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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 10:00 a.m. EDT:

Wednesday, September 8, 2004:

September 11:

Health Effects in the Aftermath of the World Trade Center Attack:

Statement of Janet Heinrich:

Director, Health Care--Public Health Issues:

GAO-04-1068T:

GAO Highlights:

Highlights of GAO-04-1068T, a testimony before the Subcommittee on 
National Security, Emerging Threats, and International Relations, 
Committee on Government Reform, House of Representatives

Why GAO Did This Study:

When the World Trade Center (WTC) buildings collapsed on September 11, 
2001, nearly 3,000 people died and an estimated 250,000 to 400,000 
people who were visiting, living, working, and attending school 
nearby, or responding to the attack, were exposed to a mixture of 
dust, debris, smoke, and various chemicals. In the months to follow, 
thousands of people who returned to the area to live and work, as well 
as responders who were involved in the search for remains and site 
cleanup, were also exposed. In addition, people in New York City and 
across the country were exposed to the emotional trauma of a terrorist 
attack on American soil.

Concerns have been raised about the short- and long-term physical and 
mental health effects of the attack. Various government agencies and 
private organizations established efforts to monitor and understand 
these health effects. 

GAO was asked to describe the health effects that have been observed 
in the aftermath of the WTC attack and the efforts that are in place 
to monitor and understand those health effects. GAO searched 
bibliographic databases such as Medline to determine the pertinent 
scientific literature, reviewed that literature, and interviewed and 
reviewed documents from government officials, health professionals, 
and officials of labor groups.

What GAO Found:

In the aftermath of the September 11 attack on the World Trade Center, 
a wide variety of physical and mental health effects have been reported 
in the scientific literature. The primary health effects include 
various injuries, respiratory conditions, and mental health effects. In 
the immediate aftermath of the attack, the primary injuries were 
inhalation and musculoskeletal injuries. During the 10-month cleanup 
period, despite the dangerous work site, responders reported few 
injuries that resulted in lost workdays. A range of respiratory 
conditions have also been reported, including wheezing, shortness of 
breath, sinusitis, asthma, and a new syndrome called WTC cough, which 
consists of persistent cough accompanied by severe respiratory 
symptoms. Almost all the firefighters who responded to the attack 
experienced respiratory effects, and hundreds had to end their 
firefighting careers due to WTC-related respiratory illness. Unlike 
the physical health effects, the mental health effects were not 
limited to people in the WTC area but were also experienced 
nationwide. Because most of the information about mental health 
effects comes from questionnaire or survey data, what is reported in 
most cases are symptoms associated with a psychiatric disorder, rather 
than a clinical diagnosis of disorder. The most commonly reported 
mental health effects include symptoms associated with depression, 
stress, anxiety, and posttraumatic stress disorder (PTSD)a disorder 
that can develop after experiencing or witnessing a traumatic event 
and includes such symptoms as intrusive memories and distressing 
dreamsas well as behavioral effects such as increased use of alcohol 
and tobacco and difficulty coping with daily responsibilities.

Six programs were established to monitor and understand the health 
effects of the attack, and these programs vary in terms of which 
people are eligible to participate, methods for collecting information 
about the health effects, options for treatment referral, and number 
of years people will be monitored. Although five of the programs focus 
on various responder populations, the largest programthe WTC Health 
Registryis open not only to responders but also to people living or 
attending school in the vicinity of the WTC site, or working or 
present in the vicinity on September 11. The monitoring programs vary 
in their methods for identifying those who may require treatment, and 
although none of these programs are funded to provide treatment, they 
provide varying options for treatment referral. Under current plans, 
HHS funding for the programs will not extend beyond 2009. Some long-
term health effects, such as lung cancer, may not appear until several 
decades after a person has been exposed to a harmful agent.

GAO provided a draft of this testimony to DHS, EPA, HHS, and the 
Department of Labor. In its written comments, HHS noted that the 
testimony does not include significant discussion of ways in which 
mental health symptoms have changed over time. The evidence GAO 
examined did not support a full discussion of changes in mental or 
physical health effects over time. 

www.gao.gov/cgi-bin/getrpt?GAO-04-1068T

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact Janet Heinrich at (202) 
512-7119.

[End of section]

Mr. Chairman and Members of the Subcommittee:

I appreciate the opportunity to be here today as you discuss the health 
effects of the September 11, 2001, terrorist attack on the World Trade 
Center (WTC).[Footnote 1] When the WTC buildings collapsed on that day, 
nearly 3,000 people died and an estimated 250,000 to 400,000 people 
were immediately exposed to a mixture of dust, debris, smoke, and 
various chemicals.[Footnote 2] These people included those living, 
working, and attending school in the vicinity as well as the thousands 
of emergency response workers who rushed to the scene. Also exposed to 
these substances were the thousands of responders[Footnote 3] who were 
involved in some capacity in the rescue operations, search for remains, 
and site cleanup in the days, weeks, and months to follow and the 
thousands of residents, commuters, and students who returned to the 
area to live and work while the cleanup continued.[Footnote 4] In 
addition, people in New York City (NYC) and across the country were 
exposed to the emotional trauma of a terrorist attack intended to 
instill fear and anxiety in the American population.

Concerns have been raised about the short-and long-term physical and 
mental health effects of the attack. Experts have stressed the 
importance of understanding the health effects related to the attacks 
and ensuring that these effects are investigated and that people 
needing treatment are identified. Under challenging circumstances due 
to the unprecedented nature of the events and the need for rapid 
response, various government agencies and private-sector organizations 
established several efforts to monitor and understand the health 
effects resulting from the attack. You asked us to examine these 
efforts.

In this testimony, we describe (1) health effects that have been 
observed in the aftermath of the WTC attack and (2) efforts that are in 
place to monitor and understand those health effects. My colleague's 
testimony addresses workers' compensation for people who were injured 
while working during the attack or its aftermath.[Footnote 5]

To describe the health effects of the WTC attack and the efforts to 
monitor and understand them, we reviewed the scientific literature 
related to efforts to identify, track, or treat the physical and mental 
health effects of the September 11 attack[Footnote 6] and interviewed 
and reviewed documents from federal, state, and local agency officials, 
as well as medical and public health professionals and officials of 
labor groups. We searched 19 bibliographic databases such as Medline to 
determine the pertinent literature. The studies of health effects vary 
in study design, measures used, survey instruments, time periods, and 
populations studied, and thus in many cases the reported results cannot 
be directly compared. The federal, state, and local officials we 
interviewed were from the U.S. Departments of Defense (DOD), Education, 
Health and Human Services (HHS), Homeland Security (DHS), Justice 
(DOJ), Labor (DOL), and Veterans Affairs (VA); the Environmental 
Protection Agency (EPA); the New York State Department of Health; the 
New York State Office of Mental Health; and the New York City 
Department of Health and Mental Hygiene. The medical and public health 
professionals we interviewed were affiliated with the Association of 
Occupational and Environmental Clinics, the City University of New 
York's Queens College, the New York City Fire Department's (FDNY) 
Bureau of Health Services, the Greater New York Hospital Association, 
the Johns Hopkins Bloomberg School of Public Health, the Mailman School 
of Public Health at Columbia University, the Mount Sinai-Irving J. 
Selikoff Clinical Center for Occupational and Environmental Medicine, 
the New York Academy of Medicine, the New York University School of 
Medicine's Child Study Center, and the National Child Traumatic Stress 
Network. We also interviewed representatives of labor groups, including 
the American Federation of State, County and Municipal Employees 
District Council 37; the Communications Workers of America; the New 
York State American Federation of Labor-Congress of Industrial 
Organizations; and the Uniformed Firefighters Association.

We relied primarily on data from published, peer-reviewed articles and 
government reports and did not independently verify the data contained 
in the scientific literature or documents obtained from agency 
officials and medical professionals. However, we did review the methods 
used in the studies and discussed any questions we had about the 
studies with their authors. We determined that the data reported from 
these studies were sufficiently reliable for our objectives. We 
conducted our work from March 2004 through September 2004 in accordance 
with generally accepted government auditing standards.

In summary, in the aftermath of the September 11 attack on the World 
Trade Center, a wide variety of physical and mental health effects have 
been reported in the scientific literature. The primary health effects 
include various injuries, respiratory conditions, and mental health 
effects. In the immediate aftermath of the attack, the primary injuries 
were inhalation and musculoskeletal injuries. During the 10-month 
cleanup period, despite the dangerous nature of the work site, 
responders reported few injuries that resulted in lost workdays. A 
range of respiratory conditions have also been reported, including 
wheezing, shortness of breath, sinusitis, asthma, and a new syndrome 
called WTC cough, which consists of persistent cough accompanied by 
severe respiratory symptoms. Almost all the firefighters who responded 
to the attack experienced respiratory effects, and hundreds had to end 
their firefighting careers due to WTC-related respiratory illness. 
Whereas the physical health effects were limited to people in the WTC 
area, the mental health effects, although more pronounced in the NYC 
area, were experienced nationwide. Because most of the information 
about mental health effects comes from questionnaire or survey data, 
what is reported in most cases are symptoms associated with a 
psychiatric disorder, rather than a clinical diagnosis of the disorder 
itself. The most commonly reported mental health effects include 
symptoms associated with depression, stress, anxiety, and posttraumatic 
stress disorder (PTSD)--an often debilitating and potentially chronic 
disorder that can develop after experiencing or witnessing a traumatic 
event and includes such symptoms as intrusive memories and distressing 
dreams--as well as behavioral effects such as increased use of alcohol 
and tobacco and difficulty coping with daily responsibilities.

Six programs have been established by federal, state, and local 
government agencies and private organizations to monitor and understand 
the health effects of the attack. These programs vary in terms of which 
people are eligible to participate, methods for collecting information 
about the health effects, options for treatment referral, and number of 
years people will be monitored. Although five of the monitoring 
programs focus on various responder populations, the largest program--
the WTC Health Registry--is open not only to responders--that is, those 
involved in the rescue, recovery, and cleanup efforts--but also to 
people living or attending school in the vicinity of the WTC site, or 
working or present in the vicinity on September 11. The monitoring 
programs vary in their methods for identifying those who may require 
treatment, and although none of these programs are funded to provide 
treatment, they provide varying options for treatment referral. Under 
current plans, HHS funding for the programs will not extend beyond 
2009. Some long-term health effects, such as lung cancer, may not 
appear until several decades after a person has been exposed to a 
harmful agent.

We provided a draft of this testimony to DHS, DOL, EPA, and HHS. In its 
written comments, HHS noted that the testimony does not include 
significant discussion of ways in which mental health symptoms have 
changed over time. The evidence we examined did not support a full 
discussion of changes in mental or physical health effects over time. 
HHS and the other agencies also provided technical comments, which we 
incorporated as appropriate.

Background:

Although people across the country were exposed through the media to 
the emotional trauma of the WTC attack, the residents, office workers, 
and others living, working, or attending school in the WTC area and the 
WTC responders not only experienced the traumatic event in person but 
also were exposed to a complex mixture of potentially toxic 
contaminants in the air and on the ground, such as pulverized concrete, 
fibrous glass, particulate matter, and asbestos. Almost 3,000 people, 
including some who were trapped above the impact zone and others who 
entered the buildings to assist in the evacuation, were killed in the 
attack.[Footnote 7] The majority of the estimated 16,400 to 18,800 
people who were in the WTC complex that morning were able to evacuate, 
however, with minor or no injuries.[Footnote 8] An estimated 40,000 
responders were at or in the vicinity of the WTC site or the Staten 
Island Fresh Kills landfill, participating in rescue, recovery, and 
cleanup efforts[Footnote 9]; conducting environmental and occupational 
health assessments; providing crisis counseling and other treatment; 
providing security; and assisting with the criminal investigation.

The responders included personnel from many agencies at the federal, 
state, and local levels, as well as from organizations in the private 
sector, and various other workers and volunteers. The agencies and 
organizations include HHS's Agency for Toxic Substances and Disease 
Registry (ATSDR), HHS's Centers for Disease Control and Prevention 
(CDC), the Department of Energy, EPA, DOJ's Federal Bureau of 
Investigation (FBI), DHS's Federal Emergency Management Agency (FEMA), 
HHS's National Institute for Occupational Safety and Health (NIOSH), 
HHS's National Institute of Environmental Health Sciences (NIEHS), the 
Department of the Interior's National Park Service, DOL's Occupational 
Safety and Health Administration (OSHA), HHS's Public Health Service 
Commissioned Corps, HHS's Substance Abuse and Mental Health Services 
Administration (SAMHSA), DOD's U.S. Coast Guard, DOJ's U.S. Marshals 
Service, the New York State Department of Environmental Conservation, 
the New York State Emergency Management Office, the New York State 
National Guard, the New York State Office of Mental Health, the New 
York State Department of Health, the Metropolitan Transportation 
Authority's New York City Transit, FDNY and emergency medical services 
(EMS), the New York City Department of Health and Mental Hygiene, the 
New York City Police Department (NYPD), the New York City Department of 
Design and Construction, the New York City Department of Environmental 
Protection, the New York City Department of Sanitation, the New York 
City Office of Emergency Management, the American Red Cross, and the 
Salvation Army.

Recognizing a need to monitor and understand the full health effects of 
the WTC collapse, officials from various organizations secured federal 
funding to establish programs to monitor the health of affected 
people.[Footnote 10] FDNY sought federal support in order to provide 
comprehensive medical evaluations to its firefighters, and established 
its WTC Medical Monitoring Program (referred to here as the FDNY 
program). The Mount Sinai Clinical Center for Occupational and 
Environmental Medicine also sought federal support in the weeks 
following the attack to develop its WTC Worker and Volunteer Medical 
Monitoring Program (referred to here as the Mount Sinai 
program).[Footnote 11] Through its Federal Occupational Health (FOH) 
services, HHS initiated a WTC responder screening program for federal 
workers (referred to here as the FOH program) involved in WTC rescue, 
recovery, and cleanup activities. Similarly, the New York State 
Department of Health established the medical monitoring program for New 
York State responders (referred to here as the NYS program) engaged in 
emergency activities related to the September 11 attack. In addition, 
two registries were established to compile lists of exposed persons and 
collect information through interviews and surveys in order to provide 
a basis for understanding the health effects of the attack. The New 
York City Department of Health and Mental Hygiene contacted ATSDR in 
February 2002 to develop the WTC Health Registry. ATSDR provided 
technical assistance to the New York City Department of Health and 
Mental Hygiene and worked with FEMA to obtain funds for the WTC Health 
Registry for responders and people living or attending school in the 
vicinity of the WTC site, or working or present in the vicinity on 
September 11. Separately, Johns Hopkins received a grant from NIEHS to 
create another registry (referred to here as the Johns Hopkins 
registry) of WTC site workers who were involved in cleanup 
efforts.[Footnote 12]

Varied Physical and Mental Health Effects Have Been Observed and 
Reported across a Wide Range of People:

A wide variety of physical and mental health effects have been observed 
and reported across a wide range of people in the aftermath of the 
September 11 attacks. The health effects include various injuries, 
respiratory conditions, reproductive health effects, and mental health 
effects. Unlike the physical health effects, the mental health effects 
of the September 11 attacks were not limited to responders and people 
who were in the WTC area but were also experienced by people across the 
nation. Because most of the information about mental health effects 
comes from questionnaire or survey data, what is reported in most cases 
are symptoms associated or consistent with a disorder, such as PTSD, 
rather than a clinical diagnosis of a disorder. The most commonly 
reported mental health effects were symptoms associated with PTSD, 
depression, stress, and anxiety, as well as behavioral effects such as 
increases in substance use and difficulties coping with daily 
responsibilities.

Injuries:

Although the total number of people injured during the WTC attack is 
unknown, data on hospital visits show that thousands of people were 
treated in its immediate aftermath for injuries, including inhalation 
injuries, musculoskeletal injuries, burns, and eye injuries. 
Unpublished data collected by the Greater New York Hospital Association 
from September 11 through September 28, 2001, showed 6,232 emergency 
room visits and 477 hospitalizations related to the attack in 103 
hospitals in New York State and 1,018 emergency room visits and 84 
hospitalizations related to the attack in nearby New Jersey hospitals. 
These numbers do not include injured people who may have been treated 
in more distant New York State, New Jersey, and Connecticut hospitals, 
in triage stations,[Footnote 13] or by private physicians, and those 
who did not seek professional treatment. More detailed information on 
injuries is available from the four hospitals closest to the WTC and a 
fifth hospital that served as a burn referral center. According to the 
New York City Department of Health and Mental Hygiene, between 
September 11 and September 13, 2001, these hospitals treated 790 
people, 2 of whom later died, for injuries related to the attack (CDC, 
2002c). The most common of these injuries were musculoskeletal 
injuries--such as fractures, sprains, and crush injuries--and 
inhalation injuries. The majority of people with injuries were treated 
and released, although about 18 percent required 
hospitalization.[Footnote 14]

In addition, thousands of responders were treated for injuries, a small 
proportion of which were classified as serious, during the 10-month 
cleanup period. The disaster site was considered to be extremely 
dangerous, yet no additional life was lost after September 11. Using 
data from five Disaster Medical Assistance Teams (DMAT) temporary 
medical facilities[Footnote 15] and the four hospitals closest to the 
WTC site, researchers documented 5,222 visits by rescue workers to DMAT 
facilities and emergency rooms in the first month of the cleanup period 
(Berrios-Torres et al., 2003). During this month, musculoskeletal 
injuries were the leading cause of rescue worker visits and 
hospitalizations. Other injuries included burns and eye injuries. 
According to OSHA, despite logging more than 3.7 million work hours 
over the 10-month cleanup period, WTC site workers reported only 57 
injuries that OSHA classified as serious because they resulted in lost 
workdays, yielding a lost workday injury rate of 3.1 injuries per 100 
workers per year. This rate is lower than that seen in the type of 
construction deemed by OSHA to be the most similar to the WTC cleanup, 
specialty construction, which has a lost workday injury rate of 4.3.

Respiratory Health Effects:

A range of respiratory health effects, including a new syndrome called 
WTC cough and chronic diseases such as asthma, were observed among 
people exposed to the WTC collapse and its aftermath. Many of the 
programs examining respiratory health effects are ongoing and have 
published only preliminary results. Nevertheless, the studies present a 
consistent collection of conditions among those people who were 
involved in rescue, recovery, and cleanup as well as those who lived 
and worked in the WTC vicinity. The most commonly reported conditions 
include cough, wheezing, shortness of breath, sinusitis, and asthma. 
Many of the findings on respiratory effects published to date have 
focused on firefighters, and FDNY medical staff first described WTC 
cough, which consists of persistent cough accompanied by severe 
respiratory symptoms,[Footnote 16] often in conjunction with sinusitis, 
asthma, and gastroesophageal reflux disease (GERD).[Footnote 17] 
Several studies report on other WTC responders, such as the police, 
ironworkers, and cleanup workers, and a few studies report on the 
respiratory effects among people living and working in lower Manhattan.

FDNY Firefighters:

Almost all of the FDNY firefighters who had responded to the attack 
experienced respiratory effects, and hundreds had to end their 
firefighting careers due to WTC-related respiratory illness. Within 48 
hours of the attack, FDNY found that about 90 percent of its 10,116 
firefighters and EMS workers who were evaluated at the WTC site 
reported an acute cough. The FDNY Bureau of Health Services also noted 
wheezing, sinusitis, sore throats, asthma, and GERD among firefighters 
who had been on the scene. During the first 6 months after the attack, 
FDNY observed that of the 9,914 firefighters who were present at the 
WTC site within 7 days of the collapse, 332 firefighters had WTC cough 
(Prezant et al., 2002). Eighty-seven percent of the firefighters with 
WTC cough reported symptoms of GERD. According to the FDNY Bureau of 
Health Services, symptoms of GERD are typically reported by less than 
25 percent of patients with chronic cough. Some FDNY firefighters 
exhibited WTC cough that was severe enough for them to require at least 
4 weeks of medical leave. Despite treatment of all symptoms, 173 of the 
332 firefighters and one EMS technician with WTC cough showed only 
partial improvement. FDNY also found that the risk of reactive airway 
dysfunction syndrome, or irritant-induced asthma, and WTC cough was 
associated with intensity of the exposure, defined as the time of 
arrival at the site (Banauch et al., 2003). In addition, FDNY reports 
that one firefighter who worked 16-hour days for 13 days and did not 
use respiratory protection during the first 7 to 10 days was diagnosed 
with a rare form of pneumonia that results from acute high dust 
exposure (Rom et al., 2002). According to an official from the FDNY 
Bureau of Health Services, because one of the criteria for being a 
firefighter is having no respiratory illness, about 380 firefighters 
were no longer able to serve as firefighters as of March 2004 as a 
consequence of respiratory illnesses they developed after WTC exposure.

Other WTC Responders:

Studies and screenings conducted among other responders--carpenters, 
cleanup workers, federal civilian employees, heavy equipment operators, 
ironworkers, mechanics, National Guard members, police officers, 
telecommunications technicians, truck drivers, and U.S. Army military 
personnel--have found respiratory health effects similar to those seen 
in FDNY firefighters. Some of the responders with existing respiratory 
conditions reported that symptoms worsened, and others reported that 
they developed new respiratory symptoms on or after September 11. The 
most commonly reported symptom was cough. For example, about 63 percent 
of officers from NYPD's Emergency Services Unit who were evaluated 
about 1 to 4 months after September 11 reported having a cough (Salzman 
et al., 2004). Other symptoms observed among responders included chest 
tightness, nasal congestion, shortness of breath, sore throat, and 
wheezing. Unpublished results from respiratory health assessments of 
WTC site workers--including truck drivers, heavy equipment operators, 
mechanics, laborers, and carpenters--conducted by Johns Hopkins in 
December 2001 show that among those who reported no previous history of 
lower respiratory symptoms, 34 percent reported developing a cough and 
19 percent reported wheezing. While some responders reported that 
symptoms improved or resolved a few months after the attack, others 
reported that they continued to experience symptoms. For example, 
initial results from screenings of 250 participants in Mount Sinai's 
monitoring program show that 46 percent of these responders were still 
experiencing at least one pulmonary symptom and 52 percent were still 
experiencing an ear, nose, or throat symptom 9 months after the attack 
(Herbert and Levin, 2003).

People Living or Working in Lower Manhattan:

Surveys conducted among people living or working in lower Manhattan 
show that these people experienced respiratory health effects similar 
to those experienced by responders, such as nose or throat irritation 
and cough. For example, a door-to-door survey conducted by the New York 
City Department of Health and Mental Hygiene in three residential areas 
in lower Manhattan between October 25 and November 2, 2001, showed that 
the most frequently reported symptoms were nose or throat irritation 
(about 66 percent) and cough (about 47 percent) (CDC, 2002a). A NIOSH 
survey of federal employees working near the WTC site found that 56 
percent of respondents reported having a cough (Trout et al., 2002). 
Other symptoms observed among those living or working in lower 
Manhattan include chest tightness, head or sinus congestion, shortness 
of breath, and wheezing. Some people reported that the WTC collapse and 
its aftermath exacerbated existing respiratory conditions, such as 
asthma, and others reported symptoms that developed after September 11, 
2001. For example, a review of medical charts of children with existing 
asthma from a lower Manhattan clinic found that after September 11 
there was a significant increase in asthma-related clinic visits among 
children who lived within 5 miles of the WTC site (Szema et al., 2004). 
Unpublished preliminary findings from a New York State Department of 
Health survey of NYC residents found that almost three-fourths of 
respondents living near the WTC site experienced new upper respiratory 
symptoms after September 11.

Reproductive Health Effects:

For all measures of reproductive health studied except birth weight for 
gestational age,[Footnote 18] no differences were found between infants 
born to women who were in or near the WTC on September 11 and infants 
of those who were not. The Mount Sinai School of Medicine conducted a 
study of the 187 pregnant women[Footnote 19] who were either in or near 
the WTC on September 11. This study found no significant differences in 
average gestational duration at birth or average birth weight between 
infants of the women who were in or near the WTC on September 11 during 
their pregnancy and infants of the 2,367 women in the study's 
comparison group, who were not (Berkowitz et al., 2003). Additionally, 
no significant differences in frequency of preterm births (less than 37 
weeks of gestation) or in incidence of low birth weight (less than 
2,500 grams) were observed. Nor was an association observed between 
symptoms of posttraumatic stress in the mother and frequency of preterm 
birth, low birth weight, or small-for-gestational-age[Footnote 20] 
infants. However, 8.2 percent of infants born to women who were in or 
near the WTC on September 11 were born with a birth weight below the 
tenth percentile for gestational age, compared to 3.8 percent of 
infants born to women in the study's control group. This difference was 
still statistically significant after variables such as maternal age, 
race/ethnicity, sex of the infant, and maternal smoking history were 
taken into account.[Footnote 21] Because small-for-gestational-age 
infants are at risk for developmental problems, the Mount Sinai program 
includes a follow-up study in which researchers plan to obtain physical 
measurements of growth and perform assessments of early cognitive 
development.

Symptoms Associated with PTSD:

In the weeks and months after the WTC attack, people living, working, 
or attending school in NYC and responders involved in the rescue, 
recovery, and cleanup reported symptoms associated with PTSD, as did 
people across the nation. PTSD is an often debilitating and potentially 
chronic disorder that can develop after experiencing or witnessing a 
traumatic event. It includes such symptoms as difficulty sleeping, 
irritability or anger, detachment or estrangement, poor concentration, 
distressing dreams, intrusive memories and images, and avoidance of 
reminders of the trauma.

People living or working near the WTC site reported a higher rate of 
symptoms associated with PTSD than did those living or working farther 
from the site. For example, researchers found that about 7.5 percent of 
Manhattan residents reported symptoms consistent with PTSD 5 to 8 weeks 
after the attack, with 20 percent of those living in close proximity to 
the WTC reporting symptoms (Galea et al., 2002a). Similarly, NIOSH 
surveys found that reports of symptoms consistent with PTSD were 
significantly higher among school staff in the WTC vicinity than among 
school staff working at least 6 miles from the WTC site (CDC, 2002a).

Some groups of people, such as children and responders, were found to 
have experienced traumatic reactions to the attack. For example, a 
citywide survey of a representative sample of NYC fourth to twelfth 
graders 6 months after the attack found that over 10 percent reported 
having symptoms consistent with PTSD. The researchers who conducted 
this survey noted that these symptoms were five times more prevalent 
than pre-September 11 rates reported for other communities (Hoven et 
al., 2002). Responders, many of whom lost colleagues, were also 
affected. Initial findings from the Mount Sinai program show that about 
22 percent of a sample of 250 WTC responders reported symptoms 
consistent with PTSD (Herbert and Levin, 2003).

People across the nation also reported symptoms associated with PTSD. A 
nationwide survey comparing reactions in NYC to those across the 
country using a nationally representative sample of U.S. adults found 
that the prevalence of symptoms associated with PTSD 1 to 2 months 
after the attack was significantly higher in the NYC metropolitan area 
(11.2 percent) than in other major metropolitan areas (3.6 percent) and 
the rest of the country (4 percent) (Schlenger et al., 2002). Another 
nationally representative sample in a nationwide survey of U.S. adults 
shows that 17 percent of the U.S. population outside of NYC reported 
symptoms associated with PTSD 2 months after the attack (Silver et al., 
2002). Although no baseline data are available on the prevalence of 
symptoms related to PTSD, typically about 3.6 percent of U.S. adults 
have a psychiatric diagnosis of PTSD during the course of a 
year.[Footnote 22]

Symptoms Associated with Depression, Stress, and Anxiety:

People living, working, and attending school in NYC and WTC responders, 
as well as people across the nation, reported symptoms associated with 
depression, stress, and anxiety. For example, in NYC, researchers found 
that about 9.7 percent of Manhattan residents surveyed 5 to 8 weeks 
after the attack reported symptoms consistent with depression (Galea et 
al., 2002a). Nine hospitals in NYC reported that from September 11 to 
September 24, 2001, the predominant symptoms related to the WTC attack 
were those associated with anxiety, stress, and depression (Greater New 
York Hospital Association, 2001). Data from these hospitals show that 
anxiety declined over the month following the attack but increased 
again around the time that the first case of anthrax in NYC was 
announced in mid-October 2001. A NIOSH survey of people working in 
schools near the WTC site also reported symptoms of depression (CDC, 
2002a). Among the responders, initial screenings from the Mount Sinai 
program show that nearly 37 percent of 250 program participants 
reported symptoms associated with anxiety, insomnia, and depression 
(Herbert and Levin, 2003). In addition, a nationwide survey conducted 3 
to 5 days after the attack in a nationally representative sample of 
U.S. adults found that 44 percent of those surveyed reported one or 
more substantial symptoms of stress, including having difficulty 
concentrating, feeling irritable, feeling upset when something reminds 
the person of the attack, having disturbing thoughts or dreams, and 
having trouble sleeping (Schuster et al., 2001).

Behavioral Effects:

The behavioral effects in the aftermath of the WTC attack included 
increased use of substances such as alcohol, tobacco, and marijuana. 
Increased use of alcohol and tobacco was identified through surveys of 
the general population conducted by the states of Connecticut, New 
Jersey, and New York in the 3 months following the attack (CDC, 2002b). 
In Manhattan, researchers found that almost 29 percent of people who 
responded to a survey administered 5 to 8 weeks after September 11 
reported increased use of cigarettes, alcohol, or marijuana after the 
attack (Vlahov et al., 2002). According to these researchers, this 
increase in substance use was still evident 6 months after September 11 
(Vlahov et al., 2004a,b).

The behavioral effects also included difficulty coping with daily 
responsibilities. Some NYC children and adolescents, family members, 
and other adults, including members of the response community, are 
still having difficulty coping 3 years after September 11. For example, 
an ongoing SAMHSA-supported youth mental health program in NYC is 
treating 220 children and adolescents who are having problems coping, 
such as having difficulties functioning in school. In addition, 
researchers affiliated with the New York University School of 
Medicine's Child Study Center's bereavement program for families of 
uniformed personnel killed in responding to the WTC attacks noted that 
the psychological and emotional reactions of children and adolescents 
directly affected by the attacks have diminished somewhat over time but 
that some children continue to be affected by the emotional state and 
coping difficulties of their parents. Of particular concern to these 
researchers are the widowed mothers, who are experiencing sustained 
distress at twice the level typically found in the general population 
and are having difficulty coping with their daily responsibilities, 
such as single parenthood, almost 3 years later. Some responders, such 
as members of FDNY, also report having difficulty coping in the 
aftermath of September 11.

Programs Established to Monitor and Understand Health Effects Vary in 
Eligibility Requirements, Methods, Treatment Referrals, and Duration:

The programs established to monitor and understand the health effects 
of the attack vary in terms of which people are eligible to 
participate, methods for collecting information about the health 
effects, options for treatment referral, and number of years people 
will be monitored. (See table 1.) FEMA provided funding for most of 
these programs through interagency agreements with HHS. These programs 
are not centrally coordinated, but some of them are collaborating with 
each other.

Table 1: Programs to Monitor Health Effects in the Aftermath of the 
World Trade Center (WTC) Attack:

WTC Health Registry; 
Administrator: NYC Department of Health and Mental Hygiene; 
Eligible Populations: Between 250,000 and 400,000 responders and 
people living or attending school in the area of the WTC or working or 
being present in the vicinity on September 11; 
Participation: As of 9/2004, 60,483 people were enrolled[B]; 
Monitoring Methods: Telephone- based health interview; plan to re-
interview subset of population in 2005; 
Treatment Referral: Provides information on where treatment can be 
sought; 
refers participants to LIFENET[C] for mental health services; 
Intended Duration and Federal Funding[A]: Agency for Toxic Substances 
and Disease Registry intends to fund through fiscal year 2008 --$20 
million total Environmental Protection Agency allocated in fiscal year 
2004 --$1.5 million total.

FDNY WTC Medical Monitoring Program (FDNY program); 
Administrator: FDNY Bureau of Health Services (FDNY-BHS); 
Eligible Populations: About 11,000 firefighters and 3,500 emergency 
medical service (EMS) technicians; 
Participation: As of 4/2004, 11,770 firefighters and EMS technicians 
were enrolled; 
Monitoring Methods: Medical examination and questionnaire; three 
follow-up examinations planned; 
Treatment Referral: Refers to FDNY-BHS; 
Intended Duration and Federal Funding[A]: National Institute for 
Occupational Safety and Health (NIOSH) intends to fund through 6/2009 
--$25 million total National Center for Environmental Health funded 
initial monitoring --$4.8 million total.

WTC Worker and Volunteer Medical Monitoring Program (Mount Sinai 
program); 
Administrator: Mount Sinai's Irving J. Selikoff Clinical Center for 
Occupational and Environmental Medicine[D]; 
Eligible Populations: About 12,000 responders[E]; 
Participation: As of 8/2004, about 11,793 people were enrolled; 
Monitoring Methods: Medical examination and questionnaire; three 
follow-up examinations planned; 
Treatment Referral: Refers to privately funded program available for 
responders; 
Intended Duration and Federal Funding[A]: NIOSH intends to fund 
through 7/2009 --$56 million total NIOSH funded initial monitoring[F] 
--$15.8 million total.

The medical monitoring program for New York State workers (NYS 
program); 
Administrator: New York State Department of Health; 
Eligible Populations: About 9,800 New York State employees and 
National Guard personnel; 
Participation: As of 10/2003, 1,677 employees received medical 
evaluations; 
Monitoring Methods: Medical examination and questionnaire; 
follow-up on subset of 300 employees planned; 
Treatment Referral: Instructs participants to see their primary care 
physician or the state's occupational health unit; 
Intended Duration and Federal Funding[A]: National Center for 
Environmental Health funded through fiscal year 2003 --$2.4 million 
total.

WTC cleanup and recovery worker registry (Johns Hopkins registry); 
Administrator: Johns Hopkins Bloomberg School of Public Health; 
Eligible Populations: About 12,000 members from three unions[G] and 
the NYC Department of Sanitation; 
Participation: As of 6/2003, 1,337 workers responded to the mailed 
questionnaire; 
Monitoring Methods: Mail-in health survey; 
Treatment Referral: Provides participants with brochures about health 
services; 
refers uninsured to Columbia University for mental health services; 
Intended Duration and Federal Funding[A]: National Institute of 
Environmental Health Sciences (NIEHS) funded through fiscal year 
2003[H] --$1.2 MILLION total.

WTC responder screening program for federal workers[J]; 
(FOH program); 
Administrator: Department of Health and Human Services' (HHS) Federal 
Occupational Health services; 
Eligible Populations: About 10,000 federal workers responding to WTC; 
Participation: As of 3/2004, 412 exams were completed and reviewed; 
Monitoring Methods: Medical examination and questionnaire; 
Treatment Referral: Instructs participants to see their primary care 
physician; 
Intended Duration and Federal Funding[A]: HHS intends to fund through 
12/2005 --$3.7 million total. 

Sources: FDNY, HHS, Mount Sinai, New York City Department of Health and 
Mental Hygiene, and New York State Department of Health.

Note: Programs are ordered according to participation level.

[A] Except as noted, FEMA provided funds to the agencies listed below 
through interagency agreements with HHS to support efforts to monitor 
the health effects of the WTC attack.

[B] The WTC Heath Registry officials told us that they have generated a 
list of 185,000 potential participants gathered from various sources, 
including employers and registration via the Web or telephone. Registry 
officials told us that the registry will continue to interview and 
enroll people who are on this list after the registration period ends.

[C] LIFENET is a 24-hour mental health information and referral service 
provided by the New York State Office of Mental Health.

[D] Mount Sinai is the coordinating center for the five clinics in this 
program.

[E] People eligible to participate in the Mount Sinai program are those 
who worked primarily at or immediately adjacent to the WTC site, either 
during or after the disaster, including firefighters from outside NYC, 
police officers from NYC and surrounding communities, emergency rescue 
workers from a variety of organizations (including emergency medical 
technicians and paramedics), building and construction trade workers 
from the NYC metropolitan area and throughout the nation, members of 
the press and news media, health care workers, food service workers, 
structural and other engineers, and a variety of other public-and 
private-sector workers, and people who worked in the immediate vicinity 
of the WTC site restoring essential services, such as telephone 
services, electricity, and transportation, or performing services 
necessary to reopen buildings in the area, including cleaning and 
assessing the structural integrity of nearby buildings. The program 
excluded federal employees, FDNY firefighters, and, initially, New York 
State employees, who were all eligible for other programs. New York 
State responders were initially screened in the NYS program. The NYS 
program plans to follow 300 of these responders. All New York State 
responders are now eligible to participate in the Mount Sinai program.

[F] Initial medical monitoring conducted through this program was 
supported by funds appropriated to CDC.

[G] The International Brotherhood of Teamsters, the International Union 
of Operating Engineers, and the Laborers International Union of North 
America.

[H] Funds appropriated to NIEHS to support research, worker training, 
and education activities supported this grant.

[I] Includes funding for other activities, including Johns Hopkins' WTC 
Cleanup and Recovery Worker Health Assessment and community outreach.

[J] HHS officials told us that HHS is making modifications to the 
program and no screenings are taking place.

[End of table]

Program Eligibility:

The six programs that have been created to monitor people who were 
exposed to the WTC attack and its aftermath vary in terms of 
populations eligible to participate. Although five of the programs 
focus on various responder populations, the largest program--the WTC 
Health Registry--is open not only to responders but also to people 
living or attending school in the vicinity of the WTC site, or working 
or present in the vicinity on September 11. Specifically, people 
eligible for participation in the WTC Health Registry include anyone 
who was in a building, on the street, or on the subway south of 
Chambers Street on September 11; residents and staff of or students 
enrolled in schools (prekindergarten through twelfth grade) or day care 
centers south of Canal Street on September 11; and those involved in 
rescue, recovery, cleanup, or other activities at the WTC site and/or 
WTC recovery operations on Staten Island anytime between September 11, 
2001, and June 30, 2002. (See figure 1.) An estimated 250,000 to 
400,000 people are eligible for the WTC Health Registry[Footnote 23]; 
however, the registry was planned with the expectation that 100,000 to 
200,000 people would enroll. Together the FDNY program and the Mount 
Sinai program cover more than half of the estimated 40,000 WTC 
responders.[Footnote 24] The FDNY program is open to all 11,000 FDNY 
firefighters and all 3,500 FDNY EMS technicians, including firefighters 
and technicians who were not exposed. Some 12,000 other responders are 
eligible to participate in the Mount Sinai program. Responders who were 
government employees are eligible for participation in programs such as 
the FOH program, which is open to the estimated 10,000 federal workers 
who responded to the WTC attacks, and the NYS program, which was open 
to about 9,800 New York State employees and New York National Guard 
personnel who were directed to respond to the WTC disaster. In 
addition, approximately 12,000 members from three NYC unions and the 
NYC Department of Sanitation, whether they were responders or not, were 
eligible to participate in the Johns Hopkins registry.

Figure 1: Map of Lower Manhattan Showing Canal Street, Chambers Street, 
and the WTC Site:

[See PDF for image]

[End of figure]

Concerns have been raised by community and labor representatives 
regarding the eligibility requirements for some of these programs, and 
while changes have been made to accommodate some of these concerns, 
others remain unresolved, particularly with respect to the WTC Health 
Registry. For example, the eligibility criteria for participation in 
the Mount Sinai program were initially more restrictive, covering 
responders who had been at the site at least 24 hours between September 
11 and 14, 2001. After discussions with labor representatives and CDC 
officials, the program expanded its eligibility criteria to include 
additional responders who may not have been there on those days but 
were there later in September. In contrast, community and labor 
representatives have been unsuccessful in their attempts to expand the 
eligibility criteria of the WTC Health Registry. These representatives 
have noted that the geographic boundaries used by the registry exclude 
office workers below Chambers Street who were not at work on September 
11 but returned to work in the following weeks; office workers, 
including several groups of city employees, working between Chambers 
and Canal Streets; and Brooklyn residents who may have been exposed to 
the cloud of dust and smoke. Registry officials told us that they 
understand the desire to be included but they believe coverage is 
adequate to provide a basis for understanding the health effects of the 
WTC attack.

Monitoring Methods and Options for Treatment Referral:

The monitoring programs vary in their methods for identifying those who 
may require treatment, and although none of these programs are funded 
to provide treatment, they provide varying options for treatment 
referral. Some programs refer participants to affiliated treatment 
programs, whereas others provide information on where participants can 
seek care. The FDNY program offers a comprehensive medical evaluation 
that includes collection of blood and urine for analysis, a pulmonary 
function test, a chest X-ray, a renal toxicity evaluation, a 
cardiogram, a hepatitis C test, and hearing and vision tests, as well 
as self-administered questionnaires on exposures and physical and 
mental health. Funds for the monitoring program do not cover treatment 
services. However, FDNY members who require treatment after being 
screened can obtain treatment and counseling services from the FDNY 
Bureau of Health Services and the FDNY Counseling Services Unit as a 
benefit of their employment. Similarly, under the Mount Sinai program, 
people receive a comprehensive physical examination that includes blood 
and urine analysis, a chest X-ray, a pulmonary function test, and 
complete self-administered as well as nurse-administered 
questionnaires on exposure, clinical history, and mental 
health.[Footnote 25] If a person requires follow-up medical care or 
mental health services but is unable to pay for the services, he or she 
can be referred for care to other Mount Sinai programs such as the 
Health for Heroes program, which is supported through philanthropic 
donations.

The FOH and NYS programs also consist of medical evaluations of 
participants and self-administered health and exposure questionnaires. 
The FOH program conducted about 400 medical evaluations of federal 
workers. These evaluations included a physical examination, a pulmonary 
function test, a chest X-ray, and blood tests. Under the NYS program, 
the New York State Department of Civil Service Employee Health Service 
clinics or affiliated clinics conducted medical evaluations that 
included a physical examination and a pulmonary evaluation of almost 
1,700 state workers. The questionnaires for both programs are more 
limited than the FDNY or Mount Sinai questionnaires; for example, they 
have fewer mental health questions. Under the FOH and NYS programs, 
workers who require care have been told to follow up with their primary 
care physicians under their own insurance.

Unlike most of the other monitoring programs, the WTC Health Registry 
and the Johns Hopkins registry do not include a medical evaluation, and 
neither effort is affiliated with a treatment facility or program. 
Instead, the programs collect information from participants solely 
through questionnaires and provide information on where participants 
can seek care. The WTC Health Registry questionnaire is generally 
administered over the telephone. The program provides all participants 
with a resource guide of occupational, respiratory, environmental, and 
mental health facilities in New York State, New Jersey, and Connecticut 
where people can seek treatment. Some of the services provided by these 
facilities require health insurance, whereas others are free of charge. 
If in the course of a telephone questionnaire, a person's responses to 
the mental health questions suggest that he or she may need to speak 
with a mental health professional, the person is given the option of 
being connected directly to a LIFENET counselor. The LIFENET counselor 
provides the person with information on where to go and whom to call 
for help with problems related to the WTC disaster. For the Johns 
Hopkins registry, the participants complete a mail-in questionnaire on 
physical and mental health. Responders who report mental health 
symptoms and agree to be recontacted may receive follow-up calls to 
refer them to mental health services. The referral process is 
facilitated by Columbia University's Resiliency Program, which provides 
free, short-term mental health services to affected people. The Johns 
Hopkins registry also provides participants with brochures about health 
services and programs they may find useful, including information about 
the Mount Sinai program.

Duration and Funding:

The duration of the monitoring programs may not be long enough to fully 
capture critical information on health effects. Under current plans, 
HHS funding for the programs will not extend beyond 2009. For example, 
ATSDR entered into a cooperative agreement with the New York City 
Department of Health and Mental Hygiene in fiscal year 2003 with the 
intent to continue support of the WTC Health Registry for 5 years of 
its planned 20-year duration. Similarly, NIOSH awarded 5-year grants in 
July 2004 to continue the FDNY and Mount Sinai programs, which had 
begun in 2001 and 2002, respectively. Health experts involved in the 
monitoring programs, however, cite the need for long-term monitoring of 
affected groups because some possible health effects, such as cancer, 
do not appear until several decades after a person has been exposed to 
a harmful agent.[Footnote 26] They also emphasize that monitoring is 
important for identifying and assessing the occurrence of newly 
identified conditions, such as WTC cough, and chronic conditions, such 
as asthma.

Collaboration:

Although the monitoring programs began as separate efforts, some of the 
programs are collaborating with each other. In addition, there are 
other kinds of collaborative efforts, including those in which programs 
receive advice from various outside partners.

The WTC Responder Health Consortium is an example of collaboration 
between monitoring programs. It was established by NIOSH in March 2004 
to coordinate the existing health monitoring of WTC responders 
initiated by the FDNY and Mount Sinai programs and to facilitate data 
sharing. It awarded $81 million in 5-year grants to six institutions to 
become clinical centers for WTC health monitoring. FDNY and Mount Sinai 
serve as coordinating centers under the consortium, and the other four 
institutions are coordinated with Mount Sinai.[Footnote 27] Together, 
these institutions will provide follow-up health evaluations to a total 
of about 12,000 NYC firefighters and EMS technicians and up to 12,000 
other WTC responders.[Footnote 28]

Collaboration efforts have also been fostered between the monitoring 
programs and outside partners and researchers. For example, the WTC 
Registry has a Scientific Advisory Group that includes representatives 
from the Mount Sinai School of Medicine, FDNY, the Johns Hopkins 
University, Columbia University, Hunter College, New York Academy of 
Medicine, New York University, the New York State Department of Health, 
and the New Jersey Department of Health. The group has assisted the New 
York City Department of Health and Mental Hygiene and ASTDR in 
development of the WTC Registry protocol, selection of the eligible 
population, and analysis methods. It has been meeting with WTC 
officials quarterly since early 2002 to advise on such issues as data 
collection, study options, and guidelines for research studies to be 
done using the registry.

In addition, EPA convened an expert review panel in March 2004 to 
obtain greater input on ongoing efforts to monitor the health effects 
of workers and residents affected by the WTC collapse. The panel 
consists of representatives from federal and NYC agencies involved in 
air monitoring; from WTC health effects monitoring programs; and from 
academic institutions and the affected community. The goals of the 
panel include identification of unmet public health needs, gaps in 
exposure data, gaps in efforts to understand the health effects of the 
WTC attack, and ways in which the WTC Health Registry could be enhanced 
to allow better tracking of workers and residents.

Concluding Observations:

A multitude of physical and mental health effects have been reported in 
the years since the terrorist attack on the World Trade Center on 
September 11, 2001, but the full health impact of the attack is 
unknown. Concern about potential long-term effects on people affected 
by the attack remains. The monitoring programs may not be in operation 
long enough to adequately capture information about new conditions, 
chronic conditions, and diseases whose onset may occur decades after 
exposure to a harmful agent, such as many cancers. Nevertheless, these 
programs are providing a more complete picture of the health impact of 
such events, and as they proceed they are also providing the 
opportunity to identify people needing treatment.

Agency Comments:

We provided a draft of this testimony to DHS, DOL, EPA, and HHS. HHS 
provided written comments, in which it noted that the testimony does 
not include significant discussion on the ways in which mental health 
symptoms have changed over time. We relied primarily on data from 
published, peer-reviewed articles and government reports, and some of 
the researchers we spoke with emphasized that their studies are ongoing 
and they expect to publish further results. In the absence of these 
results, the evidence we examined did not support a full discussion of 
changes in mental or physical health effects over time. HHS and the 
other agencies also provided technical comments, which we incorporated 
as appropriate.

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

Contact and Staff Acknowledgments:

For further information about this testimony, please contact Janet 
Heinrich at (202) 512-7119. Michele Orza, Angela Choy, Alice London, 
Nkeruka Okonmah, and Roseanne Price made key contributions to this 
statement.

[End of section]

Appendix I: Abbreviations:

ATSDR: Agency for Toxic Substances and Disease Registry: 
CDC: Centers for Disease Control and Prevention: 
DOD: Department of Defense: 
DHS: Department of Homeland Security: 
DOJ: Department of Justice: 
DOL: Department of Labor: 
DMAT: Disaster Medical Assistance Teams: 
EMS: emergency medical services: 
EPA: Environmental Protection Agency: 
FBI: Federal Bureau of Investigation: 
FEMA: Federal Emergency Management Agency: 
FOH: Federal Occupational Health: 
FDNY: New York City Fire Department: 
GERD: gastroesophageal reflux disease: 
HHS: Department of Health and Human Services: 
NIEHS: National Institute of Environmental Health Sciences: 
NIOSH: National Institute for Occupational Safety and Health: 
NYC: New York City: 
NYPD: New York City Police Department: 
OSHA: Occupational Safety and Health Administration: 
PTSD: posttraumatic stress disorder: 
SGA: small for gestational age: 
SAMHSA: Substance Abuse and Mental Health Services Administration: 
VA: Department of Veterans Affairs: 
WTC: World Trade Center: 

[End of section]

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FOOTNOTES

[1] A list of abbreviations used in this testimony is given in Appendix 
I.

[2] New York City Department of Health and Mental Hygiene and U.S. 
Department of Health and Human Services, Agency for Toxic Substances 
and Disease Registry, Protocol for the World Trade Center Health 
Registry (New York, 2003).

[3] For purposes of this testimony, the term responders refers to 
anyone involved in rescue, recovery, and cleanup efforts at or in the 
vicinity of the WTC site and Staten Island Fresh Kills landfill (the 
off-site location of the WTC recovery operation), including 
firefighters, law enforcement officers, emergency medical technicians 
and paramedics, morticians, health care professionals, construction 
workers, ironworkers, carpenters, heavy equipment operators, 
mechanics, truck drivers, engineers, laborers, telecommunications 
workers, and various federal, state, and local agency employees who 
assisted with rescue, recovery, and cleanup activities. 

[4] For more information on exposures to these substances, see, for 
example, U.S. Environmental Protection Agency, Exposure and Human 
Health Evaluation of Airborne Pollution from the World Trade Center 
Disaster (External Review Draft) (Washington, D.C., 2002), and J.D. 
Pleil et al., "Air Levels of Carcinogenic Polycyclic Aromatic 
Hydrocarbons after the World Trade Center Disaster," Proceedings of the 
National Academy of Sciences of the United States of America, vol. 101, 
no. 32 (2004).

[5] GAO, September 11: Federal Assistance for New York Workers' 
Compensation Costs, GAO-04-1013T (Washington, D.C.: Sept. 8, 2004). 

[6] See the bibliography for a list of the scientific literature that 
we relied on in producing this testimony.

[7] National Commission on Terrorist Attacks upon the United States, 
The 9/11 Commission Report (Washington, D.C., 2004).

[8] National Commission on Terrorist Attacks upon the United States, 
2004.

[9] Department of Health and Human Services, "HHS Awards $81 Million 
for Five-Year Health Screening of World Trade Center Rescue, Recovery 
Workers," Department of Health and Human Services, http://www.hhs.gov/
news/press/2004pres/20040318.html (accessed Aug. 9, 2004).

[10] FEMA provided funds appropriated for disaster relief and emergency 
response to the September 11, 2001, terrorist attacks to HHS through 
interagency agreements to support monitoring efforts. See Consolidated 
Appropriations Resolution, 2003, Pub. L. No. 108-7, 117 Stat. 11, 517; 
see also 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. 220-1. 

[11] Initial medical screenings of responders conducted by this program 
were supported by funds appropriated to CDC for disease control, 
research, and training. See Department of Defense and Emergency 
Supplemental Appropriations for Recovery from and Response to Terrorist 
Attacks on the United States Act, 2002, 115 Stat. at 2313.

[12] The grant was funded by an appropriation to NIEHS to support 
research, worker training, and education activities. See Department of 
Defense and Emergency Supplemental Appropriations for Recovery from and 
Response to Terrorist Attacks on the United States Act, 2002, 115 Stat. 
at 2337.

[13] Triage stations are temporary facilities set up in the aftermath 
of a disaster where medical assessments of patients are performed to 
determine their relative priority for treatment, based on the severity 
of illness or injury.

[14] In an assessment of the cardiovascular effects of the WTC attack 
in eight hospitals in NYC, no significant increases in hospitalization 
for cardiac events immediately following the attack were found (Chi et 
al., 2003).

[15] The DMAT facilities were set up around the disaster site by FEMA's 
National Disaster Medical System, which was activated on September 11. 
The DMATs maintained a 24-hour presence at the WTC site for 2 months 
after the disaster. In addition to the DMATs, the National Disaster 
Medical System also includes teams of morticians, veterinarians, 
nurses, pharmacists, and management personnel.

[16] Severe respiratory symptoms are defined by the FDNY Bureau of 
Health Services as symptoms that are severe enough to require at least 
4 consecutive weeks of medical leave.

[17] GERD occurs when the lower esophageal sphincter does not close 
properly and stomach contents leak back, or reflux, into the esophagus. 
When refluxed stomach acid touches the lining of the esophagus, it 
causes a burning sensation in the chest or throat called heartburn. 

[18] Gestation is the period between conception and birth of a baby, 
and gestational age is duration of gestation. 

[19] Of the 187 women, 3 miscarried and 2 were unavailable for follow-
up, leaving 182 women with live births. The last delivery occurred in 
June 2002.

[20] The term "small for gestational age" (SGA) means a fetus or infant 
is smaller in size than is expected for the baby's sex, genetic 
heritage, and duration of gestation. Birth weight below the population 
tenth percentile, taking into account gestational age, is the most 
widely used definition of SGA.

[21] Additionally, an unpublished study conducted by the Mailman School 
of Public Health at Columbia University found no differences in birth 
weight, length, head circumference, or Apgar scores (the Apgar is a 
test performed at 1 and 5 minutes after birth to determine the physical 
condition of the newborn). However, in this study, the gestational 
duration observed among pregnant women who lived or worked near the WTC 
during the 2 weeks after September 11 was shorter than that of those 
who did not (274.3 versus 275.9 days). Though this difference was 
statistically significant, its clinical significance is unclear. 
Researchers planned to assess cognitive and motor functions of the 
infants at a 1-year follow-up visit.

[22] Department of Veterans Affairs, "What Is Posttraumatic Stress 
Disorder? A National Center for PTSD Fact Sheet," www.ncptsd.org/facts/
general/fs_what_is_ptsd.html, updated May 14, 2003 (accessed Aug. 16, 
2004).

[23] New York City Department of Health and Mental Hygiene and 
Department of Health and Human Services, Agency for Toxic Substances 
and Disease Registry, Protocol for the World Trade Center Health 
Registry (New York, 2003).

[24] Officials involved in the monitoring efforts acknowledge the 
potential for duplication across programs--for example, a responder 
could be enrolled in the Mount Sinai program, the Johns Hopkins 
registry, and the WTC Health Registry--but they have not determined the 
extent of duplication.

[25] In addition, a standardized evaluation of nasal passages and upper 
airways is performed on a subgroup of 1,000 participants.

[26] For example, symptoms of lung cancer may not appear for decades 
after exposure.

[27] These four institutions are 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.

[28] NYPD also applied to be in the consortium to provide monitoring 
for its officers who were responders to the WTC disaster, but was not 
able to secure funding to support its monitoring activities. However, 
NYPD responders are eligible for enrollment in the Mount Sinai program.