United States Government Accountability Office

GAO Testimony 

Before the Subcommittee on National Security, 

Emerging Threats, and International Relations, 

Committee on Government Reform, House of 

Representatives

SEPTEMBER 11 

Monitoring of World Trade 

Center Health Effects Has 

Progressed, but Program for 

Federal Responders Lags 

Behind 

Statement of Cynthia A. Bascetta 

Director, Health Care 

For Release on Delivery

Expected at 2:00 p.m. EST 

Tuesday, February 28, 2006 

 

GAO-06-481T 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

February 28, 2006

SEPTEMBER 11

Monitoring of World Trade Center Health 

Effects Has Progressed, but Program for 

Federal Responders Lags Behind 

Highlights of GAO-06-481T, a testimony 

before the subcommittee on National 

Security, Emerging Threats, and 

International Relations, Committee on 

Government Reform, House of 

Representatives 

After the 2001 attack on the World 

Trade Center (WTC), nearly 3,000 

people died and an estimated 

250,000 to 400,000 people in the

vicinity were affected. An

estimated 40,000 people who 

responded to the disaster—

including New York City Fire 

Department (FDNY) personnel and 

other government and privatesector workers and volunteers—

were exposed to physical and 

mental health hazards. Concerns 

remain about the long-term health 

effects of the attack and about the 

nation’s capacity to plan for and 

respond to health effects resulting 

from future disasters. 

Several federally funded programs 

have monitored the physical and 

mental health effects of the WTC 

attack. These monitoring programs 

include one-time screening

programs and programs that also

conduct follow-up monitoring. 

GAO was asked to assess the 

progress of these programs and

examined (1) federally funded

programs implemented by state 

and local government agencies or 

private institutions, (2) federally

administered programs to monitor 

the health of federal workers who

responded to the disaster in an 

official capacity, and (3) lessons 

learned from WTC monitoring 

programs. GAO reviewed program

documents and interviewed

federal, state, and local officials 

and others involved in WTC 

monitoring programs. This 

statement updates information 

GAO provided to the Subcommittee

on September 10, 2005.

Three federally funded monitoring programs implemented by state and local 

governments or private organizations after the WTC attack, with total 

funding of about $104 million, have provided initial medical examinations--

and in some cases follow-up examinations--to thousands of affected 

responders to screen for health problems. For example, the FDNY medical 

monitoring program completed initial screening for over 15,000 firefighters

and emergency medical service personnel, and the worker and volunteer 

program screened over 14,000 other responders. The New York State 

responder screening program screened about 1,700 state responders before 

ending its examinations in 2003. These monitoring programs and the WTC 

Health Registry, with total federal funding of $23 million, have collected 

information that program officials believe researchers could use to help 

better understand the health consequences of the attack and improve 

treatment. Program officials expressed concern, however, that current time 

frames for federal funding arrangements may be too short to allow for 

identification of all future health effects. CDC recently received a $75 million 

appropriation to fund health screening, long-term monitoring, and treatment 

for WTC responders and is deciding how to allocate these funds. 

In contrast to the progress made by other federally funded programs, the 

Department of Health and Human Services’ (HHS) program to screen federal 

workers who were sent by their agencies to respond to the WTC disaster has 

accomplished little and lags behind. The program—which started in June 

2003, about one year later than other WTC monitoring programs—completed

screening of 527 of the estimated 10,000 federal workers who responded in 

an official capacity to the disaster, and in early 2004, examinations were

suspended for almost 2 years. The program’s limited activity and the 

exclusion of federal workers from other monitoring programs because of the 

assumption that they could receive screening examinations through the HHS 

program may have resulted in many federal responders losing the 

opportunity to identify and seek treatment for their WTC-related health 

problems. 

Officials involved in WTC health monitoring programs cited lessons from 

their experiences that could help others who may be responsible for 

designing and implementing health monitoring efforts that follow other 

disasters, such as Hurricane Katrina. These include the need to quickly 

identify and contact people affected by a disaster; to monitor for mental 

health effects, as well as physical injuries and illnesses; and to anticipate 

when designing disaster-related monitoring efforts that there will likely be 

many people who require referrals for follow-up care and that handling the 

referral process may require substantial effort. 

www.gao.gov/cgi-bin/getrpt?GAO-06-481T.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Cynthia A. 

Bascetta at (202) 512-7101 or 

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

Thank you for inviting me to participate in today’s hearing to discuss 

issues related to the health effects that people continue to experience in

the aftermath of the September 11, 2001, terrorist attack on the World 

Trade Center (WTC).1 My testimony today updates information we 

reported to you in September 2005.2

 After the collapse of the WTC 

buildings, nearly 3,000 people died, and an estimated 250,000 to 400,000

people who lived, worked, or attended school in the vicinity were affected.

An estimated 40,000 people responded to the disaster, including New York 

City Fire Department (FDNY) personnel and other government and 

private-sector workers and volunteers from New York and other locations

across the nation. These responders,3

 as they took part in various rescue, 

recovery, and cleanup activities in the days, weeks, and months following

the attack, were exposed to numerous physical hazards and environmental 

toxins because of the destruction caused by the attack. The magnitude and 

unprecedented nature of this event also exposed responders and many 

other people to considerable psychological trauma. 

Four years after the destruction of the WTC buildings, concerns remain 

about the long-term physical and mental health effects of the attack. 

Several recent studies of responders report that many of them have high 

rates of physical and mental health symptoms, of which respiratory 

problems are the most persistent physical effects.4

 While the nature and 

severity of a future terrorist attack cannot be predicted, our prior work on 

the health effects of the WTC attack, the 2001 anthrax attacks, and 

bioterrorism preparedness, as well as reports by other organizations, 

 1

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

2

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). 

3

In this testimony, the term responders refers to anyone involved in rescue, recovery, or

cleanup activities at or near the vicinity of the WTC site and Staten Island Fresh Kills 

landfill (the off-site location of the WTC recovery operation). 

4

See, for example, Centers for Disease Control and Prevention, “Mental Health Status of 

World Trade Center Rescue and Recovery Workers and Volunteers—New York City, July 

2002-August 2004,” Morbidity and Mortality Weekly Report, vol. 53 (2004); Centers for 

Disease Control and Prevention, “Physical Health Status of World Trade Center Rescue and 

Recovery Workers and Volunteers—New York City, July 2002-August 2004,” Morbidity and

Mortality Weekly Report, vol. 53 (2004); and Gisela I. Banauch and others, “Bronchial 

Hyperreactivity and Other Inhalation Lung Injuries in Rescue/Recovery Workers after the 

World Trade Center Collapse,” Critical Care Medicine, vol. 33, no. 1 (2005). 

Page 1 GAO-06-481T
highlight the importance of ensuring the nation’s capacity to plan for and 

respond to the short- and long-term health consequences likely to result in

the event of a future attack or other disaster, such as the destruction 

recently caused by Hurricane Katrina.

5

As we testified in September 2004, in the aftermath of the WTC attack, five 

key federally funded programs were implemented to assess the short-term, 

and in some cases long-term, effects on people’s physical and mental 

health. These programs include the FDNY WTC Medical Monitoring 

Program, WTC Medical Monitoring Program (worker and volunteer 

program),6

 New York State responder screening program, WTC Health 

Registry, and Department of Health and Human Services’ (HHS) WTC 

Federal Responder Screening Program. You asked us to provide 

information on the progress of these monitoring programs7

 in September 

2005, and to update that information for this hearing. My testimony today 

updates the information we reported to you in September 2005 on 

(1) progress made by federally funded programs that are implemented by 

state and local government agencies or private organizations and were 

established to monitor the health of people in the aftermath of the attack, 

(2) progress made by federally administered programs established to 

monitor the health of federal workers who responded to the disaster in an 

official capacity, and (3) lessons from WTC monitoring programs that 

could assist those who may be responsible for future disaster-related 

health monitoring efforts. 

To provide the information we reported in September 2005, we conducted 

our work from July through September 2005. We obtained and reviewed 

program documents dating from the beginning of the programs, including 

grantee progress reports, budget documents, clinical protocols, health 

screening and other assessment tools, and selected peer-reviewed articles 

 5

See, for example, GAO, September 11: Health Effects in the Aftermath of the World Trade

Center Attack, GAO-04-1068T (Washington, D.C.: Sept. 8, 2004); GAO, Bioterrorism: Public

Health Response to Anthrax Incidents of 2001, GAO-04-152 (Washington, D.C.: Oct. 15, 

2003); GAO, Public Health Preparedness: Response Capacity Improving, but Much 

Remains to Be Accomplished, GAO-04-458T (Washington, D.C.: Feb. 12, 2004); and 

Institute of Medicine, Preparing for the Psychological Consequences of Terrorism: A 

Public Health Strategy (Washington, D.C.: 2003). 

6

This program was formerly known as the WTC Worker and Volunteer Medical Screening

Program. In this testimony, we refer to the program as the worker and volunteer program. 

7

In this testimony, we use the term monitoring program to refer to both one-time screening 

programs and programs that include initial screening and periodic follow-up monitoring.

Page 2 GAO-06-481T
based on information collected by WTC monitoring programs. We also 

interviewed federal, state, and local officials and others involved in 

administering WTC monitoring programs, including officials from HHS and 

the Department of Homeland Security (DHS);8

 New York State Department 

of Health; New York City Department of Health and Mental Hygiene; and 

FDNY. Within HHS, we interviewed officials from the Agency for Toxic 

Substances and Disease Registry (ATSDR); the Centers for Disease 

Control and Prevention’s (CDC) National Center for Environmental Health

and National Institute for Occupational Safety and Health (NIOSH); 

Federal Occupational Health Services (FOH);9

 and the Office of Public 

Health Emergency Preparedness (OPHEP). We also obtained information 

from the Department of Defense (DOD) and the Department of Justice. We 

interviewed medical professionals affiliated with the New York University 

School of Medicine, FDNY’s Bureau of Health Services (FDNY-BHS), 

Long Island Occupational and Environmental Health Center, Mount SinaiIrving J. Selikoff Center for Occupational and Environmental Medicine, 

Mount Sinai School of Medicine Department of Psychiatry, and the 

University of Medicine and Dentistry of New Jersey’s Robert Wood 

Johnson Medical School. HHS and New York State officials provided 

comments on the information we provided in September 2005, and we 

made changes as appropriate. To prepare today’s testimony, we conducted 

our work during February 2006 and obtained updated information from 

officials at the New York State responder screening program and the WTC 

Federal Responder Screening Program. We also obtained updated 

information from officials at the WTC Registry about their monitoring 

plans. In addition, we obtained information from CDC officials about a 

$75 million appropriation the agency received in fiscal year 2006 to fund 

health services for WTC responders. For the information in this statement, 

we relied on data provided by agency officials and contained in 

government publications and did not independently verify the data we 

obtained. In our judgment the reliability of the information we obtained 

was adequate for our purposes. We conducted our work in accordance 

with generally accepted government auditing standards. 

In summary, three federally funded programs implemented by state and 

local governments or private organizations in the aftermath of the WTC 

attack, with total federal funding of about $104 million, have provided 

 8

The DHS officials we spoke with were from the Federal Emergency Management Agency,

which became part of DHS in March 2003. 

9

FOH is a part of HHS’s Program Support Center. 

Page 3 GAO-06-481T
initial medical examinations—and in some cases follow-up 

examinations—to thousands of affected responders to screen for health 

problems. For example, the FDNY program completed initial screening for 

over 15,000 firefighters and emergency medical service personnel, and the 

worker and volunteer program has screened over 14,000 other responders. 

The New York State program screened about 1,700 state responders 

before ending its screening examinations in November 2003; in general, 

the program did not inform the approximately 9,800 state responders 

when they became eligible to participate in the worker and volunteer 

program in February 2004. Worker and volunteer program officials are 

working with state employee unions to inform state workers of their 

eligibility. These three programs and the WTC Health Registry, with total 

federal funding of $23 million, have collected information that monitoring 

program officials believe could be used by researchers to help better 

understand the health consequences of the attack and improve treatment, 

such as by identifying which types of treatment are effective for specific 

conditions. Officials of programs that plan to conduct long-term health 

monitoring are concerned that the time frames of current federal funding 

arrangements may be too short to allow for identification of all the health

effects that participants may eventually experience. In January 2006, CDC 

received a $75 million appropriation to fund baseline health screening, 

long-term monitoring, and treatment for WTC responders, and is in the 

process of deciding how to allocate these funds and how long the 

allocated funds will be available for each program that receives funding.

In contrast to the progress made by federally funded programs 

implemented by state and local governments or private organizations, the 

program that HHS implemented in June 2003 to screen federal workers 

who were sent by their agencies to respond to the WTC disaster has lagged 

behind and accomplished little. Through March 2004, the program—which 

started later than other WTC monitoring programs—completed screenings 

of 394 of the estimated 10,000 federal workers who responded in an 

official capacity to the disaster and were not eligible for any other WTC 

health monitoring program. HHS placed the program on hold in January 

2004, when it stopped scheduling new examinations, because it wanted to

resolve several operational issues. The program resumed providing 

examinations for current federal workers in December 2005, and had 

completed 133 additional examinations as of early February 2006. While 

examinations have not resumed for WTC responders who are no longer 

federal employees, OPHEP recently executed an agreement with NIOSH to 

arrange for the worker and volunteer program to provide examinations to 

these WTC responders. In addition to the HHS program, we identified two 

federal agencies that, in the aftermath of the WTC attack, have 

Page 4 GAO-06-481T
implemented programs to assess the health of their own employees who 

responded to the disaster. 

Officials involved in WTC health monitoring programs cited lessons from 

their experiences that could help others who may be responsible for 

designing and implementing disaster-related health monitoring efforts in 

the future. These include the need to quickly identify and contact people 

affected by a disaster; to monitor for mental health effects, as well as the 

more obvious physical injuries and illnesses; and when developing health

monitoring efforts in the wake of disasters, to anticipate that there will 

likely be many people who require referrals for further diagnostic and 

treatment services and that handling the referral process may require a 

substantial level of effort. 

When the WTC buildings collapsed on September 11, 2001, an estimated 

250,000 to 400,000 people were immediately exposed to a noxious mixture 

of dust, debris, smoke, and potentially toxic contaminants in the air and on

the ground, such as pulverized concrete, fibrous glass, particulate matter,

and asbestos. Those affected included people residing, working, or 

attending school in the vicinity of the WTC and thousands of emergency 

response workers. Also affected were the estimated 40,000 responders 

who were involved in some capacity in the days, weeks, and months that 

followed, including personnel from many government agencies and private 

organizations as well as other workers and volunteers.10

Background 

A wide variety of physical and mental health effects have been observed 

and reported among people who were involved in rescue, recovery, and 

cleanup operations and among those who lived and worked in the vicinity

of the WTC.11 Physical health effects included injuries and respiratory 

conditions, such as sinusitis; asthma; and a new syndrome called WTC 

cough, which consists of persistent coughing accompanied by severe 

respiratory symptoms. Almost all firefighters who responded to the attack 

experienced respiratory effects, including WTC cough, and hundreds had 

 10The responders included firefighters; law enforcement officers; emergency medical 

technicians and paramedics; morticians; health care professionals; and other workers and

volunteers, including those in the construction and ironwork trades, heavy equipment 

operators, mechanics, engineers, truck drivers, carpenters, day laborers, and 

telecommunications workers. Numerous federal, state, and New York City agencies sent 

personnel to respond to the WTC disaster (see app. II). 

11GAO-04-1068T. 

Page 5 GAO-06-481T
to end their firefighting careers because of WTC-related respiratory 

illnesses. The most commonly reported mental health effects among 

responders and others were symptoms associated with posttraumatic 

stress disorder—an often debilitating disorder that can develop after a 

person experiences or witnesses a traumatic event, and which may not 

develop for months or years after the event. Behavioral effects such as 

alcohol and tobacco use and difficulty coping with daily responsibilities 

were also reported.12

Several federally funded programs monitor the health of people who were 

exposed to the WTC attack and its aftermath. The monitoring programs 

vary in such aspects as eligibility requirements, methods used for 

collecting information about people’s health, and approaches for offering 

referrals. Of the four programs that offer medical examinations to WTC 

responders, the only one that is open to federal workers who responded to 

the disaster in an official capacity is the one implemented by HHS. (See 

table 1.) None of the monitoring programs receives federal funds to 

provide clinical treatment for health problems that are identified. 

 12In fiscal year 2002, Substance Abuse and Mental Health Services Administration grant 

programs provided funds that could be used to treat mental health and substance abuse 

conditions. The Post-September 11 State Disaster Relief grant program awarded about 

$10 million in grants to the 9 states most directly affected by the September 11, 2001, 

terrorist attacks to fund substance abuse and mental health assessment and treatment

services for people affected by the attacks, including WTC responders. The Public Safety

Workers Mental Health grant program awarded a total of about $2.4 million to 7 grantees to 

provide mental health services to public safety workers in New York and Virginia who

responded to the terrorist attacks. 

Page 6 GAO-06-481T
Table 1: Key Federally Funded WTC Health Monitoring Programs

Implementing 

agency or

organization 

Federal 

administering

agency 

Eligible 

populations

Monitoring 

methods Treatment referral 

FDNY WTC Medical

Monitoring Programa

FDNY Bureau of 

Health Services 

(FDNY-BHS) 

National Institute for 

Occupational Safety 

and Health (NIOSH) 

Firefighters and

emergency medical 

service technicians 

Medical

questionnaire and 

examination 

Refers to FDNYBHS 

WTC Medical 

Monitoring Program 

(worker and 

volunteer program)a

Five clinical centers, 

one of which, the 

Mount Sinai-Irving J. 

Selikoff Center for 

Occupational and 

Environmental

Medicine, also 

serves as a data and 

coordination centerb

 

NIOSH Rescue and

recovery workers 

and volunteers, 

except for federal 

workers who were 

official responders 

and New York City 

(NYC) firefightersc

 

Medical

questionnaire and 

examination 

Refers to privately 

funded programs 

available to 

responders; some 

privately funded 

treatment provided 

at the clinical 

centers 

New York State 

responder screening 

programd

New York State 

Department of 

Health 

National Center for 

Environmental

Health 

New York State 

employees and

National Guard

personnel who 

responded to the 

WTC attack in an 

official capacity

Medical

questionnaire and 

examination 

Instructed 

participants to see 

their primary care 

physician or a 

specialist 

WTC Health 

Registry 

NYC Department of 

Health and Mental 

Hygiene 

Agency for Toxic 

Substances and 

Disease Registry 

(ATSDR) 

Responders and

people living or

attending school in 

the area of the WTC, 

or working or 

present in the vicinity 

on September 11, 

2001e

Telephone-based 

health and exposure 

interview

Provides information 

on where treatment 

can be sought;f 

refers participants to 

LIFENETg

 for mental 

health services

WTC Federal 

Responder 

Screening Program 

Department of 

Health and Human 

Services’ (HHS) 

Office of Public

Health Emergency 

Preparedness 

HHS Federal workers who 

responded to the 

WTC attack in an 

official capacity

Medical

questionnaire and 

examination 

Instructs participants 

to see their primary 

care physician; as of 

July 2005, may refer 

participants with

mental health 

symptoms to an 

FOH employee

assistance program 

Source: GAO analysis of information from ATSDR, FDNY, Mount Sinai, National Center for Environmental Health, New York City 

Department of Health and Mental Hygiene, New York State Department of Health, and NIOSH.

a

The FDNY WTC Medical Monitoring Program and the WTC Medical Monitoring Program constitute 

the WTC Responder Health Consortium. NIOSH established the consortium in March 2004 to 

coordinate the health monitoring of the two programs and to facilitate data sharing. 

b

The other clinical centers are located at the Long Island Occupational and Environmental Health 

Center, the New York University School of Medicine, the City University of New York’s Queens

College, and the University of Medicine and Dentistry of New Jersey’s Robert Wood Johnson Medical 

School. The responsibilities of the Mount Sinai data and coordination center include coordination of 

the clinical centers, outreach and education, quality assurance, and data management. 

Page 7 GAO-06-481T
c

The worker and volunteer program excludes responders who were paid as federal workers or as

NYC firefighters for their WTC work; these employees are eligible for other programs. The program 

initially excluded responders who were paid as New York State employees for their WTC work and 

were eligible for the New York State responder screening program. That program ended its screening

examinations in November 2003, and as of February 2004, New York State responders became

eligible for the worker and volunteer program. 

d

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

e

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

f

The registry program provides enrollees with a resource guide of occupational, respiratory,

environmental, and mental health facilities where they can seek treatment. Some of the services

provided by these facilities require payment, while others are free of charge. 

g

LIFENET is a 24-hour mental health information and referral service provided by the New York State 

Office of Mental Health. In cases where WTC Health Registry interviewers think a person is

experiencing moderate distress, they can immediately transfer the call so the person can speak to a 

LIFENET counselor. 

The majority of federal funding for these monitoring programs was 

provided by DHS’s Federal Emergency Management Agency (FEMA),13 as 

part of the approximately $8.8 billion in federal assistance that the 

Congress appropriated to FEMA for response and recovery activities after 

the WTC disaster.14 One appropriation in 2003 specifically authorized 

FEMA to use a portion of its WTC-related funding for screening and longterm monitoring of emergency services and rescue and recovery 

personnel.15 Generally, however, FEMA may fund only short-term care 

after a disaster, such as emergency medical services, and not ongoing 

clinical treatment.16

 13FEMA is the agency responsible for coordinating federal disaster response efforts under

the National Response Plan. 

14FEMA provided funds to HHS to support screening and long-term monitoring efforts from

funds appropriated for disaster relief and emergency response to the September 11, 2001, 

terrorist attacks. See Consolidated Appropriations Resolution, 2003, Pub. L. No. 108-7, 117 

Stat. 11, 517; 2002 Supplemental Appropriations Act for Further Recovery from and 

Response to Terrorist Attacks on the United States, Pub. L. No. 107-206, 116 Stat. 820, 894; 

Department of Defense and Emergency Supplemental Appropriations for Recovery from 

and Response to Terrorist Attacks on the United States Act, 2002, Pub. L. No. 107-117, 115

Stat. 2230, 2338; and 2001 Emergency Supplemental Appropriations Act for Recovery from

and Response to Terrorist Attacks on the United States, Pub. L. No. 107-38, 115 Stat. 220-

221. 

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

16The Robert T. Stafford Disaster Relief and Emergency Assistance Act, as amended, 

authorizes FEMA to, among other things, make appropriated funds available for disaster 

relief and emergency assistance. Pub. L. No. 93-288, 88 Stat. 143 (1974), as amended. The

Stafford Act does not specifically authorize ongoing clinical treatment. 

Page 8 GAO-06-481T
FEMA entered into interagency agreements with HHS to fund most of 

these health monitoring programs. HHS is the designated lead agency for

the public health and medical support function under the National 

Response Plan and is responsible for coordinating the medical resources 

of all federal departments and agencies. HHS’s OPHEP coordinates and 

directs HHS’s emergency preparedness and response program. 

Three federally funded programs implemented by state and local 

governments or private organizations, with total federal funding of about 

$104 million—the FDNY WTC Medical Monitoring Program, WTC Medical 

Monitoring Program (worker and volunteer program), and New York State 

responder screening program—have made progress in monitoring the 

physical and mental health of people affected by the WTC attack. Federal 

employees who responded to the WTC disaster in an official capacity were 

not eligible for these programs because it was expected that another 

program would be developed for them. The New York State program 

stopped providing health screening examinations in November 2003, and

in February 2004 state workers became eligible for initial or continued 

monitoring through the worker and volunteer program. The state program, 

in general, did not inform state responders that they were eligible to 

participate in the worker and volunteer program. Worker and volunteer 

program officials are working with state employee unions to inform state 

workers of their eligibility. All three programs and the WTC Health 

Registry, with total federal funding of $23 million, have collected 

information that could contribute to better understanding of the health

consequences of the attack and improve health care for affected 

individuals. Officials from the FDNY, worker and volunteer, and WTC 

Health Registry programs are concerned that federal funding for their 

programs could end before sufficient monitoring occurs to identify all 

long-term health problems related to the WTC disaster. In January 2006, 

CDC received a $75 million appropriation to fund baseline health 

screening, long-term monitoring, and treatment for WTC responders. CDC 

officials are in the process of deciding how they are going to allocate these

funds among programs and how long the allocated funds will be available 

for each program that receives funding. 

Health Monitoring 

Programs 

Implemented by State 

and Local 

Governments or 

Private Organizations 

Have Made Progress 

Page 9 GAO-06-481T
Three federally funded programs implemented by state and local 

governments or private organizations, with total funding of about 

$104 million, have provided medical examinations to identify physical and

mental health problems related to the WTC attack. (See table 2.) Two of 

these programs—the FDNY WTC Medical Monitoring Program and the 

worker and volunteer program—are tracking the health of WTC rescue, 

recovery, and cleanup workers and volunteers over time. The third 

program, the New York State responder screening program, offered onetime screening examinations to state employees, including National Guard 

personnel, who participated in WTC rescue, recovery, and cleanup work. 

Federal employees who responded to the WTC disaster in an official 

capacity were not eligible for any of these programs because it was 

expected that another program would be developed for them. 

Three WTC Monitoring 

Programs Provided 

Medical Examinations to 

Identify Responders’ 

Health Problems 

Page 10 GAO-06-481T
Table 2: Monitoring Activities and Associated Federal Funding for WTC Monitoring Programs Implemented by State and Local 

Governments or Private Organizations

Completed monitoring activities Planned monitoring activities Federal fundinga

FDNY WTC Medical 

Monitoring Program

Through June 2005, 15,284 

firefighters and emergency medical

service technicians received

screening examinations, and 522 of 

these participants completed a 

follow-up examination. 

By June 2009, conduct three 

follow-up examinations of each 

participant. 

$4.8 million was provided 

beginning in October 2001 for initial 

program; additional $25 million is 

available through June 2009.

WTC Medical 

Monitoring Program

(worker and

volunteer program) 

Through June 2005, 14,110 people 

received screening examinations, 

and 1,699 of these participants 

completed a follow-up examination.

By July 2009, conduct three followup examinations of each 

participant. 

$15.9 million was provided for

initial program;b

 additional $56

million is available through July

2009. 

New York State 

responder screening 

program

As of November 2003, 1,677 of 

approximately 9,800 eligible 

employees and National Guard 

personnel received screening 

examinations. 

No further examinations are 

planned. Participants are now 

eligible to participate in the worker 

and volunteer program. 

$2.4 million was provided in 

January 2002 and is available 

through mid-January 2007.c

WTC Health Registry As of November 2004, the program 

completed baseline data collection 

through interviews with the 71,437 

people who enrolled in the registry;d

registry officials estimate that about 

385,000 people had been eligible 

to enroll. In 2005, the program 

updated contact information 

obtained at the time of enrollment. 

In 2006, conduct follow-up survey 

of participants. 

Registry officials are developing 

plans to track participants’ health 

through 2023. 

$20 million was provided beginning 

in July 2002,e

 and additional 

funding of about $3 million has

since been provided.f

Source: GAO analysis of information from ATSDR, FDNY, Mount Sinai, National Center for Environmental Health, New York City 

Department of Health and Mental Hygiene, New York State Department of Health, and NIOSH.

Note: The funding information in this table does not include an appropriation of $75 million to CDC in

fiscal year 2006 to fund health screening, long-term monitoring, and treatment for WTC responders. 

As of February 2006, CDC had not decided how to allocate these funds. 

a

Except as noted, FEMA provided these funds to the federal administering agency for each 

monitoring program. 

b

Of this amount, $11.8 million was provided beginning in July 2002 through funds appropriated to

CDC. An additional $4.1 million was provided in fiscal year 2003 through an interagency agreement 

with FEMA. 

c

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

d

Registry officials told us that final enrollment numbers may be revised pending internal verification of

data. 

e

The grant agreement is between ATSDR and the New York City Department of Health and Mental 

Hygiene. However, ATSDR contracted directly with Research Triangle Institute (RTI), a private notfor-profit organization, for most of the work to establish the registry, and about $16 million of the 

$20 million went directly from ATSDR to RTI. 

f

The Environmental Protection Agency provided $2 million of these funds. In addition, CDC and 

ATSDR provided $500,000 each.

Page 11 GAO-06-481T
The FDNY program completed initial screening for over 15,000 firefighters 

and emergency medical service personnel, and the worker and volunteer 

program completed initial screening for over 14,000 other responders. In 

both programs, screenings include physical examinations, pulmonary 

function tests, blood and urine analysis, a chest Xray, and questionnaires 

on exposures and mental health issues. Both programs have begun to 

conduct follow-up examinations of participants and continue to accept 

new enrollees who desire initial screening. Current plans are to conduct a 

total of three follow-up examinations for each participant by 2009. As part 

of their federally funded activities, both programs provide referrals for 

participants who require treatment. FDNY employees and retirees can 

obtain treatment and counseling services from the FDNY Bureau of Health 

Services and the FDNY Counseling Services Unit, or they can use their 

health insurance to obtain treatment and counseling services elsewhere. 

The worker and volunteer program also provides referrals for its 

participants, including referrals to programs funded by the American Red 

Cross and other nonprofit organizations. 

The New York State program provided health screenings to about 1,700 of 

the estimated 9,800 state workers and National Guard personnel who 

responded to the WTC disaster. Officials sent letters to all state responders 

to inform them about the program and their eligibility for it.17 For each 

participant, the screening included a health and exposure questionnaire 

and physical and pulmonary examinations. Participants who required 

further evaluation or treatment after screening were told to follow up with 

their personal physician or a specialist. The program stopped screening 

participants in November 2003, in part because the number of responders 

requesting examinations was dwindling, and no follow-up examinations 

are planned.

In February 2004, worker and volunteer program officials began to allow 

New York State responders to participate in that monitoring program. The 

officials determined that the worker and volunteer program would have 

sufficient funding to accommodate state workers who want to join the 

program. The state program did not notify the 9,800 state responders, 

including the approximately 1,700 workers it had screened that they were

now eligible for continued monitoring from the worker and volunteer 

 17When state officials contacted the estimated 9,800 state responders, some of them 

informed the program that they were not interested in participating. Officials sent followup letters to state employees who did not respond to the initial mailing. National Guard 

personnel were sent only an initial letter. 

Page 12 GAO-06-481T
program. State program officials relayed this development only to those 

state responders who inquired about screening or monitoring

examinations following the decision to permit state responders to 

participate in the worker and volunteer program. However, officials from 

the worker and volunteer program told us that they are working with state 

employee unions to inform state workers about their eligibility for the 

worker and volunteer program. For example, starting in November 2005,

letters have been sent to union members telling them about the program 

and how they can enroll in it. According to worker and volunteer program 

officials, as of February 2006, 13 state workers who responded to the WTC 

disaster in an official capacity had received examinations from the worker 

and volunteer program,18 and as of mid-February 2006, 9 additional state 

workers had registered to obtain examinations through this program. 

Worker and volunteer program officials told us that any state worker that 

had been screened by the state program would need to receive a new 

baseline examination through the worker and volunteer program, because

the screening data collected by the state program differ from the data 

collected by the worker and volunteer program. For example, the worker 

and volunteer program offers a breathing test not provided by the state 

program. 

Programs Provide Data for 

WTC-Related Health 

Research 

In addition to providing medical examinations, these three programs—the 

FDNY program, the worker and volunteer program, and the New York 

State program—have collected information for use in scientific research to

better understand the health consequences of the WTC attack and other 

disasters. A fourth program, the WTC Health Registry, includes health and 

exposure information obtained through interviews with participants; it is 

designed to track participants’ health for 20 years and to provide data on

the long-term health consequences of the disaster (see table 2). Physicians 

who evaluate and treat WTC responders told us they expect that research 

on health effects from the disaster will not only help researchers 

understand the health consequences, but also provide information on 

appropriate treatment options for affected individuals. 

 18The worker and volunteer program has established a network of providers to serve state 

responders outside the New York City metropolitan area. State responders had been 

eligible for monitoring at New York City area clinics since February 2004, and can now visit 

providers in Albany and Syracuse. According to worker and volunteer program officials, 

state responders will be able to obtain examinations at another clinic location that is 

scheduled to open in Rochester in March 2006. 

Page 13 GAO-06-481T
Both the FDNY program and the worker and volunteer program have been

the basis for published research articles on the health of WTC responders. 

For example, the FDNY program reported on the injuries and illnesses 

experienced by firefighters and emergency medical service workers after 

responding to the attack.19 In addition, the worker and volunteer program 

published information on the physical and mental health of responders in 

2004.

20 Officials from both programs plan to publish additional findings as 

they track participants’ health over time. Although the New York State 

program has stopped offering examinations, program officials are 

continuing to analyze data from the program with plans for eventual 

publication.

The WTC Health Registry program has collected health information 

through interviews with responders, people living or attending school in 

the vicinity of the WTC site, and people working or present in the vicinity 

on September 11, 2001. The registry program, with total federal funding of

$23 million, completed enrollment and conducted interviews with over 

71,000 participants by November 2004. Officials updated contact 

information for all participants in 2005, and they plan to start conducting 

the first follow-up health survey of participants in late March 2006. 

Registry officials would like to conduct subsequent follow-up surveys 

every 2 years until about 2023—20 years after the program began in 2003—

but have not yet secured funding for long-term monitoring.21

The registry is designed to provide a basis for research to evaluate the 

long-term health consequences of the disaster. It includes contact 

information for people affected by the WTC attack, information on 

individuals’ experiences and exposures during the disaster, and 

information on their health. In November 2004, registry officials published 

 19See, for example, Centers for Disease Control and Prevention, “Injuries and Illnesses

among New York City Fire Department Rescue Workers after Responding to the World 

Trade Center Attacks,” Morbidity and Mortality Weekly Report, vol. 51 (2002), and 

Elizabeth M. Fireman and others, “Induced Sputum Assessment in NYC Firefighters

Exposed to World Trade Center Dust,” Environmental Health Perspectives, vol. 112

(2004). 

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

53, 807, and Centers for Disease Control and Prevention, Morbidity and Mortality Weekly 

Report, vol. 53, 812. 

21Program officials told us that the registry was designed as a 20-year program because 

most long-term health effects that might result from the WTC disaster would likely begin to

appear in the population within that period of time. 

Page 14 GAO-06-481T
preliminary results on the health status of registry participants, and 

officials expect to submit several research papers for publication within 

the next year. In addition, in May 2005, registry officials published 

guidelines for allowing registry information to be used in scientific 

research,22 and as of February 2006, they approved three proposals for 

external research projects that use registry information. These proposals 

include two studies of building evacuations and a study of psychological 

responses to terrorism. 

Program Officials Are 

Concerned That Current 

Federal Funding 

Arrangements Will End 

before Needed Monitoring 

Is Complete 

Officials from the FDNY, worker and volunteer, and WTC Health Registry 

programs are concerned that current time frames for federal funding 

arrangements for programs designed to track participants’ health over 

time may be too short to allow for identification of all the health effects 

that may eventually develop. ATSDR’s 5-year cooperative agreement with 

the New York City Department of Health and Mental Hygiene to support 

the WTC Health Registry went into effect April 30, 2003, and extends 

through April 29, 2008. Similarly, NIOSH awarded 5-year grants in 

July 2004 to continue the FDNY and worker and volunteer programs 

through mid-2009; the programs had begun in 2001 and 2002, respectively. 

Health experts involved in these monitoring programs, however, cite the 

need for long-term monitoring of affected groups because some possible 

health effects, such as cancer, may not appear until decades after a person 

has been exposed to a harmful agent. They noted that long-term 

monitoring could result in earlier detection and treatment of cancers that 

might develop. Health experts also told us that monitoring is important for 

identifying and assessing the occurrence of newly identified conditions, 

such as WTC cough, and chronic conditions, such as asthma. 

 22Under the guidelines, a review committee consisting of public health scientists and 

stakeholder representatives evaluates each proposed research project based on criteria 

such as the proposal’s scientific and technical merit, funding, and contribution to a

community or individuals. 

Page 15 GAO-06-481T
CDC Is in Process of 

Deciding How to 

Distribute New Funds for 

Monitoring and Treating 

WTC Responders 

In January 2006, CDC received a $75 million appropriation for purposes 

related to the September 11, 2001, terrorist attacks. It is available to fund 

baseline screening, long-term monitoring, and health care treatment of 

emergency services and recovery personnel who responded to the WTC 

disaster.23 CDC is required to give first priority to funding baseline, followup screening, long-term medical health monitoring, or treatment programs 

implemented by the worker and volunteer program, the FDNY Medical 

Monitoring Program, the WTC Health Registry, the New York Police 

Foundation’s Project COPE, and the Police Organization Providing Peer 

Assistance of New York City. CDC is required to give second priority to 

funding similar programs that are coordinated by other organizations that 

are working with New York State and New York City. The programs that 

may qualify for secondary consideration are not specified in the law. 

In mid-February 2006, CDC officials told us that they were engaged in 

discussions with congressional stakeholders and the organizations 

specified in the law to help the agency decide how to spend the 

appropriated funds. Officials said that to aid their decisionmaking they 

were also consulting with private philanthropic organizations, including 

the American Red Cross, to learn more about the grant funds the 

organizations have provided to support the recovery needs of people 

affected by the WTC attack.24 CDC officials told us that they plan to first 

decide how they will allocate funds among screening, monitoring, and 

treatment programs and then make other decisions, such as how long the 

allocated funds will be available for each program. They said that they 

anticipated reaching a decision about the allocation of the funds by the 

end of February 2006, but did not know when they would reach other 

decisions. 

 23These funds are available to CDC until expended. See Department of Defense

Appropriations Act, 2006, Pub. L. No. 109-148, Sec. 5011 (b), 119 Stat. 2680,____. 

24In 2005, the American Red Cross September 11 Recovery Program developed a plan for 

distributing $50 million in grant funds over a 2-year period to support the recovery of 

September 11 victims and their families. The first grant was awarded in June 2005 to Mount 

Sinai’s WTC Health Effects Treatment Program, which supports workers and volunteers

dealing with ongoing physical and mental health problems following their service at WTC

disaster sites. The Red Cross program has also awarded grants to the four additional 

clinical centers that are part of the worker and volunteer program. 

Page 16 GAO-06-481T
HHS’s OPHEP established the WTC Federal Responder Screening Program 

to provide medical screening examinations for an estimated 10,000 federal

workers who responded to the WTC disaster in an official capacity and 

were not eligible for any other medical monitoring program. OPHEP did 

not initially develop a comprehensive list of federal responders who were

eligible for the program. The program began in June 2003—about a year 

later than other monitoring programs—and had completed screenings for 

394 workers through March 2004. No additional examinations were 

provided until the program resumed in December 2005, because OPHEP 

officials had temporarily suspended new examinations until they could 

resolve several operational issues. The program resumed conducting 

examinations for current federal workers in December 2005, and 

completed 133 additional examinations for current federal workers as of 

early February 2006. The examination process has not resumed for WTC 

responders who are no longer federal employees, but OPHEP recently 

executed an agreement with NIOSH to arrange for the worker and 

volunteer program to provide examinations to these WTC responders. We 

also identified two additional federal agencies that established screening 

programs for their own personnel who responded to the disaster. 

HHS’s Program for 

Screening Federal 

Responders Has 

Accomplished Little 

HHS Program Screened 

Few Federal Workers and 

Recently Started 

Conducting Examinations 

after a Hiatus of Almost 

2 Years 

HHS’s WTC Federal Responder Screening Program was established to 

provide free voluntary medical screening examinations for an estimated 

10,000 federal workers25 whom their agencies sent to respond to the WTC 

disaster from September 11, 2001, through September 10, 2002, and who 

were not eligible for any other monitoring program.26 FEMA provided 

$3.74 million through an interagency agreement with HHS’s OPHEP for the 

purpose of developing and implementing the program. OPHEP entered 

into an agreement with HHS’s FOH to schedule and conduct the screening 

examinations. 

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

intermittent federal employee. 

26According to a FEMA official, federal workers who did not receive official orders from

their agencies to respond to the WTC disaster are not eligible for this program. According

to an official of the worker and volunteer program, federal workers who volunteered on

their own in the aftermath of the disaster were eligible to participate in that screening 

program.

Page 17 GAO-06-481T
The launching of the federal responder screening program lagged behind 

the implementation of other federally funded monitoring programs for 

WTC responders. For example, the medical screening program for 

New York State employees and the worker and volunteer program started 

conducting screening examinations in May 2002 and July 2002, 

respectively. However, OPHEP did not launch its program until June 2003.

(Figure 1 highlights key actions in developing and implementing the 

program.) 

Page 18 GAO-06-481T
Figure 1: Timeline of Key Actions Related to WTC Federal Responder Screening Program 

Source: GAO analysis of information from HHS’s OPHEP, FOJ, and NIOSH, and FEMA.

Period during which program was conducting examinations

April 2005:

OPHEP 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

September 11, 2001:

WTC attack

July 2005:

OPHEP and FOH revise agreement to 

expand clinical services and provide 

referrals for follow-up care

March 2004:

FOH conducts last 

screening examination

December 2003:

FEMA approves no-cost 

extension of program 

through December 2005

March 2003:

FEMA and OPHEP enter agreement to implement 

WTC Federal Responder Screening Program

April 2003:

OPHEP and FOH enter agreement for 

conducting screening examinations

September 2005:

OPHEP initiates action to identify federal 

responders and to schedule examinations

for people on waiting list

2001 2002 2003 2004 2005 2006

October 2005:

OPHEP opens new Web site and 

federal responders begin registering 

for screening examinations

December 2005:

FEMA approves no-cost extension 

of screening program through 

December 2006 

FOH resumes examinations for 

current federal workers

OPHEP reaches decision to 

enter agreement with NIOSH to 

provide former federal workers

with examinations

February 2006:

OPHEP and NIOSH reach 

agreement for screening 

former federal workers

Page 19 GAO-06-481T
Initially, OPHEP did not develop a plan for identifying all federal agencies

and their personnel that responded to the WTC disaster or for contacting 

all federal personnel eligible for the screening program. Although OPHEP 

and FEMA developed a partial list of federal responders—consisting 

primarily of HHS and FEMA personnel—OPHEP did not have a 

comprehensive list of agencies and personnel, and so could not inform all 

eligible federal responders about the WTC screening program. The 

program’s principal action to communicate with the federal responders 

was to place program information and registration forms on FEMA’s 

National Disaster Medical System (NDMS) Web site.27

The screening program had operated for about 6 months when OPHEP 

officials decided in January 2004 to place it on hold by temporarily 

suspending examinations. FOH officials told us that after examinations 

were suspended, 35 additional people requested examinations and they 

were placed on a waiting list. FOH officials told us that they completed 

394 screening examinations28 from June 2003 through March 2004,29 with 

most completed by the end of September 2003. According to FOH, a total 

of $177,967 was spent on examinations through March 2004.30

OPHEP officials told us that three operational issues contributed to the 

decision to suspend the program. First, OPHEP could not inform all 

eligible federal responders about the program because it lacked a 

comprehensive list of eligible federal responders. Second, there were 

concerns about what actions FOH clinicians could take when screening 

examinations identified problems. Based on the examinations that had 

 27NDMS provides medical care to victims and responders to domestic disaster, including

acts of terrorism and natural disasters. According to HHS officials, when NDMS was 

transferred to FEMA in 2003 as part of the formation of DHS, key NDMS staff involved in

the initial planning of the screening program were also transferred. During the transition 

period, these NDMS staff continued to carry out some tasks related to the screening 

program, including working to identify agencies that had sent employees to the WTC 

disaster, developing a list of federal responders, and placing information about the program 

on the NDMS Web site. Officials said that overall program management responsibility and 

funding remained with HHS. 

28FOH officials told us that although FOH clinicians had seen approximately 460 federal 

personnel, not all of them completed the entire examination process. 

29FOH continued to schedule and conduct examinations for those people who had

requested an examination before the program was placed on hold in January 2004. 

30FOH officials told us that this amount includes spending on the 394 completed 

examinations and on examinations that were partially completed. 

Page 20 GAO-06-481T
been completed before the program was placed on hold, FOH clinicians 

determined that many participants needed additional diagnostic testing 

and follow-up care, primarily in the areas of respiratory functioning and 

mental health. However, under the existing interagency agreement there 

was no provision for providing follow-up care and no direction for 

clinicians on how to handle the provision of further diagnostic tests, 

treatment, or referrals. FOH officials told us that they were concerned 

about continuing to provide screening examinations without the ability to 

provide participants with additional needed services. Third, although the 

screening program had been established to provide examinations to all 

federal responders regardless of their current federal employment status, 

HHS officials told us that the department determined that FOH does not 

have the authority to provide examinations to people who are no longer in

federal service. 

In April 2005, OPHEP began to prepare for resuming the examination 

program by enlisting the assistance of ATSDR—which had successfully 

developed the WTC Health Registry—to establish a database containing

the names of federal responders, develop a new registration Web site, and 

develop and implement recruitment and enrollment plans for current and 

former federal workers. OPHEP executed an agreement with ATSDR 

allocating about $491,000 of the funds remaining from FEMA for these 

activities. OPHEP officials told us that, as part of the program’s 

recruitment and enrollment efforts, in mid-October 2005, a letter was sent 

to about 1,700 people identified as having responded to the WTC disaster 

to inform them about the program.31 According to OPHEP, the new 

registration Web site was activated in October 2005, and through early

February 2006, 345 additional current federal workers and 32 former 

workers had registered to obtain an examination.

 31OPHEP officials told us that they contacted a total of 132 federal agencies, requesting 

them to provide ATSDR’s contractor with contact information on the employees they sent

to respond to the WTC disaster. Of these agencies, 92 indicated that they sent employees to

respond to the WTC disaster, and 39 of the 92 agencies provided information on people

they believed might be eligible for OPHEP’s screening program. OPHEP officials said that

14 federal agencies told them that they wished to contact their employees themselves to 

inform them about the program. OPHEP provided these agencies with outreach materials

but has no information on what actions they took. According to OPHEP, five agencies

refused to provide information on their employees and the remaining agencies have agreed

to provide information but have not yet done so. 

Page 21 GAO-06-481T
In July 2005, OPHEP and FOH executed a new agreement for providing 

examinations to WTC responders who are current federal workers. Under 

this agreement, FOH clinicians can now make referrals for follow-up care. 

For example, they can refer participants with mental health symptoms to 

an FOH employee assistance program for a telephone assessment. If 

appropriate, the participant can then be referred to an employee 

assistance program counselor for up to six in-person sessions. If the 

assessment indicates that longer treatment is necessary, the participant 

can instead be advised to use health insurance to obtain care or to contact 

a local Department of Labor Office of Workers’ Compensation to file a 

claim, receive further evaluation, and possibly obtain compensation for 

mental health services. The new agreement between OPHEP and FOH also 

allows FOH clinicians to order additional clinical tests, such as special 

pulmonary and breathing tests. FOH officials told us that they resumed 

providing examinations in December 2005 and that 133 examinations have 

since been completed.32

The examination process has not resumed for WTC responders who are no 

longer federal employees, but in late February 2006, OPHEP executed an 

agreement with NIOSH to arrange for the worker and volunteer program 

to provide examinations to these WTC responders.33 Under this agreement, 

former federal workers will receive a one-time examination comparable to 

the type of examination that FOH is now providing to current federal 

workers. Patients with eligible conditions will be referred to the treatment

programs supported by the American Red Cross or other available 

programs. 

Two Federal Agencies 

Established Their Own 

Screening Programs 

In addition to the OPHEP program, we identified two federal agencies that 

established medical screening programs to assess the health of the 

personnel they had sent to respond to the WTC disaster. One agency, the 

Army, established two screening programs—one specifically for Army 

Corps of Engineers personnel and one that also included other Army 

responders. The Army Corps of Engineers established a voluntary program 

 32FOH officials told us that, as of early February 2006, they completed examinations for 128

current federal workers who registered on the program’s new Web site that opened in 

October 2005, and for 5 current federal workers who were on the waiting list after the 

screening program was placed on hold in January 2004. 

33This agreement also provides for examinations for other federal responders who are

ineligible to receive examinations from FOH, such as DOD employees.

Page 22 GAO-06-481T
to assess the health of 356 employees it had sent to respond to the 

disaster.34 The program, initiated in November 2001, consists of sending 

employees an initial medical screening questionnaire covering physical 

health issues.

35 If questionnaire results indicate symptoms or concerns that

need further evaluation, the employee is offered a medical examination.36

As of August 2004, 92 Corps of Engineers employees had participated in

the program, with 40 receiving follow-up examinations. The Army’s Center 

for Health Promotion and Preventive Medicine initiated a program—the 

World Trade Center Support Health Assessment Survey—in January 2002.

It was designed as a voluntary medical screening for Army military and 

civilian personnel, including contractors. From January 2002 through 

September 2003, questionnaires were sent to 256 employees.37 According 

to DOD, 162 employees completed and returned their questionnaires. In 

addition, the U.S. Marshals Service, within the Department of Justice, 

modified an existing agreement with FOH in 2003 for FOH to screen 

approximately 200 U.S. Marshals Service employees assigned to the WTC 

or Pentagon recovery sites. The one-time assessment includes a screening 

questionnaire and a medical examination.38 FOH officials said that as of 

August 2005, 88 of the 200 U.S. Marshals Service employees had requested 

and obtained examinations.39

 34The screening program has no closing date, and employees can request a screening 

examination at any time. 

35The questionnaire collects information on prior and WTC-related occupational exposures

and prior and current physical health status. 

36The medical examination includes a comprehensive history and physical examination; 

chest Xray; and pulmonary function, blood, and urine tests. 

37The Army’s questionnaire was distributed to active-duty service members, activated 

members of the Reserves and National Guard, civilian employees, and civilian contractors. 

These included 125 New Jersey Army National Guard members. The 474 active-duty 

members of the New York Army National Guard who responded to the WTC disaster were 

not included due to their eligibility to participate in the medical screening program

established for New York State workers. 

38The medical examination includes an occupational exposure history and physical 

examination, chest X-ray, blood and urine tests, pulmonary function test, audiogram, and 

electrocardiogram. 

39FOH officials told us that under the terms of the agreement, eligible employees can still 

request a screening examination. 

Page 23 GAO-06-481T
Lessons from WTC 

Health Monitoring 

Programs Could 

Assist Future 

Monitoring Efforts 

Officials involved in the WTC health monitoring programs implemented by

state and local governments or private organizations—including officials 

from the federal administering agencies—derived lessons from their 

experiences that could help officials design such programs in the future. 

They include the need to quickly identify and contact people affected by a 

disaster, the value of a centrally coordinated approach for assessing 

individuals’ health, the importance of monitoring both physical and mental 

health, and the need to plan for providing referrals for treatment when 

screening examinations identify health problems. 

Officials involved in the monitoring programs emphasized the importance 

of quickly identifying and contacting people affected by a disaster. They 

said that potential monitoring program participants can become more 

difficult to locate as time passes.40 In addition, potential participants’ 

ability to recall the events of a disaster may decrease over time, making it 

more difficult to collect accurate information about their experiences and 

health. However, the time it takes to design, fund, approve, and implement 

monitoring programs can lead to delays in contacting the people who were 

affected. For example, the WTC Health Registry received funding in July 

2002 but did not begin collecting data until September 2003—2 years after 

the disaster. From July 2002 through September 2003, the program’s 

activities included developing the registry protocol, testing the 

questionnaire, and obtaining approval from institutional review boards.41

To expedite such information collection during the response to future 

disasters, ATSDR officials have developed a model data collection 

instrument, known as the Rapid Response Registry, to allow officials to 

identify and locate potentially affected individuals immediately after a 

disaster and collect basic preliminary information, such as their current 

contact information and their location during the disaster. ATSDR officials 

expect that using this instrument would reduce delays in collecting timesensitive information while officials take the time necessary to develop a

monitoring program for disaster-related health effects. According to 

ATSDR officials, state and local agencies can request the instrument and 

 40The extent of the challenge of locating potential participants varied among WTC 

monitoring programs, depending on the population involved. For example, FDNY had 

contact information for all potential participants in its monitoring program because they

were employed by FDNY during or after the disaster. In contrast, the worker and volunteer 

program and the WTC Health Registry had to expend considerable effort to identify people 

who were eligible to participate and inform them about the programs. 

41Institutional review boards are groups that have been formally designated to review and 

monitor biomedical research involving human subjects. 

Page 24 GAO-06-481T
adapt it to their specific needs, and ATSDR can provide technical 

assistance on how to use the instrument. To date, 14 states have requested 

the Rapid Response Registry from ATSDR.42

Furthermore, officials told us that health monitoring for future disasters 

could benefit from additional centrally coordinated planning. Such 

planning could facilitate the collection of compatible data among 

monitoring efforts, to the extent that this is appropriate. Collecting 

compatible data could allow information from different programs to be 

integrated and contribute to improved data analysis and more useful 

research. In addition, centrally coordinated planning could help officials 

determine whether separate programs are necessary to serve different 

groups of people. For example, worker and volunteer program officials 

indicated that it might have been possible for that program to serve federal 

workers who responded to the disaster in an official capacity, which might 

have eliminated the need to organize and administer a separate program 

for them. 

Officials also stated that screening and monitoring programs should be 

comprehensive, encompassing both physical and mental health 

evaluations. This observation is supported by CDC’s recent report that 

about half of the adults that CDC assessed in areas heavily affected by

Hurricane Katrina exhibited levels of emotional distress that indicated a 

potential need for mental health services.43 Officials from the WTC worker 

and volunteer medical monitoring program told us that the initial planning 

for their program had focused primarily on screening participants’ 

physical health, and that they did not originally budget for extensive 

mental health screening. Subsequently, they recognized a need for more 

extensive mental health screening, including greater participation of 

mental health professionals, but the program’s federal funding was not 

sufficient to cover such screening. By collaborating with the Mount Sinai 

School of Medicine Department of Psychiatry, program officials were able

to obtain philanthropic funding to develop a more comprehensive mental

 42The following states have requested the instrument: Arizona, California, Colorado, 

Connecticut, Florida, Georgia, Michigan, Minnesota, North Carolina, Oklahoma, Rhode

Island, South Carolina, Tennessee, and Texas. 

43Centers for Disease Control and Prevention, “Assessment of Health-Related Needs After 

Hurricanes Katrina and Rita—Orleans and Jefferson Parishes, New Orleans Area, 

Louisiana, October 17-22, 2005,” Morbidity and Mortality Weekly Report, Vol. 55, page 38. 

Page 25 GAO-06-481T
health questionnaire; provide on-site psychiatric screening; and when 

necessary, provide more extensive evaluations. 

Many participants in the monitoring programs required additional testing 

or needed treatment for health problems that were identified during 

screening examinations. Officials told us that finding treatment sources for 

such participants is an important, but challenging, part of the programs’ 

responsibility. For example, officials from the worker and volunteer 

program stated that identifying providers available to treat participants 

became a major part of their operations, and was especially difficult when 

participants lacked health insurance. The officials said that planning for 

future monitoring programs should include a determination of how best to 

help participants obtain needed treatment. 

Federally funded programs implemented by state and local governments 

or private organizations to monitor the health effects of the WTC attack on

thousands of people who responded to the disaster have made progress. 

However, the program HHS established to screen the federal employees 

whose agencies sent them to the WTC after the attack has accomplished 

little, completing screenings of 527 of the thousands of federal responders. 

Moreover, no examinations occurred for a period of almost 2 years, and 

examinations for former federal workers have not yet resumed. Because 

of this program’s limited activity, and the inability of federal workers to 

participate in other monitoring programs because of the assumption that 

they would have the opportunity to receive screening examinations 

through the HHS program, many federal responders may not have had an 

opportunity to identify and seek treatment for health problems related to 

the WTC disaster. 

Concluding 

Observations 

Based on their experiences, officials involved in the monitoring programs 

have made a number of useful observations that will apply to future 

terrorist attacks and natural disasters, such as Hurricane Katrina. For 

example, screening for mental as well as physical health problems in New 

Orleans and along the Gulf Coast will be critical to the recovery of 

survivors of Hurricane Katrina and the responders to the disaster, as 

indicated by CDC’s early assessment of the extent of mental health 

distress among people affected by Hurricane Katrina. Another observation 

was the importance of quickly identifying and contacting people affected 

by a disaster. The model data collection instrument developed by ATSDR 

has the potential to enable officials to quickly and systematically identify

people involved in future disasters, a necessary first step in conducting 

health monitoring. Finally, officials noted the value of centrally 

Page 26 GAO-06-481T
coordinated planning of health monitoring, which could improve the 

underlying database for research and eliminate the need for separate and 

sometimes incompatible monitoring programs for different populations. 

Mr. Chairman, this completes my prepared remarks. I would be happy to 

respond to any questions you or other members of the subcommittee may 

have at this time. 

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

Bascetta at (202) 512-7101 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; George H. 

Bogart; Alice L. London; Roseanne Price; and William R. Simerl made key 

contributions to this statement. 

Contact and 

Acknowledgments 

Page 27 GAO-06-481T
Page 28 GAO-06-481T

Appendix I: Abbreviations 

ATSDR Agency for Toxic Substances and Disease Registry 

CDC Centers for Disease Control and Prevention 

DHS Department of Homeland Security 

DOD Department of Defense 

FDNY New York City Fire Department 

FDNY-BHS New York City Fire Department Bureau of Health Services 

FEMA Federal Emergency Management Agency 

FOH Federal Occupational Health Services 

HHS Department of Health and Human Services 

NDMS National Disaster Medical System 

NIOSH National Institute for Occupational Safety and Health 

NYC New York City 

OPHEP Office of Public Health Emergency Preparedness

RTI Research Triangle Institute 

WTC World Trade Center 
Page 29 GAO-06-481T

Appendix II: Government Agencies That Sent 

Responders Following the World Trade 

Center Attack 

Through our work, we identified the following agencies that sent 

employees to respond to the World Trade Center attack of September 11, 

2001. 

Department of Defense 

Department of Energy 

Department of Health and Human Services 

 Agency for Toxic Substances and Disease Registry 

 Centers for Disease Control and Prevention 

 National Institutes of Health 

 Substance Abuse and Mental Health Services Administration

Department of Homeland Security 

 Federal Emergency Management Agency1

 U.S. Coast Guard2

Department of the Interior 

 National Park Service 

Department of Justice 

 Federal Bureau of Investigation 

 U.S. Marshals Service 

Department of Labor 

 Occupational Safety and Health Administration 

Environmental Protection Agency 

Department of Environmental Conservation 

Department of Health 

Division of Military and Naval Affairs 

Emergency Management Office 

Office of Mental Health 

Department of Design and Construction 

Department of Environmental Protection 

Department of Health and Mental Hygiene 

Department of Sanitation

Federal Agencies 

New York State 

Agencies 

New York City 

Agencies 

 1

At the time of the World Trade Center attack, the Federal Emergency Management Agency

was an independent agency. 

2

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

of Transportation. 
Fire Department 

Metropolitan Transportation Authority 

Office of Emergency Management 

Police Department 

(290526) Page 30 GAO-06-481T
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