September 11: HHS Has Screened Additional Federal Responders for 
World Trade Center Health Effects, but Plans for Awarding Funds  
for Treatment Are Incomplete (08-SEP-06, GAO-06-1092T). 	 
                                                                 
Responders to the World Trade Center (WTC) attack--individuals	 
involved in rescue, recovery, or cleanup--included New York City 
Fire Department (FDNY) personnel, federal government workers, and
others from New York and elsewhere. They were exposed to numerous
hazards, and concerns remain about the long-term effects on their
physical and mental health. In February 2006, GAO testified that 
four of the five key federally funded programs that were	 
monitoring health effects in responders had made progress but	 
that the Department of Health and Human Services' (HHS) WTC	 
Federal Responder Screening Program, implemented by the Office of
Public Health Emergency Preparedness (OPHEP), lagged behind	 
(GAO-06-481T). GAO also reported that the Congress appropriated  
$75 million in December 2005 to HHS's Centers for Disease Control
and Prevention (CDC) for monitoring and treatment for responders 
and that CDC was deciding how to allocate the funds. This	 
statement updates GAO's February 2006 testimony. GAO examined (1)
progress made by HHS's WTC federal responder program and (2)	 
actions CDC has taken to award the $75 million appropriated. GAO 
reviewed program documents and interviewed HHS officials and	 
others involved in WTC monitoring and treatment programs.	 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-06-1092T					        
    ACCNO:   A60492						        
  TITLE:     September 11: HHS Has Screened Additional Federal	      
Responders for World Trade Center Health Effects, but Plans for  
Awarding Funds for Treatment Are Incomplete			 
     DATE:   09/08/2006 
  SUBJECT:   Appropriated funds 				 
	     First responders					 
	     Health care programs				 
	     Health hazards					 
	     Health research programs				 
	     Locally administered programs			 
	     Medical examinations				 
	     Mental health					 
	     Monitoring 					 
	     Performance measures				 
	     State-administered programs			 
	     FDNY WTC Medical Monitoring Program		 
	     HHS WTC Federal Responder Screening		 
	     Program						 
                                                                 
	     WTC Health Registry				 
	     WTC Medical Monitoring Program			 

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GAO-06-1092T

     

     * Background
          * Health Effects
          * Monitoring Programs
          * New Federal Funding for Monitoring and Treatment
     * HHS Has Registered and Screened Additional Federal Responder
          * HHS's Outreach Resulted in Registration of Additional Federa
          * HHS Has Screened Additional Current Federal Workers
          * Screening of Former Federal Workers Has Resumed, but Group I
     * CDC Has Awarded a Small Portion of the $75 Million Appropria
          * CDC Plans to Award the $75 Million to the Five First-Priorit
          * CDC Has Awarded about $4.5 Million of the $75 Million Appro
          * CDC Is Waiting to Award Additional Funds for Treatment Until
     * Contact and Acknowledgments
     * GAO's Mission
     * Obtaining Copies of GAO Reports and Testimony
          * Order by Mail or Phone
     * To Report Fraud, Waste, and Abuse in Federal Programs
     * Congressional Relations
     * Public Affairs

Testimony

Before the Subcommittee on National Security, Emerging Threats, and
International Relations, Committee on Government Reform, House of
Representatives

United States Government Accountability Office

GAO

For Release on Delivery Expected at 10:30 a.m. EDT

in New York, New York,

Friday, September 8, 2006

SEPTEMBER 11

HHS Has Screened Additional Federal Responders for World Trade Center
Health Effects, but Plans for Awarding Funds for Treatment Are Incomplete

Statement of Cynthia A. Bascetta

Director, Health Care

GAO-06-1092T

Mr. Chairman and Members of the Subcommittee:

Thank you for inviting me to participate in today's hearing on programs
that monitor and provide treatment for health effects of the World Trade
Center (WTC) terrorist attack on September 11, 2001.1 My testimony today
updates information we reported to you in February 2006.2 An estimated
40,000 people served as responders in the aftermath of the WTC disaster,
including New York City Fire Department (FDNY) personnel, federal
government personnel, and other government and private-sector workers and
volunteers from New York and elsewhere. By responders we are referring to
anyone involved in rescue, recovery, or cleanup activities at or near the
vicinity of the WTC or Staten Island site.3 These responders were exposed
to numerous physical hazards, environmental toxins, and psychological
trauma. Five years after the destruction of the WTC buildings, concerns
remain about the long-term physical and mental health effects of the
attack on responders as well as other affected individuals, including
residents and workers.

As we testified in September 2004,4 in the aftermath of the WTC attack,
five key federally funded programs were implemented to assess the
short-term, and in some cases long-term, effects on the physical and
mental health of WTC responders. These programs are the FDNY WTC Medical
Monitoring Program; WTC Medical Monitoring Program, which we refer to as
the worker and volunteer WTC program;5 New York State responder screening
program; WTC Health Registry;6 and the Department of Health and Human
Services' (HHS) WTC Federal Responder Screening Program. We provided
information on the progress of these monitoring programs7 in our February
2006 testimony.8 We noted that federal employees who responded in an
official capacity in the aftermath of the WTC attack were eligible only
for the federal responder program but that it had accomplished little and
lagged behind the other four programs. The other programs had provided
thousands of health screenings and collected information that could
contribute to better understanding of the health consequences of the
attack and improve treatment for affected individuals. Officials of the
three programs that planned to conduct long-term health monitoring-the
FDNY WTC program, the worker and volunteer WTC program, and the WTC Health
Registry-told us they were concerned, however, that federal funding for
their programs could end before sufficient monitoring occurred to identify
all long-term health problems related to the WTC attack, some of which,
such as cancer, might not appear until decades after exposure to a harmful
agent.9 We also reported that HHS's Centers for Disease Control and
Prevention (CDC) had recently received a $75 million appropriation to fund
programs providing health screening, long-term monitoring, and treatment
for WTC responders and was deciding how to allocate those funds.10

1A list of abbreviations used in this testimony is in app. I.

2GAO, September 11: Monitoring of World Trade Center Health Effects Has
Progressed, but Program for Federal Responders Lags Behind, GAO-06-481T
(Washington, D.C.: Feb. 28, 2006). See also GAO, September 11: Monitoring
of World Trade Center Health Effects Has Progressed, but Not for Federal
Responders, GAO-05-1020T (Washington, D.C.: Sept. 10, 2005).

3The Staten Island site is the landfill that is the off-site location of
the WTC recovery operation.

4GAO, September 11: Health Effects in the Aftermath of the World Trade
Center Attack, GAO-04-1068T  (Washington, D.C.: Sept. 8, 2004).

5This program was formerly known as the WTC Worker and Volunteer Medical
Screening Program. In this testimony, we refer to the program as the
worker and volunteer WTC program.

6The WTC Health Registry also includes residents and other workers
affected by the attack.

My testimony today revisits these issues. I will discuss (1) progress made
by HHS's WTC Federal Responder Screening Program, and (2) actions CDC has
taken to award the $75 million that the Congress appropriated to the
agency in December 2005 for programs that provide screening, monitoring,
or treatment for WTC responders.

To assess progress made by HHS's WTC Federal Responder Screening Program,
we obtained and reviewed program data and documents from HHS, including
applicable interagency agreements and budget documents. We interviewed
officials from the Agency for Toxic Substances and Disease Registry
(ATSDR); CDC's National Institute for Occupational Safety and Health
(NIOSH); Federal Occupational Health Services (FOH);11 and the Office of
Public Health Emergency Preparedness (OPHEP). To determine actions taken
by CDC to award funds from the $75 million appropriated, we obtained
documents and interviewed officials from NIOSH and ATSDR. We also
interviewed officials from organizations implementing programs designated
in the appropriations act as having first priority for receiving the
funds-including the Mount Sinai-Irving J. Selikoff Center for Occupational
and Environmental Medicine, one of the clinical centers of the worker and
volunteer WTC program; FDNY's Bureau of Health Services (FDNY-BHS); the
New York City Department of Health and Mental Hygiene; the Police
Organization Providing Peer Assistance (the POPPA program); and the New
York City Police Foundation's Project COPE-and officials from the American
Red Cross, which has funded treatment services for responders. We relied
on data provided by agency officials and contained in government
publications and did not independently verify the data we obtained.
Although we could not independently verify the reliability of all of this
information, we compared it with other supporting documents, when
available, to determine data consistency and reasonableness. Based on
these efforts, we believe the information we obtained is sufficiently
reliable for this report. We conducted our work from July 2006 to
September 2006 in accordance with generally accepted government auditing
standards.

7In this testimony, we use the term monitoring program to refer to both
one-time screening programs and programs that include initial screening
and periodic follow-up monitoring.

8 GAO-06-481T .

9At that time, funding for the FDNY WTC and worker and volunteer WTC
programs was available through mid-2009, and funding for the WTC Health
Registry was available through April 29, 2008.

10See Department of Defense Appropriations Act, 2006, Pub. L. No. 109-148,
S:5011 (b), 119 Stat. 2680, 2814 (2005). These funds are available to CDC
until expended.

In summary, since February 2006, HHS has registered and screened
additional federal responders, and arrangements are being developed for
screening responders who are former federal workers residing outside the
New York metropolitan area. An additional 1,385 federal responders have
registered for screening examinations, including 1,134 current federal
workers and 251 former federal workers, bringing the total number
registered on the WTC Federal Responder Screening Program Web site as of
late August 2006 to 1,762, including 283 former federal workers. Because
the total number of federal responders involved in the WTC disaster is
uncertain, it is not possible to determine what proportion of the total
number of federal responders have registered. As of late August 2006, FOH
had completed screening examinations for a total of 907 federal workers;
380 of the 907 were screened since February 2006. Under an OPHEP agreement
with NIOSH, screening examinations for former federal workers are to be
provided through the worker and volunteer WTC program. As of July 31,
2006, the worker and volunteer WTC program provided screening examinations
to 13 former federal workers and scheduled 11 more. Most of the former
federal workers reside outside the New York metropolitan area, where the
worker and volunteer WTC program is located, and NIOSH is working to
establish a national network of providers to screen these workers.

11FOH is a part of HHS's Program Support Center.

CDC plans to award the $75 million appropriated for screening, monitoring,
and treatment to the five organizations that the law identified as having
priority for funding. CDC officials expect to make awards to the WTC
Health Registry, Project COPE, and the POPPA program over a 3-year period
and to award funds to the FDNY WTC and worker and volunteer WTC programs
in response to their treatment costs. CDC officials have a proposed
spending plan that allocates about $53.5 million for the latter two
programs' treatment costs, but the officials told us that because they are
uncertain about how quickly treatment costs could deplete the available
funds, they may need to make adjustments. Officials from the FDNY WTC and
worker and volunteer WTC programs told us that they expected that their
estimated portion of the appropriated funds would be depleted well before
the end of 3 years. As of August 2006, CDC awarded about $4.5 million of
the $75 million. The agency awarded about $1.9 million to the WTC Health
Registry, $1.5 million to the FDNY WTC program, and almost $1.1 million to
the worker and volunteer WTC program. In addition, CDC expects to award
$1.5 million to the POPPA program and $3 million to Project COPE in
September 2006. CDC is waiting to make further awards until it has reached
certain decisions about the coverage of treatment services, such as which
prescription drugs would be covered in the FDNY WTC and worker and
volunteer WTC programs. CDC expects to begin making further awards around
February 2007.

                                   Background

When the WTC buildings collapsed on September 11, 2001, an estimated
250,000 to 400,000 people in the vicinity were immediately exposed to a
noxious mixture of dust, debris, smoke, and potentially toxic contaminants
in the air and on the ground, such as pulverized concrete, fibrous glass,
particulate matter, and asbestos. Those affected included people residing,
working, or attending school in the vicinity of the WTC and thousands of
emergency responders. Subsequently, an estimated 40,000 responders who
were involved in some capacity in the days, weeks, and months that
followed, including personnel from many government agencies and private
organizations as well as other workers and volunteers, were also
exposed.12

Health Effects

A wide variety of physical and mental health effects have been observed
and reported among people who were involved in rescue, recovery, and
cleanup operations and among those who lived and worked in the vicinity of
the WTC.13 Many health effects have persisted or worsened over time.

Physical health effects included injuries and respiratory conditions, such
as sinusitis, asthma, and a new syndrome called WTC cough, which consists
of persistent coughing accompanied by severe respiratory symptoms. Almost
all firefighters who responded to the attack experienced respiratory
effects, including WTC cough. A recent study suggested that exposed
firefighters on average experienced a decline in lung function equivalent
to that which would be produced by 12 years of aging.14

Commonly reported mental health effects among responders and other
affected individuals included symptoms associated with posttraumatic
stress disorder-an often debilitating disorder that can develop after a
person experiences or witnesses a traumatic event, and which may not
develop for months or years after the event. Behavioral effects such as
alcohol and tobacco use and difficulty coping with daily responsibilities
have also been reported.

12The responders included firefighters; law enforcement officers;
emergency medical technicians and paramedics; morticians; health care
professionals; and other workers and volunteers, including those in the
construction and ironwork trades, heavy equipment operators, mechanics,
engineers, truck drivers, carpenters, day laborers, and telecommunications
workers. Numerous federal, state, and New York City agencies sent
personnel to respond to the WTC disaster.

13See, for example, CDC, "Mental Health Status of World Trade Center
Rescue and Recovery Workers and Volunteers-New York City, July 2002-August
2004," Morbidity and Mortality Weekly Report, vol. 53 (2004); CDC,
"Physical Health Status of World Trade Center Rescue and Recovery Workers
and Volunteers-New York City, July 2002-August 2004," Morbidity and
Mortality Weekly Report, vol. 53 (2004); CDC, "Surveillance for World
Trade Center Disaster Health Effects among Survivors of Collapsed and
Damaged Buildings," Morbidity and Mortality Weekly Report, vol. 55 (2006);
and G.I. Banauch et al., "Pulmonary Function after Exposure to the World
Trade Center in the New York City Fire Department," American Journal of
Respiratory and Critical Care Medicine, vol. 174, no. 3 (2006).

14Banauch et al., "Pulmonary Function," vol. 174, no. 3 (2006).

Monitoring Programs

The five programs that were created for monitoring the health of WTC
responders vary in aspects such as the implementing agency (i.e., federal,
state, or local governments or private organizations) and eligibility
requirements. (See table 1.) Each program received federal funding, the
majority of which was provided by the Department of Homeland Security's
Federal Emergency Management Agency (FEMA),15 as part of the approximately
$8.8 billion in federal assistance that the Congress appropriated to FEMA
for response and recovery activities after the WTC disaster.16 FEMA is
authorized to use a portion of its WTC-related funding for screening and
long-term monitoring of responders.17 With regard to treatment, however,
FEMA may generally fund only short-term care after a disaster, such as
emergency medical services, and not ongoing clinical treatment.18 FEMA
entered into interagency agreements with HHS to fund most of the health
monitoring programs. OPHEP, which coordinates and directs HHS's emergency
preparedness and response program, entered into separate interagency
agreements with FOH to implement the federal responder screening program
for current federal workers and with NIOSH to implement the screening
program for former federal workers.

15FEMA is the agency responsible for coordinating federal disaster
response efforts under the National Response Plan.

16FEMA provided funds to HHS to support screening and long-term monitoring
efforts from funds appropriated for disaster relief and emergency response
to the September 11, 2001, terrorist attacks. See Consolidated
Appropriations Resolution, 2003, Pub. L. No. 108-7, 117 Stat. 11, 517;
2002 Supplemental Appropriations Act for Further Recovery from and
Response to Terrorist Attacks on the United States, Pub. L. No. 107-206,
116 Stat. 820, 894; Department of Defense and Emergency Supplemental
Appropriations for Recovery from and Response to Terrorist Attacks on the
United States Act, 2002, Pub. L. No. 107-117, 115 Stat. 2230, 2338; and
2001 Emergency Supplemental Appropriations Act for Recovery from and
Response to Terrorist Attacks on the United States, Pub. L. No. 107-38,
115 Stat. 220-221.

17Consolidated Appropriations Resolution, 2003, Pub. L. No. 108-7 117,
Stat. 11, 517.

18The Robert T. Stafford Disaster Relief and Emergency Assistance Act, as
amended, authorizes FEMA to, among other things, make appropriated funds
available for disaster relief and emergency assistance. Pub. L. No.
93-288, 88 Stat. 143 (1974), as amended. The Stafford Act does not
specifically authorize ongoing clinical treatment.

Table 1: Key Federally Funded WTC Health Monitoring Programs

                                              Completed                       
                                              monitoring                      
                                              activities, as    
               Implementing                   reported by GAO   
               agency or       Eligible       in September      Federal
Program     organization    population     2005a             funding
FDNY WTC    FDNY Bureau of  Firefighters   Through June      $4.8 million  
Medical     Health Services and emergency  2005, 15,284      was provided  
Monitoring  (FDNY-BHS)      medical        firefighters and  beginning in  
Programb                    technicians    emergency medical October 2001  
                                              technicians       for initial   
                                              received          program;      
                                              screening         additional    
                                              examinations, and $25 million   
                                              522 of these      is available  
                                              participants      through June  
                                              completed a       2009.         
                                              follow-up         
                                              examination.      
WTC Medical Five clinical   Rescue and     Through June      $15.9 million 
Monitoring  centers, one of recovery       2005, 14,110      was provided  
Program     which, the      workers and    people received   for initial   
(worker and Mount           volunteers,d   screening         program;e     
volunteer   Sinai-Irving J. excluding NYC  examinations, and additional    
WTC         Selikoff Center firefighters   1,699 of these    $56 million   
program)b   for             and emergency  participants      is available  
               Occupational    medical        completed a       through July  
               and             technicians    follow-up         2009.         
               Environmental                  examination.      
               Medicine, also                                   
               serves as a                                      
               data and                                         
               coordination                                     
               centerc                                          
New York    New York State  New York State As of November    $2.4 million  
State       Department of   employees and  2003, 1,677       was provided  
responder   Health          National Guard employees and     in January    
screening                   personnel who  National Guard    2002 and is   
programf                    responded to   personnel         available     
                               the WTC attack received          through       
                               in an official screening         mid-January   
                               capacity       examinations.     2007.g        
WTC Health  NYC Department  Responders and As of November    $20 million   
Registryh   of Health and   people living  2004, the program was provided  
               Mental Hygiene  or attending   completed         beginning in  
                               school in the  baseline data     July 2002,k   
                               area of the    collection        and as of     
                               WTC, or        through           September     
                               working or     interviews with   2005,         
                               present in the the 71,437 people additional    
                               vicinity on    who enrolled in   funding of    
                               September 11,  the registry;j in about $3      
                               2001i          2005, the program million had   
                                              updated contact   been          
                                              information       provided.l    
                                              obtained at the   
                                              time of           
                                              enrollment.       
WTC Federal HHS Office of   Federal        From June 2003    $3.74 million 
Responder   Public Health   workers who    through March     was provided  
Screening   and Emergency   responded to   2004, 394         beginning in  
Program     Preparedness    the WTC attack screening         March 2003    
               (OPHEP);        in an official examinations were and is        
               Federal         capacitym      completed. When   available     
               Occupational                   the program       through       
               Health (FOH)                   resumed in        December      
               Services; and                  December 2005, an 2006.         
               CDC's National                 additional 133    
               Institute for                  examinations were 
               Occupational                   completed as of   
               Safety and                     early February    
               Health (NIOSH)                 2006.             

Source: GAO analysis of information from ATSDR, FDNY, Mount Sinai,
National Center for Environmental Health, New York City Department of
Health and Mental Hygiene, New York State Department of Health, and NIOSH.
Some of the information in this table originally appeared as tables 1 and
2 in GAO-06-481T .

a GAO-05-1020T . The monitoring activities completed by the WTC Federal
Responder Screening Program are as reported by GAO in February 2006 (
GAO-06-481T ). The monitoring methods used by all programs except the WTC
Health Registry consist of screening examinations that include a medical
questionnaire and physical examination; the Registry's monitoring method
is a telephone-based health and exposure interview.

bThe FDNY WTC Medical Monitoring Program and the WTC Medical Monitoring
Program constitute the WTC Responder Health Consortium. NIOSH established
the consortium in March 2004 to coordinate the health monitoring of the
two programs and to facilitate data sharing.

cThe other clinical centers are located at the Long Island Occupational
and Environmental Health Center, the New York University School of
Medicine, the City University of New York's Queens College, and the
University of Medicine and Dentistry of New Jersey's Robert Wood Johnson
Medical School. The responsibilities of the Mount Sinai data and
coordination center include coordination of the clinical centers, outreach
and education, quality assurance, and data management.

dThe worker and volunteer WTC program excludes NYC firefighters and
emergency medical technicians, as they are eligible for FDNY's program.
The program initially excluded responders who were paid as New York State
employees for their WTC work and were eligible for the New York State
responder screening program. That program ended its screening examinations
in November 2003, and as of February 2004, New York State responders
became eligible for the worker and volunteer WTC program. Beginning in
February 2006, former federal workers enrolled in the HHS WTC Federal
Responder Screening Program were eligible to be screened in the worker and
volunteer WTC program.

eOf this amount, $11.8 million was provided beginning in July 2002 through
funds appropriated to CDC, and $4.1 million was provided in fiscal year
2003 through an interagency agreement with FEMA.

fThe New York State program ended its screening examinations in November
2003.

gThe primary program activity since November 2003 has been data analysis.

hThe registry includes health and exposure information obtained through
interviews with participants and was designed to track participants'
health for 20 years and to provide data on the long-term health
consequences of the WTC attack.

iParticipants in the other WTC monitoring programs may also participate in
the registry program.

jRegistry officials told us that final enrollment numbers may be revised
pending internal verification of data.

kThe grant agreement is between ATSDR and the New York City Department of
Health and Mental Hygiene. However, ATSDR contracted directly with
Research Triangle Institute, a private not-for-profit organization, for
most of the work to establish the registry, and about $16 million of the
$20 million went directly from ATSDR to Research Triangle Institute.

lThe Environmental Protection Agency provided $2 million of these funds.
In addition, CDC and ATSDR provided $500,000 each.

mScreening examinations for current federal workers are provided by FOH
under an agreement with OPHEP. Screening examinations for former federal
workers are provided by NIOSH through the worker and volunteer WTC
program.

We reported in February 2006 that four of the five monitoring programs had
made progress in screening and monitoring affected individuals and
gathering data.19 (See table 1.) These four programs-the FDNY WTC Medical
Monitoring Program, the worker and volunteer WTC program, the New York
State responder screening program, and the WTC Health Registry-had
collected information that monitoring officials said could be used by
researchers to help better understand the health consequences of the
attack and improve treatment, such as by identifying which types of
treatment are effective for specific conditions. In contrast to the
progress made by the other programs, the HHS WTC Federal Responder
Screening Program had lagged behind and accomplished little.20 The program
was established to provide free voluntary medical screening examinations
for federal workers21 whom their agencies sent to respond to the WTC
disaster from September 11, 2001, through September 10, 2002,22 and who
were not eligible for any other WTC health monitoring program.23 Through
March 2004, the program-which started about a year later than the other
WTC monitoring programs-completed screenings of 394 federal workers.24 HHS
put the program on hold in January 2004, when it stopped scheduling new
examinations, because it wanted to resolve several operational issues,
including HHS's determination that FOH did not have the authority to
provide examinations to people who are no longer in federal service. Under
an agreement between OPHEP and FOH that was established in July 2005, the
program resumed providing examinations for current federal workers in
December 2005, and in February 2006, OPHEP executed an agreement with
NIOSH calling for NIOSH to arrange for the worker and volunteer WTC
program to provide examinations to former federal workers.

19 GAO-06-481T .

20 GAO-06-481T .

21For this program, a federal worker is defined as being either a
permanent, temporary, or intermittent federal employee.

22In addition to the federal responder program, we identified three other,
smaller-scale programs that were implemented by two federal agencies to
assess the health of their own employees who responded in the aftermath of
the WTC attack. The Army established two screening programs-one
specifically for Army Corps of Engineers personnel and one that was
designed as a voluntary medical screening for Army military and civilian
personnel, including contractors. As of August 2004, 92 Corps of Engineers
employees had participated in the first program, with 40 receiving
follow-up examinations, and 162 employees had completed and returned
questionnaires in the second program. In the third program, 88 employees
of the U.S. Marshals Service, within the Department of Justice, had
obtained a one-time assessment including a screening questionnaire and a
medical examination as of August 2005.

23According to a FEMA official, federal workers who did not receive
official orders from their agencies to respond to the WTC disaster are not
eligible for the WTC Federal Responder Screening Program. According to an
official of the worker and volunteer WTC program, federal workers who
volunteered on their own in the aftermath of the disaster were eligible to
participate in that screening program.

24We testified in February 2006 that OPHEP entered into an agreement with
FOH in April 2003 to provide screening examinations for federal workers
who had responded to the WTC disaster and that these examinations began in
June 2003.

Many participants in the monitoring programs required additional testing
or needed treatment for health problems that were identified during
screening examinations. The FDNY WTC Medical Monitoring Program referred
participants to the FDNY Bureau of Health Services, but the other programs
primarily referred participants to their primary care physician or to
privately funded programs available to responders, such as treatment
services provided by the Mount Sinai clinical center that are funded by
the American Red Cross. We previously reported that officials told us that
finding treatment services for such participants was an important, but
challenging, part of the programs' responsibility.25 For example,
officials from the worker and volunteer WTC program stated that
identifying providers available to treat participants became a major part
of their operations, and was especially difficult when participants lacked
health insurance.

New Federal Funding for Monitoring and Treatment

In December 2005, the Congress appropriated $75 million to CDC to fund
programs providing baseline screening, long-term monitoring, and health
care treatment for emergency services and recovery personnel who responded
to the WTC disaster. The law required CDC to give first priority to
programs coordinated by the FDNY-BHS, Mount Sinai-Irving J. Selikoff
Center for Occupational and Environmental Medicine, and New York City
Department of Health and Mental Hygiene, which have existing monitoring
programs, and to programs coordinated by the POPPA program and Project
COPE.26 The mission of the POPPA program, which offers peer-to-peer mental
health counseling to New York City Police Department (NYPD) officers, is
to reduce unresolved emotional trauma that can result in problems ranging
from poor performance to suicide. The POPPA program counseled over 5,000
NYPD officers in the 10 months following the WTC attack. Project COPE, a
collaboration of the New York City Police Foundation and Columbia
University Medical Center, uses a hotline and outreach efforts to
encourage NYPD uniformed and civilian employees to obtain mental health
services, which are provided by Columbia University Medical Center and
private providers. As of August 2006, over 18,000 employees had attended
educational sessions held at police facilities, and over 5,000 had
received individual counseling or therapy consultations.

25 GAO-06-481T .

26Both organizations operate independently of the New York City Police
Department.

HHS Has Registered and Screened Additional Federal Responders, and Arrangements
for Screening Former Federal Workers outside the New York Metropolitan Area Are
                               under Development

Since February 2006, an additional 1,385 federal responders have
registered for screening examinations, bringing the total number
registered on the WTC Federal Responder Screening Program Web site to
1,762 as of late August 2006, including 283 former federal workers.
Because the total number of federal responders involved in the WTC
disaster is uncertain, it is not possible to determine what proportion of
the total number of federal responders have registered. HHS's efforts to
conduct outreach to federal agencies resulted in the identification of
2,200 federal responders. As of late August 2006, FOH had completed
screening examinations for a total of 907 federal workers, 380 of whom
were screened since February 2006. Through OPHEP's agreement with NIOSH,
the worker and volunteer WTC program has provided screening examinations
to 13 former federal workers and scheduled 11 more. Most of the former
federal workers reside outside the New York metropolitan area, where the
worker and volunteer WTC program is located, and NIOSH is working to
establish a national network of providers to screen these workers.

HHS's Outreach Resulted in Registration of Additional Federal Workers Involved
in WTC Disaster Response

HHS reported that as of late August 2006, a total of 1,762 federal
responders had registered for screening examinations on the WTC Federal
Responder Screening Program Web site, including 1,479 current federal
workers and 283 former federal workers. Of the 1,762 federal responders
who registered, 1,385 had registered since February 2006, including 1,134
current federal workers and 251 former federal workers. It is not possible
to determine what proportion of the total number of federal responders
involved in the WTC disaster have registered because the total number
involved is uncertain. In determining the total number of individuals
eligible for its program, the WTC Health Registry developed an estimate of
8,621 federal responders, based on information from 31 federal agencies in
the New York area and information from FEMA on 22 Urban Search and Rescue
teams that were deployed to the WTC area.27 This estimate does not account
for all federal responders from other geographic areas.

As we reported previously, in the aftermath of the WTC disaster, HHS did
not have a comprehensive list of all federal agencies and federal
responders who were involved. In an effort to develop such a list, OPHEP
and ATSDR entered into an agreement in April 2005 for ATSDR-which had
developed the WTC Health Registry-to identify and register federal
responders.28 Under the agreement, ATSDR, through a contractor, contacted
federal agencies, developed a list of WTC federal responders, and
conducted outreach to encourage the responders to register on the new Web
site that the contractor established.29 As a result of this effort, 46
federal agencies were identified and provided contact information for
2,200 federal responders.30

27This estimate consisted of 5,122 responders from the 31 federal agencies
and 3,499 responders from the 22 Urban Search and Rescue teams.

The agreement between OPHEP and ATSDR expired on April 30, 2006, ending
the outreach efforts to federal agencies.31 Under an agreement with OPHEP,
NIOSH assumed responsibility for maintaining the WTC Federal Responder
Screening Program Web site through December 31, 2006.32

28Before the federal responder program was placed on hold in January 2004,
its principal action to communicate with the federal responders had been
to place program information and registration forms on FEMA's National
Disaster Medical System Web site.

29See "The WTC Federal Responder Screening Program,"
https://wtcophep.rti.org/ , downloaded Aug. 30, 2006.

30Of the 90 other agencies contacted, 60 were determined to be ineligible
because some were found to be nongovernmental agencies, some did not have
federal workers at the WTC or Staten Island site, and some, such as the
Department of Defense, participated in other screening programs; 21 opted
to contact their federal workers on their own; and 9 refused to provide
information.

31ATSDR spent $372,961 of the $491,000 OPHEP originally allocated to the
activities carried out under this agreement. The $491,000 was part of
$3.74 million that FEMA had provided to OPHEP to develop and implement a
monitoring program for federal responders. According to OPHEP, it will
reallocate the $118,039 remaining from its expired agreement with ATSDR to
FOH or NIOSH for screening, depending on where there is a need.

32According to OPHEP officials, FEMA funds are to expire at this time.

HHS Has Screened Additional Current Federal Workers

As of late August 2006, FOH had completed screening examinations for a
total of 907 of the federal workers who had registered;33 380 of the 907
were screened since February 2006.34 Under its agreement with OPHEP, FOH
is responsible for regularly retrieving from the registration Web site
requests for screening examinations for current federal workers and for
assigning individuals to a provider for screening.35 FOH officials told us
that they contact the individual and the provider to inform them of the
need to arrange an appointment for screening. The program relies on
individuals to call the designated provider and schedule their
appointment. FOH officials told us that individuals who have registered do
not always contact the provider to schedule an appointment or may not keep
an appointment or call to reschedule it. FOH officials said that they have
attempted to contact such individuals but often received no response.

We reported in our February 2006 testimony that under the July 2005
agreement FOH clinicians can refer current federal workers for follow-up
care if the screening examination-which includes a medical questionnaire,
clinical tests such as a chest X-ray, and a full physical
examination-reveals significant physical or mental health symptoms.36 On
July 31, 2006, FOH told us that it had referred 39 current federal workers
with mental health symptoms to an FOH employee assistance program (EAP)
for counseling;37 24 to ear, nose, and throat specialists; 19 to pulmonary
medicine specialists; and 1 to a cardiology specialist.

33Some of these federal workers registered on FEMA's National Disaster
Medical System Web site, which was used before the WTC Federal Responder
Screening Program Web site was created.

34The 907 workers screened by FOH include 139 former federal workers that
FOH screened after the program resumed because FOH thought they were
current federal workers. In addition, FOH also screened an unknown number
of former federal workers before the federal program was placed on hold,
and they would also be included in the 907. FOH officials told us that
they have taken steps to ensure that they can better identify which
registered workers are current federal employees.

35Individuals are assigned to either an FOH clinic or a private provider
participating in FOH's network, based on their proximity to either type of
provider. Appointments are made within 50 miles of an individual's
designated zip code.

36The estimated cost of each screening examination is between $400 and
$500, and additional costs may be incurred depending on the need for
further diagnostic testing.

37FOH can refer individuals with mental health symptoms to an FOH EAP for
a telephone assessment. If appropriate, the individual can then be
referred to an EAP counselor for up to six in-person sessions.

Screening of Former Federal Workers Has Resumed, but Group Is Widely Dispersed
and Nationwide Network of Providers Is Still Being Established

As of late August 2006, 283 former federal workers had registered to
receive screening examinations, which under OPHEP's agreement with NIOSH
are to be provided by the worker and volunteer WTC program.38 Under the
agreement, former federal workers receive a one-time examination
comparable to the examination that FOH is providing to current federal
workers. As of July 31, 2006, 13 screening examinations had been completed
and 11 were scheduled. These completed and scheduled examinations are in
addition to the 139 former federal workers that FOH screened after the WTC
Federal Responder Screening Program resumed because FOH thought they were
current federal workers.39

A key challenge in providing screening examinations to former federal
workers has been that a large number do not reside in the New York
metropolitan area, where the worker and volunteer WTC program is based.
The 283 former federal workers who have registered for screening
examinations reside in 40 states, and about 240 of them reside outside the
New York metropolitan area. NIOSH officials said that making arrangements
to screen these widely dispersed responders has presented challenges, such
as ensuring that the arrangements comply with federal privacy protections.
NIOSH is negotiating with the Association of Occupational and
Environmental Clinics (AOEC)40 in an effort to establish a national
network of providers to screen these federal workers.

38This agreement also provides for examinations for other federal
responders who are ineligible to receive examinations from FOH, such as
Department of Defense employees, and responders having intermittent
periods of federal employment such as Urban Search and Rescue workers.

39When FOH officials realized those individuals were former federal
workers, they communicated this information to NIOSH so NIOSH could take
responsibility for any follow-up care the workers might need.

40The AOEC is a nonprofit organization committed to improving the practice
of occupational and environmental health through information sharing and
collaborative research. The AOEC consists of a network of
university-affiliated and other private clinics across the United States
and in other countries.

 CDC Has Awarded a Small Portion of the $75 Million Appropriation and Plans to
Make Decisions about Treatment Coverage before Awarding Most of the Funds

CDC plans to award the $75 million appropriated for screening, monitoring,
and treatment to the five organizations that the law identified as having
priority for funding. CDC officials expect to make awards to the WTC
Health Registry, Project COPE, and the POPPA program over a 3-year period
and to award funds to the FDNY WTC and worker and volunteer WTC programs
in response to their treatment costs. CDC officials have a proposed
spending plan but told us that because they are uncertain about how
quickly treatment costs could deplete the available funds, they may need
to make adjustments. Officials from the FDNY WTC and worker and volunteer
WTC programs told us that they expected that their estimated portion of
the appropriated funds would be depleted well before the end of 3 years.
As of August 2006, CDC awarded about $4.5 million of the $75 million-about
$1.9 million to the WTC Health Registry, $1.5 million to the FDNY WTC
program, and almost $1.1 million to the worker and volunteer WTC program.
In addition, CDC expects to award $1.5 million to the POPPA program and $3
million to Project COPE in September 2006. CDC is waiting to make further
awards until agency officials have reached certain decisions about the
coverage of treatment services, such as which prescription drugs would be
covered in the FDNY WTC and worker and volunteer WTC programs. CDC expects
to begin making further awards around February 2007.

CDC Plans to Award the $75 Million to the Five First-Priority Organizations

CDC has decided to award the $75 million for screening, monitoring, and
treatment that was appropriated to the agency in December 2005 to the five
organizations identified as having first priority for funding.41 The
organizations to which CDC plans to provide funds are

           o  the FDNY WTC program, for monitoring and treatment;
           o  the worker and volunteer WTC program, for monitoring and
           treatment;
           o  the WTC Health Registry, for monitoring;
           o  Project COPE, for treatment; and
           o  the POPPA program, for treatment.

           CDC plans to make awards through cooperative agreements with the
           programs.42 In general, it plans to send letters to the
           organizations inviting them to submit applications for funding;
           the applications would then undergo a two-stage peer review
           process. At the first stage a panel of outside experts would
           assess the merit of the application, and at the second stage CDC
           officials would determine the amount of funding the applicant
           would receive.

           CDC has made preliminary decisions about how to allocate the $75
           million among the five organizations. As of September 1, 2006,
           CDC's proposed spending plan indicated that awards would be made
           in the following way:

           o  $53.5 million for treatment and $8 million for monitoring, to
           be divided between the FDNY WTC and worker and volunteer WTC
           programs;43 
           o  $9 million for the WTC Health Registry;
           o  $3 million for Project COPE; and
           o  $1.5 million for the POPPA program.

           CDC officials expect to make awards to the WTC Health Registry,
           Project COPE, and the POPPA program over a 3-year period, but are
           not sure over what period they will make awards to the FDNY WTC
           and worker and volunteer WTC programs. A CDC official told us that
           the agency would award funds to the latter two programs in
           response to the treatment costs they incur. He said that agency
           officials are uncertain about how quickly treatment costs could
           deplete the available funds, because CDC does not know how many
           additional people will seek monitoring and what the extent of
           their treatment needs will be. For example, previous media reports
           about illnesses diagnosed in responders have resulted in increases
           in responders seeking examinations. Officials from the FDNY WTC
           and worker and volunteer WTC programs told us that they expected
           that their estimated portion of the appropriated funds would be
           depleted well before the end of 3 years. CDC has developed a
           proposed spending plan that indicates that about 36 percent of the
           funds would be awarded by the end of fiscal year 2007 and about 63
           percent would be awarded during fiscal year 2008, although a CDC
           official told us that, depending on the extent of treatment needs,
           the funds could be used more quickly. The current plan is based in
           part on an agreement CDC made with the American Red Cross in April
           2006.44 According to a CDC official, under this agreement,
           American Red Cross funds would be used for the treatment services
           that are eligible for American Red Cross support-such as basic
           clinical examinations and certain tests-for as long as such funds
           are available and the CDC funds would be used to cover other
           program expenses-such as infrastructure costs, more sophisticated
           diagnostic tests, and the conversion of medical records into an
           electronic format.
			  
			  CDC Has Awarded about $4.5 Million of the $75 Million Appropriated

           As of August 2006, CDC had awarded a total of about $4.5 million
           of the $75 million to the WTC Health Registry, FDNY WTC program,
           and worker and volunteer WTC program. According to CDC officials,
           the WTC Health Registry applied for about $1.9 million in April
           2006 for continuation of its collection of health data, and CDC
           awarded the registry $1.9 million in May 2006 and about $56,000 in
           July 2006.45 On August 10 and 11, 2006, respectively, the worker
           and volunteer WTC and FDNY WTC programs submitted applications to
           CDC for funds related to treatment services. In response to these
           applications, CDC made what an agency official termed emergency
           awards to the FDNY WTC and worker and volunteer WTC programs on
           August 11, 2006.46 CDC provided $1.5 million to the FDNY WTC
           program for leasing treatment space that previously had been
           provided by New York City at no cost. CDC provided almost $1.1
           million to the worker and volunteer WTC program to hire an
           additional physician to help reduce the 3- to 4-month waiting time
           for treatment appointments that recently developed at the Mount
           Sinai clinical center, as well as to hire three administrators and
           a medical assistant. Officials from the clinical center told us
           that this waiting time had developed because additional people
           were seeking monitoring due to media reports about illnesses
           diagnosed in responders and because the proportion of responders
           who needed to be referred for treatment had increased.

           In addition to having awarded about $4.5 million, CDC plans to
           award an additional $4.5 million in September 2006. In spring
           2006, CDC invited Project COPE and the POPPA program, two programs
           that provide mental health services to members of the NYPD, to
           apply for funding through a peer review process. In their
           applications, the POPPA program requested $1.5 million over 3
           years, and Project COPE requested funding of $3 million over 3
           years. CDC received their applications in June and July,
           respectively, and plans to implement the application review
           process in time to be in a position to make awards in September
           2006.

           CDC Is Waiting to Award Additional Funds for Treatment Until It
			  Makes Decisions about Coverage
			  
			  CDC does not plan to award additional funds from the $75 million
           to the FDNY WTC and worker and volunteer WTC programs until it
           makes certain decisions about the coverage of treatment services.
           These decisions include determining which medical conditions will
           be covered;47 developing a prescription drug formulary, that is,
           the list of drugs that will be covered; and determining the extent
           to which inpatient care will be covered. CDC officials said that
           they expected to make the coverage decisions in late 2006 and that
           they would obtain input from the American Red Cross and the
           programs.

           A CDC official told us that making decisions about which
           prescription drugs to cover could be the greatest challenge CDC
           and the programs face, because of the potentially high cost of
           drugs needed to treat responders. An FDNY WTC program official
           said that prescription drug costs are a looming financial problem
           for the FDNY WTC program. The CDC official told us that the most
           common diagnoses of WTC responders-gastroesophageal reflux
           disease, obstructive pulmonary disease, and mental health
           conditions-frequently are treated with prolonged and expensive
           drug therapy. For example, medications for respiratory therapy can
           cost $1,000 a month and may continue for a year. The FDNY WTC
           program official estimated that 100 percent coverage of
           prescriptions for firefighters and emergency medical technicians
           could cost $10 million to $18 million per year and potentially
           consume all of the funding that CDC would provide to the program.
           Clinicians at the worker and volunteer WTC clinical center at
           Mount Sinai stated that spending on prescription drugs at their
           center was increasing by $5,000 to $10,000 each month and amounted
           to $60,000 in July 2006.

           Another coverage decision that CDC faces is to determine the
           extent to which inpatient care will be covered. Currently, the
           FDNY WTC and worker and volunteer WTC programs provide only
           outpatient care, but officials involved with these programs
           believe that the treatment funds from the $75 million should cover
           some inpatient care, such as when a responder's WTC-linked asthma
           becomes exacerbated to an extent that requires hospitalization.

           CDC officials told us that they plan to reach decisions about
           treatment coverage in fall 2006. They also plan to invite the FDNY
           WTC and worker and volunteer WTC programs to submit applications
           for treatment funding in the fall. If the applications are
           submitted by December 2006, CDC officials expect to be able to
           review them in time to provide funding to the programs by February
           2007.

           CDC is also in the process of resolving issues related to
           providing access to screening, monitoring, and treatment services
           for WTC responders, including former federal workers, who reside
           outside the New York metropolitan area. CDC is negotiating with
           AOEC about possibly using AOEC clinics around the country to
           provide these services. CDC officials told us they intend that
           monitoring and treatment services available to responders around
           the country would be comparable to services provided by the worker
           and volunteer WTC program.

           Mr. Chairman, this completes my prepared remarks. I would be happy
           to respond to any questions you or other members of the
           subcommittee may have at this time.

           Contact and Acknowledgments
			  
			  For further information about this testimony, please contact
           Cynthia A. Bascetta at (202) 512-7101 or [email protected].
           Contact points for our Offices of Congressional Relations and
           Public Affairs may be found on the last page of this statement.
           Helene F. Toiv, Assistant Director; Fred Caison; Anne Dievler;
           Keyla Lee; and Roseanne Price made key contributions to this
           statement.

           Appendix I: Abbreviations
			  
			  AOEC Association of Occupational and Environmental Clinics ATSDR
           Agency for Toxic Substances and Disease Registry CDC Centers for
           Disease Control and Prevention EAP employee assistance program
           FDNY New York City Fire Department FDNY-BHS New York City Fire
           Department Bureau of Health Services FEMA Federal Emergency
           Management Agency FOH Federal Occupational Health Services HHS
           Department of Health and Human Services NIOSH National Institute
           for Occupational Safety and Health NYPD New York City Police
           Department OPHEP Office of Public Health Emergency Preparedness
           POPPA Police Organization Providing Peer Assistance WTC World
           Trade Center

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41Within CDC, NIOSH has lead responsibility for making decisions about the
$75 million, and ATSDR is involved in decisions relating to the WTC Health
Registry.

42A cooperative agreement is a mechanism used to provide financial support
when substantial interaction is expected between a federal agency and a
state, local government, or other recipient carrying out the funded
activity.

43Any funds not needed for monitoring could be used for treatment.

44This agreement provides for the American Red Cross to assist CDC in
estimating program costs and developing the federally funded treatment
programs.

45The registry subsequently applied for an additional $1 million to
support its operations through April 2007.

46The official told us that CDC was able to make these awards so quickly
after receiving the applications because agency officials had been
discussing the programs' needs for treatment funds with program officials
for several months and the programs had provided draft applications a week
before submitting the final applications.

47The medical conditions that now receive treatment funded by the American
Red Cross provided the baseline for conditions that will be included. CDC
will determine whether any additional conditions will be included and will
continue to assess whether all appropriate conditions are included over
time.

(290562)

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www.gao.gov/cgi-bin/getrpt? GAO-06-1092T .

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For more information, contact Cynthia A. Bascetta at (202) 512-7101 or
[email protected].

Highlights of GAO-06-1092T , a testimony before the Subcommittee on
National Security, Emerging Threats, and International Relations,
Committee on Government Reform, House of Representatives

September 8, 2006

SEPTEMBER 11

HHS Has Screened Additional Federal Responders for World Trade Center
Health Effects, but Plans for Awarding Funds for Treatment Are Incomplete

Responders to the World Trade Center (WTC) attack-individuals involved in
rescue, recovery, or cleanup-included New York City Fire Department (FDNY)
personnel, federal government workers, and others from New York and
elsewhere. They were exposed to numerous hazards, and concerns remain
about the long-term effects on their physical and mental health.

In February 2006, GAO testified that four of the five key federally funded
programs that were monitoring health effects in responders had made
progress but that the Department of Health and Human Services' (HHS) WTC
Federal Responder Screening Program, implemented by the Office of Public
Health Emergency Preparedness (OPHEP), lagged behind (GAO-06-481T). GAO
also reported that the Congress appropriated $75 million in December 2005
to HHS's Centers for Disease Control and Prevention (CDC) for monitoring
and treatment for responders and that CDC was deciding how to allocate the
funds.

This statement updates GAO's February 2006 testimony. GAO examined (1)
progress made by HHS's WTC federal responder program and (2) actions CDC
has taken to award the $75 million appropriated. GAO reviewed program
documents and interviewed HHS officials and others involved in WTC
monitoring and treatment programs.

The WTC federal responder program has registered and screened additional
federal responders since February 2006, and arrangements are being
developed to screen responders who are former federal workers residing
outside the New York area. An additional 1,385 federal responders have
registered for screening, including 1,134 current federal workers and 251
former federal workers, bringing the total number registered as of late
August 2006 to 1,762, including 283 former federal workers. Because the
total number of federal responders is uncertain, the proportion of the
total who have registered is unknown. As of late August 2006, Federal
Occupational Health Services (FOH) had completed screening of 907 federal
workers, 380 of whom were screened since February 2006. Under an OPHEP
agreement with CDC's National Institute for Occupational Safety and Health
(NIOSH), former federal workers are being screened through the worker and
volunteer WTC program, one of the five key federally funded programs. As
of July 31, 2006, the worker and volunteer WTC program provided screenings
to 13 former federal workers and scheduled 11 more, and 139 former workers
had been screened by FOH as part of the 907 workers. Most of the former
federal workers reside outside the New York area, where the worker and
volunteer WTC program is located, and NIOSH is working to establish a
national network of providers to screen these workers.

CDC has awarded a small portion of the $75 million appropriated for
screening, monitoring, and treatment and plans to make decisions about
treatment coverage before awarding most of the funds. The agency plans to
award the $75 million to the five organizations that the law identified as
having priority for funding. CDC officials expect to make awards to the
WTC Health Registry, the Police Organization Providing Peer Assistance
(the POPPA program), and the New York City Police Foundation's Project
COPE over a 3-year period and to award funds to the FDNY WTC and worker
and volunteer WTC programs in response to the treatment costs they incur.
CDC officials have a proposed spending plan that allocates about $53.5
million for the latter two programs' treatment costs, but the officials
told GAO that because they are uncertain about how quickly treatment costs
could deplete the available funds, they may need to make adjustments.
Officials from the FDNY WTC and worker and volunteer WTC programs told GAO
that they anticipated that their estimated portion of the funds would be
depleted well before the end of 3 years. As of August 2006, CDC awarded
about $4.5 million of the $75 million: about $1.9 million to the WTC
Health Registry, $1.5 million to the FDNY WTC program, and almost $1.1
million to the worker and volunteer WTC program. In addition, CDC expects
to award $1.5 million to the POPPA program and $3 million to Project COPE
in September 2006. CDC is waiting to make further awards until it has
reached certain decisions about the coverage of treatment services, such
as which prescription drugs would be covered. CDC expects to begin making
further awards around February 2007.
*** End of document. ***