September 11: Monitoring of World Trade Center Health Effects Has
Progressed, but Program for Federal Responders Lags Behind	 
(28-FEB-06, GAO-06-481T).					 
                                                                 
After the 2001 attack on the World Trade Center (WTC), nearly	 
3,000 people died and an estimated 250,000 to 400,000 people in  
the vicinity were affected. An estimated 40,000 people who	 
responded to the disaster--including New York City Fire 	 
Department (FDNY) personnel and other government and		 
private-sector workers and volunteers--were exposed to physical  
and mental health hazards. Concerns remain about the long-term	 
health effects of the attack and about the nation's capacity to  
plan for and respond to health effects resulting from future	 
disasters. Several federally funded programs have monitored the  
physical and mental health effects of the WTC attack. These	 
monitoring programs include one-time screening programs and	 
programs that also conduct follow-up monitoring. GAO was asked to
assess the progress of these programs and examined (1) federally 
funded programs implemented by state and local government	 
agencies or private institutions, (2) federally administered	 
programs to monitor the health of federal workers who responded  
to the disaster in an official capacity, and (3) lessons learned 
from WTC monitoring programs. GAO reviewed program documents and 
interviewed federal, state, and local officials and others	 
involved in WTC monitoring programs. This statement updates	 
information GAO provided to Congress on September 10, 2005.	 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-06-481T					        
    ACCNO:   A47937						        
  TITLE:     September 11: Monitoring of World Trade Center Health    
Effects Has Progressed, but Program for Federal Responders Lags  
Behind								 
     DATE:   02/28/2006 
  SUBJECT:   First responders					 
	     Health care programs				 
	     Health hazards					 
	     Health research programs				 
	     Lessons learned					 
	     Locally administered programs			 
	     Medical examinations				 
	     Monitoring 					 
	     Performance measures				 
	     Program management 				 
	     State-administered programs			 
	     FDNY WTC Medical Monitoring Program		 
	     HHS WTC Federal Responder Screening		 
	     Program						 
                                                                 
	     New York State Responder Screening 		 
	     Program						 
                                                                 
	     World Trade Center (NY)				 
	     WTC Health Registry				 
	     WTC Medical Monitoring Program			 

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GAO-06-481T

     

     * Background
     * Health Monitoring Programs Implemented by State and Local Go
          * Three WTC Monitoring Programs Provided Medical Examinations
          * Programs Provide Data for WTC-Related Health Research
          * Program Officials Are Concerned That Current Federal Funding
          * CDC Is in Process of Deciding How to Distribute New Funds fo
     * HHS's Program for Screening Federal Responders Has Accomplis
          * HHS Program Screened Few Federal Workers and Recently Starte
          * Two Federal Agencies Established Their Own Screening Program
     * Lessons from WTC Health Monitoring Programs Could Assist Fut
     * Concluding Observations
     * Contact and Acknowledgments
     * Federal Agencies
     * New York State Agencies
     * New York City Agencies
     * 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 2:00 p.m. EST

Tuesday, February 28, 2006

SEPTEMBER 11

Monitoring of World Trade Center Health Effects Has Progressed, but
Program for Federal Responders Lags Behind

Statement of Cynthia A. Bascetta

Director, Health Care

GAO-06-481T

Mr. Chairman and Members of the Subcommittee:

Thank you for inviting me to participate in today's hearing to discuss
issues related to the health effects that people continue to experience in
the aftermath of the September 11, 2001, terrorist attack on the World
Trade Center (WTC).1 My testimony today updates information we reported to
you in September 2005.2 After the collapse of the WTC buildings, nearly
3,000 people died, and an estimated 250,000 to 400,000 people who lived,
worked, or attended school in the vicinity were affected. An estimated
40,000 people responded to the disaster, including New York City Fire
Department (FDNY) personnel and other government and private-sector
workers and volunteers from New York and other locations across the
nation. These responders,3 as they took part in various rescue, recovery,
and cleanup activities in the days, weeks, and months following the
attack, were exposed to numerous physical hazards and environmental toxins
because of the destruction caused by the attack. The magnitude and
unprecedented nature of this event also exposed responders and many other
people to considerable psychological trauma.

Four years after the destruction of the WTC buildings, concerns remain
about the long-term physical and mental health effects of the attack.
Several recent studies of responders report that many of them have high
rates of physical and mental health symptoms, of which respiratory
problems are the most persistent physical effects.4 While the nature and
severity of a future terrorist attack cannot be predicted, our prior work
on the health effects of the WTC attack, the 2001 anthrax attacks, and
bioterrorism preparedness, as well as reports by other organizations,
highlight the importance of ensuring the nation's capacity to plan for and
respond to the short- and long-term health consequences likely to result
in the event of a future attack or other disaster, such as the destruction
recently caused by Hurricane Katrina.5

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 Not for Federal Responders, GAO-05-1020T (Washington,
D.C.: Sept. 10, 2005).

3In this testimony, the term responders refers to anyone involved in
rescue, recovery, or cleanup activities at or near the vicinity of the WTC
site and Staten Island Fresh Kills landfill (the off-site location of the
WTC recovery operation).

4See, for example, Centers for Disease Control and Prevention, "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); Centers for Disease Control and Prevention,
"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); and Gisela I. Banauch and others,
"Bronchial Hyperreactivity and Other Inhalation Lung Injuries in
Rescue/Recovery Workers after the World Trade Center Collapse," Critical
Care Medicine, vol. 33, no. 1 (2005).

As we testified in September 2004, 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 people's physical and
mental health. These programs include the FDNY WTC Medical Monitoring
Program, WTC Medical Monitoring Program (worker and volunteer program),6
New York State responder screening program, WTC Health Registry, and
Department of Health and Human Services' (HHS) WTC Federal Responder
Screening Program. You asked us to provide information on the progress of
these monitoring programs7 in September 2005, and to update that
information for this hearing. My testimony today updates the information
we reported to you in September 2005 on (1) progress made by federally
funded programs that are implemented by state and local government
agencies or private organizations and were established to monitor the
health of people in the aftermath of the attack, (2) progress made by
federally administered programs established to monitor the health of
federal workers who responded to the disaster in an official capacity, and
(3) lessons from WTC monitoring programs that could assist those who may
be responsible for future disaster-related health monitoring efforts.

To provide the information we reported in September 2005, we conducted our
work from July through September 2005. We obtained and reviewed program
documents dating from the beginning of the programs, including grantee
progress reports, budget documents, clinical protocols, health screening
and other assessment tools, and selected peer-reviewed articles based on
information collected by WTC monitoring programs. We also interviewed
federal, state, and local officials and others involved in administering
WTC monitoring programs, including officials from HHS and the Department
of Homeland Security (DHS);8 New York State Department of Health; New York
City Department of Health and Mental Hygiene; and FDNY. Within HHS, we
interviewed officials from the Agency for Toxic Substances and Disease
Registry (ATSDR); the Centers for Disease Control and Prevention's (CDC)
National Center for Environmental Health and National Institute for
Occupational Safety and Health (NIOSH); Federal Occupational Health
Services (FOH);9 and the Office of Public Health Emergency Preparedness
(OPHEP). We also obtained information from the Department of Defense (DOD)
and the Department of Justice. We interviewed medical professionals
affiliated with the New York University School of Medicine, FDNY's Bureau
of Health Services (FDNY-BHS), Long Island Occupational and Environmental
Health Center, Mount Sinai-Irving J. Selikoff Center for Occupational and
Environmental Medicine, Mount Sinai School of Medicine Department of
Psychiatry, and the University of Medicine and Dentistry of New Jersey's
Robert Wood Johnson Medical School. HHS and New York State officials
provided comments on the information we provided in September 2005, and we
made changes as appropriate. To prepare today's testimony, we conducted
our work during February 2006 and obtained updated information from
officials at the New York State responder screening program and the WTC
Federal Responder Screening Program. We also obtained updated information
from officials at the WTC Registry about their monitoring plans. In
addition, we obtained information from CDC officials about a $75 million
appropriation the agency received in fiscal year 2006 to fund health
services for WTC responders. For the information in this statement, we
relied on data provided by agency officials and contained in government
publications and did not independently verify the data we obtained. In our
judgment the reliability of the information we obtained was adequate for
our purposes. We conducted our work in accordance with generally accepted
government auditing standards.

5See, for example, GAO, September 11: Health Effects in the Aftermath of
the World Trade Center Attack, GAO-04-1068T (Washington, D.C.: Sept. 8,
2004); GAO, Bioterrorism: Public Health Response to Anthrax Incidents of
2001, GAO-04-152  (Washington, D.C.: Oct. 15, 2003); GAO, Public Health
Preparedness: Response Capacity Improving, but Much Remains to Be
Accomplished, GAO-04-458T (Washington, D.C.: Feb. 12, 2004); and Institute
of Medicine, Preparing for the Psychological Consequences of Terrorism: A
Public Health Strategy (Washington, D.C.: 2003).

6This 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 program.

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.

In summary, three federally funded programs implemented by state and local
governments or private organizations in the aftermath of the WTC attack,
with total federal funding of about $104 million, have provided initial
medical examinations-and in some cases follow-up examinations-to thousands
of affected responders to screen for health problems. For example, the
FDNY program completed initial screening for over 15,000 firefighters and
emergency medical service personnel, and the worker and volunteer program
has screened over 14,000 other responders. The New York State program
screened about 1,700 state responders before ending its screening
examinations in November 2003; in general, the program did not inform the
approximately 9,800 state responders when they became eligible to
participate in the worker and volunteer program in February 2004. Worker
and volunteer program officials are working with state employee unions to
inform state workers of their eligibility. These three programs and the
WTC Health Registry, with total federal funding of $23 million, have
collected information that monitoring program officials believe 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. Officials of programs
that plan to conduct long-term health monitoring are concerned that the
time frames of current federal funding arrangements may be too short to
allow for identification of all the health effects that participants may
eventually experience. In January 2006, CDC received a $75 million
appropriation to fund baseline health screening, long-term monitoring, and
treatment for WTC responders, and is in the process of deciding how to
allocate these funds and how long the allocated funds will be available
for each program that receives funding.

8The DHS officials we spoke with were from the Federal Emergency
Management Agency, which became part of DHS in March 2003.

9FOH is a part of HHS's Program Support Center.

In contrast to the progress made by federally funded programs implemented
by state and local governments or private organizations, the program that
HHS implemented in June 2003 to screen federal workers who were sent by
their agencies to respond to the WTC disaster has lagged behind and
accomplished little. Through March 2004, the program-which started later
than other WTC monitoring programs-completed screenings of 394 of the
estimated 10,000 federal workers who responded in an official capacity to
the disaster and were not eligible for any other WTC health monitoring
program. HHS placed the program on hold in January 2004, when it stopped
scheduling new examinations, because it wanted to resolve several
operational issues. The program resumed providing examinations for current
federal workers in December 2005, and had completed 133 additional
examinations as of early February 2006. While examinations have not
resumed for WTC responders who are no longer federal employees, OPHEP
recently executed an agreement with NIOSH to arrange for the worker and
volunteer program to provide examinations to these WTC responders. In
addition to the HHS program, we identified two federal agencies that, in
the aftermath of the WTC attack, have implemented programs to assess the
health of their own employees who responded to the disaster.

Officials involved in WTC health monitoring programs cited lessons from
their experiences that could help others who may be responsible for
designing and implementing disaster-related health monitoring efforts in
the future. These include the need to quickly identify and contact people
affected by a disaster; to monitor for mental health effects, as well as
the more obvious physical injuries and illnesses; and when developing
health monitoring efforts in the wake of disasters, to anticipate that
there will likely be many people who require referrals for further
diagnostic and treatment services and that handling the referral process
may require a substantial level of effort.

                                   Background

When the WTC buildings collapsed on September 11, 2001, an estimated
250,000 to 400,000 people 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
response workers. Also affected were the 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.10

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.11 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, and hundreds had to
end their firefighting careers because of WTC-related respiratory
illnesses. The most commonly reported mental health effects among
responders and others were 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 were also
reported.12

10The 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 (see app. II).

11 GAO-04-1068T .

Several federally funded programs monitor the health of people who were
exposed to the WTC attack and its aftermath. The monitoring programs vary
in such aspects as eligibility requirements, methods used for collecting
information about people's health, and approaches for offering referrals.
Of the four programs that offer medical examinations to WTC responders,
the only one that is open to federal workers who responded to the disaster
in an official capacity is the one implemented by HHS. (See table 1.) None
of the monitoring programs receives federal funds to provide clinical
treatment for health problems that are identified.

12In fiscal year 2002, Substance Abuse and Mental Health Services
Administration grant programs provided funds that could be used to treat
mental health and substance abuse conditions. The Post-September 11 State
Disaster Relief grant program awarded about $10 million in grants to the 9
states most directly affected by the September 11, 2001, terrorist attacks
to fund substance abuse and mental health assessment and treatment
services for people affected by the attacks, including WTC responders. The
Public Safety Workers Mental Health grant program awarded a total of about
$2.4 million to 7 grantees to provide mental health services to public
safety workers in New York and Virginia who responded to the terrorist
attacks.

Table 1: Key Federally Funded WTC Health Monitoring Programs

           Implementing  Federal                                                  
           agency or     administering Eligible      Monitoring      Treatment    
           organization  agency        populations   methods         referral
FDNY WTC   FDNY Bureau   National      Firefighters  Medical         Refers to    
Medical    of Health     Institute for and emergency questionnaire   FDNY-BHS     
Monitoring Services      Occupational  medical       and examination 
Programa   (FDNY-BHS)    Safety and    service                       
                         Health        technicians                   
                         (NIOSH)                                     
WTC        Five clinical NIOSH         Rescue and    Medical         Refers to    
Medical    centers, one                recovery      questionnaire   privately    
Monitoring of which, the               workers and   and examination funded       
Program    Mount                       volunteers,                   programs     
(worker    Sinai-Irving                except for                    available to 
and        J. Selikoff                 federal                       responders;  
volunteer  Center for                  workers who                   some         
program)a  Occupational                were official                 privately    
           and                         responders                    funded       
           Environmental               and New York                  treatment    
           Medicine,                   City (NYC)                    provided at  
           also serves                 firefightersc                 the clinical 
           as a data and                                             centers      
           coordination                                              
           centerb                                                   
New York   New York      National      New York      Medical         Instructed   
State      State         Center for    State         questionnaire   participants 
responder  Department of Environmental employees and and examination to see their 
screening  Health        Health        National                      primary care 
programd                               Guard                         physician or 
                                       personnel who                 a specialist 
                                       responded to                  
                                       the WTC                       
                                       attack in an                  
                                       official                      
                                       capacity                      
WTC Health NYC           Agency for    Responders    Telephone-based Provides     
Registry   Department of Toxic         and people    health and      information  
           Health and    Substances    living or     exposure        on where     
           Mental        and Disease   attending     interview       treatment    
           Hygiene       Registry      school in the                 can be       
                         (ATSDR)       area of the                   sought;f     
                                       WTC, or                       refers       
                                       working or                    participants 
                                       present in                    to LIFENETg  
                                       the vicinity                  for mental   
                                       on September                  health       
                                       11, 2001e                     services     
WTC        Department of HHS           Federal       Medical         Instructs    
Federal    Health and                  workers who   questionnaire   participants 
Responder  Human                       responded to  and examination to see their 
Screening  Services'                   the WTC                       primary care 
Program    (HHS) Office                attack in an                  physician;   
           of Public                   official                      as of July   
           Health                      capacity                      2005, may    
           Emergency                                                 refer        
           Preparedness                                              participants 
                                                                     with mental  
                                                                     health       
                                                                     symptoms to  
                                                                     an FOH       
                                                                     employee     
                                                                     assistance   
                                                                     program      

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.

aThe 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.

bThe 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.

cThe worker and volunteer program excludes responders who were paid as
federal workers or as NYC firefighters for their WTC work; these employees
are eligible for other programs. 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 program.

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

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

fThe registry program provides enrollees with a resource guide of
occupational, respiratory, environmental, and mental health facilities
where they can seek treatment. Some of the services provided by these
facilities require payment, while others are free of charge.

gLIFENET is a 24-hour mental health information and referral service
provided by the New York State Office of Mental Health. In cases where WTC
Health Registry interviewers think a person is experiencing moderate
distress, they can immediately transfer the call so the person can speak
to a LIFENET counselor.

The majority of federal funding for these monitoring programs was provided
by DHS's Federal Emergency Management Agency (FEMA),13 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.14 One appropriation in 2003 specifically authorized FEMA to use
a portion of its WTC-related funding for screening and long-term
monitoring of emergency services and rescue and recovery personnel.15
Generally, however, FEMA may fund only short-term care after a disaster,
such as emergency medical services, and not ongoing clinical treatment.16

13FEMA is the agency responsible for coordinating federal disaster
response efforts under the National Response Plan.

14FEMA 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.

15Consolidated Appropriations Resolution, 2003, Pub. L. No. 108-7 117,
Stat. 11, 517.

16The 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.

FEMA entered into interagency agreements with HHS to fund most of these
health monitoring programs. HHS is the designated lead agency for the
public health and medical support function under the National Response
Plan and is responsible for coordinating the medical resources of all
federal departments and agencies. HHS's OPHEP coordinates and directs
HHS's emergency preparedness and response program.

Health Monitoring Programs Implemented by State and Local Governments or Private
                        Organizations Have Made Progress

Three federally funded programs implemented by state and local governments
or private organizations, with total federal funding of about $104
million-the FDNY WTC Medical Monitoring Program, WTC Medical Monitoring
Program (worker and volunteer program), and New York State responder
screening program-have made progress in monitoring the physical and mental
health of people affected by the WTC attack. Federal employees who
responded to the WTC disaster in an official capacity were not eligible
for these programs because it was expected that another program would be
developed for them. The New York State program stopped providing health
screening examinations in November 2003, and in February 2004 state
workers became eligible for initial or continued monitoring through the
worker and volunteer program. The state program, in general, did not
inform state responders that they were eligible to participate in the
worker and volunteer program. Worker and volunteer program officials are
working with state employee unions to inform state workers of their
eligibility. All three programs and the WTC Health Registry, with total
federal funding of $23 million, have collected information that could
contribute to better understanding of the health consequences of the
attack and improve health care for affected individuals. Officials from
the FDNY, worker and volunteer, and WTC Health Registry programs are
concerned that federal funding for their programs could end before
sufficient monitoring occurs to identify all long-term health problems
related to the WTC disaster. In January 2006, CDC received a $75 million
appropriation to fund baseline health screening, long-term monitoring, and
treatment for WTC responders. CDC officials are in the process of deciding
how they are going to allocate these funds among programs and how long the
allocated funds will be available for each program that receives funding.

Three WTC Monitoring Programs Provided Medical Examinations to Identify
Responders' Health Problems

Three federally funded programs implemented by state and local governments
or private organizations, with total funding of about $104 million, have
provided medical examinations to identify physical and mental health
problems related to the WTC attack. (See table 2.) Two of these
programs-the FDNY WTC Medical Monitoring Program and the worker and
volunteer program-are tracking the health of WTC rescue, recovery, and
cleanup workers and volunteers over time. The third program, the New York
State responder screening program, offered one-time screening examinations
to state employees, including National Guard personnel, who participated
in WTC rescue, recovery, and cleanup work. Federal employees who responded
to the WTC disaster in an official capacity were not eligible for any of
these programs because it was expected that another program would be
developed for them.

Table 2: Monitoring Activities and Associated Federal Funding for WTC
Monitoring Programs Implemented by State and Local Governments or Private
Organizations

                  Completed monitoring    Planned monitoring                  
                  activities              activities         Federal fundinga
FDNY WTC       Through June 2005,      By June 2009,      $4.8 million was 
Medical        15,284 firefighters and conduct three      provided         
Monitoring     emergency medical       follow-up          beginning in     
Program        service technicians     examinations of    October 2001 for 
                  received screening      each participant.  initial program; 
                  examinations, and 522                      additional $25   
                  of these participants                      million is       
                  completed a follow-up                      available        
                  examination.                               through June     
                                                             2009.            
WTC Medical    Through June 2005,      By July 2009,      $15.9 million    
Monitoring     14,110 people received  conduct three      was provided for 
Program        screening examinations, follow-up          initial          
(worker and    and 1,699 of these      examinations of    program;b        
volunteer      participants completed  each participant.  additional $56   
program)       a follow-up                                million is       
                  examination.                               available        
                                                             through July     
                                                             2009.            
New York State As of November 2003,    No further         $2.4 million was 
responder      1,677 of approximately  examinations are   provided in      
screening      9,800 eligible          planned.           January 2002 and 
program        employees and National  Participants are   is available     
                  Guard personnel         now eligible to    through          
                  received screening      participate in the mid-January      
                  examinations.           worker and         2007.c           
                                          volunteer program. 
WTC Health     As of November 2004,    In 2006, conduct   $20 million was  
Registry       the program completed   follow-up survey   provided         
                  baseline data           of participants.   beginning in     
                  collection through                         July 2002,e and  
                  interviews with the     Registry officials additional       
                  71,437 people who       are developing     funding of about 
                  enrolled in the         plans to track     $3 million has   
                  registry;d registry     participants'      since been       
                  officials estimate that health through     provided.f       
                  about 385,000 people    2023.              
                  had been eligible to                       
                  enroll. In 2005, the                       
                  program updated contact                    
                  information obtained at                    
                  the time of enrollment.                    

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.

Note: The funding information in this table does not include an
appropriation of $75 million to CDC in fiscal year 2006 to fund health
screening, long-term monitoring, and treatment for WTC responders. As of
February 2006, CDC had not decided how to allocate these funds.

aExcept as noted, FEMA provided these funds to the federal administering
agency for each monitoring program.

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

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

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

eThe grant agreement is between ATSDR and the New York City Department of
Health and Mental Hygiene. However, ATSDR contracted directly with
Research Triangle Institute (RTI), 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 RTI.

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

The FDNY program completed initial screening for over 15,000 firefighters
and emergency medical service personnel, and the worker and volunteer
program completed initial screening for over 14,000 other responders. In
both programs, screenings include physical examinations, pulmonary
function tests, blood and urine analysis, a chest Xray, and questionnaires
on exposures and mental health issues. Both programs have begun to conduct
follow-up examinations of participants and continue to accept new
enrollees who desire initial screening. Current plans are to conduct a
total of three follow-up examinations for each participant by 2009. As
part of their federally funded activities, both programs provide referrals
for participants who require treatment. FDNY employees and retirees can
obtain treatment and counseling services from the FDNY Bureau of Health
Services and the FDNY Counseling Services Unit, or they can use their
health insurance to obtain treatment and counseling services elsewhere.
The worker and volunteer program also provides referrals for its
participants, including referrals to programs funded by the American Red
Cross and other nonprofit organizations.

The New York State program provided health screenings to about 1,700 of
the estimated 9,800 state workers and National Guard personnel who
responded to the WTC disaster. Officials sent letters to all state
responders to inform them about the program and their eligibility for
it.17 For each participant, the screening included a health and exposure
questionnaire and physical and pulmonary examinations. Participants who
required further evaluation or treatment after screening were told to
follow up with their personal physician or a specialist. The program
stopped screening participants in November 2003, in part because the
number of responders requesting examinations was dwindling, and no
follow-up examinations are planned.

In February 2004, worker and volunteer program officials began to allow
New York State responders to participate in that monitoring program. The
officials determined that the worker and volunteer program would have
sufficient funding to accommodate state workers who want to join the
program. The state program did not notify the 9,800 state responders,
including the approximately 1,700 workers it had screened that they were
now eligible for continued monitoring from the worker and volunteer
program. State program officials relayed this development only to those
state responders who inquired about screening or monitoring examinations
following the decision to permit state responders to participate in the
worker and volunteer program. However, officials from the worker and
volunteer program told us that they are working with state employee unions
to inform state workers about their eligibility for the worker and
volunteer program. For example, starting in November 2005, letters have
been sent to union members telling them about the program and how they can
enroll in it. According to worker and volunteer program officials, as of
February 2006, 13 state workers who responded to the WTC disaster in an
official capacity had received examinations from the worker and volunteer
program,18 and as of mid-February 2006, 9 additional state workers had
registered to obtain examinations through this program. Worker and
volunteer program officials told us that any state worker that had been
screened by the state program would need to receive a new baseline
examination through the worker and volunteer program, because the
screening data collected by the state program differ from the data
collected by the worker and volunteer program. For example, the worker and
volunteer program offers a breathing test not provided by the state
program.

17When state officials contacted the estimated 9,800 state responders,
some of them informed the program that they were not interested in
participating. Officials sent follow-up letters to state employees who did
not respond to the initial mailing. National Guard personnel were sent
only an initial letter.

Programs Provide Data for WTC-Related Health Research

In addition to providing medical examinations, these three programs-the
FDNY program, the worker and volunteer program, and the New York State
program-have collected information for use in scientific research to
better understand the health consequences of the WTC attack and other
disasters. A fourth program, the WTC Health Registry, includes health and
exposure information obtained through interviews with participants; it is
designed to track participants' health for 20 years and to provide data on
the long-term health consequences of the disaster (see table 2).
Physicians who evaluate and treat WTC responders told us they expect that
research on health effects from the disaster will not only help
researchers understand the health consequences, but also provide
information on appropriate treatment options for affected individuals.

18The worker and volunteer program has established a network of providers
to serve state responders outside the New York City metropolitan area.
State responders had been eligible for monitoring at New York City area
clinics since February 2004, and can now visit providers in Albany and
Syracuse. According to worker and volunteer program officials, state
responders will be able to obtain examinations at another clinic location
that is scheduled to open in Rochester in March 2006.

Both the FDNY program and the worker and volunteer program have been the
basis for published research articles on the health of WTC responders. For
example, the FDNY program reported on the injuries and illnesses
experienced by firefighters and emergency medical service workers after
responding to the attack.19 In addition, the worker and volunteer program
published information on the physical and mental health of responders in
2004.20 Officials from both programs plan to publish additional findings
as they track participants' health over time. Although the New York State
program has stopped offering examinations, program officials are
continuing to analyze data from the program with plans for eventual
publication.

The WTC Health Registry program has collected health information through
interviews with responders, people living or attending school in the
vicinity of the WTC site, and people working or present in the vicinity on
September 11, 2001. The registry program, with total federal funding of
$23 million, completed enrollment and conducted interviews with over
71,000 participants by November 2004. Officials updated contact
information for all participants in 2005, and they plan to start
conducting the first follow-up health survey of participants in late March
2006. Registry officials would like to conduct subsequent follow-up
surveys every 2 years until about 2023-20 years after the program began in
2003-but have not yet secured funding for long-term monitoring.21

The registry is designed to provide a basis for research to evaluate the
long-term health consequences of the disaster. It includes contact
information for people affected by the WTC attack, information on
individuals' experiences and exposures during the disaster, and
information on their health. In November 2004, registry officials
published preliminary results on the health status of registry
participants, and officials expect to submit several research papers for
publication within the next year. In addition, in May 2005, registry
officials published guidelines for allowing registry information to be
used in scientific research,22 and as of February 2006, they approved
three proposals for external research projects that use registry
information. These proposals include two studies of building evacuations
and a study of psychological responses to terrorism.

19See, for example, Centers for Disease Control and Prevention, "Injuries
and Illnesses among New York City Fire Department Rescue Workers after
Responding to the World Trade Center Attacks," Morbidity and Mortality
Weekly Report, vol. 51 (2002), and Elizabeth M. Fireman and others,
"Induced Sputum Assessment in NYC Firefighters Exposed to World Trade
Center Dust," Environmental Health Perspectives, vol. 112 (2004).

20Centers for Disease Control and Prevention, Morbidity and Mortality
Weekly Report, vol. 53, 807, and Centers for Disease Control and
Prevention, Morbidity and Mortality Weekly Report, vol. 53, 812.

21Program officials told us that the registry was designed as a 20-year
program because most long-term health effects that might result from the
WTC disaster would likely begin to appear in the population within that
period of time.

Program Officials Are Concerned That Current Federal Funding Arrangements Will
End before Needed Monitoring Is Complete

Officials from the FDNY, worker and volunteer, and WTC Health Registry
programs are concerned that current time frames for federal funding
arrangements for programs designed to track participants' health over time
may be too short to allow for identification of all the health effects
that may eventually develop. ATSDR's 5-year cooperative agreement with the
New York City Department of Health and Mental Hygiene to support the WTC
Health Registry went into effect April 30, 2003, and extends through April
29, 2008. Similarly, NIOSH awarded 5-year grants in July 2004 to continue
the FDNY and worker and volunteer programs through mid-2009; the programs
had begun in 2001 and 2002, respectively. Health experts involved in these
monitoring programs, however, cite the need for long-term monitoring of
affected groups because some possible health effects, such as cancer, may
not appear until decades after a person has been exposed to a harmful
agent. They noted that long-term monitoring could result in earlier
detection and treatment of cancers that might develop. Health experts also
told us that monitoring is important for identifying and assessing the
occurrence of newly identified conditions, such as WTC cough, and chronic
conditions, such as asthma.

22Under the guidelines, a review committee consisting of public health
scientists and stakeholder representatives evaluates each proposed
research project based on criteria such as the proposal's scientific and
technical merit, funding, and contribution to a community or individuals.

CDC Is in Process of Deciding How to Distribute New Funds for Monitoring and
Treating WTC Responders

In January 2006, CDC received a $75 million appropriation for purposes
related to the September 11, 2001, terrorist attacks. It is available to
fund baseline screening, long-term monitoring, and health care treatment
of emergency services and recovery personnel who responded to the WTC
disaster.23 CDC is required to give first priority to funding baseline,
follow-up screening, long-term medical health monitoring, or treatment
programs implemented by the worker and volunteer program, the FDNY Medical
Monitoring Program, the WTC Health Registry, the New York Police
Foundation's Project COPE, and the Police Organization Providing Peer
Assistance of New York City. CDC is required to give second priority to
funding similar programs that are coordinated by other organizations that
are working with New York State and New York City. The programs that may
qualify for secondary consideration are not specified in the law.

In mid-February 2006, CDC officials told us that they were engaged in
discussions with congressional stakeholders and the organizations
specified in the law to help the agency decide how to spend the
appropriated funds. Officials said that to aid their decisionmaking they
were also consulting with private philanthropic organizations, including
the American Red Cross, to learn more about the grant funds the
organizations have provided to support the recovery needs of people
affected by the WTC attack.24 CDC officials told us that they plan to
first decide how they will allocate funds among screening, monitoring, and
treatment programs and then make other decisions, such as how long the
allocated funds will be available for each program. They said that they
anticipated reaching a decision about the allocation of the funds by the
end of February 2006, but did not know when they would reach other
decisions.

23These funds are available to CDC until expended. See Department of
Defense Appropriations Act, 2006, Pub. L. No. 109-148, Sec. 5011 (b), 119
Stat. 2680,____.

24In 2005, the American Red Cross September 11 Recovery Program developed
a plan for distributing $50 million in grant funds over a 2-year period to
support the recovery of September 11 victims and their families. The first
grant was awarded in June 2005 to Mount Sinai's WTC Health Effects
Treatment Program, which supports workers and volunteers dealing with
ongoing physical and mental health problems following their service at WTC
disaster sites. The Red Cross program has also awarded grants to the four
additional clinical centers that are part of the worker and volunteer
program.

     HHS's Program for Screening Federal Responders Has Accomplished Little

HHS's OPHEP established the WTC Federal Responder Screening Program to
provide medical screening examinations for an estimated 10,000 federal
workers who responded to the WTC disaster in an official capacity and were
not eligible for any other medical monitoring program. OPHEP did not
initially develop a comprehensive list of federal responders who were
eligible for the program. The program began in June 2003-about a year
later than other monitoring programs-and had completed screenings for 394
workers through March 2004. No additional examinations were provided until
the program resumed in December 2005, because OPHEP officials had
temporarily suspended new examinations until they could resolve several
operational issues. The program resumed conducting examinations for
current federal workers in December 2005, and completed 133 additional
examinations for current federal workers as of early February 2006. The
examination process has not resumed for WTC responders who are no longer
federal employees, but OPHEP recently executed an agreement with NIOSH to
arrange for the worker and volunteer program to provide examinations to
these WTC responders. We also identified two additional federal agencies
that established screening programs for their own personnel who responded
to the disaster.

HHS Program Screened Few Federal Workers and Recently Started Conducting
Examinations after a Hiatus of Almost 2 Years

HHS's WTC Federal Responder Screening Program was established to provide
free voluntary medical screening examinations for an estimated 10,000
federal workers25 whom their agencies sent to respond to the WTC disaster
from September 11, 2001, through September 10, 2002, and who were not
eligible for any other monitoring program.26 FEMA provided $3.74 million
through an interagency agreement with HHS's OPHEP for the purpose of
developing and implementing the program. OPHEP entered into an agreement
with HHS's FOH to schedule and conduct the screening examinations.

25For this program, a federal worker is defined as being either a
permanent, temporary, or intermittent federal employee.

26According 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 this program. According to an official of the worker and
volunteer program, federal workers who volunteered on their own in the
aftermath of the disaster were eligible to participate in that screening
program.

The launching of the federal responder screening program lagged behind the
implementation of other federally funded monitoring programs for WTC
responders. For example, the medical screening program for New York State
employees and the worker and volunteer program started conducting
screening examinations in May 2002 and July 2002, respectively. However,
OPHEP did not launch its program until June 2003. (Figure 1 highlights key
actions in developing and implementing the program.)

Figure 1: Timeline of Key Actions Related to WTC Federal Responder
Screening Program

Initially, OPHEP did not develop a plan for identifying all federal
agencies and their personnel that responded to the WTC disaster or for
contacting all federal personnel eligible for the screening program.
Although OPHEP and FEMA developed a partial list of federal
responders-consisting primarily of HHS and FEMA personnel-OPHEP did not
have a comprehensive list of agencies and personnel, and so could not
inform all eligible federal responders about the WTC screening program.
The program's principal action to communicate with the federal responders
was to place program information and registration forms on FEMA's National
Disaster Medical System (NDMS) Web site.27

The screening program had operated for about 6 months when OPHEP officials
decided in January 2004 to place it on hold by temporarily suspending
examinations. FOH officials told us that after examinations were
suspended, 35 additional people requested examinations and they were
placed on a waiting list. FOH officials told us that they completed 394
screening examinations28 from June 2003 through March 2004,29 with most
completed by the end of September 2003. According to FOH, a total of
$177,967 was spent on examinations through March 2004.30

OPHEP officials told us that three operational issues contributed to the
decision to suspend the program. First, OPHEP could not inform all
eligible federal responders about the program because it lacked a
comprehensive list of eligible federal responders. Second, there were
concerns about what actions FOH clinicians could take when screening
examinations identified problems. Based on the examinations that had been
completed before the program was placed on hold, FOH clinicians determined
that many participants needed additional diagnostic testing and follow-up
care, primarily in the areas of respiratory functioning and mental health.
However, under the existing interagency agreement there was no provision
for providing follow-up care and no direction for clinicians on how to
handle the provision of further diagnostic tests, treatment, or referrals.
FOH officials told us that they were concerned about continuing to provide
screening examinations without the ability to provide participants with
additional needed services. Third, although the screening program had been
established to provide examinations to all federal responders regardless
of their current federal employment status, HHS officials told us that the
department determined that FOH does not have the authority to provide
examinations to people who are no longer in federal service.

27NDMS provides medical care to victims and responders to domestic
disaster, including acts of terrorism and natural disasters. According to
HHS officials, when NDMS was transferred to FEMA in 2003 as part of the
formation of DHS, key NDMS staff involved in the initial planning of the
screening program were also transferred. During the transition period,
these NDMS staff continued to carry out some tasks related to the
screening program, including working to identify agencies that had sent
employees to the WTC disaster, developing a list of federal responders,
and placing information about the program on the NDMS Web site. Officials
said that overall program management responsibility and funding remained
with HHS.

28FOH officials told us that although FOH clinicians had seen
approximately 460 federal personnel, not all of them completed the entire
examination process.

29FOH continued to schedule and conduct examinations for those people who
had requested an examination before the program was placed on hold in
January 2004.

30FOH officials told us that this amount includes spending on the 394
completed examinations and on examinations that were partially completed.

In April 2005, OPHEP began to prepare for resuming the examination program
by enlisting the assistance of ATSDR-which had successfully developed the
WTC Health Registry-to establish a database containing the names of
federal responders, develop a new registration Web site, and develop and
implement recruitment and enrollment plans for current and former federal
workers. OPHEP executed an agreement with ATSDR allocating about $491,000
of the funds remaining from FEMA for these activities. OPHEP officials
told us that, as part of the program's recruitment and enrollment efforts,
in mid-October 2005, a letter was sent to about 1,700 people identified as
having responded to the WTC disaster to inform them about the program.31
According to OPHEP, the new registration Web site was activated in October
2005, and through early February 2006, 345 additional current federal
workers and 32 former workers had registered to obtain an examination.

31OPHEP officials told us that they contacted a total of 132 federal
agencies, requesting them to provide ATSDR's contractor with contact
information on the employees they sent to respond to the WTC disaster. Of
these agencies, 92 indicated that they sent employees to respond to the
WTC disaster, and 39 of the 92 agencies provided information on people
they believed might be eligible for OPHEP's screening program. OPHEP
officials said that 14 federal agencies told them that they wished to
contact their employees themselves to inform them about the program. OPHEP
provided these agencies with outreach materials but has no information on
what actions they took. According to OPHEP, five agencies refused to
provide information on their employees and the remaining agencies have
agreed to provide information but have not yet done so.

In July 2005, OPHEP and FOH executed a new agreement for providing
examinations to WTC responders who are current federal workers. Under this
agreement, FOH clinicians can now make referrals for follow-up care. For
example, they can refer participants with mental health symptoms to an FOH
employee assistance program for a telephone assessment. If appropriate,
the participant can then be referred to an employee assistance program
counselor for up to six in-person sessions. If the assessment indicates
that longer treatment is necessary, the participant can instead be advised
to use health insurance to obtain care or to contact a local Department of
Labor Office of Workers' Compensation to file a claim, receive further
evaluation, and possibly obtain compensation for mental health services.
The new agreement between OPHEP and FOH also allows FOH clinicians to
order additional clinical tests, such as special pulmonary and breathing
tests. FOH officials told us that they resumed providing examinations in
December 2005 and that 133 examinations have since been completed.32

The examination process has not resumed for WTC responders who are no
longer federal employees, but in late February 2006, OPHEP executed an
agreement with NIOSH to arrange for the worker and volunteer program to
provide examinations to these WTC responders.33 Under this agreement,
former federal workers will receive a one-time examination comparable to
the type of examination that FOH is now providing to current federal
workers. Patients with eligible conditions will be referred to the
treatment programs supported by the American Red Cross or other available
programs.

Two Federal Agencies Established Their Own Screening Programs

In addition to the OPHEP program, we identified two federal agencies that
established medical screening programs to assess the health of the
personnel they had sent to respond to the WTC disaster. One agency, the
Army, established two screening programs-one specifically for Army Corps
of Engineers personnel and one that also included other Army responders.
The Army Corps of Engineers established a voluntary program to assess the
health of 356 employees it had sent to respond to the disaster.34 The
program, initiated in November 2001, consists of sending employees an
initial medical screening questionnaire covering physical health issues.35
If questionnaire results indicate symptoms or concerns that need further
evaluation, the employee is offered a medical examination.36 As of August
2004, 92 Corps of Engineers employees had participated in the program,
with 40 receiving follow-up examinations. The Army's Center for Health
Promotion and Preventive Medicine initiated a program-the World Trade
Center Support Health Assessment Survey-in January 2002. It was designed
as a voluntary medical screening for Army military and civilian personnel,
including contractors. From January 2002 through September 2003,
questionnaires were sent to 256 employees.37 According to DOD, 162
employees completed and returned their questionnaires. In addition, the
U.S. Marshals Service, within the Department of Justice, modified an
existing agreement with FOH in 2003 for FOH to screen approximately 200
U.S. Marshals Service employees assigned to the WTC or Pentagon recovery
sites. The one-time assessment includes a screening questionnaire and a
medical examination.38 FOH officials said that as of August 2005, 88 of
the 200 U.S. Marshals Service employees had requested and obtained
examinations.39

32FOH officials told us that, as of early February 2006, they completed
examinations for 128 current federal workers who registered on the
program's new Web site that opened in October 2005, and for 5 current
federal workers who were on the waiting list after the screening program
was placed on hold in January 2004.

33This agreement also provides for examinations for other federal
responders who are ineligible to receive examinations from FOH, such as
DOD employees.

34The screening program has no closing date, and employees can request a
screening examination at any time.

35The questionnaire collects information on prior and WTC-related
occupational exposures and prior and current physical health status.

36The medical examination includes a comprehensive history and physical
examination; chest Xray; and pulmonary function, blood, and urine tests.

37The Army's questionnaire was distributed to active-duty service members,
activated members of the Reserves and National Guard, civilian employees,
and civilian contractors. These included 125 New Jersey Army National
Guard members. The 474 active-duty members of the New York Army National
Guard who responded to the WTC disaster were not included due to their
eligibility to participate in the medical screening program established
for New York State workers.

38The medical examination includes an occupational exposure history and
physical examination, chest X-ray, blood and urine tests, pulmonary
function test, audiogram, and electrocardiogram.

39FOH officials told us that under the terms of the agreement, eligible
employees can still request a screening examination.

Lessons from WTC Health Monitoring Programs Could Assist Future Monitoring
                                    Efforts

Officials involved in the WTC health monitoring programs implemented by
state and local governments or private organizations-including officials
from the federal administering agencies-derived lessons from their
experiences that could help officials design such programs in the future.
They include the need to quickly identify and contact people affected by a
disaster, the value of a centrally coordinated approach for assessing
individuals' health, the importance of monitoring both physical and mental
health, and the need to plan for providing referrals for treatment when
screening examinations identify health problems.

Officials involved in the monitoring programs emphasized the importance of
quickly identifying and contacting people affected by a disaster. They
said that potential monitoring program participants can become more
difficult to locate as time passes.40 In addition, potential participants'
ability to recall the events of a disaster may decrease over time, making
it more difficult to collect accurate information about their experiences
and health. However, the time it takes to design, fund, approve, and
implement monitoring programs can lead to delays in contacting the people
who were affected. For example, the WTC Health Registry received funding
in July 2002 but did not begin collecting data until September 2003-2
years after the disaster. From July 2002 through September 2003, the
program's activities included developing the registry protocol, testing
the questionnaire, and obtaining approval from institutional review
boards.41 To expedite such information collection during the response to
future disasters, ATSDR officials have developed a model data collection
instrument, known as the Rapid Response Registry, to allow officials to
identify and locate potentially affected individuals immediately after a
disaster and collect basic preliminary information, such as their current
contact information and their location during the disaster. ATSDR
officials expect that using this instrument would reduce delays in
collecting time-sensitive information while officials take the time
necessary to develop a monitoring program for disaster-related health
effects. According to ATSDR officials, state and local agencies can
request the instrument and adapt it to their specific needs, and ATSDR can
provide technical assistance on how to use the instrument. To date, 14
states have requested the Rapid Response Registry from ATSDR.42

40The extent of the challenge of locating potential participants varied
among WTC monitoring programs, depending on the population involved. For
example, FDNY had contact information for all potential participants in
its monitoring program because they were employed by FDNY during or after
the disaster. In contrast, the worker and volunteer program and the WTC
Health Registry had to expend considerable effort to identify people who
were eligible to participate and inform them about the programs.

41Institutional review boards are groups that have been formally
designated to review and monitor biomedical research involving human
subjects.

Furthermore, officials told us that health monitoring for future disasters
could benefit from additional centrally coordinated planning. Such
planning could facilitate the collection of compatible data among
monitoring efforts, to the extent that this is appropriate. Collecting
compatible data could allow information from different programs to be
integrated and contribute to improved data analysis and more useful
research. In addition, centrally coordinated planning could help officials
determine whether separate programs are necessary to serve different
groups of people. For example, worker and volunteer program officials
indicated that it might have been possible for that program to serve
federal workers who responded to the disaster in an official capacity,
which might have eliminated the need to organize and administer a separate
program for them.

Officials also stated that screening and monitoring programs should be
comprehensive, encompassing both physical and mental health evaluations.
This observation is supported by CDC's recent report that about half of
the adults that CDC assessed in areas heavily affected by Hurricane
Katrina exhibited levels of emotional distress that indicated a potential
need for mental health services.43 Officials from the WTC worker and
volunteer medical monitoring program told us that the initial planning for
their program had focused primarily on screening participants' physical
health, and that they did not originally budget for extensive mental
health screening. Subsequently, they recognized a need for more extensive
mental health screening, including greater participation of mental health
professionals, but the program's federal funding was not sufficient to
cover such screening. By collaborating with the Mount Sinai School of
Medicine Department of Psychiatry, program officials were able to obtain
philanthropic funding to develop a more comprehensive mental health
questionnaire; provide on-site psychiatric screening; and when necessary,
provide more extensive evaluations.

42The following states have requested the instrument: Arizona, California,
Colorado, Connecticut, Florida, Georgia, Michigan, Minnesota, North
Carolina, Oklahoma, Rhode Island, South Carolina, Tennessee, and Texas.

43Centers for Disease Control and Prevention, "Assessment of
Health-Related Needs After Hurricanes Katrina and Rita-Orleans and
Jefferson Parishes, New Orleans Area, Louisiana, October 17-22, 2005,"
Morbidity and Mortality Weekly Report, Vol. 55, page 38.

Many participants in the monitoring programs required additional testing
or needed treatment for health problems that were identified during
screening examinations. Officials told us that finding treatment sources
for such participants is an important, but challenging, part of the
programs' responsibility. For example, officials from the worker and
volunteer 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. The officials said
that planning for future monitoring programs should include a
determination of how best to help participants obtain needed treatment.

                            Concluding Observations

Federally funded programs implemented by state and local governments or
private organizations to monitor the health effects of the WTC attack on
thousands of people who responded to the disaster have made progress.
However, the program HHS established to screen the federal employees whose
agencies sent them to the WTC after the attack has accomplished little,
completing screenings of 527 of the thousands of federal responders.
Moreover, no examinations occurred for a period of almost 2 years, and
examinations for former federal workers have not yet resumed. Because of
this program's limited activity, and the inability of federal workers to
participate in other monitoring programs because of the assumption that
they would have the opportunity to receive screening examinations through
the HHS program, many federal responders may not have had an opportunity
to identify and seek treatment for health problems related to the WTC
disaster.

Based on their experiences, officials involved in the monitoring programs
have made a number of useful observations that will apply to future
terrorist attacks and natural disasters, such as Hurricane Katrina. For
example, screening for mental as well as physical health problems in New
Orleans and along the Gulf Coast will be critical to the recovery of
survivors of Hurricane Katrina and the responders to the disaster, as
indicated by CDC's early assessment of the extent of mental health
distress among people affected by Hurricane Katrina. Another observation
was the importance of quickly identifying and contacting people affected
by a disaster. The model data collection instrument developed by ATSDR has
the potential to enable officials to quickly and systematically identify
people involved in future disasters, a necessary first step in conducting
health monitoring. Finally, officials noted the value of centrally
coordinated planning of health monitoring, which could improve the
underlying database for research and eliminate the need for separate and
sometimes incompatible monitoring programs for different populations.

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; George H.
Bogart; Alice L. London; Roseanne Price; and William R. Simerl made key
contributions to this statement.

Appendix I: Abbreviations

ATSDR Agency for Toxic Substances and Disease Registry CDC Centers for
Disease Control and Prevention DHS Department of Homeland Security DOD
Department of Defense 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 NDMS National Disaster Medical System NIOSH
National Institute for Occupational Safety and Health NYC New York City
OPHEP Office of Public Health Emergency Preparedness RTI Research Triangle
Institute WTC World Trade Center

Appendix II: Government Agencies That Sent Responders Following the World
Trade Center Attack

Through our work, we identified the following agencies that sent employees
to respond to the World Trade Center attack of September 11, 2001.

                                Federal Agencies

Department of Defense Department of Energy Department of Health and Human
Services Agency for Toxic Substances and Disease Registry Centers for
Disease Control and Prevention National Institutes of Health Substance
Abuse and Mental Health Services Administration Department of Homeland
Security Federal Emergency Management Agency1 U.S. Coast Guard2 Department
of the Interior National Park Service Department of Justice Federal Bureau
of Investigation U.S. Marshals Service Department of Labor Occupational
Safety and Health Administration Environmental Protection Agency

                            New York State Agencies

Department of Environmental Conservation Department of Health Division of
Military and Naval Affairs Emergency Management Office Office of Mental
Health

                             New York City Agencies

Department of Design and Construction Department of Environmental
Protection Department of Health and Mental Hygiene Department of
Sanitation Fire Department Metropolitan Transportation Authority Office of
Emergency Management Police Department

1At the time of the World Trade Center attack, the Federal Emergency
Management Agency was an independent agency.

2At the time of the World Trade Center attack, the U.S. Coast Guard was in
the Department of Transportation.

(290526)

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Highlights of GAO-06-481T , a testimony before the subcommittee on
National Security, Emerging Threats, and International Relations,
Committee on Government Reform, House of Representatives

February 28, 2006

SEPTEMBER 11

Monitoring of World Trade Center Health Effects Has Progressed, but
Program for Federal Responders Lags Behind

After the 2001 attack on the World Trade Center (WTC), nearly 3,000 people
died and an estimated 250,000 to 400,000 people in the vicinity were
affected. An estimated 40,000 people who responded to the
disaster-including New York City Fire Department (FDNY) personnel and
other government and private-sector workers and volunteers-were exposed to
physical and mental health hazards. Concerns remain about the long-term
health effects of the attack and about the nation's capacity to plan for
and respond to health effects resulting from future disasters.

Several federally funded programs have monitored the physical and mental
health effects of the WTC attack. These monitoring programs include
one-time screening programs and programs that also conduct follow-up
monitoring. GAO was asked to assess the progress of these programs and
examined (1) federally funded programs implemented by state and local
government agencies or private institutions, (2) federally administered
programs to monitor the health of federal workers who responded to the
disaster in an official capacity, and (3) lessons learned from WTC
monitoring programs. GAO reviewed program documents and interviewed
federal, state, and local officials and others involved in WTC monitoring
programs. This statement updates information GAO provided to the
Subcommittee on September 10, 2005.

Three federally funded monitoring programs implemented by state and local
governments or private organizations after the WTC attack, with total
funding of about $104 million, have provided initial medical
examinations--and in some cases follow-up examinations--to thousands of
affected responders to screen for health problems. For example, the FDNY
medical monitoring program completed initial screening for over 15,000
firefighters and emergency medical service personnel, and the worker and
volunteer program screened over 14,000 other responders. The New York
State responder screening program screened about 1,700 state responders
before ending its examinations in 2003. These monitoring programs and the
WTC Health Registry, with total federal funding of $23 million, have
collected information that program officials believe researchers could use
to help better understand the health consequences of the attack and
improve treatment. Program officials expressed concern, however, that
current time frames for federal funding arrangements may be too short to
allow for identification of all future health effects. CDC recently
received a $75 million appropriation to fund health screening, long-term
monitoring, and treatment for WTC responders and is deciding how to
allocate these funds.

In contrast to the progress made by other federally funded programs, the
Department of Health and Human Services' (HHS) program to screen federal
workers who were sent by their agencies to respond to the WTC disaster has
accomplished little and lags behind. The program-which started in June
2003, about one year later than other WTC monitoring programs-completed
screening of 527 of the estimated 10,000 federal workers who responded in
an official capacity to the disaster, and in early 2004, examinations were
suspended for almost 2 years. The program's limited activity and the
exclusion of federal workers from other monitoring programs because of the
assumption that they could receive screening examinations through the HHS
program may have resulted in many federal responders losing the
opportunity to identify and seek treatment for their WTC-related health
problems.

Officials involved in WTC health monitoring programs cited lessons from
their experiences that could help others who may be responsible for
designing and implementing health monitoring efforts that follow other
disasters, such as Hurricane Katrina. These include the need to quickly
identify and contact people affected by a disaster; to monitor for mental
health effects, as well as physical injuries and illnesses; and to
anticipate when designing disaster-related monitoring efforts that there
will likely be many people who require referrals for follow-up care and
that handling the referral process may require substantial effort.
*** End of document. ***