATIONAL SAFETY AND HEALTH

    Dr. Howard. Thank you, Mr. Chairman, and distinguished 
members of the committee. My name is John Howard, and I am the 
administrator of the World Trade Center Health Program. I am 
very pleased to appear before you today to discuss the program 
and those it serves, who responded to or survived the September 
11, 2001, terrorist attacks on New York City, and those who 
responded at the Pentagon and in Shanksville, Pennsylvania.
    The program's members responded to an epic disaster, and as 
a result, suffer mental and physical injury, illness, and the 
risk of premature death. The program's members responded to the 
9/11 disaster from all 50 States, and as has been stated, from 
429 of the 435 congressional districts. The original effort to 
care for those affected by 9/11 toxic exposures operated as a 
series of cooperative agreements and grants. As a 
discretionarily funded program, it depended on year-to-year 
appropriations, making it challenging to plan adequately to--
for the members' ongoing health needs. In January 2011, as has 
been stated, the James Zadroga 9/11 Health and Compensation Act 
became law. Stabilization of funding allows the program to more 
adequately care for 9/11 responders. In calendar year 2014, of 
the 71,942 current members enrolled in the program, 20,883 
members received treatment for health conditions arising from 
hazardous exposures from 9/11, and 28,059 members received 
health monitoring to ensure early medical intervention for any 
developing health condition that is specified for coverage by 
the program.
    Since the program's implementation, members have been 
treated for a number of different health conditions. For 
example, 11,473 members have been treated for asthma, 6,672 
members have been treated for post-traumatic stress disorder, 
and 6,497 members have been treated for chronic respiratory 
disorders. The majority of our members suffer from multiple 
mental and physical health conditions, and take multiple 
medications for these conditions. Certain types of cancer were 
added to the list of health conditions covered by the program 
in late 2012. Since then, the program has certified 4,265 cases 
of cancer.
    The World Trade Center Health Program fills a unique need 
in the lives of our members and for our society. First, members 
are evaluated and treated by medical providers who have a depth 
of experience dating back to September 11, 2001, and the 
physical and mental health needs of 9/11 responders and 
survivors they are very familiar with. Their extensive clinical 
experience with the responder and survivor populations, as well 
as their understanding of the role of exposure in causing 
disease, exceeds the training of providers unfamiliar with the 
types of exposures and health conditions common to the 9/11 
population, and how to make the connection between exposure and 
illness that the Zadroga Act requires.
    Second, our members are receiving health care that cannot 
be provided, or only provided with great difficulty, by other 
types of insurance plans. For example, health insurance plans 
do not routinely cover work-related health conditions, leaving 
such coverage to Workers' Compensation insurance. However, 
Workers' Compensation insurance often presents coverage 
challenges to members because their 9/11 health conditions 
often first manifest after 9/11, many years later, beyond the 
statute of limitations found in most State Workers' 
Compensation laws. The World Trade Center Health Program serves 
a vital role in overcoming the difficulties that members might 
otherwise experience in its absence. Without the program, 9/11 
responders and survivors might end up in limbo instead of in 
treatment.
    Third, by providing evaluation and treatment for those most 
affected by 9/11 as a unified cohort, the program greatly aids 
not only the individual members, but also our national 
understanding of the long-term health effects of 9/11, 
including its effects on children. The program helps us better 
prepare for the medical needs arising from large-scale, long 
duration disasters that might not, hopefully, occur ever in the 
future.
    Thank you for the opportunity to testify, and I am happy to 
answer any questions you may have.
    [The prepared statement of Dr. Howard follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] 
    
    Mr. Pitts. The Chair thanks the gentleman, and I will begin 
the questioning and recognize myself 5 minutes for that 
purpose.
    Dr. Howard, would you continue to elaborate a little bit on 
the history of the World Trade Center Health Program, how it 
came to be, how it has changed over time?
    Dr. Howard. Thank you. The program started as a--an 
immediate response to what doctors were seeing, especially with 
the New York City Fire Department, in what was called at that 
time a World Trade Center cough, and those doctors and others 
that were recruited to the effort began to observe that 
individuals who were responding were becoming ill from 
inhalation of the dust and the toxins contained in the dust. So 
immediately, through FEMA appropriations, CDC and then the 
National Institute for Occupational Safety and Health, was able 
to offer grants and cooperative agreements so that those 
doctors could begin now many, many years later, their first 
work in trying to articulate, characterize the issues that 
responders were facing, and survivors.
    Mr. Pitts. Another question: What are the consequences of 
letting the World Trade Center Health Program expire in 
September of 2015? How would it affect the operation of the 
Centers of Excellence across the country, and the patients who 
use these facilities and services?
    Dr. Howard. Certainly, any of us that receive health care 
from a particular health plan, if we are notified that that 
plan no longer exists, creates great stress in our life. We 
have to adjust to new providers and other changes. Our efforts 
to help those who may be a part of our discontinued program, 
let's hope that does not happen, would have to receive other 
providers of care, and it would be our responsibility to make 
sure they did.
    The Centers of Excellence would not operate anymore as a 
coordinated care operation for responders and survivors.
    Mr. Pitts. Thank you. Now, we are aware that Special Master 
Sheila Birnbaum administers the Victim Compensation Fund, which 
is housed at the Department of Justice. Is there coordination 
between the operations of the Victim Compensation Fund and the 
World Trade Center Health Program?
    Dr. Howard. Yes, sir, there is. We have data sharing and 
medical review agreements with the Victim Compensation Fund. We 
regularly meet with the staff. Our staff is embedded with their 
staff to assist in the medical review. The Victim Compensation 
Fund has adopted our program requirements for their medical 
review. To date, we have provided information to them on 18,262 
of their VCF claimants. We continue to work very closely with 
the Victim Compensation Fund.
    Mr. Pitts. How much higher is the Federal Employees 
Compensation Act, FECA, compensation rate compared to Medicare 
Parts A and B reimbursements for hospitals?
    Dr. Howard. The statute--the Zadroga Act sets the 
reimbursement rate according to the Workers' Compensation rates 
of the Federal Government, the FECA rates. Medicare rates are 
lower, but maybe by 10 to 20 percent lower. So they are a--the 
FECA rates are higher and our reimbursement rates for providers 
are higher than Medicare.
    Mr. Pitts. Dr. Howard, I can imagine that it is a 
logistical challenge to provide care for the responders and 
survivors who are scattered all across the country. What can 
you do to ensure that a physician in another part of the 
country, seeing only a few World Trade Center patients, 
benefits from the clinical experience of the physicians in the 
New York metropolitan region who have more experience treating 
these WTC-related health conditions?
    Dr. Howard. The Nationwide Provider Network that we have, 
which is currently seeing about 8,287 individuals, we have 
total coordination with that provider network. On the one hand, 
all of those individuals who do monitoring for our survivors 
and responders that are in the nationwide program are trained--
occupationally trained physicians so that they are equivalent 
to the physicians that we have in our Centers of Excellence in 
New York and New Jersey. We also provide them with additional 
training. We are working with Medscape right now to have online 
training available for all of our providers. We work with the--
our contractor, LHI, which has the Nationwide Provider Network, 
and that physician, their medical director, sits in all of our 
groups and committees, and we engage actively with those 
physicians. So I would say that for our relationship with the 
Nationwide Provider Network, those physicians are on par with 
our physicians at the CCEs.
    Mr. Pitts. Good. Thank you very much. My time has expired.
    The Chair now recognizes the ranking member of the 
subcommittee, Mr. Green, 5 minutes for questions.
    Mr. Green. Dr. Howard, prior to the passage of the James 
Zadroga 9/11 Health and Compensation Act of 2010, you 
administered the CDC grant program that funded medical 
monitoring and treatment services for 9/11 survivors and 
responders. That program was funded through discretionary 
dollars, and there is always uncertainty about whether and what 
amount of discretionary funding would be appropriated for the 
grant program.
    Dr. Howard, can you describe how the creation of the World 
Trade Center Health Program, through the Zadroga Act, has 
improved your ability to ensure that responders and survivors 
get the quality medical services that they need?
    Dr. Howard. Thank you. I would respond in 2 ways. One, on 
behalf of the members, it is very stressful to constantly be 
told on a year-by-year basis that your care may go away, your 
doctor and the institution, the facility that you go to, may 
change. So it created a pervasive sense of stress. Mind you, in 
our population, we have many thousands of individuals that 
suffer from PTSD, and some highly resistant PTSD, and I am sure 
that if they were here with me, they would say how stressful 
year-by-year funding is to the program.
    From the administrative perspective, it is very difficult 
because we were always up to the last minute, thinking should 
we start preparing for the program not to be funded, and that 
was certainly something that we did not want to happen, but it 
requires a long process of preparation. So we were never sure 
about that.
    Mr. Green. So the dedicated mandatory fundings helped you 
not only plan better, but also the reaction from the patients.
    Dr. Howard. It is like night and day. When the Zadroga Act 
passed, I think all of us, members and us that were 
administrating the program, breathed a sigh of relief that we 
had 5 years. We never had that before.
    Mr. Green. OK. The James Zadroga 9/11 Health and 
Compensation Reauthorization would permanently extend the 
program. Could you explain how a permanent extension of the 
program would ensure that responders and survivors have that 
peace of mind? You talked about that medical monitoring and 
treatments it is--they come to rely on will continue to meet 
their needs.
    Dr. Howard. Well, as I say, I think that the assurance of 
having the same provider, especially for our patients that 
suffer from very serious mental and physical conditions, is a 
peace of mind that can only be bought from mandatory funding 
without a--an end date. For us in the program, it really helps 
us do long-term strategic planning. It is very hard to do 
contracts when you can only provide a year or 2, or 5 years, 
but being able to look beyond that 5-year horizon is extremely 
helpful for the efficiency and the integrity of the program.
    Mr. Green. It seems the patients enjoy a great deal of 
understanding from the providers--the doctors and providers in 
the program. How do you think this affects the patient 
outcomes?
    Dr. Howard. Without doubt, the providers that I first met 
in August of 2002, when I became first involved in this 
program, are the very same providers that I see now in June of 
2015. Their dedication to this population has been worthy of 
note.
    Mr. Green. So the doctor-patient relation is important 
because of the continuation of the program.
    Dr. Howard. The trust that our members have to the 
providers that we are fortunate to have cannot be duplicated 
anywhere else.
    Mr. Green. Do you think continuing the program is so 
important it--to ensuring the same level of knowledge and 
expertise?
    Dr. Howard. Very definitely. Our providers have a wealth of 
clinical information that other providers would take them years 
to develop.
    Mr. Green. OK. Thank you, Mr. Chairman. I yield back my 
time.
    Mr. Pitts. The Chair thanks the gentleman.
    Now recognize the vice chairman of the subcommittee, 
gentleman from Kentucky, Mr. Guthrie, 5 minutes for questions.
    Mr. Guthrie. Thank you, Mr. Chairman. Thank you, Dr. 
Howard, for being here.
    And I spent, I guess, 6 years of my life in college and 
grad school in metro New York, and one of my favorite things to 
do back when I was an undergrad is use the USO, and spent a lot 
of time at the USO off Times Square. There was always uniformed 
public servants there, and it was always enjoyed getting to 
know and talk to them. I am a talker, so I engaged with them, 
and what a great service that people feel.
    You had--actually I wasn't going to go this direction, but 
I think it is important to talk about, and it has opened my 
eyes a little bit in what you said. I will kind of emphasize or 
maybe go a little bit further. You know, I live in Bowling 
Green, Kentucky, so where we take care of our servants as well 
as--if a fire--if there is a fire, someone goes into the 
firehouse and they get injured or whatever, you know, we have 
assistance in place to--disability, insurance and so forth. And 
so I think a lot of us that aren't, you know, in New York 
continuously and the surrounding areas, like some of my friends 
here, is that, you know, are the programs already in place, and 
so what you have hit on today is probably the first time I have 
thought of it. I know it is unique in the massiveness of it, 
but why is it unique in terms of other injuries that people 
might receive in other--that requires its own system, other 
than just the volume. But--so could you hit the challenges, 
because that--because you have opened my eyes to some things 
today, and hit the challenges that--you have already kind of 
said, but emphasize why this is completely unique, that needs 
its own program, why diseases are different than if you were in 
a normal or
    a--well, I don't know if normal is the right word, but a 
more standard, I guess, kind of situation that firefighters or 
other people would be in?
    Dr. Howard. I would be happy to. And I think the best way 
to answer that question is by looking at some of the findings 
that we have gotten from the investment that the Act has 
allowed us to make in research, looking at this population and 
the conditions. And I will just mention a few issues. On the 
mental health issue, we have seen a delayed onset of PTSD. Now, 
that is not normally seen in other types of situations. That is 
something that we are seeing in this population. It is--we have 
also seen a worsening of PTSD despite conventional treatments. 
So that is something that is new in this population. In terms 
of respiratory disease, we are seeing an onset of obstructive 
airways disease beyond 5 years after exposure. We are also 
seeing bronchial hyper-reactivity persist over a decade, and 
that is something new. In terms of asthma, we have seen 
patients in our program who have asthma, who have lost full-
time employment because of their asthma, more than we have seen 
in the general asthmatic population.
    So there are a number of findings that we are seeing from a 
clinical perspective in this population that we would never 
have learned had we not had the group together.
    Mr. Guthrie. If it was just normal Workers' Comp or other 
things. And so I want to get to another thing. So you said 
there are 71,000 people in the program. How do you--what are 
the criteria--do you have--did you have to be on-site for so 
many days, or I mean----
    Dr. Howard. Well----
    Mr. Guthrie [continuing]. Or did you have to actually be in 
the rubble, or are you----
    Dr. Howard. The simple answer----
    Mr. Guthrie [continuing]. Blocks away, I mean what is the--
--
    Dr. Howard. The simple answer is that the Zadroga Act is 
highly specific about the criteria for eligibility in the 
program. And it includes for--let's say for New York City 
police officers--location, the duration of their exposure, and 
other factors. So eligibility criteria are pretty well spelled 
out in the Act.
    Mr. Guthrie. What about the non-public safety personnel 
that can be in the program?
    Dr. Howard. Right. There are criteria for eligibility for 
volunteers that came from all over the country to volunteer as 
responders. Similarly, in the section of the Act that has to do 
with survivors, there are eligibility--5 levels of eligibility 
requirements for survivors. So if someone comes to our program, 
wants to be a member, the first step is filling out an 
application in which they--a lengthy application, 
unfortunately, I might add, in which all of that information is 
solicited so that we can establish whether or not their 
experience meets the eligibility requirements of the Act.
    Mr. Guthrie. And I think some concerns, as we debated 
before, I just want to emphasize this, is that anywhere in 
terms of health care and people getting the care whatever they 
deserve, I think--I know I remember asking the question, why 
such a separate, unique program, and you have given me some 
really good things to think about, so I really appreciate it 
very much.
    Appreciate it and I yield back.
    Dr. Howard. Thank you.
    Mr. Pitts. The Chair thanks the gentleman.
    And now recognize the ranking member of the full committee, 
Mr. Pallone, 5 minutes for questions.
    Mr. Pallone. Thank you, Mr. Chairman.
    Dr. Howard, the World Trade Center Health Program relies on 
Clinical Centers of Excellence to provide most of the 
monitoring and medical care through the program, and those 
centers employ clinicians that have both the specialized 
knowledge base and deep experience in treating the unique 
physical and mental health needs of 9/11 responders. And I know 
you have already talked about this, I am kind of following up 
on what Mr. Guthrie said. I know that patients in the New York 
City metropolitan region continue to see their personal 
physicians for their general health care needs, but often 
obtain monitoring and treatment services for their conditions 
at these centers. And I also understand that, you know, if 
somebody is in another part of the country they can go to a 
network of doctors that are provided through the program. But 
some of them also come to the centers. I know that at the New 
Jersey centers we get people from all over the country that 
will travel just because of the expertise that exists.
    So if you could just comment on the treatment benefits of 
individuals using these centers rather than their personal 
physicians for their 9/11-related health conditions, or even, 
you know, traveling when they can see someone who is part of 
the WTC network, they could come to the centers.
    Dr. Howard. Yes, I would be happy to. And I think it boils 
down to the difference in physicians in terms of their 
expertise, as you said. Occupational and environmental 
physicians who are schooled in that particular subspecialty 
know how to connect an exposure with a health condition. When I 
went to medical school, I did not learn that. I learned how to 
take care of a health condition; I didn't learn to go back and 
do an extensive history to try to figure out what were your 
exposures, and was that exposure related to this health 
condition that I see. That is a specialty of occupational and 
environmental medicine where we try to correlate the exposure 
and the health condition.
    So physicians that are--that we use both in the CCEs that 
are--have been involved since 2001, and in the Nationwide 
Provider Network, have that capability. Physicians that don't 
have that capability would not be able to listen to the 
patient's symptoms and be able to say, yes, your exposure--I am 
going to make a determination that your exposure caused that 
health condition, or contributed to that health condition, or 
aggravated that health condition.
    Mr. Pallone. All right. I am trying to speed up here 
because I wanted to ask you----
    Dr. Howard. Right.
    Mr. Pallone [continuing]. A few more things. Have there 
been any problems with misdiagnosis or improper treatment of 9/
11-related health conditions when individuals have relied on 
their personal physicians?
    Dr. Howard. Not that I am aware of.
    Mr. Pallone. OK.
    Dr. Howard. Within the program, of course, we have a 
quality assurance where we look at all of the care that is----
    Mr. Pallone. OK. And can you just discuss briefly how the 
Clinical Centers of Excellence coordinate the care delivered to 
responders and survivors at the centers, with care delivered by 
their personal medical providers outside the centers, briefly?
    Dr. Howard. Sure. As many of you know, the World Trade 
Center Health Program is a hybrid program. It is not your 
normal health plan where you go in and everything that you may 
complain about relative to your body, a physician takes care 
of. We have a limited number of conditions. So many conditions 
we don't cover, so you have to see an additional physician, 
your personal physician. So that coordination is done in the 
CCEs so that if those CCE physicians see a condition that we do 
not cover, then appropriate referral is made.
    Mr. Pallone. OK. Now, let me just--I am going to try to 
summarize this last question. My concern, obviously, is that I 
don't want this program terminated before we have an 
opportunity to reauthorize it, and that is why we are having 
this hearing and trying to move quickly. But in preparation, 
you know, if reauthorization legislation is not signed into law 
by September of next year, the program is terminated. And in 
preparation for termination, or possible termination, I 
understand that HHS has certain notice requirements you would 
have to follow. Can you just tell us, you know, what you would 
have to do? I mean, obviously, this isn't what we want to 
happen, but I want to stress that, you know, there is always 
that danger.
    Dr. Howard. Well, it would be a nightmare for me 
personally, and it would be a nightmare for our members, it 
would be a nightmare for our CCE physicians. You cannot abandon 
a patient ever as a care provider. So we must ensure that that 
patient is taken care of somewhere, and finding a place for 
each of our 71,942 members would be a gargantuan task.
    Mr. Pallone. And there are notice requirements. How--when--
--
    Dr. Howard. Yes. We have to inform our patients ahead of 
time that this may happen, even though we may not be sure that 
it is happening, and certainly when it happens, and all of the 
efforts that we can make to help them support their efforts in 
finding additional----
    Mr. Pallone. But when does that process begin? Like do you 
have a term notice requirement?
    Dr. Howard. Well, the 90-day time limit is sort of an 
unwritten notice requirement now. It can vary State by State 
because these are often State laws, but we have to go back and 
look--since we have members from every State, we would have to 
look at every State's abandonment requirements.
    Mr. Pallone. All right. Thank you very much.
    Thank you, Mr. Chairman.
    Mr. Pitts. The Chair thanks the gentleman.
    Now recognize the gentleman from Kentucky, Mr. Whitfield, 5 
minutes for questions.
    Mr. Whitfield. Well, thank you very much. And, Dr. Howard, 
thank you for being with us this morning.
    I want to just follow up briefly. When we think about 
health care systems, frequently people all work with some 
company that provides health care, or with Medicare, you have 
to be over a certain age, and Medicaid, income below, the trio 
of Tricare. So here, the common element is people from around 
the country, whether emergency responders or volunteers, came 
to respond to this emergency in New York, this disaster on 9/
11. And you touched on the criteria. I think you have indicated 
there are 71,000-plus members enrolled in this program. And is 
it still eligible--if I am someone that worked there during 
that time, would I still be able to enroll today if I am not 
enrolled right now?
    Dr. Howard. Yes, sir, you would be. And we hope that anyone 
listening who is not enrolled in our program, who may be 
eligible, will call our eligibility line and sign up for our 
program.
    Mr. Whitfield. OK. And I won't get into the details, but 
the criteria for eligibility, I am assuming you had to have 
been there X-days and--is that correct?
    Dr. Howard. Right. They are very detailed eligibility 
requirements spelled out in the Act itself.
    Mr. Whitfield. And does your office make the decision on 
whether or not a person is eligible or not?
    Dr. Howard. Yes, sir.
    Mr. Whitfield. OK. Now, of the patients that you are caring 
for right now, what percent of them would you say--or maybe you 
don't have this information--had an insurance program already, 
they were already covered under?
    Dr. Howard. Well, first of all, even if you had health 
insurance----
    Mr. Whitfield. Right.
    Dr. Howard [continuing]. As a responder, you would not be 
able to use that insurance because health insurance does not 
cover work-related issues. For instance, if you have ever gone 
in for an MRI or a CT scan, at the bottom of that form it will 
say, ``Is this a result of an auto accident, is this a result 
of a work accident?'' If it is, the health insurer will not pay 
for it; they will refer you to other insurances. For survivors, 
then health insurance could be an issue, and then we recoup as 
much as we can----
    Mr. Whitfield. Um-hum.
    Dr. Howard [continuing]. From the health insurer.
    Mr. Whitfield. Well, what percent would have been covered 
under, say, the Workers' Compensation Program?
    Dr. Howard. Well, theoretically, work-related injuries and 
illnesses would all be covered, but there are great 
difficulties for responders in accessing Workers' Compensation 
benefits because oftentimes their condition, not the original 
conditions where, on the event, someone had an acute injury and 
it happened within a short period of time, but some of our 
diseases in our program, their onset are years later, and a lot 
of statutes draw a line----
    Mr. Whitfield. Um-hum.
    Dr. Howard [continuing]. And say no----
    Mr. Whitfield. Um-hum.
    Dr. Howard [continuing]. That is beyond our statute of 
limitations, we will not cover something that started----
    Mr. Whitfield. Um-hum.
    Dr. Howard [continuing]. Five years later. So many of our 
members are in that situation.
    Mr. Whitfield. So would it be unusual that Workers' Comp 
may pick up part of it and then this program would pick up--
sort of playing a supplemental role, or----
    Dr. Howard. It is not unusual. It is--many of our members 
have had Workers' Compensation benefits given, and we are in 
the process of recouping----
    Mr. Whitfield. Right.
    Dr. Howard [continuing]. From Workers' Compensation.
    Mr. Whitfield. Um-hum.
    Dr. Howard. But it is not the majority, or even near the 
majority of our members.
    Mr. Whitfield. Um-hum. We know some people have indicated 
early on, I remember when there was first discussion about 
this, that this was sort of a unique program, but I know that 
there are health programs in effect for employees at Savannah 
River, Paducah, Oak Ridge, and so forth, which is kind of 
similar to this because those workers were exposed to certain 
elements many of them were not even aware of, and they came 
down with a lot of different cancers. And so those programs are 
similar to this program, would you say?
    Dr. Howard. Yes, sir. And, in fact, we administer the 
Energy Employees Occupational Illness Compensation Program, 
together with the Department of Labor and the Department of 
Energy. It is a program that bears a lot of similarities to our 
program at the World Trade Center.
    Mr. Whitfield. Yes. And so if you worked at the World Trade 
Center and you are covered, and you have 1 of, say, 12 or 14 
illnesses that you all have set out, is there a presumption 
that, since you were there and exposed, that you would be 
covered under this program?
    Dr. Howard. Not a presumption. A physician, not in the 
administration of the program, but in our Centers of 
Excellence, would examine you, take your history, and make the 
connection between the exposure history that you give that 
physician and that health condition, and they and they alone 
say I think the 2 are connected.
    Mr. Whitfield. Right. Well, thank you very much for the 
great job you do at NIOSH.
    Dr. Howard. Thank you.
    Mr. Pitts. The Chair thanks the gentleman.
    Now recognize the gentleman from Oregon, Mr. Schrader, 5 
minutes for questions.
    Mr. Schrader. My questions have been answered, Mr. 
Chairman. Thank you.
    Voice. Ms. Castor.
    Mr. Pitts. All right, then the Chair recognizes the 
gentlelady, Ms. Castor, 5 minutes for questions.
    Ms. Castor. I want to thank you, Mr. Chairman, for calling 
this hearing. And I would like to thank all of the first 
responders and survivors, and the medical professionals who 
take care of them, for traveling here to Capitol Hill to 
encourage the Congress to provide some continuity and certainty 
in the World Trade Center Health Program. I would like to thank 
my colleagues, especially from New Jersey and New York, 
Congressman Pallone and Congressman Lance, you all have been 
champions on this committee for this endeavor, along with 
Congresswoman Clarke and Congresswoman Maloney, I see 
Congresswoman King I think was still here, and the entire New 
York delegation, especially.
    I strongly support the James Zadroga 9/11 Health and 
Compensation Reauthorization Act because it will provide that 
important certainty and continuity of care from this point 
forward. And when you--it is interesting to see the list and 
understand that there are first responders and survivors from 
the World Trade Center terrorist attacks all across America 
now. And Florida comes in right behind New York and New Jersey. 
So it will be very important, and I think that the folks that I 
represent back home will be strongly in support of taking care 
of their neighbors who were there on September 11, and the 
weeks, months, and years afterwards. It is vital that we 
continue this specialized care for all of our neighbors, and 
all of the brave folks who were there on September 11.
    So, Dr. Howard, thank you for being here today. One of the 
important parts of the World Trade Center Zadroga Health 
Initiative that often gets overlooked is the funding provided 
for research into 9/11-related health conditions. Between 
fiscal year 2011 and 2014, the program funded 35 projects to 
investigate questions about 9/11 related to physical and mental 
health conditions. Could you provide examples of the research 
that has been funded by the Zadroga Act?
    Dr. Howard. I would be happy to. We are very grateful for 
the original drafters of the legislation to provide money for 
research into the health conditions that our members face. And 
as I mentioned before, we have already learned quite a bit from 
that research. And I would like to highlight just one aspect of 
it, in addition to mental health and respiratory and 
cardiovascular, and our cancer research, our research in 
autoimmune diseases and others, is the research that we have 
done on individuals who were children at the time of 2001 
attacks. There were a number of elementary schools and 
Stuyvesant High School, for instance, that were immediately 
impacted. And we have a number of those projects that are going 
on now, about 7 that are funded, and we are learning the 
effect--effects on developmental issues in the children's 
population. To date, we have funded $88.5 million worth of 
research, and we have a significant body of research that is 
published in peer review journals. The World Trade Center 
Registry alone has published about 60 papers, and our various 
clinical researchers at our clinical centers have published the 
other papers. Our pivotal papers in cancer, autoimmune 
diseases, asthma, and other respiratory disorders have allowed 
us to provide better care, more focused care for our members.
    Ms. Castor. And are these--the results of the research, are 
they disseminated in an organized way to the providers and the 
families so that they have access----
    Dr. Howard. Yes.
    Ms. Castor [continuing]. To all of that information?
    Dr. Howard. We have membership newsletters that highlights 
various findings that we have from research so that they know. 
All of our papers are published on our--on the World Trade 
Center Health Program's Web site. And, of course, these are all 
peer reviewed publications so they appear in the science 
journals. And I am happy to say that the New York media picks 
up on those papers and reports them probably more effectively 
and more widely than we can on our Web site.
    Ms. Castor. So if the Zadroga Act is not reauthorized, will 
these research efforts come to an end, and explain to me why 
that would be harmful?
    Dr. Howard. They would cease altogether, and we would lose 
one of, I think, the most important advantages to the program 
to our society, is looking at the long-term health effects from 
9/11.
    Ms. Castor. OK. And you testified earlier that health 
conditions often manifest themselves years later. The Zadroga 
Act provided funding for outreach efforts to individuals who 
may be eligible. We are now several years into the existence of 
the program, and you have successfully enrolled more than 
71,000 responders and survivors. It seems to me that in 
addition to outreach, the continuity of care and retention of 
members will be important to protecting the health moving 
forward. That is why the Reauthorization Act here clarifies 
that funding may be used for continuity of care and retention. 
Give me your opinion on why efforts on continuity of care and 
retention of members will be important moving forward.
    Dr. Howard. Well, as you say, you know, our program 
overall, since its inception in July of 2011 with the Zadroga 
Act, has grown about 18 percent overall in membership, and we 
credit that to the wonderful contractors that we have who have 
done recruitment. But the other side of that is once you 
recruit a patient into our program, we want them to remain in 
our program. And every health plan loses members because we do 
not go and do outreach to retain them. So that is on balance 
now after our first 5 years. We hope to emphasize, in what we 
hope is our second phase, that retention of our patient 
population is as important as their original recruitment.
    Ms. Castor. And how do you propose to do that for first 
responders and survivors outside of the New York/New Jersey 
area, say, in the State of Florida?
    Dr. Howard. I think, first of all, you know, we do things 
as a team. We sit down with our representatives from survivors 
and responders. We have a Responder Steering Committee which is 
very active, meets every month, and we have a Survivors 
Steering Committee that is very active and meets every month. 
All of our ideas, suggestions, we go to them and say how are we 
going to do this, and together as a group we figure out how to 
do it. There are many modalities that we could use, and 
oftentimes we are told by our members what is the most 
effective.
    Ms. Castor. Thank you very much, sir.
    I yield back.
    Mr. Pitts. The Chair thanks the gentlelady.
    Now recognizes the gentleman from Texas, Dr. Burgess, 5 
minutes for questions.
    Mr. Burgess. Thank you, Mr. Chairman. Thank you for having 
the hearing. Dr. Howard, thank you very much for being here 
today. And to all our witnesses on the second panel, thank you 
for your participation, and the people who are here in 
testament to the work that you have done. I also feel obligated 
to recognize the work of one of our colleagues, a former 
member, Vito Fossella, who was on this committee with us and, 
in fact, was responsible for my early interest in this shortly 
after I arrived in Congress in 2003. And it was because of that 
interest that I did become an early supporter of Representative 
King's work on this. And, in fact, I was the one who ran the 
bill on the floor in the waning days of the 111th Congress, in 
that late lame duck session in December when the bill finally 
did pass on the floor of the House.
    But, Dr. Howard, I am interested in--you said in your 
testimony that you provided for us today that certain types of 
cancer were added to the list of health conditions covered 
under this Act. Could you share with us what those cancers--
what types of cancers those were--are?
    Dr. Howard. Yes. Currently covered in the program are every 
type of cancer, is just the short way to approach this--every 
type of cancer except uterine cancer.
    Mr. Burgess. Are there--but are there those that are more--
I mean what are some--what--if you were to pick the top 3 
malignancies, what would those be?
    Dr. Howard. I think if you looked at our 4,000 or so cases 
right now, probably the top ones would be thyroid cancer. There 
are 5 common cancers that Americans get, skin being the one 
that is our top cancer. There is breast cancer, that is also a 
top cancer for us. There is colon cancer, which is a top cancer 
for us. Thyroid cancer is another cancer for us. But we have 
seen a lot of very common cancers like that, and we have also 
seen some very rare-type cancers, and oftentimes, from an 
epidemiological basis, the appearance of rare cancers is 
extremely helpful in terms of doing research on a population to 
figure out what their exposures are, causing rare cancers.
    Mr. Burgess. Sure. That speaks then also to the value in 
having people who have expertise in treating the types of 
injuries encountered because an uncommon cancer can be a 
difficult diagnosis to which to arrive.
    Dr. Howard. Exactly. And if they--if this cohort were 
distributed, we would not be able to count those. It would be 
very hard to find all those rare cancers if they were not--if 
the patients were not seen in our clinical centers, and rather, 
they were seeing their own personal physicians throughout the 
United States. It would be very difficult to do that.
    Mr. Burgess. So it provides a focus that otherwise would 
not be available. Just as far as just a brief comment, if you 
will, on the observed versus the expected cancer rates of the 
population that you are following, is this number of--I guess I 
calculate it to be 6 percent based on the number of patients 
you are following and the cancers you reported, how does that 
stack up to the general population?
    Dr. Howard. Well, that comparison, I am afraid, we can't do 
at this time. That would be something that we would have to 
wait and see what our researchers could come up with in giving 
us that kind of number. We are now looking at, and the Fire 
Department of New York City is doing some research using as a 
referent population to compare our World Trade Center 
firefighters to, another cohort that was assembled by the 
Institute of Firefighters not involved in World Trade Center--
--
    Mr. Burgess. Great.
    Dr. Howard [continuing]. So we hoped that line of research 
could answer your question someday.
    Mr. Burgess. So it would give them a better control if you 
age-match for people who are in similar occupations.
    Dr. Howard. Yes, sir.
    Mr. Burgess. Just switching gears a little bit, and you 
mentioned also in your testimony that, you know, you are trying 
to aid not just the individual members, but help grow the body 
of evidence and the body of information so that you can help in 
other situations. Are you going to be able to provide feedback 
to municipalities and boroughs as to the type of Workers' 
Compensation coverage that may be provided to members of the 
firefighting community, or the type of health insurance that is 
provided? Some of the shortcomings you mentioned were in--
within the Workers' Compensation system. Are there lessons you 
have learned that can be extrapolated to other communities?
    Dr. Howard. Well, certainly, and I think New York State 
itself, its legislature and Governor have already responded to 
this issue significantly by providing a mechanism by which 
responders, survivors can sign up to a program. They don't have 
to actually make a claim, but they can register, and then if 
they should develop a condition later on, that their claim 
would not be beyond the statute of limitations. So other States 
have also looked at that, and we hope that people will learn, 
especially from these long-duration disasters.
    Mr. Burgess. Thanks, Mr. Chairman. I will yield back.
    Mr. Pitts. The Chair thanks the gentleman.
    Now recognize the gentlelady from Illinois, Ms. Schakowsky, 
5 minutes for questions.
    Ms. Schakowsky. Thank you, Mr. Chairman. I too would like 
to thank all of the first responders, the survivors, those who 
treat them, for coming here today. For the first responders and 
the survivors, I am sure in addition to some health conditions 
that maybe more visible, that the trauma of the incident and 
the loss of friends, coworkers, family, is something that 
lingers on forever really.
    In Illinois, Dr. Howard, there are 13 first responders, and 
between 1 and 9 survivors, the way the data is kept, it is 
between 1 and 9, enrolled in the World Trade Center Health 
Program. So clearly, there is no concentration of those 
individuals in any kind of program of nationwide providers. So 
I imagine there are physicians that have 1 or 2, et cetera, so 
how do you maintain that--the cohesiveness of that network?
    Dr. Howard. I think that is a very good question, and I 
think there are a couple of ways that we do that. First of all, 
our Nationwide Provider Network is headed by a very capable 
physician who is a part of our New York-based Centers--New York 
and New Jersey-based Centers of Clinical Excellence. So he 
participates in all of our meetings, and is a great educator 
and teacher for the cadre of physicians that do monitoring and 
evaluation of that population. As you point out, a physician 
may have only 1 or 2. Those physicians themselves are 
occupationally trained, so they have the same kind of training 
to be able to connect exposure and health conditions as 
similarly situated physicians at our clinical centers.
    As I mentioned, we are also trying to--we have been very 
pleased that Medscape is helping us put together constant 
training, so to speak, 24/7, you can go to their Web site and 
get information about the latest findings from the program that 
may influence your practice. So even though we have a 
distributed network, and even though those physicians in the 
Nationwide Provider Program may have, as you say, 1 or 2 
patients, they are seeing, we want to--we want them to be as 
similarly situated knowledge-wise as the rest of our 
physicians.
    Ms. Schakowsky. Great, thank you. So my understanding of 
the data is that there are a total of 71,000 people, or 
approximately, that are in the program. And then it says, in a 
factsheet I have, that more than 30,000 responders and 
survivors have at least 1 World Trade Center-related health 
condition. So there are some people in the program, I gather, 
that are--more than half, that are simply--not simply, but that 
are being monitored. Is that the difference in number?
    Dr. Howard. Yes. We offer monitoring and treatment. So if 
you are in the monitoring program and you do not have a health 
condition that is included for coverage in our program, then 
you come on a periodic basis for monitoring. So you are not in 
treatment. There is no condition that a World Trade Center 
Health Program physician has connected to your exposure. So 
they are----
    Ms. Schakowsky. But the----
    Dr. Howard [continuing]. Continuing to be monitored.
    Ms. Schakowsky. But the monitoring is done within the 
network, and there is not an additional cost to that individual 
for the----
    Dr. Howard. Yes.
    Ms. Schakowsky [continuing]. Monitoring.
    Dr. Howard. No.
    Ms. Schakowsky. OK.
    Dr. Howard. Our members bear no costs.
    Ms. Schakowsky. So the population that you serve includes 
some number of families of--or spouses of firefighters. Some 
are in that program. Survivors that may be workers in the area, 
residents, students, daycare, participants, et cetera. I am 
wondering what the breakdown is between first responders and 
then survivors.
    Dr. Howard. In terms of enrolled members in our program? So 
currently, total enrollment of the population, as you say, is 
71,942. General responders, which would be police, construction 
workers, volunteers that came from all over----
    Ms. Schakowsky. Firefighters.
    Dr. Howard [continuing]. The United States, is about 
38,953. Our fire department members are 16,569, which leaves 
8,133 survivors in that 71,000.
    Ms. Schakowsky. Does anybody leave the program? Aside from 
this issue of reenrollment, so do they have to reenroll every 
year?
    Dr. Howard. I am sorry?
    Ms. Schakowsky. Do they have to reenroll?
    Dr. Howard. No, no, no, you are enrolled once in our 
program.
    Ms. Schakowsky. Does anybody leave?
    Dr. Howard. I hope not, but I do not know that for a fact. 
We have members who have passed away----
    Ms. Schakowsky. Well, that is certainly----
    Dr. Howard [continuing]. But leaving--they may go to 
their--as has been said by Representative Pallone, they may go 
to their private physician to obtain health care for other 
nonrelated conditions.
    Ms. Schakowsky. Thank you very much.
    Mr. Pitts. The Chair thanks the gentlelady.
    Now recognize the gentleman from New Jersey, Mr. Lance, 5 
minutes for questions.
    Mr. Lance. Thank you, Mr. Chairman.
    I don't have any questions, but I want to thank you for 
what you are doing, Dr. Howard. I want to thank Congressman 
Pallone who has worked on this issue over the course of the 
last more than a decade, and all of the Members of the Congress 
who recognize the importance of reauthorization of this 
legislation.
    This is a bittersweet hearing for me. New Jersey lost more 
than 700 residents. My son was playing freshman high school 
football, and he had a teammate whose father didn't come home. 
I lost a Princeton classmate in the South Tower, and my story 
is similar to the stories of many.
    I think the best speech that the younger President Bush 
ever delivered was on September 14 at the National Cathedral 
where he said that this world God created is of moral design. 
Grief and tragedy and hatred are only for a time. Goodness, 
remembrance, and love have no end. And he concluded by 
paraphrasing St. Paul to the Romans that no evil can separate 
us from God's love. What you have done is based on goodness, 
remembrance, and love, and that is certainly true of the first 
responders. And I thank all of the first responders, and I am 
sure this legislation will pass unanimously here, in the full 
committee, and on the floor of the House.
    Mr. Chairman, I yield back the balance of my time.
    Mr. Pitts. The Chair thanks the gentleman.
    Now recognize the gentleman from New York, Mr. Engel, 5 
minutes for questions.
    Mr. Engel. Thank you very much, Mr. Chairman. And, you 
know, I too--there are none of us that represent New York or 
New Jersey and the surrounding area that wasn't deeply 
affected. There are 1,851 people in my district who are program 
beneficiaries of all you do, Dr. Howard, so we are very 
appreciative of it.
    You have answered some of my questions, but I want to try 
to bring out certain other things. Many of us in the 
aftermath--Mr. Lance just mentioned that the Friday after the 
Tuesday of the attacks, many of us in the delegation went to 
the site of the attacks. It was surreal. You just scratched 
your head and you couldn't believe you were really--it was like 
a nightmare; you couldn't believe you were really living it, 
and then you kind of realized every few seconds this is real. 
And so we walked around--other people walked around, we really 
weren't wearing the masks. They did give us masks but didn't 
really make it seem as if it was that important, so I bet a lot 
more people got exposure. I mean I went back several times. I 
don't have any ill effects, thank God, but people who are now 
starting to get effects, do we have trouble tracing it back 
to--is it difficult for people to prove so many years later 
that their illnesses are a result of exposure they got at the 
World Trade Center site?
    Dr. Howard. It is difficult. It is difficult for any of us 
to recall exact details of what we did a month ago, a year ago, 
let alone this many years ago. So for new members coming in our 
program, a lot of the questions that we ask about their 
exposure is--they are very difficult to answer. Recall is 
imperfect in all of us, but we take that into consideration in 
terms of the questions we ask and the answers they give us.
    Mr. Engel. First of all, Doctor, thank you for the great 
work you do. Really great work. It makes me proud to have been 
an original cosponsor of this legislation, and I think in all 
the years I have been in Congress, I have never seen our 
delegations more united on 1 thing, particularly the New York 
delegation. Since the program has been continuing, and 
obviously when things continue, you see what works, what 
doesn't work, you make adjustments, what would you change in 
the program? What have been some of the things that you have 
found difficulty with that perhaps we should consider modifying 
or changing to make it more efficient?
    Dr. Howard. Well, I don't think that we have found anything 
in the Act that has been a showstopper for us in administering 
the program. We look at all of the items in the Act as helping 
us, and we consider the Act to be a well-written document that 
has given us a roadmap and, as for so many years, for over a 
decade, we had no authorizing language, so we made it up as we 
went along, together with our Clinical Centers of Excellence. 
So we are extremely happy to have this authorizing outline for 
us.
    Mr. Engel. How much flexibility exists with regard to the 
World Trade Center Health Program's eligibility requirements? 
For example, if someone meets 9 out of 10 benchmarks but is 
desperately in need of care, can exceptions be made to ensure 
that care gets to those who need it? How does that work?
    Dr. Howard. We look at every case on a case-by-case basis. 
As I said, you know, recall is not perfect this many years 
later, and we take that into consideration. We only decide that 
somebody is not eligible when we are absolutely certain that 
they do not fit any of the stated criteria in the Act. If we 
err at all, it is on the side of including someone in the 
program.
    Mr. Engel. In your written testimony, you noted the work 
that has been done through the World Trade Center Health 
Program to--work has been done to understand the impact that 9/
11 had on children, and I understand that the program has 
funded research projects to specifically examine the effects of 
9/11 on the physical and mental health of children and 
adolescents. Can you talk a little bit about that?
    Dr. Howard. Well, first of all, we are very privileged to 
have a number of researchers in New York who are interested in 
this area of pediatric research for 9/11. And as I say, we have 
7 projects that are funded in this area. They have not been 
completed as yet, so we are looking forward to those findings, 
so I can't report today about what those studies are showing, 
but it is important that the--that we have them and they 
continue, and we are very privileged to have a very--a couple 
of very good researchers working on that.
    Mr. Engel. Thank you, Doctor. And again, thank you for all 
you do and we are really very, very grateful to you. It affects 
those of us in the New York area every single day and our 
constituents are grateful. Thank you.
    Mr. Pitts. The Chair thanks the gentleman.
    I understand Dr. Bucshon doesn't have any questions. The 
Chair recognizes Mrs. Brooks from Indiana 5 minutes for 
questions.
    Mrs. Brooks. Thank you, Mr. Chairman.
    Dr. Howard, I am a former deputy mayor of Indianapolis in 
the late '90s, and we hosted the World Police and Fire Games in 
the summer of 2001, before the 9/11 attack, and there were many 
New York, New Jersey firefighters and police officers who 
perished in the attack--New York firefighters and--who perished 
that had participated in those games. But we also had a group 
called Taskforce 1 that traveled from Indiana to the World 
Trade Center, and we have--I have since learned, because of 
this hearing, that we have 53 people in the State who 
responded. I have 12 in my particular district, and I want to 
pay particular tribute, as other colleagues have done, not only 
to all of those from New York and New Jersey but people like 
individuals from Taskforce 1, engineers and technical experts 
and their search dogs traveled immediately that day, and 
continued to operate around the clock with all of their 
brothers and sisters in New York.
    There was a story several years ago about an Indianapolis 
fireman and a member of Taskforce 1, Charlie Gleason, who was 
deployed, and he said in that TV story, he said, and I quote, 
``He got a little bit of that World Trade Center cough'' from 
that mix of the fumes, and--but he said that he would gladly 
answer the call again. And I understand the risk, but we have 
to take care of the men and women that are going, and that 
continue day in and day out to risk their lives for fellow 
citizens. And I want to thank you and all of the men and women 
who are here today for their service, and all the men and women 
around the country who did answer that call.
    I would like to ask you what you lose sleep about with 
respect to this program, what are your greatest challenges, you 
have answered incredibly well so many questions posed to you, 
but what would you say are the greatest challenges facing this 
program that we must reauthorize, and how do you plan to 
respond to those programs----
    Dr. Howard. Well, the----
    Mrs. Brooks [continuing]. Or to those challenges?
    Dr. Howard. The biggest thing that worries me is that I 
would have to spend any amount of time, waste my time closing 
the program as opposed to growing the program.
    Mrs. Brooks. And the manner in which you plan to grow the 
program, how do you plan to do that?
    Dr. Howard. I think, you know, one of the issues that we 
have faced in the program, and I think I can speak for all of 
our Clinical Centers of Excellence, directors, and our 
Nationwide Provider Network, is when the bill passed, the 
President signed it on January 3, 2011, we had to be up and 
running July 2011. It was a very short implementation time. By 
a lot of work, by a lot of people, we were able to open our 
doors on July 1, 2011. But I think what we have done over the 
last 5 years, and we hope to continue to do, is quality 
improvement of the services we offer. Our pharmacy benefit 
plan, for instance, and other support for our members. We want 
to receive their input so that we can continue to improve the 
program.
    Mrs. Brooks. Thank you. Thank you for your service.
    I yield back.
    Mr. Pitts. The Chair thanks the gentlelady.
    Now recognize the gentleman from New York, Mr. Collins, 5 
minutes for questions.
    Mr. Collins. Thank you, Mr. Chairman. And I too want to 
recognize all our first responders here. I think any time you 
come, as you have, it just helps Members of Congress in what we 
know is going to be a bipartisan support, as previously stated, 
to unanimously pass this reauthorization.
    But first of all, Mr. Chairman, I would like unanimous 
consent to enter into the record a statement from 
Representative Dan Donovan who represents Staten Island and a 
portion of Brooklyn.
    Mr. Pitts. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Collins. And I would also like to recognize 
Representative Peter King that is with me today, and thank Dr. 
Howard for all you have done. You have pretty much answered, I 
think, most of our questions. I represent 105 towns of western 
New York in the Buffalo, into the Finger Lakes area, and I 
believe probably most, if not all, of our volunteer fire 
departments--and we are mostly volunteer; we have 1 paid fire 
department in my district--sent individuals down to Ground 
Zero. That is what firefighters do and first responders. It is 
the community of brotherhood, and I am just happy to have 
learned more today about how those individuals are more than 
likely in your program being monitored, and I think, again, in 
a bipartisan way we are with you, and you are doing great work. 
And I don't believe you are going to have to lose any sleep 
about shutting this program down.
    With that, Mr. Chairman, I would like to yield the 
remainder of my time to Representative King if he would have 
any comments that he would like to add.
    Mr. King. If that is appropriate?
    Mr. Pitts. The Chair recognizes the gentleman.
    Mr. King. Thank you, Mr. Chairman. And I do appreciate the 
opportunity of you allowing me to sit in and take part in the 
hearing. And I thank the gentleman from Upstate New York, Mr. 
Collins, for yielding time.
    I would just like to say that there is probably no more 
important bill that we have passed during the time, you know, 
that I have been in Congress than this 9/11 Zadroga Act. I had 
about 150 fatalities from my district, but more than that, I 
see every day to this day people still have rare lung diseases, 
respiratory illnesses, blood cancers, so this is something that 
is absolutely necessary to continue. And I know that people may 
find this might be wrong or that might be wrong, the fact is 
this is as effective as any program I have seen since all the 
time I have been in Congress, and it provides a need which is a 
lasting need. It is absolutely essential to go forward, and I 
want to thank all these men and women who are here today, the 
first responders, FDNY, NYPD, construction contractors, I saw--
before certainly, you know, people who are residents of the 
area, and really everyone who answered the call that day, 
everyone did what they had to do, and those who are suffering 
these illnesses, people in the prime of life who have, again, 
lost their jobs, have these debilitating illnesses which have 
changed their lives so radically, all because they did what had 
to be done.
    So again, I thank the chairman for holding this hearing. I 
thank the committee for taking this issue up. I thank all of 
you for being here today. And I certainly thank Mr. Collins for 
yielding me the time. And I yield back to him. Thank you, Mr. 
Collins.
    Mr. Pitts. The Chair thanks the gentleman.
    And now recognize the gentlelady from North Carolina, Mrs. 
Ellmers, 5 minutes for questions.
    Mrs. Ellmers. Thank you, Mr. Chairman. And thank you, Dr. 
Howard, for being with us. And I too want to thank all of the 
first responders who are here today.
    You know, a very emotional subcommittee hearing, and so I 
am going to try hard to stick to the information and get into 
some of these questions. Along the lines of where we are today, 
and I know that you have already stated, Dr. Howard, that as 
the number of affected first responders have come forward, 
those who have been determined to have cancer, how many are in 
existence right now? How many are with us? What number do you 
have of potentially affected patients who have a diagnosis of 
cancer?
    Dr. Howard. Well, right now, we have about 3,400 cases of 
cancer--individual cases of cancer. Some of those cases may 
represent an individual that may have more than 1 cancer----
    Mrs. Ellmers. Um-hum.
    Dr. Howard [continuing]. But generally speaking, that is 
the number of members that we have who we are--we have 
certified with cancer.
    Mrs. Ellmers. Now, as far as the certification process, I 
am just curious as to how you determine approval or denial and, 
you know, do you have numbers that play out as far as the 
possibility of being approved or denied?
    Dr. Howard. Sure, and let me just briefly explain the 
process. The physician who is seeing the patient makes the 
connection between their exposure and the health condition, in 
this case, cancer.
    Mrs. Ellmers. Um-hum.
    Dr. Howard. So they can say that it is caused by, 
contributed to, or aggravated by their exposure. That is the 
determination that is made by the physician.
    Mrs. Ellmers. I see.
    Dr. Howard. We don't make it in the program. That is an 
independent view that the physician has. Then they submit it to 
us----
    Mrs. Ellmers. Um-hum.
    Dr. Howard [continuing]. And we make sure that all of the 
supporting information is there, and then we certify it. If the 
supporting information isn't there, we have a question, we go 
back and forth----
    Mrs. Ellmers. Um-hum.
    Dr. Howard [continuing]. Until we are all absolutely sure, 
including the determining physician and us that this is a case 
to be certified. Certification then means that you get your 
cancer covered for health care.
    Ms. Ellmers. Um-hum. And having the concentration on cancer 
leads me to the next question, which is, Do you anticipate 
adding other possible diseases outside of the cancer realm?
    Dr. Howard. Well, we have received to date 7 petitions----
    Mrs. Ellmers. Um-hum.
    Dr. Howard [continuing]. For requests adding conditions. 
Two of those were cancer. The original cancer petition that 
Chairman Pitts referred to----
    Mrs. Ellmers. Um-hum.
    Dr. Howard [continuing]. 001, and then soon after that we 
had a petition with regard to prostate cancer, and then 5 
others. With the 5 others, we did not find sufficient 
scientific evidence----
    Mrs. Ellmers. Um-hum.
    Dr. Howard [continuing]. To support their addition. We get 
quite a few requests for adding conditions. It is hard to 
estimate----
    Mrs. Ellmers. Um-hum.
    Dr. Howard [continuing]. What conditions we would add in 
the future, but we evaluate each of those requests on their 
scientific basis.
    Mrs. Ellmers. And then in regard to autoimmune diseases, I 
understand that you have made a determination that those would 
not be identified or added.
    Dr. Howard. Right.
    Mrs. Ellmers. And can you just expand on that?
    Dr. Howard. Right. We received a petition, our last 
petition, to add a large number of autoimmune diseases to our 
statutory list. We reviewed all of the information, including 
the very excellent study that had recently stimulated that 
petition by FDNY----
    Mrs. Ellmers. Um-hum.
    Dr. Howard [continuing]. And we found that it was 
insufficient at this time.
    Mrs. Ellmers. Um-hum. Um-hum.
    Dr. Howard. It doesn't mean that--and this is why we are--I 
emphasize so much the importance of research----
    Mrs. Ellmers. Um-hum.
    Dr. Howard [continuing]. Funding in this program, is the 
additional work that is going on by other CCEs and our World 
Trade Center Health Registry to look into that----
    Mrs. Ellmers. Um-hum.
    Dr. Howard [continuing]. Issue. So it doesn't mean that 
forever and ever----
    Mrs. Ellmers. Right.
    Dr. Howard [continuing]. It will not be added, but at this 
time----
    Mrs. Ellmers. Um-hum.
    Dr. Howard [continuing]. We are not adding it.
    Mrs. Ellmers. Well, thank you, Dr. Howard. I do appreciate 
all of the information that you have helped us with, and I am 
glad to know that this is considered to be an ongoing process 
into the future, because we don't know what the future holds 
for this. And again, God bless all of the first responders who 
are here, and your families. Thank you so much.
    I yield back.
    Mr. Pitts. The Chair thanks the gentlelady.
    Now that all the members of the subcommittee have had an 
opportunity to ask questions, with unanimous consent I ask that 
the member of the full committee, Ms. Clarke, be given 5 
minutes for questioning.
    The Chair recognizes Ms. Clarke.
    Ms. Clarke. Thank you very much, Mr. Chairman. We have been 
joined here by Congressman Gerald Nadler of New York, original 
sponsor of the Zadroga Act, and I wanted to yield some time to 
him if it is----
    Mr. Nadler. I thank you for yielding, and let me thank the 
chairman for holding the hearing, and the members.
    I simply want to say that as someone who is one of--along 
with Mr. King and Ms. Maloney, was one of the 3 original 
sponsors of this bill, we struggled for years and years to pass 
it, I am glad to--and the history has proven the necessity of 
this bill, and I want to thank Dr. Howard for his wonderful 
service. I am glad that the chairman has called this hearing, 
and that, judging from the comments at the hearing, there seems 
to be a lot of bipartisan support for extending this bill. We 
know the necessity of that so I just want to urge that that be 
done, and that--and I thank the chairman and the committee 
again. Extension of this bill is essential because the diseases 
won't go away, and this is for both the first responders and 
the survivors in the community. And so I urge the extension of 
the bill.
    I thank Ms. Clarke for yielding, and I yield back to her.
    Ms. Clarke. Thank you.
    Dr. Howard, just following up on a couple of the questions 
that Mrs. Ellmers asked about the conditions. For the record, 
what is the process by which you can add new conditions to the 
program?
    Dr. Howard. Well, first of all, the administrator has the 
ability to add a condition on his or her own motion. The other 
very common route that we have seen so far is the public can 
petition the administrator to add a condition. As I said, we 
have received 7 petitions so far; 2 of those we have added the 
condition, the first one being cancer, the second one being a 
particular type of cancer; prostate cancer. The other 5 we have 
found insufficient evidence for.
    Ms. Clarke. I understand that the statute outlines specific 
timing requirements for you to respond to those petitions. 
Could you describe that for us?
    Dr. Howard. Right. The administrator has 60 days to respond 
to a petition, unless the administrator refers the petition to 
our Scientific and Technical Advisory Committee, and then the 
time frame is 180 days. So for the--for instance, in terms of 
the first petition on cancer, we referred that to our Science 
and Technical Advisory Committee. They had 180 days to make 
their decision.
    Ms. Clarke. Do you have any concerns with the statutory 
time frames under which you would have to respond to such 
petitions?
    Dr. Howard. Well, one of the things that the GAO report 
pointed out in their review of our cancer petition and--or 
addition of cancer was that there was no external peer review 
of our science that we used to justify the addition of cancer. 
We believe in peer review very, very much, and we want to do 
external peer review, but the time frame of 60 days was just--
given the enormity of the task of adding all those numbers of 
cancers, that was a very short period of time, so we were 
unable to engage in external peer review.
    Ms. Clarke. Very well. Can you briefly tell us about the 
registry? It is our understanding it was created to follow 
individuals who were exposed to environmental toxins related to 
the World Trade Center terrorist attack. Tell us a bit more 
about the registry and why it is important--an important tool 
for studying the WTC-related health effects.
    Dr. Howard. The World Trade Center Health Registry, which 
is operated by the New York City Department of Public Health 
and Mental Hygiene is a vital participant in the research 
aspects of the program. They started very soon after 9/11. They 
have, interestingly enough, about 71,000 members also, and I 
might add, I was told by the director last week that they have 
registrants in the registry from every congressional district, 
all 435. And they have produced almost 60 papers in this area. 
They followed the same people over periods of time, so they--
every so many years, they study them to figure out what their 
experience is. So their research is vital to this program.
    Ms. Clarke. Do we have a sense of any of their findings so 
far?
    Dr. Howard. All of their findings are not only on their Web 
site, but also on ours. And I think some of the things that we 
have learned already, the issues about asthma, mental health, 
persistent PTSD, et cetera, have come largely from the World 
Trade Center Health Registry studies.
    Ms. Clarke. So you think it is important that we continue 
our work?
    Dr. Howard. It is absolutely vital.
    Ms. Clarke. I thank you very much, Dr. Howard.
    And I yield back. Thank you, Mr. Chairman. And I thank the 
ranking member.
    Mr. Pitts. The Chair thanks the gentlelady.
    That concludes the questions of members who are present.
    I am sure, Doctor, we will have follow-up questions from 
members. We will send those to you in writing. We ask that you 
please respond promptly.
    Dr. Howard. Thank you, Mr. Chairman.
    Mr. Pitts. Thank you.
    That concludes our first panel. We will take a 3-minute 
recess as the staff sets up the witness table for the next 
panel.
    Committee stands in recess.
    [Recess.]
    Mr. Pitts. All right, the time of recess having expired, we 
will reconvene. I will ask the guests to please take their 
seats.
    Ladies and gentlemen. Ladies and gentlemen, please take 
your seats. The committee will reconvene. I would ask the 
guests to please take their seats, and I will introduce the 
second panel.
    We have 3 witnesses on the second panel, and I will 
introduce them in the order in which they will present 
testimony.
    First, we have Dr. Iris Udasin, Medical Director, 
Environmental and Occupational Health Sciences Institute, 
Robert Wood Johnson Medical School. Welcome, Dr. Udasin. 
Secondly, we have Mr. David Howley, retired police officer, New 
York City Police Department. And finally, we have Ms. Barbara 
Burnette, a former detective, New York City Police Department. 
Thank you very much for your patience, for coming, for your 
testimony. Your written testimony will be made a part of the 
record. You will each be given 5 minutes to summarize. There 
are a series of lights on the table, so you will see green 
fist, then yellow. When red appears, we ask that you please 
conclude your testimony.
    So at this time, Dr. Udasin, you are recognized for 5 
minutes to summarize your testimony.

STATEMENTS OF IRIS G. UDASIN, M.D., DIRECTOR, ENVIRONMENTAL AND 
  OCCUPATIONAL HEALTH SCIENCES INSTITUTE, ROBERT WOOD JOHNSON 
 MEDICAL SCHOOL; DAVID G. HOWLEY, RETIRED POLICE OFFICER, NEW 
   YORK CITY POLICE DEPARTMENT; AND BARBARA BURNETTE, FORMER 
           DETECTIVE, NEW YORK CITY POLICE DEPARTMENT

                  STATEMENT OF IRIS G. UDASIN

    Dr. Udasin. My name is Iris Udasin, and I serve as Director 
of Rutgers Clinical Center of Excellence in New Jersey. We are 
1 of 6 clinics in the New York/New Jersey area that provide 
medical monitoring and treatment for World Trade Center first 
responders. I am a physician who is board certified in internal 
and occupational medicine, and am a professor at Rutgers, and a 
member of the National Toxicology Panel, an expert panel that 
advises the National Institute of Environmental Health Sciences 
concerning the relationship between exposure to toxic chemicals 
and health.
    I want to thank the committee for giving me the opportunity 
today to testify concerning the importance of our Clinical 
Centers of Excellence, and for the opportunity to provide the 
best quality medical care through the Zadroga Act to those 
brave responders who have suffered from multiple, chronic and 
often disabling medical illnesses, including pulmonary 
fibrosis, sarcoidosis, asthma, gastric reflux, sinusitis, and 
sleep apnea.
    We have been monitoring World Trade Center patients in New 
Jersey since January 2003, and began treating patients with 
Federal funding starting in 2007. In addition to the treatment 
of the aforementioned conditions, over the past 3 years we have 
been able to use our funding under the Zadroga Act to optimize 
cancer care. This is critical, since as early as 2008, our 
responders were already showing a cancer rate that was 15 
percent higher than people their age, who were not at the 
disaster site. This rate is only increasing, and our patients 
are much younger than usual cancer patients and are nonsmokers. 
They were highly exposed to environmental toxins as well as 
severe mental health trauma from what they witnessed at Ground 
Zero. From seeing people jumping off tall buildings to their 
death, or finding charred remains.
    Our designation as a Clinical Center of Excellence has 
allowed us to provide quality of care for these responders by 
centering all their care in a convenience location with staff 
members sensitive to their needs, coordinating treatment from 
start to finish. The combination of program-wide knowledge 
gained over 12 years of care delivery, in addition to my 
personal knowledge in New Jersey, has allowed us to understand 
this cohort of patients using medical and pharmaceutical 
resources wisely to accomplish the following objectives, which 
I will illustrate with specific patient examples. Coordination 
of care for complex cases. Diagnosis and treatment of patients 
considering both physical and mental health aspects of disease. 
Use of state-of-the-art diagnostic techniques for early 
diagnosis and treatment. Use of knowledge gained in our 
treatment of patients to allow for early intervention, enabling 
our skilled patients to stay at work.
    I am proud to share this panel with David Howley, a retired 
police officer, who performed many months of search and rescue 
work at the site. David presented with swelling in his neck in 
2006, which was eventually diagnosed as an aggressive 
metastatic cancer of the throat. This is an unusual and rare 
cancer in healthy, nonsmoking Americans. However, in my center, 
we have seen 8 other patients with this cancer in New Jersey 
alone. David's treatment has required a team of doctors, 
including myself as primary care, the general oncologist, the 
radiation oncologist, the general surgeons, the ear, nose, and 
throat surgeons. Because of the complicated nature and location 
of his cancer, it has been extremely difficult to treat, but at 
the present time, he is tumor-free since April of 2014.
    The second patient I want to tell you about is a retired 
detective, with severe shortness of breath, chest discomfort, 
fatigue, and inability to perform his duties as a police 
officer, who was present at the 9/11 site on the date of 
disaster, reported being engulfed in the dust cloud, and 
witnessing people jumping out of buildings. He was treated by 
his personal physician, with 5 medications for his respiratory 
issues, but no other conditions. His evaluation at our center 
confirmed the presence of asthma, but we were also able to 
diagnose rhinitis, gastric reflux, sleep apnea, post-traumatic 
stress disorder, and panic attacks. This patient was given 
treatment for those conditions, and received therapy for PTSD 
and panic disorder. The patient was able to recognize that his 
panic attacks were causing him to use increased amounts of his 
asthma medication, and he learned to control his attacks. At 
his most recent examination, he no longer needs mental health 
medications, and is enjoying his retirement.
    The third patient I want to speak about works as a 
consultant to prevent tax fraud. An abnormality was noted on 
his chest x ray, and he was referred for a CT scan. A small 
nodule was noted in November of 2014, which grew larger in 
January. This was evaluated by a radiologist who is an expert 
in interpreting lung CT scans. She was concerned about the 
suspicious nature of this nodule and its growth since the 
original CT scan. This patient was referred to our university 
surgeon who removed a stage 1 lung cancer, which does not need 
chemotherapy or radiation. And I want to say this patient is 
back at work. He is overseas looking for people who have 
cheated the Government paying taxes.
    And finally, Rutgers University and NYU have combined to do 
research, finding markers for sleep apnea associated with 
environmental exposure. This expertise has allowed for early 
diagnosis and treatment of obstructive sleep apnea, enabling us 
to get people to work safely.
    My fourth patient is a pilot for a law enforcement agency, 
with a history of GERD and sinusitis, which are risk factors 
for sleep apnea. Thanks to early diagnosis, this patient has 
been successfully treated for his conditions, and he is fully 
qualified under Federal standards to skillfully operate his 
aircraft. He asked how he could thank me for his treatment, and 
I said that he should continue catching terrorists.
    In summary, all of our patients are honored and treated by 
skilled clinicians. We believe we are continuing to acquire the 
knowledge to provide early diagnosis and treatment of emergency 
responders who were exposed to toxic agents and psychosocial 
stressors. We are striving to continue to achieve excellence 
and cost-effectiveness in treating our patients, as well as 
preparation for providing the best possible medical care for 
any emergency responders who were exposed to a multitude of 
unpredictable exposures.
    [The prepared statement of Dr. Udasin follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] 
    
    Mr. Pitts. The Chair thanks----
    Dr. Udasin. Thanks for the extra time.
    Mr. Pitts [continuing]. The gentlelady.
    And now recognizes Mr. Howley, 5 minutes for your summary.

                  STATEMENT OF DAVID G. HOWLEY

    Mr. Howley. Thank you, sir. First thing I would like to do 
is thank you for having this hearing. It is obviously very 
important by the amount of people that are here today, and it 
is both an honor and a privilege to be here and address you.
    There are a lot of things I would like to say about this, 
but I think the most important is to answer a question that you 
all basically posed to Dr. Howard, and that is what happens if. 
And Dr. Howard was wonderful in his answers, but I think I am 
going to be a little more blunt about it. People are going to 
die. The men and women that are sick, that are being taken care 
of now. I have only been cancer-free a little over a year. I 
could easily--and if it wasn't for this lady right here, I 
wouldn't be here at all. So to end this program, people are 
going to die. It is just--it is a fact. It is unquestionable, 
and that is what is going to happen.
    I was born and raised in Mr. Pallone's district, and I 
lived in his district once I retired, and then I moved a few 
years ago, and I live in Congressman Lance's district. So I 
have both sides of the aisle covered here. This is not 
something that should have any political fighting. This should 
be an absolute bipartisan, 435-to-0-type bill. This is a ground 
ball and no-brainer, as far as I am concerned.
    And as--the other--and the last point I would like to make, 
because I am going to try to keep this brief, is, I wouldn't be 
here, sitting here, if it wasn't for the doctors and Dr. 
Udasin's and her other colleagues' knowledge, skills, 
abilities, research. They have become the absolute experts in 
what is ailing us, and not just me but all the other people 
that are part of this program. You can't go to your regular 
doctor. They don't have the knowledge. They just don't. They 
are not bad doctors, there is nothing wrong with it, but what 
has happened to us because of the conditions that we were in 
is--has become very specific. And I didn't have a normal 
cancer, and there are a lot of other people who don't have 
normal or normal blood diseases, and because of their absolute 
dedication, they have come up with plans and outlines and--that 
they can treat and get us through these difficult diseases. And 
that is the most important thing is that we can have a quality 
of life to go forward.
    And I am going to leave it at that. I will be happy to 
answer any of your questions.
    [The prepared statement of Mr. Howley follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] 
    
    Mr. Pitts. The Chair thanks the gentleman. And now 
recognizes Ms. Burnette 5 minutes for your opening statement.

                 STATEMENT OF BARBARA BURNETTE

    Ms. Burnette. Thank you subcommittee--Ranking Member Green, 
and members of the subcommittee on Health for inviting me to 
appear before you today.
    My name is Barbara Burnette, and I live in Bayside, New 
York. I am 52 years old, a wife, a mother, and a grandmother. 
With me here today are my husband, Lebral, Sr., and my son, 
Lebral, Jr. I am a proud former New York City police detective. 
I retired from the department after 18 \1/2\ years of service. 
My career came to an end because of an illness I developed from 
the time I served at the World Trade Center site. I served 
there for more than 3 weeks; about 23 days in total. The 
morning of September 11, 2001, I was working in Brooklyn, New 
York, in the Gang Intelligence Division. When my fellow 
officers and I learned that the morning--the terrorist attacks 
in New York City, we rushed to lower Manhattan the fastest way 
possible, which was by boat. When we arrived, the towers had 
collapsed. The air was thick with dust and smoke. I put my 
hands over my mouth and noise just to breathe. My fellow 
officers and I worked all day and well into the night. We 
evacuated people from around the World Trade Center site. We 
directed them away from the disaster. There was so much dust, 
but I was not given any respirator or any kind of protection 
for my eyes, throat, or lungs. I had to wash out the debris of 
my eyes and throat, picking up a hose. My fellow officers and 
I, along with all the rescue workers and first responders, 
could not stop doing what we had to do. The first night I 
finally left the World Trade Center around 10:00 p.m., after 12 
hours. Five hours later, I reported back to the World Trade 
Center site at 4:00 a.m. in the morning on September 12. I 
removed debris by using buckets and shovels, and at no time was 
I provided with respiratory protection. If I was not crying 
over what I was seeing in the room, tears streamed down my face 
from burning, irritating dust.
    I spent weeks at the World Trade Center site, shoveling, 
clearing away debris, searching for survivors, and later 
sifting for body parts of the dead. We worked side-by-side and 
hand-in-hand with ironworkers, construction workers, 
firefighters, police officers, all of us searched in the dust 
and removed debris together. We were searching and removing 
wreckage of the World Trade Center. We were working right on 
top of the burning, smoky, hot rubble. The fires never stopped 
burning. Air quality, we were told, was not a concern. All of 
us working 24/7.
    The work was tough and dirty, we were choking, and it was 
dangerous, but there was never a time when I even thought about 
quitting or leaving. I thought of thousands of poor victims. If 
our work brought the removal and recovery efforts closer to the 
end, we were glad to contribute.
    I live with the consequences of 9/11 every day. I have been 
diagnosed with interstitial lung disease; more specifically, 
hypersensitivity pneumonitis with fibrosis in my lungs. The 
inflammation in my lungs interferes with my breathing, and 
destroys the tissues that get oxygen to my blood. My lungs are 
permanently scarred. I cannot move around my home or take the 
stairs without wheezing or gasping for breath. I start each 
morning connecting to a nebulizer and inhaling multiple doses 
of medications. I am told I will eventually need a double lung 
transplant. Long steroid use has caused weight gain and other--
and has--and other prescription medications have caused many 
additional illnesses. I have been diagnosed with diabetes, high 
blood pressure, osteoarthritis, and rheumatoid arthritis. I 
have suffered partially detached retinas in both eyes, each 
requiring surgery. Prior to my World Trade Center service, I 
was in top shape. I had no history of lung disease, I never 
smoked, I always had a physically demanding lifestyle and 
career. During my time with NYPD, I worked for 5 years in the 
Plainclothes Narcotics Unit. These assignments required me to 
walk 4 miles per day, making arrests in buy-and-bust 
operations, and executing search warrants. I have made over 200 
arrests in my career, and have assisted in hundreds more. I 
have been recognized by the NYPD numerous times for excellent 
police duty. I have also received several medals for 
meritorious police duty.
    I was born and raised in Brooklyn, New York. I played high 
school and college basketball. I played on the police league 
women's team which competed across the United States 
internationally. Life has become very different since I became 
sick. Every month, I see the doctors at Mount Sinai to receive 
care and renew my prescriptions. This program saves lives. It 
is saving my life today. It provides medical structure in my 
life by coordinating doctors and medications. My family does 
not have to suffer the financial burden of doctors' visits, 
copayments, deductibles, and the terrible cost of prescription 
medication, which I--would not be available to me without the 
program.
    I would also note that the health conditions are worsening. 
Many of the first responders' colleagues have been diagnosed 
with cancer. Many colleagues have died of cancer. The amount of 
dust to which we were exposed was unprecedented. Many of us 
fear cancer and other injuries that arise late after toxic 
exposure.
    Recently, more than 60 types of cancers have been 
identified by medical researchers as being directly related to 
the toxins found at Ground Zero. Cancer arises years and years 
later. For these reasons, I would urge the committee to approve 
the bipartisan legislation before it.
    Thank you.
    [The prepared statement of Ms. Burnette follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] 
    
    Mr. Pitts. The Chair thanks the gentlelady. And thanks to 
all the witnesses for their testimony.
    I will begin the questioning by members and recognize 
myself 5 minutes for that purpose.
    Dr. Udasin, we will begin with you. In your testimony you 
talk about the coordination of care that your client provides, 
and that you can spend time with your patients. Can you 
elaborate in more detail about that?
    Dr. Udasin. Since David is sitting next to me, it is a 
really good example. David's condition was in such a peculiar 
location that we had to find different surgeons that were able 
to get to where his cancer were--was. So this required speaking 
to people individually to determine who had the right expertise 
to actually take care of his cancer. Where he could get the 
right radiation, that was a big issue in David's case also 
because there were certain issues with how he was receiving 
radiation, and he could better go to one place and not go to 
another place. And the good news for David was that he had a 
supportive family to take care of his other needs, but we have 
had other patients not as fortunate as David where, 
unfortunately, we have had to coordinate getting them into 
things like hospice care. So my staff--and I would like to 
acknowledge Tracey Berspese, my administrator, who is sitting 
there, who helps us arrange a lot of the important things that 
we do with our patients. Getting them from place to place, 
making sure they get a good appointment and a prompt 
appointment.
    So, you know, you go into a doctor's office, and you have 
an abnormal test, and then you have to go and see a specialist. 
If you go in just by yourself, they say, oh, you can have an 
appointment next November. That is their next available 
appoint. But I can assure you, when I call up, you will be in 
by Tuesday. So if that answers your question.
    Mr. Pitts. Yes. Well, just to follow up with the 
coordination and having time, very important for the level of 
care that you give. Was it possible to provide this level of 
care before Congress established the World Trade Center Health 
Program?
    Dr. Udasin. It was not possible to obtain this degree of 
care. Initially we had, in--the end of 2002, 2003, we just had 
the monitoring program, and it was very frustrating because you 
could find something wrong with a person and we really didn't 
have the resources to make sure they got to see the correct 
person. And I am grateful for the Zadroga funding that we have 
now so that we can do that.
    Mr. Pitts. Thank you. For Mr. Howley and Ms. Burnette, can 
you talk about your care before and after the creation of the 
Centers of Excellence in the Zadroga 9/11 Health and----
    Mr. Howley. I----
    Mr. Pitts [continuing]. Compensation Act, and in your view 
is it better coordinated?
    Mr. Howley. I was thinking of a story when you just asked 
the doc a question. I am probably one of her original patients 
going back to the monitoring program back in 2003. The first 
time I went there, my blood pressure was basically somewhere 
off her chart. My sinuses were completely blown out. I had 
constant infections, I had GERD, which is acid reflux, and she 
basically refused to let me leave her office unless I went 
straight to my doctor to get treated for the blood pressure. 
And I am 6'3'' and she is about 5'1'', and I believed here that 
she wasn't going to let me out of the office.
    So yes, there is a big difference. As far as--and she is 
just wonderful, and I am sure--and I haven't really dealt--I 
have only dealt with one other of the doctors at her office, 
and I have never been to any other offices, so I can't speak 
about any of them. But the doctors at--you know, are just 
tremendous, and they--as she was saying, when the cancer has 
kept coming back for me, and it has reoccurred 4 times for me. 
You can now--she can make those phone calls now, where--and get 
me to the right--and when she says Tuesday, she is not kidding 
you.
    Mr. Pitts. Thank you. Ms. Burnette, would you respond to 
that, you know, as a patient in the World Trade Center Health 
Program, are you satisfied with your access and the care you 
have received, and compare before and after.
    Ms. Burnette. Yes, I am very satisfied with my care because 
in 2004, I started blacking-out at work and nobody knew why, 
and with the regular doctors I was just being sent out for 
different kind of tests. In the program, they send me to 1 
doctor, who sends me to another doctor to make sure everything 
is covered. They schedule everything for you. And I think it is 
very important that they follow up in what is going on, and how 
they treat us is very well.
    Mr. Pitts. thank you. My time has expired.
    The Chair recognizes the ranking member, Mr. Green, 5 
minutes for questions.
    Mr. Green. Thank you, Mr. Chairman.
    Mr. Howley, from your testimony I understand you have been 
seeing Dr. Udasin since the permanent World Trade Center Health 
Program was established under Zadroga. Would you explain what 
being able to see Dr. Udasin at the Rutgers Center of 
Excellence has meant to you? And I know it sounded like a 
little bit from the earlier question.
    Mr. Howley. That is fine. How do I phrase this in--their 
knowledge that they have acquired, because they have seen so 
many of us, when I present the next set of conditions or a 
former set of conditions that I had, she can tell me, Dave, go 
see Dr. X, Y, and Z, and not Dr. A, B, and C, because of her 
knowledge and skill and what she has been able to put together 
by seeing so many of us, she has that template, those tools in 
her belt----
    Mr. Green. Yes.
    Mr. Howley [continuing]. That will send me to the right 
person.
    Mr. Green. Do you think you would have been in worse 
condition without being in the center?
    Mr. Howley. I wouldn't be here. This chair would be filled 
with somebody else. I would not be here. There were only 3--the 
last surgery I had last year, there were only I believe it was 
4 surgeons that were qualified to do what I needed to get done.
    Mr. Green. OK. Ms. Burnette, from your testimony I 
understand you receive medical monitoring treatment services at 
the Mount Sinai Clinical Center of Excellence. Could you 
explain what care you have received at Mount Sinai, and what it 
has meant to you?
    Ms. Burnette. The care I received has been excellent. They 
did an open lung biopsy which determined that I--which lung 
disease I had and how they were able to treat it, and what 
doctors I needed to see.
    Mr. Green. OK. And could you explain what the care you 
received at Mount Sinai--I assume it is similar to what Dr. 
Udasin, you know, your--they are treating the whole person.
    Ms. Burnette. Yes. I have a primary doctor. They send me to 
individual doctors for the different diseases I have, like 
GERD, asthma, sinusitis, and one primary doctor coordinates all 
of that.
    Mr. Green. OK. Do you think your condition would be worse 
if you hadn't had--didn't have access to the 9/11 Health 
Program?
    Ms. Burnette. I believe it would be terribly worse because 
I was--I had that World Trade Center cough. I was not able to 
hold a conversation without the program providing me with the 
medications that I needed.
    Mr. Green. Dr. Udasin, why does this cohort of patients 
need the types of specialized care that is provided at the 
Clinical Centers of Excellence?
    Dr. Udasin. We have people with rare conditions like David 
that need specialists' help. We have been able to use our best 
university resources to get people that have seen many 
abnormalities on things like CT scans to get patients, like the 
gentleman I mentioned, to have the cancer removed. But I think 
really, the total--the number of conditions that we see and the 
complicated cases that we see, so you might have one condition 
and that influences another condition, and makes the third 
condition worse. So if you have mental health issues and you 
have reflux, and then you get chest pain, and you have asthma, 
you end up taking too many medications, and then you get a 
side-effect from medications. Many of the asthma medications, 
if you take too many of them, can precipitate heart disease. So 
I feel like early recognition and treatment of all the 
conditions correctly allows for much better outcomes for 
people.
    Mr. Green. It sounds like, with so many possible illnesses, 
misdiagnosis would be--would not be uncommon.
    Dr. Udasin. Well, that is correct. And Ms. Burnette 
described her shear number of conditions. And, yes, that is the 
issue because you don't want to--so you treat one condition 
really effectively, but you kill the patient while you are 
doing it because she had some other condition that you ignored. 
And so that is what I believe we are able to do. As the primary 
care gatekeeper-type person, I can make sure that all the 
specialists are talking to each other, and making sure that the 
total patient is treated correctly.
    Mr. Green. Thank you, Mr. Chairman. And I think because of 
the complications and the exposure to no telling what, that you 
need to have someone who looks at the whole person and actually 
treats all of the illnesses that you are subject to.
    Thank you, Mr. Chairman.
    Mr. Pitts. The Chair thanks the gentleman.
    Now recognize the gentleman from New Jersey, Mr. Lance, 5 
minutes for questions.
    Mr. Lance. Thank you, Mr. Chairman.
    Dr. Udasin, can you explain in a little more detail your 
Center of Excellence and what that means, and how many there 
are in the metropolitan region, and what qualifies your 
organization as being a Center of Excellence?
    Dr. Udasin. Well, thank you. We are part of the Non-FDNY 
Responder Program, and so FDNY has a separate center. We are 
one of the New York/New Jersey consortium, which includes 
centers at Mount Sinai, NYU, Stony Brook, Queens College, and 
Rutgers.
    Mr. Lance. Mount Sinai and NYU would be in Manhattan, and--
--
    Dr. Udasin. Yes.
    Mr. Lance [continuing]. Stony Brook is on Long Island, 
and----
    Dr. Udasin. And----
    Mr. Lance [continuing]. Queens is obviously in Queens, and 
Rutgers----
    Dr. Udasin. Queens is sort of in Nassau also. It is kind of 
on the border over there. And we serve as a Center of 
Excellence in New Jersey. What makes us different, our 
physicians are board certified in primary care specialties, 
internal medicine, and occupational medicine. It is double 
board certified. Almost all of our physicians have at least 2 
board certifications. As I said, Rutgers has an Environmental 
Center of Excellence in our same building, and we do extensive 
work on exposure and health effects, and that happens beside--
that is the rest of the faculty that I work with in Rutgers. So 
we have a lot of experience with exposure and illness.
    We have a pulmonary doctor that actually comes into our 
practice and sees patients with us. We have mental health 
people that come into our practice and see patients. And then 
across the street from us we have our surgeons, our 
gastroenterologists and a number of other specialties--
specialists that we need in the Rutgers Center.
    By the way, we changed our name to Rutgers. We need to get 
that on the record that we changed from UMDNJ to Rutgers. In 
any event----
    Mr. Lance. That is because our State legislature has 
permitted the combination of the University of Medicine and 
Dentistry and Rutgers.
    Dr. Udasin. Right. So in any event, then I have my 
registered nurses who are there helping us take care of 
patients, making sure that histories are obtained correctly, 
making sure that people actually know how to use their 
medications. This is really very important that we have people 
making sure that not only medications are used, but they are 
used correctly. Then I have, as mentioned, my mental health 
corps, then I have my administrative corps which Tracey 
Berspese heads, and that group of people is performing audits 
to make sure that everybody else is doing everything correctly. 
We are using our pharmacy correctly. We are doing the best that 
we can to keep costs down, using generic drugs, and that all of 
our providers and people that are writing prescriptions, that 
everybody is certified appropriate to do this, and that our 
patients actually get their medications when they get to the 
pharmacy. So that is part of coordination of care. And I can 
assure you we are performing these audits because I want to 
make sure that we have funding to treat our patients. 
Presumably you guys are going to unanimously confirm this bill, 
and I want the money to be there to treat our patients.
    Mr. Lance. Thank you very much, Doctor.
    And to Mr. Howley and Ms. Burnette, thank you for your 
superb public service, and certainly, we honor that public 
service.
    Ms. Burnette, what position did you play in basketball when 
you played basketball?
    Ms. Burnette. Point guard.
    Mr. Lance. Point guard. I was 5'8'' so I never played 
basketball.
    Mr. Chairman, I have a letter from, I think, 38 members of 
the New York and New Jersey Delegation to Speaker Boehner and 
Leader Pelosi requesting early passage of this bill. I would 
request that it be submitted for the record.
    Mr. Pitts. The gentleman seeks unanimous consent----
    Mr. Lance. I seek----
    Mr. Pitts [continuing]. To put in the record.
    Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Lance. Thank you, and I yield back 7 seconds.
    Mr. Pitts. The Chair thanks the gentleman.
    Now recognizes the ranking member of the full committee, 
Mr. Pallone, 5 minutes for questions.
    Mr. Pallone. Thank you, Mr. Chairman.
    Dr. Udasin, I wanted to get into the--try to have you 
explain, if you will, the importance of not only the Rutgers 
Center but all of the centers that are part of this World Trade 
Program in terms of research, because there is an extensive 
research component, and I want you to kind of emphasize if you 
can how you are developing diagnosis and treatment of disorders 
that, you know, people might not even be aware of, and how that 
research and, you know, the uniqueness of the center makes that 
possible. Could--so could you just kind of describe how the 
Rutgers Center is involved in research into World Trade Center-
related conditions, and how that research is improving our 
ability to diagnose and treat WTC-related health conditions, 
and the benefits of that research?
    Dr. Udasin. So answering the Rutgers only----
    Mr. Pallone. That is fine, sure.
    Dr. Udasin [continuing]. Rutgers and NYU research is, we 
have a lot of sleep apnea experts in those 2 centers, and what 
I am really proud to say is that between our laboratory 
toxicologists and our sleep experts, we have developed certain 
markers that we are seeing in certain of our patients. Dr. 
Sundaram, one of our sleep experts, presented this at the 
recent American Thoracic Society meetings, that certain markers 
were developed that certain people can be predicted possibly to 
have sleep apnea. And this is really important because these 
are inflammatory markers, and these people at 9/11 site were 
exposed to all kinds of toxins that can cause inflammation. And 
so because of that association between environmental exposures 
and inflammation, we have been able to find people a lot 
sooner, get them treated. And for people to think about sleep 
apnea and the environment, because traditionally sleep apnea 
was thought of something that you had to be enormously obese to 
get, and we have patients that are not quite playing point 
guard, but are in awfully good shape that have sleep apnea. And 
we are able to--as I said, we--because of our occupational 
expertise, sleep apnea is a very serious condition. There was 
somebody who died recently, a celebrity, on the New Jersey 
Turnpike because a bus driver fell asleep. And we have a lot of 
our patients who have to drive commercial vehicles, operate 
planes, operate the subway, operate all kinds of heavy 
equipment, and it is really good that we are able to treat them 
and keep them safe and awake. And I feel like that is one thing 
our research has accomplished, which is not only applicable to 
our patients, but it is applicable to other people with 
environmental exposures.
    Mr. Pallone. I appreciate that. The other thing I wanted 
to--if you could get across is how we can expect an increase 
among the population that--of these 9/11-related conditions. In 
other words, my understanding is as time goes on, we find more 
cancers, more disorders, you know, as people get older, that 
maybe didn't exist before and that have to be--and that now we 
are finding through your research or others in these centers 
that are related to 9/11 that we didn't know about before.
    Dr. Udasin. So I want to say that certain kinds of 
malignancies--poietic malignancies, have very short latency 
periods, and you would expect to see something like that within 
just a couple of years after exposure to toxins, but other 
toxins like asbestos have much longer latency periods, and they 
might be seen later on and at a different time.
    And if I could use just a few minutes to also answer a 
question that you asked Dr. Howard earlier about mistakes made 
by providers outside of the program. If I could just add that 
we have found in the program that people have been undertreated 
by local providers for various cancers, for various severe lung 
conditions like pulmonary fibrosis, and I do want to say, even 
though that wasn't exactly the question you asked, I do want to 
say that we have been able to improve the health care by tuning 
up, by getting better diagnostic services to our patients than 
they were able to get from some of the local people.
    Mr. Pallone. Thank you very much.
    Thank you, Mr. Chairman.
    Mr. Pitts. The Chair thanks the gentleman.
    That concludes the questions of the members. They will have 
follow-up questions in writing. We will submit those to you, 
ask that you please respond promptly.
    I would remind members they have 10 business days to submit 
questions for the record. And they should submit their 
questions by the close of business on Thursday, June 25.
    Thank you very much for sharing your personal experience, 
for your excellent testimony. The committee will take up this 
legislation, I assure you, and act on it. And you have 
performed a public service by being here today. Thank you very 
much.
    And without objection, the subcommittee is adjourned.
    [Whereupon, at 12:41 p.m., the subcommittee was adjourned.]
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