United States Government Accountability Office

GAO Testimony 

Before the Subcommittee on Health, 

Committee on Energy and Commerce, 

House of Representatives 

SEPTEMBER 11 

Improvements Needed in 

Availability of Health 

Screening and Monitoring 

Services for Responders 

Statement of Cynthia A. Bascetta 

Director, Health Care 

For Release on Delivery

Expected at 10:00 a.m. EDT 

Tuesday, September 18, 2007

 

GAO-07-1228T 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

September 18, 2007

SEPTEMBER 11

Improvements Needed in Availability of 

Health Screening and Monitoring 

Services for Responders 

Highlights of GAO-07-1228T, a testimony 

before the Subcommittee on Health, 

Committee on Energy and Commerce, 

House of Representatives

Six years after the attack on the 

World Trade Center (WTC),

concerns persist about health

effects experienced by WTC 

responders and the availability of 

health care services for those 

affected. Several federally funded

programs provide screening, 

monitoring, or treatment services 

to responders. GAO has previously 

reported on the progress made and

implementation problems faced by

these WTC health programs. 

This testimony is based on and 

updates GAO’s report, September 

11: HHS Needs to Ensure the 

Availability of Health Screening 

and Monitoring for All Responders

(GAO-07-892, July 23, 2007). In this 

testimony, GAO discusses the 

status of (1) services provided by

the Department of Health and 

Human Services’ (HHS) WTC 

Federal Responder Screening 

Program, (2) efforts by the Centers

for Disease Control and 

Prevention’s National Institute for

Occupational Safety and Health

(NIOSH) to provide services for 

nonfederal responders residing 

outside the New York City (NYC) 

area, and (3) NIOSH’s awards to

WTC health program grantees for 

treatment services. 

For the July 2007 report, GAO 

reviewed program documents and 

interviewed HHS officials,

grantees, and others. In August and 

September 2007, GAO updated 

selected information in preparing

this testimony.

In July 2007, following a re-examination of the status of the WTC health 

programs, GAO recommended that the Secretary of HHS take expeditious 

action to ensure that health screening and monitoring services are available 

to all people who responded to the WTC attack, regardless of who their 

employer was or where they reside. As of early September 2007 the 

department has not responded to this recommendation. 

As GAO reported in July 2007, HHS’s WTC Federal Responder Screening 

Program has had difficulties ensuring the uninterrupted availability of 

screening services for federal responders. From January 2007 to May 2007, 

the program stopped scheduling screening examinations because there was 

a change in the program’s administration and certain interagency 

agreements were not established in time to keep the program fully 

operational. From April 2006 to March 2007, the program stopped scheduling 

and paying for specialty diagnostic services associated with screening.

NIOSH, the administrator of the program, has been considering expanding 

the program to include monitoring, that is, follow-up physical and mental 

health examinations, but has not done so. If federal responders do not 

receive monitoring, health conditions that arise later may not be diagnosed 

and treated, and knowledge of the health effects of the WTC disaster may be 

incomplete. 

NIOSH has not ensured the availability of screening and monitoring services

for nonfederal responders residing outside the NYC area, although it recently 

took steps toward expanding the availability of these services. In late 2002, 

NIOSH arranged for a network of occupational health clinics to provide 

screening services. This effort ended in July 2004, and until June 2005 NIOSH 

did not fund screening or monitoring services for nonfederal responders 

outside the NYC area. In June 2005, NIOSH funded the Mount Sinai School of 

Medicine Data and Coordination Center (DCC) to provide screening and 

monitoring services; however, DCC had difficulty establishing a nationwide 

network of providers and contracted with only 10 clinics in seven states. In 

2006, NIOSH began to explore other options for providing these services, 

and in May 2007 it took steps toward expanding the provider network. 

NIOSH has awarded treatment funds to four WTC health programs in the 

NYC area. In fall 2006, NIOSH awarded $44 million for outpatient treatment 

and set aside $7 million for hospital care. The New York/New Jersey WTC 

Consortium and the New York City Fire Department WTC program, which 

received the largest awards, used NIOSH’s funding to continue outpatient 

services, offer full coverage for prescriptions, and cover hospital care. 

www.gao.gov/cgi-bin/getrpt?GAO-07-1228T.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Cynthia A. 

Bascetta at (202) 512-7114 or 

bascettac@gao.gov. 
Mr. Chairman and Members of the Subcommittee: 

I am pleased to be here today to discuss our work on the implementation 

of federally funded health programs for individuals affected by the 

September 11, 2001, attack on the World Trade Center (WTC).1

 Tens of 

thousands of people served as responders in the aftermath of the WTC 

disaster, including New York City Fire Department (FDNY) personnel, 

federal government personnel, and other government and private-sector 

workers and volunteers from New York and elsewhere. By responders we 

are referring to anyone involved in rescue, recovery, or cleanup activities 

at or near the vicinity of the WTC or the Staten Island site.2

 These 

responders were exposed to numerous physical hazards, environmental 

toxins, and psychological trauma. Six years after the destruction of the 

WTC buildings, concerns remain about the physical and mental health 

effects of the disaster, the long-term nature of some of these health effects, 

and the availability of health care services for those affected.

Following the WTC attack, federal funding was provided to government 

agencies and private organizations to establish programs for screening, 

monitoring, or treating responders for illnesses and conditions related to 

the WTC disaster; these programs are referred to in this testimony as the 

WTC health programs.3,4

 The Department of Health and Human Services 

(HHS) funded the programs as separate efforts serving different categories 

of responders—for example, firefighters, other workers and volunteers, or 

federal responders—and has responsibility for coordinating program 

efforts. 

 1

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

2

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

operation. 

3

In this testimony, “screening” refers to initial physical and mental health examinations of 

affected individuals. “Monitoring” refers to tracking the health of individuals over time, 

either through periodic surveys or through follow-up physical and mental health 

examinations. 

4

One of the WTC health programs, the WTC Health Registry, also includes people living or 

attending school in the area of the WTC or working or present in the vicinity on 

September 11, 2001. 

Page 1 GAO-07-1228T 
We have previously reported on the implementation of these programs and 

their progress in providing services to responders,5

 who reside in all 50 

states and the District of Columbia. In 2005 and 2006, we reported that one 

of the WTC health programs, HHS’s WTC Federal Responder Screening 

Program, which was established to provide onetime screening 

examinations for responders who were federal employees when they 

responded to the WTC attack, had accomplished little.6

 HHS established 

the program in June 2003, suspended it in March 2004, and resumed it in 

December 2005. In September 2006, we reported that the program was 

registering and screening federal responders and that a total of 907 federal 

workers had received screening examinations.7

 We also reported that the 

National Institute for Occupational Safety and Health (NIOSH), the 

component of HHS’s Centers for Disease Control and Prevention (CDC) 

responsible for administering most of the WTC health programs, had 

begun to take steps to provide access to screening, monitoring, and 

treatment services for nonfederal responders who resided outside the New 

York City (NYC) metropolitan area.8

In September 2006 we also testified that CDC had begun, but not 

completed, the process of allocating funding from a $75 million 

appropriation made in fiscal year 2006 for WTC health programs for 

responders.9,10 This was the first appropriation specifically available for 

treatment for responders. We reported that in August 2006 CDC had 

awarded $1.5 million from this appropriation to the FDNY WTC Medical 

Monitoring and Treatment Program and almost $1.1 million to the New 

York/New Jersey (NY/NJ) WTC Consortium for treatment-related 

 5

See, for example, GAO, September 11: HHS Has Screened Additional Federal Responders

for World Trade Center Health Effects, but Plans for Awarding Funds for Treatment Are

Incomplete, GAO-06-1092T (Washington, D.C.: Sept. 8, 2006). A list of related GAO products

is included at the end of this testimony. 

6

See GAO, September 11: Monitoring of World Trade Center Health Effects Has 

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

2005), and September 11: Monitoring of World Trade Center Health Effects Has 

Progressed, but Program for Federal Responders Lags Behind, GAO-06-481T (Washington,

D.C.: Feb. 28, 2006). 

7

See GAO-06-1092T. 

8

In general, the WTC health programs provide services in the NYC metropolitan area. 

9

Department of Defense Appropriations Act, 2006, Pub. L. No. 109-148, § 5011(b), 119 Stat. 

2680, 2814 (2005). 

10See GAO-06-1092T. 

Page 2 GAO-07-1228T 
activities. We also reported that CDC officials told us they could not 

predict how long the funding from the appropriation would support four 

WTC health programs that provide treatment services. 

My testimony today is primarily based on our report issued in July 2007.11

As you requested, I will discuss the status of (1) services provided by the 

WTC Federal Responder Screening Program, (2) NIOSH’s efforts to 

provide services for nonfederal responders residing outside the NYC 

metropolitan area, and (3) NIOSH’s awards to grantees for treatment 

services. 

To assess the status of services provided by the WTC Federal Responder 

Screening Program, we obtained and reviewed program data and 

documents from HHS, including applicable interagency agreements. We 

interviewed officials from the HHS entities involved in administering and 

implementing the program: NIOSH and two HHS offices, the Federal 

Occupational Health Services (FOH)12 and the Office of the Assistant 

Secretary for Preparedness and Response (ASPR).13 To assess the status of 

NIOSH’s efforts to provide services for nonfederal responders residing 

outside the NYC metropolitan area, we obtained documents and 

interviewed officials from NIOSH. We also interviewed officials of 

organizations that worked with NIOSH to provide or facilitate services for 

nonfederal responders residing outside the NYC metropolitan area, 

including the Mount Sinai School of Medicine in NYC and the Association 

of Occupational and Environmental Clinics (AOEC)—a network of 

university-affiliated and other private occupational health clinics across 

the United States and in Canada. To assess the status of NIOSH’s awards 

to grantees for treatment services, we obtained documents and 

interviewed officials from NIOSH. We also interviewed officials from two

 11See GAO, September 11: HHS Needs to Ensure the Availability of Health Screening and

Monitoring for All Responders, GAO-07-892 (Washington, D.C.: July 23, 2007). 

12FOH is a service unit within HHS’s Program Support Center that provides occupational 

health services to federal government departments and agencies located throughout the

United States. 

13ASPR coordinates and directs HHS’s emergency preparedness and response program. In

December 2006 the Office of Public Health and Emergency Preparedness became ASPR. 

We refer to that office as ASPR throughout this testimony, regardless of the time period 

discussed.

Page 3 GAO-07-1228T 
WTC health program grantees14 from which the majority of responders 

receive medical services: the NY/NJ WTC Consortium15 and the FDNY 

WTC program. In addition, we interviewed officials from the American 

Red Cross, which has funded treatment services for responders. In our 

review of the WTC health programs, we relied primarily on information 

provided by agency officials and contained in government publications. 

We compared the information with information in other supporting 

documents, when available, to determine its consistency and

reasonableness. We determined that the information we obtained was 

sufficiently reliable for our purposes. We conducted our work from 

November 2006 through July 2007—and updated selected information in 

August and September 2007—in accordance with generally accepted

government auditing standards. 

In brief, we reported in July 2007 that HHS’s WTC Federal Responder 

Screening Program had had difficulties ensuring the uninterrupted 

availability of screening services for federal responders and that NIOSH, 

the administrator of the program, was considering expanding the program 

to include monitoring but had not done so. We also reported that NIOSH 

had not ensured the availability of screening and monitoring services for 

nonfederal responders residing outside the NYC metropolitan area, 

although it had recently taken steps toward expanding the availability of

these services. As a result of our assessment of these programs, we 

recommended that the Secretary of HHS expeditiously take action to 

ensure that screening and monitoring services are available for all 

responders, including federal responders and nonfederal responders 

residing outside of the NYC metropolitan area. As of early September 2007 

the department has not responded to this recommendation. Finally, we 

also reported that NIOSH had awarded and set aside treatment funds 

totaling $51 million from its $75 million appropriation for four NYC-area 

programs. 

 14NIOSH provides funds to the programs through cooperative agreements, but refers to

award recipients as grantees. Therefore, in this testimony we use the term grantee when

referring to NIOSH’s award recipients. 

15In previous reports we have also referred to this program as the worker and volunteer 

WTC program.

Page 4 GAO-07-1228T 
The tens of thousands of individuals16 who responded to the September 11, 

2001, attack on the WTC experienced the emotional trauma of the disaster 

and were exposed to a noxious mixture of dust, debris, smoke, and 

potentially toxic contaminants, such as pulverized concrete, fibrous glass, 

particulate matter, and asbestos. A wide variety of health effects have

been experienced by responders to the WTC attack, and several federally 

funded programs have been created to address the health needs of these 

individuals.

Background 

Health Effects Numerous studies have documented the physical and mental health effects 

of the WTC attacks.17 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. One study 

suggested that exposed firefighters on average experienced a decline in

lung function equivalent to that which would be produced by 12 years of 

aging.18 A recently published study found a significantly higher risk of 

newly diagnosed asthma among responders that was associated with 

increased exposure to the WTC disaster site.19 Commonly reported mental 

health effects among responders and other affected individuals included 

symptoms associated with post-traumatic stress disorder (PTSD), 

 16There is not a definitive count of the number of people who served as responders.

Estimates have ranged from about 40,000 to about 91,000. 

17See, 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); “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 “Surveillance for World Trade Center Disaster Health Effects among Survivors of

Collapsed and Damaged Buildings,” Morbidity and Mortality Weekly Report, vol. 55 (2006). 

See also G. I. Banauch et al., “Pulmonary Function after Exposure to the World Trade 

Center in the New York City Fire Department,” American Journal of Respiratory and

Critical Care Medicine, vol. 174, no. 3 (2006); G. Izbicki et al., “World Trade Center

‘Sarcoid Like’ Granulomatous Pulmonary Disease in New York City Fire Department 

Rescue Workers,” Chest, vol. 131 (2007); and K. Wheeler et al., “Asthma Diagnosed after 

September 11, 2001 among Rescue and Recovery Workers: Findings from the World Trade

Center Health Registry,” Environmental Health Perspectives, 

http://dx.doi.org/10.1289/ehp.10248 (downloaded Aug. 27, 2007). 

18Banauch et al., “Pulmonary Function.” 

19Wheeler et al., “Asthma Diagnosed.” 

Page 5 GAO-07-1228T 
depression, and anxiety. Behavioral health effects such as alcohol and 

tobacco use have also been reported.

Some health effects experienced by responders have persisted or 

worsened over time, leading many responders to begin seeking treatment

years after September 11, 2001. Clinicians involved in screening, 

monitoring, and treating responders have found that many responders’ 

conditions—both physical and psychological—have not resolved and have 

developed into chronic disorders that require long-term monitoring. For 

example, findings from a study conducted by clinicians at the NY/NJ WTC 

Consortium show that at the time of examination, up to 2.5 years after the 

start of the rescue and recovery effort, 59 percent of responders enrolled 

in the program were still experiencing new or worsened respiratory 

symptoms.

20 Experts studying the mental health of responders found that 

about 2 years after the WTC attack, responders had higher rates of PTSD 

and other psychological conditions compared to others in similar jobs who 

were not WTC responders and others in the general population.21

Clinicians also anticipate that other health effects, such as immunological

disorders and cancers, may emerge over time. 

Overview of WTC Health 

Programs 

There are six key programs that currently receive federal funding to 

provide voluntary health screening, monitoring, or treatment at no cost to 

responders.22 The six WTC health programs, shown in table 1, are (1) the 

FDNY WTC Medical Monitoring and Treatment Program; (2) the NY/NJ 

WTC Consortium, which comprises five clinical centers in the NY/NJ 

 20R. Herbert et al., “The World Trade Center Disaster and the Health of Workers: Five-Year 

Assessment of a Unique Medical Screening Program,” Environmental Health Perspectives, 

vol. 114, no. 12 (2006). 

21For example, see R. Gross et al., “Posttraumatic Stress Disorder and Other Psychological 

Sequelae among World Trade Center Clean Up and Recovery Workers,” Annals of the New 

York Academy of Sciences, vol. 1071 (2006). M. Perrin et al., “Differences in PTSD 

Prevalence and Associated Risk Factors among World Trade Center Disaster Rescue and 

Recovery Workers,” American Journal of Psychiatry, vol. 64 (2007). 

22In addition to these programs, a New York State responder screening program received 

federal funding for screening New York State employees and National Guard personnel 

who responded to the WTC attack in an official capacity. This program ended its screening

examinations in November 2003. 

Page 6 GAO-07-1228T 
area;23 (3) the WTC Federal Responder Screening Program; (4) the WTC 

Health Registry; (5) Project COPE; and (6) the Police Organization 

Providing Peer Assistance (POPPA) program.24 The programs vary in 

aspects such as the HHS administering agency or component responsible 

for administering the funding; the implementing agency, component, or 

organization responsible for providing program services; eligibility 

requirements; and services. 

 23The NY/NJ WTC Consortium consists of five clinical centers operated by (1) Mount SinaiIrving J. Selikoff Center for Occupational and Environmental Medicine; (2) Long Island

Occupational and Environmental Health Center at SUNY, Stony Brook; (3) New York 

University School of Medicine/Bellevue Hospital Center; (4) Center for the Biology of

Natural Systems, at CUNY, Queens College; and (5) University of Medicine and Dentistry of

New Jersey Robert Wood Johnson Medical School, Environmental and Occupational 

Health Sciences Institute. Mount Sinai’s clinical center, which is the largest of the five 

centers, also receives federal funding to operate a data and coordination center to

coordinate the work of the five clinical centers and conduct outreach and education,

quality assurance, and data management for the NY/NJ WTC Consortium. 

24Project COPE and the POPPA program provide mental health services to members of the 

New York City Police Department (NYPD) and operate independently of the NYPD. 

Page 7 GAO-07-1228T 
Table 1: Key Federally Funded WTC Health Programs, June 2007 

Program 

HHS administering

agency or

component 

Implementing agency, 

component, or

organization Eligible population Services provided

FDNY WTC 

Medical

Monitoring and

Treatment 

Program 

NIOSH FDNY Bureau of Health 

Services 

Firefighters and emergency 

medical service technicians 

• Initial screening

• Follow-up medical monitoring 

• Treatment of WTC-related 

physical and mental health 

conditions 

NY/NJ WTC 

Consortium 

NIOSH Five clinical centers, one 

of which, the Mount 

Sinai-Irving J. Selikoff 

Center for Occupational 

and Environmental 

Medicine, also serves as 

the consortium’s Data 

and Coordination Center 

(DCC) 

All responders, excluding 

FDNY firefighters and 

emergency medical service 

technicians and current 

federal employeesa

 

• Initial screening

• Follow-up medical monitoring 

• Treatment of WTC-related 

physical and mental health 

conditions 

WTC Federal 

Responder 

Screening 

Program 

NIOSHbFOH Current federal employees 

who responded to the WTC 

attack in an official capacity 

• Onetime screening 

• Referrals to employee

assistance programs and 

specialty diagnostic servicesc

WTC Health 

Registry 

Agency for Toxic 

Substances and 

Disease Registry 

(ATSDR) 

NYC Department of 

Health and Mental 

Hygiene 

Responders and people living

or attending school in the 

area of the WTC or working or

present in the vicinity on 

September 11, 2001 

• Long-term monitoring through 

periodic surveys 

Project COPE NIOSH Collaboration between 

the NYC Police

Foundation and

Columbia University 

Medical Center

New York City Police 

Department (NYPD) 

uniformed and civilian 

employees and their family 

members 

• Hotline, mental health 

counseling, and referral 

services; some services 

provided by Columbia 

University clinical staff and 

some by other clinicians 

POPPA program NIOSH POPPA program NYPD uniformed employees • Hotline, mental health 

counseling, and referral 

services; some services 

provided by trained NYPD 

officers and some by mental 

health professionals 

Source: GAO analysis of information from NIOSH, ATSDR, FOH, FDNY, the NY/NJ WTC Consortium, the NYC Department of Health

and Mental Hygiene, the POPPA program, and Project COPE. 

Note: Some of these federally funded programs have also received funds from the American Red 

Cross and other private organizations. 

a

In February 2006, ASPR and NIOSH reached an agreement to have former federal employees

screened by the NY/NJ WTC Consortium. 

b

Until December 26, 2006, ASPR was the administrator. 

Page 8 GAO-07-1228T 
c

FOH can refer an individual with mental health symptoms to an employee assistance program for a 

telephone assessment. If appropriate, the individual can then be referred to a program counselor for 

up to six in-person sessions. The specialty diagnostic services are provided by ear, nose, and throat 

doctors; pulmonologists; and cardiologists. 

The WTC health programs that are providing screening and monitoring are 

tracking thousands of individuals who were affected by the WTC disaster. 

As of June 2007, the FDNY WTC program had screened about 14,500 

responders and had conducted follow-up examinations for about 13,500 of 

these responders, while the NY/NJ WTC Consortium had screened about

20,000 responders and had conducted follow-up examinations for about 

8,000 of these responders. Some of the responders include nonfederal 

responders residing outside the NYC metropolitan area. As of June 2007, 

the WTC Federal Responder Screening Program had screened 1,305 

federal responders and referred 281 responders for employee assistance 

program services or specialty diagnostic services. In addition, the WTC 

Health Registry, a monitoring program that consists of periodic surveys of

self-reported health status and related studies but does not provide inperson screening or monitoring, collected baseline health data from over 

71,000 people who enrolled in the Registry.25 In the winter of 2006, the

Registry began its first adult follow-up survey, and as of June 2007 over 

36,000 individuals had completed the follow-up survey. 

In addition to providing medical examinations, FDNY’s WTC program and 

the NY/NJ WTC Consortium have collected information for use in 

scientific research to better understand the health effects of the WTC 

attack and other disasters. The WTC Health Registry is also collecting 

information to assess the long-term public health consequences of the 

disaster. 

Federal Funding and 

Coordination of WTC 

Health Programs 

Beginning in October 2001 and continuing through 2003, FDNY’s WTC 

program, the NY/NJ WTC Consortium, the WTC Federal Responder 

Screening Program, and the WTC Health Registry received federal funding

to provide services to responders. This funding primarily came from 

appropriations to the Department of Homeland Security’s Federal 

Emergency Management Agency (FEMA),26 as part of the approximately 

 25The WTC Health Registry also provides information on where participants can seek 

health care. 

26FEMA is the agency responsible for coordinating federal disaster response efforts under

the National Response Plan. 

Page 9 GAO-07-1228T 
$8.8 billion that the Congress appropriated to FEMA for response and 

recovery activities after the WTC disaster.27 FEMA entered into 

interagency agreements with HHS agencies to distribute the funding to the 

programs. For example, FEMA entered into an agreement with NIOSH to 

distribute $90 million appropriated in 2003 that was available for 

monitoring.28 FEMA also entered into an agreement with ASPR for ASPR 

to administer the WTC Federal Responder Screening Program. A 

$75 million appropriation to CDC in fiscal year 2006 for purposes related 

to the WTC attack resulted in additional funding for the monitoring 

activities of the FDNY WTC program, NY/NJ WTC Consortium, and the 

Registry.29 The $75 million appropriation to CDC in fiscal year 2006 also 

provided funds that were awarded to the FDNY WTC program, the NY/NJ 

WTC Consortium, Project COPE, and the POPPA program for treatment 

services for responders. An emergency supplemental appropriation to 

CDC in May 2007 included an additional $50 million to carry out the same 

activities provided for in the $75 million appropriation made in fiscal year 

2006.

30 The President’s proposed fiscal year 2008 budget for HHS includes 

$25 million for treatment of WTC-related illnesses for responders. 

In February 2006, the Secretary of HHS designated the Director of NIOSH 

to take the lead in ensuring that the WTC health programs are well 

coordinated, and in September 2006 the Secretary established a WTC Task

Force to advise him on federal policies and funding issues related to 

responders’ health conditions. The chair of the task force is HHS’s 

Assistant Secretary for Health, and the vice chair is the Director of NIOSH. 

The task force reported to the Secretary of HHS in early April 2007. 

 27See 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. 

28Pub. L. No. 108-7, 117 Stat. 517. 

29The statute required CDC, in expending such funds, to give first priority to specified 

existing programs that administer baseline and follow-up screening; clinical examinations;

or long-term medical health monitoring, analysis, or treatment for emergency services 

personnel or rescue and recovery personnel. It required CDC to give secondary priority to

similar programs coordinated by other entities working with the State of New York and

NYC. Pub. L. No. 109-148, § 5011(b), 119 Stat. 2814. 

30U.S. Troop Readiness, Veterans’ Care, Katrina Recovery, and Iraq Accountability 

Appropriations Act, 2007, Pub. L. No. 110-28, ch. 5, 121 Stat. 112, 166 (2007). 

Page 10 GAO-07-1228T 
HHS’s WTC Federal Responder Screening Program has had difficulties 

ensuring the uninterrupted availability of services for federal responders. 

First, the provision of screening examinations has been intermittent. (See 

fig. 1.) After resuming screening examinations in December 200531 and 

conducting them for about a year, HHS again placed the program on hold 

and suspended scheduling of screening examinations for responders from 

January 2007 to May 2007. This interruption in service occurred because 

there was a change in the administration of the WTC Federal Responder 

Screening Program, and certain interagency agreements were not 

established in time to keep the program fully operational. In late 

December 2006, ASPR and NIOSH signed an interagency agreement giving 

NIOSH $2.1 million to administer the WTC Federal Responder Screening 

Program.32 Subsequently, NIOSH and FOH needed to sign a new 

interagency agreement to allow FOH to continue to be reimbursed for 

providing screening examinations. It took several months for the 

agreement between NIOSH and FOH to be negotiated and approved, and

scheduling of screening examinations did not resume until May 2007.33

WTC Federal 

Responder Screening 

Program Has Had 

Difficulties Ensuring 

the Availability of 

Screening Services, 

and NIOSH Was 

Considering 

Expanding the 

Program to Include 

Monitoring 

 31The program previously suspended examinations from March 2004 to December 2005. See

GAO-06-481T. 

32The agreement was a modification of ASPR’s February 2006 interagency agreement with 

NIOSH that covers screenings for former federal employees. 

33Before an agreement between NIOSH and FOH could be signed, the agreement between 

ASPR and NIOSH required several technical corrections. The revised ASPR-NIOSH 

agreement extended the availability of funding for the WTC Federal Responder Screening

Program to April 30, 2008. 

Page 11 GAO-07-1228T 
Figure 1: Timeline of Key Actions Related to the WTC Federal Responder Screening Program 

Period during which program was scheduling and paying for specialty diagnostic services

Source: GAO analysis of information from ASPR, FOH, NIOSH, and FEMA.

April 2005:

ASPR and ATSDR enter agreement to identify and contact 

federal responders and establish a database of names

January 2004:

HHS places program on hold

June 2003:

FOH begins screening examinations

July 2005:

ASPR and FOH revise agreement to expand clinical services

and provide referrals for specialty diagnostic servicesb

March 2004:

FOH conducts last 

screening examination

March 2003:

FEMA and ASPR enter agreement to establish WTC 

Federal Responder Screening Program with ASPR as

the administratora

April 2003:

ASPR and FOH enter agreement for conducting 

screening examinations

October 2005:

ASPR opens Web site for federal responders to 

register for screening examinations

December 2005:

FOH resumes examinations for current federal employees

February 2006:

ASPR and NIOSH reach agreement for screening former 

federal employees

2003 2004 2005 2006 2007

April 2006:

FOH stops scheduling and paying for specialty 

diagnostic services

December 2006:

ASPR transfers administration 

of the program to NIOSH 

January 2007:

HHS places program on holdc

March 2007:

FOH resumes scheduling 

and paying for specialty 

diagnostic services for 

previously screened 

responders

Period during which program was conducting screening examinations

May 2007:

FOH resumes

scheduling of 

screening 

examinations

Page 12 GAO-07-1228T 
Note: The WTC Federal Responder Screening Program serves current federal employees who 

responded to the WTC attack in an official capacity. In February 2006, ASPR and NIOSH reached an

agreement to have former federal employees screened by the NY/NJ WTC Consortium. 

a

In December 2006 the Office of Public Health and Emergency Preparedness became ASPR. We 

refer to that office as ASPR throughout this figure, regardless of the time period being discussed. 

b

In providing referrals for specialty diagnostic services, FOH schedules and pays for the diagnostic 

services. 

c

After HHS placed the program on hold, FOH completed examinations that had already been 

scheduled. 

Second, the program’s provision of specialty diagnostic services has also 

been intermittent. After initial screening examinations, responders often 

need further diagnostic services by ear, nose, and throat doctors; 

cardiologists; and pulmonologists; and FOH had been referring responders 

to these specialists and paying for the services. However, the program 

stopped scheduling and paying for these specialty diagnostic services in 

April 2006 because the program’s contract with a new provider network 

did not cover these services.34 In March 2007, FOH modified its contract 

with the provider network and resumed scheduling and paying for 

specialty diagnostic services for federal responders. 

In July 2007 we reported that NIOSH was considering expanding the WTC 

Federal Responder Screening Program to include monitoring 

examinations—follow-up physical and mental health examinations—and 

was assessing options for funding and delivering these services. If federal 

responders do not receive this type of monitoring, health conditions that 

arise later may not be diagnosed and treated, and knowledge of the health

effects of the WTC disaster may be incomplete. In February 2007, NIOSH 

sent a letter to FEMA, which provides the funding for the program, asking 

whether the funding could be used to support monitoring in addition to 

the onetime screening currently offered. A NIOSH official told us that as of 

August 2007 the agency had not received a response from FEMA. NIOSH 

officials told us that if FEMA did not agree to pay for monitoring of federal 

responders, NIOSH would consider using other funding. According to a 

NIOSH official, if FEMA or NIOSH agrees to pay for monitoring of federal

 34In April 2006, FOH contracted with a new provider network to provide various services 

for all federal employees, such as immunizations and vision tests. The contract with the

new provider network did not cover specialty diagnostic services by ear, nose, and throat 

doctors; cardiologists; and pulmonologists. Although the previous provider network had

provided these services, the new provider network and the HHS contract officer 

interpreted the statement of work in the new contract as not including these specialty 

diagnostic services. 

Page 13 GAO-07-1228T 
responders, this service would be provided by FOH or one of the other 

WTC health programs. 

NIOSH has not ensured the availability of screening and monitoring 

services for nonfederal responders residing outside the NYC metropolitan 

area, although it recently took steps toward expanding the availability of

these services. Initially, NIOSH made two efforts to provide screening and 

monitoring services for these responders, the exact number of which is 

unknown.35 The first effort began in late 2002 when NIOSH awarded a 

contract for about $306,000 to the Mount Sinai School of Medicine to 

provide screening services for nonfederal responders residing outside the 

NYC metropolitan area and directed it to establish a subcontract with 

AOEC.36 AOEC then subcontracted with 32 of its member clinics across the 

country to provide screening services. From February 2003 to July 2004, 

the 32 AOEC member clinics screened 588 nonfederal responders 

nationwide. AOEC experienced challenges in providing these screening 

services. For example, many nonfederal responders did not enroll in the 

program because they did not live near an AOEC clinic, and the 

administration of the program required substantial coordination among 

AOEC, AOEC member clinics, and Mount Sinai. 

NIOSH Has Not 

Ensured the 

Availability of 

Services for 

Nonfederal 

Responders Residing 

outside the NYC 

Metropolitan Area 

Mount Sinai’s subcontract with AOEC ended in July 2004, and from August 

2004 until June 2005 NIOSH did not fund any organization to provide 

services to nonfederal responders outside the NYC metropolitan area.37

During this period, NIOSH focused on providing screening and monitoring 

services for nonfederal responders in the NYC metropolitan area. In June

2005, NIOSH began its second effort by awarding $776,000 to the Mount 

 35According to the NYC Department of Health and Mental Hygiene, about 7,000 nonfederal

and federal responders residing outside the NYC metropolitan area have enrolled in the 

WTC Health Registry. 

36Around that time, NIOSH was providing screening services for nonfederal responders in

the NYC metropolitan area through the NY/NJ WTC Consortium and the FDNY WTC 

program. Nonfederal responders residing outside the NYC metropolitan area were able to 

travel at their own expense to the NYC metropolitan area to obtain screening services 

through the NY/NJ WTC Consortium. 

37In early 2004, AOEC applied to NIOSH to use its national network of member clinics to 

provide screening and monitoring for nonfederal responders residing outside the NYC 

metropolitan area, but NIOSH rejected AOEC’s application for several reasons, including 

that the application did not adequately address how to coordinate and implement a 

monitoring program with complex data collection and reporting requirements. 

Page 14 GAO-07-1228T 
Sinai School of Medicine Data and Coordination Center (DCC) to provide 

both screening and monitoring services for nonfederal responders residing 

outside the NYC metropolitan area. In June 2006, NIOSH awarded an 

additional $788,000 to DCC to provide screening and monitoring services 

for these responders. NIOSH officials told us that they assigned DCC the 

task of providing screening and monitoring services to nonfederal 

responders outside the NYC metropolitan area because the task was 

consistent with DCC’s responsibilities for the NY/NJ WTC Consortium, 

which include data monitoring and coordination. DCC, however, had 

difficulty establishing a network of providers that could serve nonfederal 

responders residing throughout the country—ultimately contracting with 

only 10 clinics in seven states to provide screening and monitoring 

services.38 DCC officials said that as of June 2007 the 10 clinics were 

monitoring 180 responders. 

In early 2006, NIOSH began exploring how to establish a national program 

that would expand the network of providers to provide screening and 

monitoring services, as well as treatment services, for nonfederal 

responders residing outside the NYC metropolitan area.39 According to 

NIOSH, there have been several challenges involved in expanding a 

network of providers to screen and monitor nonfederal responders 

nationwide. These include establishing contracts with clinics that have the 

occupational health expertise to provide services nationwide, establishing 

patient data transfer systems that comply with applicable privacy laws, 

navigating the institutional review board40 process for a large provider 

network, and establishing payment systems with clinics participating in a 

national network of providers. On March 15, 2007, NIOSH issued a formal

request for information from organizations that have an interest in and the 

capability of developing a national program for responders residing 

 38Contracts were originally established with 11 clinics in eight states, but 1 clinic 

discontinued its participation in the program after conducting one examination. The 10

active clinics are located in seven states: Arkansas, California, Illinois, Maryland, 

Massachusetts, New York, and Ohio. Of the 10 active clinics, 7 are AOEC member clinics. 

39According to NIOSH and DCC officials, efforts to provide monitoring services to federal 

responders residing outside the NYC metropolitan area may be included in the national 

program. 

40Institutional review boards are groups that have been formally designated to review and 

monitor biomedical research involving human subjects, such as research based on data

collected from screening and monitoring examinations. 

Page 15 GAO-07-1228T 
outside the NYC metropolitan area.41 In this request, NIOSH described the 

scope of a national program as offering screening, monitoring, and 

treatment services to about 3,000 nonfederal responders through a 

national network of occupational health facilities. NIOSH also specified 

that the program’s facilities should be located within reasonable driving 

distance to responders and that participating facilities must provide copies 

of examination records to DCC. In May 2007, NIOSH approved a request 

from DCC to redirect about $125,000 from the June 2006 award to 

establish a contract with a company to provide screening and monitoring 

services for nonfederal responders residing outside the NYC metropolitan 

area. Subsequently, DCC contracted with QTC Management, Inc.,42 one of 

the four organizations that had responded to NIOSH’s request for 

information. DCC’s contract with QTC does not include treatment 

services, and NIOSH officials are still exploring how to provide and pay for 

treatment services for nonfederal responders residing outside the NYC 

metropolitan area.43 QTC has a network of providers in all 50 states and the 

District of Columbia and can use internal medicine and occupational 

medicine doctors in its network to provide these services. In addition, 

DCC and QTC have agreed that QTC will identify and subcontract with 

providers outside of its network to screen and monitor nonfederal 

responders who do not reside within 25 miles of a QTC provider.44 In June 

2007, NIOSH awarded $800,600 to DCC for coordinating the provision of 

screening and monitoring examinations, and QTC will receive a portion of

this award from DCC to provide about 1,000 screening and monitoring 

examinations through May 2008. According to a NIOSH official, QTC’s 

providers have begun conducting screening examinations, and by the end

 41Department of Health and Human Services, Sources Sought Notice: National Medical

Monitoring and Treatment Program for World Trade Center (WTC) Rescue, Recovery, 

and Restoration Responders and Volunteers, SSA-WTC-001 (Mar. 15, 2007). 

42QTC is a private provider of government-outsourced occupational health and disability 

examination services. 

43Some nonfederal responders residing outside the NYC metropolitan area may have access

to privately funded treatment services. In June 2005 the American Red Cross funded AOEC

to provide treatment services for these responders. As of June 2007, AOEC had contracted 

with 40 of its member clinics located in 27 states and the District of Columbia to provide 

these services. An American Red Cross official told us in September 2007 that funding for 

AOEC to provide treatment services would continue through June 2008. 

44As of June 2007, DCC identified 1,151 nonfederal responders residing outside the NYC 

metropolitan area who requested screening and monitoring services and were too ill or 

lacked financial resources to travel to NYC or any of DCC’s 10 contracted clinics.

Page 16 GAO-07-1228T 
of August 2007, 18 nonfederal responders had completed screening 

examinations, and 33 others had been scheduled. 

In fall 2006, NIOSH awarded and set aside funds totaling $51 million from 

its $75 million appropriation for four WTC health programs in the NYC 

metropolitan area to provide treatment services to responders enrolled in 

these programs. Of the $51 million, NIOSH awarded about $44 million for 

outpatient services to the FDNY WTC program, the NY/NJ WTC 

Consortium, Project COPE, and the POPPA program. NIOSH made the 

largest awards to the two programs from which almost all responders 

receive medical services, the FDNY WTC program and NY/NJ WTC 

Consortium (see table 2). In July 2007 we reported that officials from the 

FDNY WTC program and the NY/NJ WTC Consortium expected that their 

awards for outpatient treatment would be spent by the end of fiscal year 

2007.

45,46 In addition to the $44 million it awarded for outpatient services, 

NIOSH set aside about $7 million for the FDNY WTC program and NY/NJ 

WTC Consortium to pay for responders’ WTC-related inpatient hospital 

care as needed.47

NIOSH Awarded 

Funding for 

Treatment Services to 

Four WTC Health 

Programs 

 45In August 2007 a NIOSH official told us that NIOSH did not expect that all of these funds 

would be spent by September 30, 2007. 

46In addition to funding from NIOSH, the FDNY WTC program and the NY/NJ WTC 

Consortium received funding in 2006 from the American Red Cross to provide treatment

services. In September 2007 an official from the American Red Cross told us that it was the

organization’s understanding that most of the clinics in the NY/NJ WTC Consortium had 

expended the American Red Cross funds but that one of the Consortium’s clinics was

expected to request a no-cost 6-month extension up to the end of calendar year 2007. The 

American Red Cross had already granted a similar extension for the same period to the 

FDNY WTC program. 

47Of the $24 million remaining from the $75 million appropriation to CDC, NIOSH used 

about $15 million to support monitoring and other WTC-related health services conducted 

by the FDNY WTC program and NY/NJ WTC Consortium. ATSDR awarded $9 million to the 

WTC Health Registry to continue its collection of health data. 

Page 17 GAO-07-1228T 
Table 2: NIOSH Awards to WTC Health Programs for Providing Treatment Services,

2006 

Dollars in millions 

WTC health program Amount of awardaDate of award

NY/NJ WTC Consortium $20.8 October 26, 2006 

FDNY WTC Medical Monitoring 

and Treatment Program 

18.7 October 26, 2006 

Project COPE 3.0bSeptember 19, 2006 

POPPA program 1.5cSeptember 19, 2006 

Total amount of awards $44.0 

Source: NIOSH. 

a

Amount is rounded to the nearest $0.1 million. 

b

NIOSH will provide $1 million annually to Project COPE beginning in September 2006 through 

September 2008, for a total award of $3 million. 

c

NIOSH will provide $500,000 annually to the POPPA program beginning in September 2006 through

September 2008, for a total award of $1.5 million. 

The FDNY WTC program and NY/NJ WTC Consortium used their awards 

from NIOSH to continue providing treatment services to responders and to

expand the scope of available treatment services. Before NIOSH made its 

awards for treatment services, the treatment services provided by the two 

programs were supported by funding from private philanthropies and 

other organizations. According to officials of the NY/NJ WTC Consortium, 

this funding was sufficient to provide only outpatient care and partial 

coverage for prescription medications. The two programs used NIOSH’s 

awards to continue to provide outpatient services to responders, such as 

treatment for gastrointestinal reflux disease, upper and lower respiratory 

disorders, and mental health conditions. They also expanded the scope of

their programs by offering responders full coverage for their prescription 

medications for the first time. A NIOSH official told us that some of the 

commonly experienced WTC conditions, such as upper airway conditions, 

gastrointestinal disorders, and mental health disorders, are frequently

treated with medications that can be costly and may be prescribed for an 

extended period of time. According to an FDNY WTC program official, 

prescription medications are now the largest component of the program’s 

treatment budget. 

The FDNY WTC program and NY/NJ Consortium also expanded the scope 

of their programs by paying for inpatient hospital care for the first time, 

using funds from the $7 million that NIOSH had set aside for this purpose. 

According to a NIOSH official, NIOSH pays for hospitalizations that have

Page 18 GAO-07-1228T 
been approved by the medical directors of the FDNY WTC program and 

NY/NJ WTC Consortium through awards to the programs from the funds 

NIOSH set aside for this purpose. By August 31, 2007, federal funds had 

been used to support 34 hospitalizations of responders, 28 of which were 

referred by the NY/NJ WTC Consortium’s Mount Sinai clinic, 5 by the 

FDNY WTC program, and 1 by the NY/NJ WTC Consortium’s CUNY 

Queens College program. Responders have received inpatient hospital 

care to treat, for example, asthma, pulmonary fibrosis,48 and severe cases 

of depression or PTSD. According to a NIOSH official, one responder is 

now a candidate for lung transplantation and if this procedure is 

performed, it will be covered by federal funds. If funds set aside for 

hospital care are not completely used by the end of fiscal year 2007, he 

said they could be carried over into fiscal year 2008 for this purpose or 

used for outpatient services. 

After receiving NIOSH’s funding for treatment services in fall 2006, the 

NY/NJ WTC Consortium ended its efforts to obtain reimbursement from 

health insurance held by responders with coverage.49 Consortium officials 

told us that efforts to bill insurance companies involved a heavy 

administrative burden and were frequently unsuccessful, in part because

the insurance carriers typically denied coverage for work-related health

conditions on the grounds that such conditions should be covered by state 

workers’ compensation programs. However, according to officials from 

the NY/NJ WTC Consortium, responders trying to obtain workers’ 

compensation coverage routinely experienced administrative hurdles and 

significant delays, some lasting several years. Moreover, according to 

these program officials, the majority of responders enrolled in the program 

either had limited or no health insurance coverage. According to a labor 

official, responders who carried out cleanup services after the WTC attack

often did not have health insurance, and responders who were 

construction workers often lost their health insurance when they became 

too ill to work the number of days each quarter or year required to 

maintain eligibility for insurance coverage. 

 48Pulmonary fibrosis is a condition characterized by the formation of scar tissue in the 

lungs following the inflammation of lung tissue. 

49The NY/NJ WTC Consortium now offers treatment services at no cost to responders; 

however, prior to fall 2006 the program attempted when possible to obtain reimbursement

for its services from health insurance carriers and to obtain applicable co-payments from 

responders. 

Page 19 GAO-07-1228T 
According to a NIOSH official, although the agency had not received 

authorization as of August 30, 2007, to use the $50 million emergency 

supplemental appropriation made to CDC in May 2007, NIOSH was 

formulating plans for use of these funds to support the WTC treatment 

programs in fiscal year 2008. 

Screening and monitoring the health of the people who responded to the 

September 11, 2001, attack on the World Trade Center are critical for 

identifying health effects already experienced by responders or those that 

may emerge in the future. In addition, collecting and analyzing information 

produced by screening and monitoring responders can give health care 

providers information that could help them better diagnose and treat 

responders and others who experience similar health effects. 

Concluding 

Observations 

While some groups of responders are eligible for screening and follow-up 

physical and mental health examinations through the federally funded 

WTC health programs, other groups of responders are not eligible for 

comparable services or may not always find these services available.

Federal responders have been eligible only for the initial screening 

examination provided through the WTC Federal Responder Screening 

Program. NIOSH, the administrator of the program, has been considering 

expanding the program to include monitoring but has not done so. In 

addition, many responders who reside outside the NYC metropolitan area 

have not been able to obtain screening and monitoring services because 

available services are too distant. Moreover, HHS has repeatedly 

interrupted the programs it established for federal responders and 

nonfederal responders outside of NYC, resulting in periods when no 

services were available to them. 

HHS continues to fund and coordinate the WTC health programs and has 

key federal responsibility for ensuring the availability of services to 

responders. HHS and its agencies have recently taken steps to move 

toward providing screening and monitoring services to federal responders 

and to nonfederal responders living outside of the NYC area. However, 

these efforts are not complete, and the stop-and-start history of the 

department’s efforts to serve these groups does not provide assurance that 

the latest efforts to extend screening and monitoring services to these 

responders will be successful and will be sustained over time. Therefore 

we recommended in July 2007 that the Secretary of HHS take expeditious

action to ensure that health screening and monitoring services are 

available to all people who responded to the attack on the WTC, regardless 

Page 20 GAO-07-1228T 
of who their employer was or where they reside. As of early September 

2007 the department has not responded to this recommendation. 

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. 

For further information about this testimony, please contact Cynthia A. 

Bascetta at (202) 512-7114 or bascettac@gao.gov. 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; Hernan 

Bozzolo; Frederick Caison; Anne Dievler; and Roseanne Price made key 

contributions to this statement. 

Contacts and 

Acknowledgments 

Page 21 GAO-07-1228T 
Page 22 GAO-07-1228T 

Appendix I: Abbreviations 

AOEC Association of Occupational and Environmental Clinics 

ASPR Office of the Assistant Secretary for Preparedness and 

 Response 

ATSDR Agency for Toxic Substances and Disease Registry 

CDC Centers for Disease Control and Prevention 

DCC Data and Coordination Center 

FDNY New York City Fire Department 

FEMA Federal Emergency Management Agency 

FOH Federal Occupational Health Services 

HHS Department of Health and Human Services 

NIOSH National Institute for Occupational Safety and Health 

NYC New York City 

NY/NJ New York/New Jersey 

NYPD New York City Police Department 

POPPA Police Organization Providing Peer Assistance 

PTSD post-traumatic stress disorder 

WTC World Trade Center 
Page 23 GAO-07-1228T 

Related GAO Products 

September 11: HHS Needs to Ensure the Availability of Health Screening 

and Monitoring for All Responders. GAO-07-892. Washington, D.C.: 

July 23, 2007.

September 11: HHS Has Screened Additional Federal Responders for 

World Trade Center Health Effects, but Plans for Awarding Funds for 

Treatment Are Incomplete. GAO-06-1092T. Washington, D.C.: September 8, 

2006. 

September 11: Monitoring of World Trade Center Health Effects Has 

Progressed, but Program for Federal Responders Lags Behind. 

GAO-06-481T. Washington, D.C.: February 28, 2006. 

September 11: Monitoring of World Trade Center Health Effects Has 

Progressed, but Not for Federal Responders. GAO-05-1020T. Washington,

D.C.: September 10, 2005. 

September 11: Health Effects in the Aftermath of the World Trade Center

Attack. GAO-04-1068T. Washington, D.C.: September 8, 2004. 

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