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 

HHS Has Screened 

Additional Federal 

Responders for World Trade 

Center Health Effects, but 

Plans for Awarding Funds 

for Treatment Are 

Incomplete 

Statement of Cynthia A. Bascetta 

Director, Health Care 

For Release on Delivery

Expected at 10:30 a.m. EDT 

in New York, New York, Friday, September 8, 2006

 

GAO-06-1092T 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

September 8, 2006

SEPTEMBER 11

HHS Has Screened Additional Federal 

Responders for World Trade Center 

Health Effects, but Plans for Awarding 

Funds for Treatment Are Incomplete 

Highlights of GAO-06-1092T, a testimony 

before the Subcommittee on National 

Security, Emerging Threats, and 

International Relations, Committee on 

Government Reform, House of 

Representatives 

Responders to the World Trade

Center (WTC) attack—individuals 

involved in rescue, recovery, or 

cleanup—included New York City 

Fire Department (FDNY) 

personnel, federal government 

workers, and others from New 

York and elsewhere. They were

exposed to numerous hazards, and 

concerns remain about the longterm effects on their physical and 

mental health. 

In February 2006, GAO testified 

that four of the five key federally 

funded programs that were

monitoring health effects in

responders had made progress but 

that the Department of Health and

Human Services’ (HHS) WTC 

Federal Responder Screening 

Program, implemented by the 

Office of Public Health Emergency 

Preparedness (OPHEP), lagged

behind (GAO-06-481T). GAO also 

reported that the Congress 

appropriated $75 million in 

December 2005 to HHS’s Centers 

for Disease Control and Prevention

(CDC) for monitoring and

treatment for responders and that 

CDC was deciding how to allocate 

the funds. 

This statement updates GAO’s 

February 2006 testimony. GAO 

examined (1) progress made by

HHS’s WTC federal responder

program and (2) actions CDC has 

taken to award the $75 million 

appropriated. GAO reviewed

program documents and 

interviewed HHS officials and 

others involved in WTC monitoring

and treatment programs. 

The WTC federal responder program has registered and screened additional 

federal responders since February 2006, and arrangements are being 

developed to screen responders who are former federal workers residing 

outside the New York area. An additional 1,385 federal responders have 

registered for screening, including 1,134 current federal workers and 251 

former federal workers, bringing the total number registered as of late 

August 2006 to 1,762, including 283 former federal workers. Because the 

total number of federal responders is uncertain, the proportion of the total 

who have registered is unknown. As of late August 2006, Federal 

Occupational Health Services (FOH) had completed screening of 907 federal 

workers, 380 of whom were screened since February 2006. Under an OPHEP 

agreement with CDC’s National Institute for Occupational Safety and Health 

(NIOSH), former federal workers are being screened through the worker and 

volunteer WTC program, one of the five key federally funded programs. As 

of July 31, 2006, the worker and volunteer WTC program provided

screenings to 13 former federal workers and scheduled 11 more, and 139 

former workers had been screened by FOH as part of the 907 workers. Most 

of the former federal workers reside outside the New York area, where the 

worker and volunteer WTC program is located, and NIOSH is working to 

establish a national network of providers to screen these workers. 

CDC has awarded a small portion of the $75 million appropriated for 

screening, monitoring, and treatment and plans to make decisions about 

treatment coverage before awarding most of the funds. The agency plans to

award the $75 million to the five organizations that the law identified as

having priority for funding. CDC officials expect to make awards to the WTC 

Health Registry, the Police Organization Providing Peer Assistance (the 

POPPA program), and the New York City Police Foundation’s Project COPE 

over a 3-year period and to award funds to the FDNY WTC and worker and 

volunteer WTC programs in response to the treatment costs they incur. CDC 

officials have a proposed spending plan that allocates about $53.5 million for 

the latter two programs’ treatment costs, but the officials told GAO that 

because they are uncertain about how quickly treatment costs could deplete 

the available funds, they may need to make adjustments. Officials from the 

FDNY WTC and worker and volunteer WTC programs told GAO that they 

anticipated that their estimated portion of the funds would be depleted well 

before the end of 3 years. As of August 2006, CDC awarded about 

$4.5 million of the $75 million: about $1.9 million to the WTC Health Registry, 

$1.5 million to the FDNY WTC program, and almost $1.1 million to the 

worker and volunteer WTC program. In addition, CDC expects to award 

$1.5 million to the POPPA program and $3 million to Project COPE in 

September 2006. CDC is waiting to make further awards until it has reached 

certain decisions about the coverage of treatment services, such as which 

prescription drugs would be covered. CDC expects to begin making further 

awards around February 2007. 

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

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 on programs 

that monitor and provide treatment for health effects of the World Trade 

Center (WTC) terrorist attack on September 11, 2001.

1

 My testimony today 

updates information we reported to you in February 2006.2

 An estimated 

40,000 people served as responders in the aftermath of the WTC disaster, 

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

government personnel, and other government and private-sector workers 

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

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

near the vicinity of the WTC or Staten Island site.3

 These responders were 

exposed to numerous physical hazards, environmental toxins, and 

psychological trauma. Five years after the destruction of the WTC 

buildings, concerns remain about the long-term physical and mental health

effects of the attack on responders as well as other affected individuals, 

including residents and workers. 

As we testified in September 2004,4

 in the aftermath of the WTC attack, 

five key federally funded programs were implemented to assess the shortterm, and in some cases long-term, effects on the physical and mental 

health of WTC responders. These programs are the FDNY WTC Medical 

Monitoring Program; WTC Medical Monitoring Program, which we refer to 

as the worker and volunteer WTC program;5

 New York State responder 

screening program; WTC Health Registry;6

 and the Department of Health 

and Human Services’ (HHS) WTC Federal Responder Screening Program. 

 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 Program for Federal Responders Lags Behind, GAO-06-481T (Washington, D.C.: 

Feb. 28, 2006). See also GAO, September 11: Monitoring of World Trade Center Health 

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

Sept. 10, 2005).

3

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

operation. 

4

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

GAO-04-1068T (Washington, D.C.: Sept. 8, 2004). 

5

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 WTC 

program.

6

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

Page 1 GAO-06-1092T 
We provided information on the progress of these monitoring programs7

 in 

our February 2006 testimony.8

 We noted that federal employees who 

responded in an official capacity in the aftermath of the WTC attack were 

eligible only for the federal responder program but that it had 

accomplished little and lagged behind the other four programs. The other 

programs had provided thousands of health screenings and collected 

information that could contribute to better understanding of the health

consequences of the attack and improve treatment for affected individuals. 

Officials of the three programs that planned to conduct long-term health 

monitoring—the FDNY WTC program, the worker and volunteer WTC 

program, and the WTC Health Registry—told us they were concerned, 

however, that federal funding for their programs could end before 

sufficient monitoring occurred to identify all long-term health problems 

related to the WTC attack, some of which, such as cancer, might not 

appear until decades after exposure to a harmful agent.9 We also reported 

that HHS’s Centers for Disease Control and Prevention (CDC) had recently

received a $75 million appropriation to fund programs providing health

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

was deciding how to allocate those funds.10

My testimony today revisits these issues. I will discuss (1) progress made 

by HHS’s WTC Federal Responder Screening Program, and (2) actions 

CDC has taken to award the $75 million that the Congress appropriated to 

the agency in December 2005 for programs that provide screening, 

monitoring, or treatment for WTC responders. 

To assess progress made by HHS’s WTC Federal Responder Screening 

Program, we obtained and reviewed program data and documents from

HHS, including applicable interagency agreements and budget documents. 

We interviewed officials from the Agency for Toxic Substances and 

Disease Registry (ATSDR); CDC’s National Institute for Occupational 

 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.

8

GAO-06-481T. 

9

At that time, funding for the FDNY WTC and worker and volunteer WTC programs was

available through mid-2009, and funding for the WTC Health Registry was available through 

April 29, 2008. 

10See Department of Defense Appropriations Act, 2006, Pub. L. No. 109-148, §5011 (b), 119 

Stat. 2680, 2814 (2005). These funds are available to CDC until expended. 

Page 2 GAO-06-1092T 
Safety and Health (NIOSH); Federal Occupational Health Services (FOH);11

and the Office of Public Health Emergency Preparedness (OPHEP). To 

determine actions taken by CDC to award funds from the $75 million 

appropriated, we obtained documents and interviewed officials from 

NIOSH and ATSDR. We also interviewed officials from organizations 

implementing programs designated in the appropriations act as having 

first priority for receiving the funds—including the Mount Sinai-Irving J. 

Selikoff Center for Occupational and Environmental Medicine, one of the 

clinical centers of the worker and volunteer WTC program; FDNY’s 

Bureau of Health Services (FDNY-BHS); the New York City Department of 

Health and Mental Hygiene; the Police Organization Providing Peer 

Assistance (the POPPA program); and the New York City Police 

Foundation’s Project COPE—and officials from the American Red Cross, 

which has funded treatment services for responders. We relied on data 

provided by agency officials and contained in government publications 

and did not independently verify the data we obtained. Although we could 

not independently verify the reliability of all of this information, we 

compared it with other supporting documents, when available, to 

determine data consistency and reasonableness. Based on these efforts, 

we believe the information we obtained is sufficiently reliable for this 

report. We conducted our work from July 2006 to September 2006 in 

accordance with generally accepted government auditing standards. 

In summary, since February 2006, HHS has registered and screened 

additional federal responders, and arrangements are being developed for 

screening responders who are former federal workers residing outside the 

New York metropolitan area. An additional 1,385 federal responders have 

registered for screening examinations, including 1,134 current federal 

workers and 251 former federal workers, bringing the total number 

registered on the WTC Federal Responder Screening Program Web site as 

of late August 2006 to 1,762, including 283 former federal workers. 

Because the total number of federal responders involved in the WTC 

disaster is uncertain, it is not possible to determine what proportion of the 

total number of federal responders have registered. As of late August 2006,

FOH had completed screening examinations for a total of 907 federal 

workers; 380 of the 907 were screened since February 2006. Under an 

OPHEP agreement with NIOSH, screening examinations for former federal 

workers are to be provided through the worker and volunteer WTC 

program. As of July 31, 2006, the worker and volunteer WTC program 

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

Page 3 GAO-06-1092T 
provided screening examinations to 13 former federal workers and 

scheduled 11 more. Most of the former federal workers reside outside the 

New York metropolitan area, where the worker and volunteer WTC 

program is located, and NIOSH is working to establish a national network 

of providers to screen these workers. 

CDC plans to award the $75 million appropriated for screening, 

monitoring, and treatment to the five organizations that the law identified

as having priority for funding. CDC officials expect to make awards to the 

WTC Health Registry, Project COPE, and the POPPA program over a 

3-year period and to award funds to the FDNY WTC and worker and 

volunteer WTC programs in response to their treatment costs. CDC 

officials have a proposed spending plan that allocates about $53.5 million 

for the latter two programs’ treatment costs, but the officials told us that 

because they are uncertain about how quickly treatment costs could 

deplete the available funds, they may need to make adjustments. Officials 

from the FDNY WTC and worker and volunteer WTC programs told us that 

they expected that their estimated portion of the appropriated funds 

would be depleted well before the end of 3 years. As of August 2006, CDC 

awarded about $4.5 million of the $75 million. The agency awarded about 

$1.9 million to the WTC Health Registry, $1.5 million to the FDNY WTC 

program, and almost $1.1 million to the worker and volunteer WTC 

program. In addition, CDC expects to award $1.5 million to the POPPA 

program and $3 million to Project COPE in September 2006. CDC is 

waiting to make further awards until it has reached certain decisions 

about the coverage of treatment services, such as which prescription 

drugs would be covered in the FDNY WTC and worker and volunteer WTC 

programs. CDC expects to begin making further awards around February 

2007. 

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

250,000 to 400,000 people in the vicinity were immediately exposed to a 

noxious mixture of dust, debris, smoke, and potentially toxic 

contaminants in the air and on the ground, such as pulverized concrete, 

fibrous glass, particulate matter, and asbestos. Those affected included 

people residing, working, or attending school in the vicinity of the WTC 

and thousands of emergency responders. Subsequently, an estimated 

40,000 responders who were involved in some capacity in the days, weeks, 

and months that followed, including personnel from many government 

Background 

Page 4 GAO-06-1092T 
agencies and private organizations as well as other workers and 

volunteers, were also exposed.12

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

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

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

of the WTC.13 Many health effects have persisted or worsened over time. 

Physical health effects included injuries and respiratory conditions, such 

as sinusitis, asthma, and a new syndrome called WTC cough, which 

consists of persistent coughing accompanied by severe respiratory 

symptoms. Almost all firefighters who responded to the attack 

experienced respiratory effects, including WTC cough. A recent study 

suggested that exposed firefighters on average experienced a decline in

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

aging.14

Commonly reported mental health effects among responders and other 

affected individuals included symptoms associated with posttraumatic 

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

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

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

alcohol and tobacco use and difficulty coping with daily responsibilities 

have also been reported.

 12The responders included firefighters; law enforcement officers; emergency medical 

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

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

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

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

personnel to respond to the WTC disaster. 

13See, for example, CDC, “Mental Health Status of World Trade Center Rescue and 

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

Mortality Weekly Report, vol. 53 (2004); CDC, “Physical Health Status of World Trade

Center Rescue and Recovery Workers and Volunteers—New York City, July 2002-August

2004,” Morbidity and Mortality Weekly Report, vol. 53 (2004); CDC, “Surveillance for 

World Trade Center Disaster Health Effects among Survivors of Collapsed and Damaged 

Buildings,” Morbidity and Mortality Weekly Report, vol. 55 (2006); and G.I. Banauch et al., 

“Pulmonary Function after Exposure to the World Trade Center in the New York City Fire 

Department,” American Journal of Respiratory and Critical Care Medicine, vol. 174, 

no. 3 (2006). 

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

Page 5 GAO-06-1092T 
The five programs that were created for monitoring the health of WTC 

responders vary in aspects such as the implementing agency (i.e., federal,

state, or local governments or private organizations) and eligibility 

requirements. (See table 1.) Each program received federal funding, the 

majority of which was provided by the Department of Homeland Security’s 

Federal Emergency Management Agency (FEMA),15 as part of the 

approximately $8.8 billion in federal assistance that the Congress 

appropriated to FEMA for response and recovery activities after the WTC 

disaster.16 FEMA is authorized to use a portion of its WTC-related funding 

for screening and long-term monitoring of responders.17 With regard to 

treatment, however, FEMA may generally fund only short-term care after a 

disaster, such as emergency medical services, and not ongoing clinical 

treatment.18 FEMA entered into interagency agreements with HHS to fund 

most of the health monitoring programs. OPHEP, which coordinates and 

directs HHS’s emergency preparedness and response program, entered 

into separate interagency agreements with FOH to implement the federal

responder screening program for current federal workers and with NIOSH 

to implement the screening program for former federal workers. 

Monitoring Programs 

 15FEMA is the agency responsible for coordinating federal disaster response efforts under

the National Response Plan. 

16FEMA provided funds to HHS to support screening and long-term monitoring efforts from

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

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

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

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

Department of Defense and Emergency Supplemental Appropriations for Recovery from 

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

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

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

221. 

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

18The Robert T. Stafford Disaster Relief and Emergency Assistance Act, as amended, 

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

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

Stafford Act does not specifically authorize ongoing clinical treatment. 

Page 6 GAO-06-1092T 
Table 1: Key Federally Funded WTC Health Monitoring Programs

Program 

Implementing agency or

organization Eligible population 

Completed monitoring 

activities, as reported by GAO

in September 2005a

Federal funding 

FDNY WTC Medical

Monitoring Programb

FDNY Bureau of Health 

Services (FDNY-BHS) 

Firefighters and

emergency medical 

technicians 

Through June 2005, 15,284 

firefighters and emergency 

medical technicians received

screening examinations, and 522 

of these participants completed a 

follow-up examination. 

$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 WTC 

program)b

Five clinical centers, one of 

which, the Mount SinaiIrving J. Selikoff Center for 

Occupational and 

Environmental Medicine, 

also serves as a data and 

coordination centerc

Rescue and recovery 

workers and 

volunteers,d excluding 

NYC firefighters and 

emergency medical 

technicians 

Through June 2005, 14,110 

people received screening 

examinations, and 1,699 of these 

participants completed a followup examination.

$15.9 million was 

provided for initial 

program;e additional 

$56 million is 

available through 

July 2009. 

New York State 

responder screening 

programf

New York State Department 

of Health 

New York State 

employees and

National Guard

personnel who 

responded to the WTC 

attack in an official 

capacity 

As of November 2003, 1,677 

employees and National Guard 

personnel received screening 

examinations. 

$2.4 million was 

provided in January 

2002 and is 

available through 

mid-January 2007.g

WTC Health 

Registryh

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, 2001i

As of November 2004, the 

program completed baseline data 

collection through interviews with 

the 71,437 people who enrolled

in the registry;j

in 2005, the 

program updated contact 

information obtained at the time 

of enrollment. 

$20 million was 

provided beginning 

in July 2002,k

 and as 

of September 2005, 

additional funding of 

about $3 million had 

been provided.l

WTC Federal 

Responder 

Screening Program 

HHS Office of Public Health 

and Emergency 

Preparedness (OPHEP); 

Federal Occupational 

Health (FOH) Services; and 

CDC’s National Institute for 

Occupational Safety and 

Health (NIOSH) 

Federal workers who 

responded to the WTC 

attack in an official 

capacitym

From June 2003 through March 

2004, 394 screening 

examinations were completed. 

When the program resumed in

December 2005, an additional

133 examinations were 

completed as of early February 

2006. 

$3.74 million was 

provided beginning 

in March 2003 and is 

available through 

December 2006. 

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

Department of Health and Mental Hygiene, New York State Department of Health, and NIOSH. Some of the information in this table 

originally appeared as tables 1 and 2 in GAO-06-481T. 

a

GAO-05-1020T. The monitoring activities completed by the WTC Federal Responder Screening 

Program are as reported by GAO in February 2006 (GAO-06-481T). The monitoring methods used by 

all programs except the WTC Health Registry consist of screening examinations that include a 

medical questionnaire and physical examination; the Registry’s monitoring method is a telephonebased health and exposure interview. 

Page 7 GAO-06-1092T 
b

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. 

c

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. 

d

The worker and volunteer WTC program excludes NYC firefighters and emergency medical 

technicians, as they are eligible for FDNY’s program. The program initially excluded responders who 

were paid as New York State employees for their WTC work and were eligible for the New York State 

responder screening program. That program ended its screening examinations in November 2003, 

and as of February 2004, New York State responders became eligible for the worker and volunteer 

WTC program. Beginning in February 2006, former federal workers enrolled in the HHS WTC Federal

Responder Screening Program were eligible to be screened in the worker and volunteer WTC 

program. 

e

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

CDC, and $4.1 million was provided in fiscal year 2003 through an interagency agreement with 

FEMA. 

f

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

g

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

h

The registry includes health and exposure information obtained through interviews with participants 

and was designed to track participants’ health for 20 years and to provide data on the long-term 

health consequences of the WTC attack. 

i

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

j

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

data. 

k

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, a private not-for-profit

organization, for most of the work to establish the registry, and about $16 million of the $20 million 

went directly from ATSDR to Research Triangle Institute. 

l

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

ATSDR provided $500,000 each.

m

Screening examinations for current federal workers are provided by FOH under an agreement with 

OPHEP. Screening examinations for former federal workers are provided by NIOSH through the

worker and volunteer WTC program. 

We reported in February 2006 that four of the five monitoring programs 

had made progress in screening and monitoring affected individuals and 

gathering data.19 (See table 1.) These four programs—the FDNY WTC 

Medical Monitoring Program, the worker and volunteer WTC program, the 

New York State responder screening program, and the WTC Health 

Registry—had collected information that monitoring officials said could 

be used by researchers to help better understand the health consequences 

 19GAO-06-481T. 

Page 8 GAO-06-1092T 
of the attack and improve treatment, such as by identifying which types of

treatment are effective for specific conditions. In contrast to the progress 

made by the other programs, the HHS WTC Federal Responder Screening 

Program had lagged behind and accomplished little.20 The program was 

established to provide free voluntary medical screening examinations for 

federal workers21 whom their agencies sent to respond to the WTC disaster 

from September 11, 2001, through September 10, 2002,22 and who were not 

eligible for any other WTC health monitoring program.23 Through March 

2004, the program—which started about a year later than the other WTC 

monitoring programs—completed screenings of 394 federal workers.24

HHS put the program on hold in January 2004, when it stopped scheduling 

new examinations, because it wanted to resolve several operational issues, 

including HHS’s determination that FOH did not have the authority to 

provide examinations to people who are no longer in federal service. 

Under an agreement between OPHEP and FOH that was established in 

July 2005, the program resumed providing examinations for current 

federal workers in December 2005, and in February 2006, OPHEP 

executed an agreement with NIOSH calling for NIOSH to arrange for the 

worker and volunteer WTC program to provide examinations to former 

federal workers. 

 20GAO-06-481T. 

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

intermittent federal employee. 

22In addition to the federal responder program, we identified three other, smaller-scale 

programs that were implemented by two federal agencies to assess the health of their own

employees who responded in the aftermath of the WTC attack. The Army established two 

screening programs—one specifically for Army Corps of Engineers personnel and one that 

was designed as a voluntary medical screening for Army military and civilian personnel,

including contractors. As of August 2004, 92 Corps of Engineers employees had

participated in the first program, with 40 receiving follow-up examinations, and 162

employees had completed and returned questionnaires in the second program. In the third

program, 88 employees of the U.S. Marshals Service, within the Department of Justice, had 

obtained a one-time assessment including a screening questionnaire and a medical 

examination as of August 2005. 

23According to a FEMA official, federal workers who did not receive official orders from

their agencies to respond to the WTC disaster are not eligible for the WTC Federal 

Responder Screening Program. According to an official of the worker and volunteer WTC 

program, federal workers who volunteered on their own in the aftermath of the disaster 

were eligible to participate in that screening program.

24We testified in February 2006 that OPHEP entered into an agreement with FOH in April 

2003 to provide screening examinations for federal workers who had responded to the 

WTC disaster and that these examinations began in June 2003. 

Page 9 GAO-06-1092T 
Many participants in the monitoring programs required additional testing 

or needed treatment for health problems that were identified during 

screening examinations. The FDNY WTC Medical Monitoring Program 

referred participants to the FDNY Bureau of Health Services, but the other 

programs primarily referred participants to their primary care physician or 

to privately funded programs available to responders, such as treatment 

services provided by the Mount Sinai clinical center that are funded by the 

American Red Cross. We previously reported that officials told us that 

finding treatment services for such participants was an important, but 

challenging, part of the programs’ responsibility.25 For example, officials 

from the worker and volunteer WTC program stated that identifying 

providers available to treat participants became a major part of their 

operations, and was especially difficult when participants lacked health

insurance. 

New Federal Funding for 

Monitoring and Treatment 

In December 2005, the Congress appropriated $75 million to CDC to fund 

programs providing baseline screening, long-term monitoring, and health

care treatment for emergency services and recovery personnel who 

responded to the WTC disaster. The law required CDC to give first priority 

to programs coordinated by the FDNY-BHS, Mount Sinai-Irving J. Selikoff 

Center for Occupational and Environmental Medicine, and New York City 

Department of Health and Mental Hygiene, which have existing monitoring 

programs, and to programs coordinated by the POPPA program and 

Project COPE.26 The mission of the POPPA program, which offers peer-topeer mental health counseling to New York City Police Department 

(NYPD) officers, is to reduce unresolved emotional trauma that can result 

in problems ranging from poor performance to suicide. The POPPA 

program counseled over 5,000 NYPD officers in the 10 months following 

the WTC attack. Project COPE, a collaboration of the New York City 

Police Foundation and Columbia University Medical Center, uses a hotline 

and outreach efforts to encourage NYPD uniformed and civilian 

employees to obtain mental health services, which are provided by 

Columbia University Medical Center and private providers. As of August 

2006, over 18,000 employees had attended educational sessions held at 

police facilities, and over 5,000 had received individual counseling or 

therapy consultations. 

 25GAO-06-481T. 

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

Page 10 GAO-06-1092T 
Since February 2006, an additional 1,385 federal responders have 

registered for screening examinations, bringing the total number 

registered on the WTC Federal Responder Screening Program Web site to 

1,762 as of late August 2006, including 283 former federal workers. 

Because the total number of federal responders involved in the WTC 

disaster is uncertain, it is not possible to determine what proportion of the 

total number of federal responders have registered. HHS’s efforts to 

conduct outreach to federal agencies resulted in the identification of 2,200 

federal responders. As of late August 2006, FOH had completed screening 

examinations for a total of 907 federal workers, 380 of whom were 

screened since February 2006. Through OPHEP’s agreement with NIOSH, 

the worker and volunteer WTC program has provided screening 

examinations to 13 former federal workers and scheduled 11 more. Most 

of the former federal workers reside outside the New York metropolitan 

area, where the worker and volunteer WTC program is located, and NIOSH 

is working to establish a national network of providers to screen these 

workers. 

HHS Has Registered 

and Screened 

Additional Federal 

Responders, and 

Arrangements for 

Screening Former 

Federal Workers 

outside the New York 

Metropolitan Area Are 

under Development 

HHS’s Outreach Resulted 

in Registration of 

Additional Federal 

Workers Involved in WTC 

Disaster Response 

HHS reported that as of late August 2006, a total of 1,762 federal 

responders had registered for screening examinations on the WTC Federal 

Responder Screening Program Web site, including 1,479 current federal 

workers and 283 former federal workers. Of the 1,762 federal responders 

who registered, 1,385 had registered since February 2006, including 1,134 

current federal workers and 251 former federal workers. It is not possible 

to determine what proportion of the total number of federal responders 

involved in the WTC disaster have registered because the total number 

involved is uncertain. In determining the total number of individuals 

eligible for its program, the WTC Health Registry developed an estimate of 

8,621 federal responders, based on information from 31 federal agencies in

the New York area and information from FEMA on 22 Urban Search and 

Rescue teams that were deployed to the WTC area.

27 This estimate does 

not account for all federal responders from other geographic areas. 

As we reported previously, in the aftermath of the WTC disaster, HHS did 

not have a comprehensive list of all federal agencies and federal 

responders who were involved. In an effort to develop such a list, OPHEP 

and ATSDR entered into an agreement in April 2005 for ATSDR—which 

 27This estimate consisted of 5,122 responders from the 31 federal agencies and 3,499 

responders from the 22 Urban Search and Rescue teams. 

Page 11 GAO-06-1092T 
had developed the WTC Health Registry—to identify and register federal 

responders.28 Under the agreement, ATSDR, through a contractor, 

contacted federal agencies, developed a list of WTC federal responders, 

and conducted outreach to encourage the responders to register on the 

new Web site that the contractor established.29 As a result of this effort, 46 

federal agencies were identified and provided contact information for 

2,200 federal responders.30

The agreement between OPHEP and ATSDR expired on April 30, 2006, 

ending the outreach efforts to federal agencies.31 Under an agreement with 

OPHEP, NIOSH assumed responsibility for maintaining the WTC Federal 

Responder Screening Program Web site through 

December 31, 2006.32

 28Before the federal responder program was placed on hold in January 2004, its principal 

action to communicate with the federal responders had been to place program information 

and registration forms on FEMA’s National Disaster Medical System Web site. 

29See “The WTC Federal Responder Screening Program,” https://wtcophep.rti.org/, 

downloaded Aug. 30, 2006. 

30Of the 90 other agencies contacted, 60 were determined to be ineligible because some 

were found to be nongovernmental agencies, some did not have federal workers at the 

WTC or Staten Island site, and some, such as the Department of Defense, participated in 

other screening programs; 21 opted to contact their federal workers on their own; and 9 

refused to provide information.

31ATSDR spent $372,961 of the $491,000 OPHEP originally allocated to the activities carried 

out under this agreement. The $491,000 was part of $3.74 million that FEMA had provided 

to OPHEP to develop and implement a monitoring program for federal responders. 

According to OPHEP, it will reallocate the $118,039 remaining from its expired agreement

with ATSDR to FOH or NIOSH for screening, depending on where there is a need. 

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

Page 12 GAO-06-1092T 
As of late August 2006, FOH had completed screening examinations for a 

total of 907 of the federal workers who had registered;33 380 of the 907 

were screened since February 2006.34 Under its agreement with OPHEP, 

FOH is responsible for regularly retrieving from the registration Web site 

requests for screening examinations for current federal workers and for 

assigning individuals to a provider for screening.

35 FOH officials told us 

that they contact the individual and the provider to inform them of the 

need to arrange an appointment for screening. The program relies on 

individuals to call the designated provider and schedule their appointment. 

FOH officials told us that individuals who have registered do not always 

contact the provider to schedule an appointment or may not keep an 

appointment or call to reschedule it. FOH officials said that they have 

attempted to contact such individuals but often received no response. 

HHS Has Screened 

Additional Current Federal 

Workers

We reported in our February 2006 testimony that under the July 2005 

agreement FOH clinicians can refer current federal workers for follow-up 

care if the screening examination—which includes a medical 

questionnaire, clinical tests such as a chest X-ray, and a full physical 

examination—reveals significant physical or mental health symptoms.36 On 

July 31, 2006, FOH told us that it had referred 39 current federal workers 

with mental health symptoms to an FOH employee assistance program 

(EAP) for counseling;37 24 to ear, nose, and throat specialists; 19 to 

pulmonary medicine specialists; and 1 to a cardiology specialist. 

 33Some of these federal workers registered on FEMA’s National Disaster Medical System 

Web site, which was used before the WTC Federal Responder Screening Program Web site

was created. 

34The 907 workers screened by FOH include 139 former federal workers that FOH screened

after the program resumed because FOH thought they were current federal workers. In

addition, FOH also screened an unknown number of former federal workers before the

federal program was placed on hold, and they would also be included in the 907. FOH 

officials told us that they have taken steps to ensure that they can better identify which 

registered workers are current federal employees. 

35Individuals are assigned to either an FOH clinic or a private provider participating in 

FOH’s network, based on their proximity to either type of provider. Appointments are 

made within 50 miles of an individual’s designated zip code. 

36The estimated cost of each screening examination is between $400 and $500, and 

additional costs may be incurred depending on the need for further diagnostic testing. 

37FOH can refer individuals with mental health symptoms to an FOH EAP for a telephone

assessment. If appropriate, the individual can then be referred to an EAP counselor for up

to six in-person sessions.

Page 13 GAO-06-1092T 
As of late August 2006, 283 former federal workers had registered to 

receive screening examinations, which under OPHEP’s agreement with 

NIOSH are to be provided by the worker and volunteer WTC program.38

Under the agreement, former federal workers receive a one-time 

examination comparable to the examination that FOH is providing to 

current federal workers. As of July 31, 2006, 13 screening examinations 

had been completed and 11 were scheduled. These completed and 

scheduled examinations are in addition to the 139 former federal workers 

that FOH screened after the WTC Federal Responder Screening Program 

resumed because FOH thought they were current federal workers.39

Screening of Former 

Federal Workers Has 

Resumed, but Group Is 

Widely Dispersed and 

Nationwide Network of 

Providers Is Still Being 

Established 

A key challenge in providing screening examinations to former federal 

workers has been that a large number do not reside in the New York 

metropolitan area, where the worker and volunteer WTC program is 

based. The 283 former federal workers who have registered for screening 

examinations reside in 40 states, and about 240 of them reside outside the 

New York metropolitan area. NIOSH officials said that making

arrangements to screen these widely dispersed responders has presented 

challenges, such as ensuring that the arrangements comply with federal 

privacy protections. NIOSH is negotiating with the Association of 

Occupational and Environmental Clinics (AOEC)40 in an effort to establish 

a national network of providers to screen these federal workers. 

 38This agreement also provides for examinations for other federal responders who are

ineligible to receive examinations from FOH, such as Department of Defense employees, 

and responders having intermittent periods of federal employment such as Urban Search

and Rescue workers. 

39When FOH officials realized those individuals were former federal workers, they

communicated this information to NIOSH so NIOSH could take responsibility for any 

follow-up care the workers might need. 

40The AOEC is a nonprofit organization committed to improving the practice of 

occupational and environmental health through information sharing and collaborative 

research. The AOEC consists of a network of university-affiliated and other private clinics 

across the United States and in other countries. 

Page 14 GAO-06-1092T 
CDC plans to award the $75 million appropriated for screening, 

monitoring, and treatment to the five organizations that the law identified

as having priority for funding. CDC officials expect to make awards to the 

WTC Health Registry, Project COPE, and the POPPA program over a 

3-year period and to award funds to the FDNY WTC and worker and 

volunteer WTC programs in response to their treatment costs. CDC 

officials have a proposed spending plan but told us that because they are 

uncertain about how quickly treatment costs could deplete the available 

funds, they may need to make adjustments. Officials from the FDNY WTC 

and worker and volunteer WTC programs told us that they expected that 

their estimated portion of the appropriated funds would be depleted well 

before the end of 3 years. As of August 2006, CDC awarded about 

$4.5 million of the $75 million—about $1.9 million to the WTC Health 

Registry, $1.5 million to the FDNY WTC program, and almost $1.1 million 

to the worker and volunteer WTC program. In addition, CDC expects to 

award $1.5 million to the POPPA program and $3 million to Project COPE 

in September 2006. CDC is waiting to make further awards until agency 

officials have reached certain decisions about the coverage of treatment 

services, such as which prescription drugs would be covered in the FDNY 

WTC and worker and volunteer WTC programs. CDC expects to begin 

making further awards around February 2007. 

CDC Has Awarded a 

Small Portion of the 

$75 Million 

Appropriation and 

Plans to Make 

Decisions about 

Treatment Coverage 

before Awarding Most 

of the Funds 

CDC Plans to Award the 

$75 Million to the Five 

First-Priority 

Organizations 

CDC has decided to award the $75 million for screening, monitoring, and 

treatment that was appropriated to the agency in December 2005 to the 

five organizations identified as having first priority for funding.

41 The 

organizations to which CDC plans to provide funds are 

• the FDNY WTC program, for monitoring and treatment; 

• the worker and volunteer WTC program, for monitoring and treatment; 

• the WTC Health Registry, for monitoring; 

• Project COPE, for treatment; and 

• the POPPA program, for treatment. 

CDC plans to make awards through cooperative agreements with the 

programs.42 In general, it plans to send letters to the organizations inviting 

 41Within CDC, NIOSH has lead responsibility for making decisions about the $75 million, 

and ATSDR is involved in decisions relating to the WTC Health Registry. 

42A cooperative agreement is a mechanism used to provide financial support when 

substantial interaction is expected between a federal agency and a state, local government, 

or other recipient carrying out the funded activity. 

Page 15 GAO-06-1092T 
them to submit applications for funding; the applications would then 

undergo a two-stage peer review process. At the first stage a panel of 

outside experts would assess the merit of the application, and at the 

second stage CDC officials would determine the amount of funding the 

applicant would receive.

CDC has made preliminary decisions about how to allocate the $75 million 

among the five organizations. As of September 1, 2006, CDC’s proposed 

spending plan indicated that awards would be made in the following way: 

• $53.5 million for treatment and $8 million for monitoring, to be divided 

between the FDNY WTC and worker and volunteer WTC programs;43

• $9 million for the WTC Health Registry; 

• $3 million for Project COPE; and 

• $1.5 million for the POPPA program. 

CDC officials expect to make awards to the WTC Health Registry, Project 

COPE, and the POPPA program over a 3-year period, but are not sure over 

what period they will make awards to the FDNY WTC and worker and 

volunteer WTC programs. A CDC official told us that the agency would 

award funds to the latter two programs in response to the treatment costs 

they incur. He said that agency officials are uncertain about how quickly 

treatment costs could deplete the available funds, because CDC does not 

know how many additional people will seek monitoring and what the 

extent of their treatment needs will be. For example, previous media 

reports about illnesses diagnosed in responders have resulted in increases 

in responders seeking examinations. Officials from the FDNY WTC and 

worker and volunteer WTC programs told us that they expected that their 

estimated portion of the appropriated funds would be depleted well before 

the end of 3 years. CDC has developed a proposed spending plan that 

indicates that about 36 percent of the funds would be awarded by the end 

of fiscal year 2007 and about 63 percent would be awarded during fiscal 

year 2008, although a CDC official told us that, depending on the extent of 

treatment needs, the funds could be used more quickly. The current plan is 

based in part on an agreement CDC made with the American Red Cross in 

April 2006.44 According to a CDC official, under this agreement, American 

Red Cross funds would be used for the treatment services that are eligible 

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

44This agreement provides for the American Red Cross to assist CDC in estimating program 

costs and developing the federally funded treatment programs. 

Page 16 GAO-06-1092T 
for American Red Cross support—such as basic clinical examinations and

certain tests—for as long as such funds are available and the CDC funds 

would be used to cover other program expenses—such as infrastructure 

costs, more sophisticated diagnostic tests, and the conversion of medical

records into an electronic format. 

As of August 2006, CDC had awarded a total of about $4.5 million of the 

$75 million to the WTC Health Registry, FDNY WTC program, and worker 

and volunteer WTC program. According to CDC officials, the WTC Health 

Registry applied for about $1.9 million in April 2006 for continuation of its 

collection of health data, and CDC awarded the registry $1.9 million in 

May 2006 and about $56,000 in July 2006.45 On August 10 and 11, 2006, 

respectively, the worker and volunteer WTC and FDNY WTC programs 

submitted applications to CDC for funds related to treatment services. In 

response to these applications, CDC made what an agency official termed 

emergency awards to the FDNY WTC and worker and volunteer WTC 

programs on August 11, 2006.46 CDC provided $1.5 million to the FDNY 

WTC program for leasing treatment space that previously had been 

provided by New York City at no cost. CDC provided almost $1.1 million to

the worker and volunteer WTC program to hire an additional physician to 

help reduce the 3- to 4-month waiting time for treatment appointments 

that recently developed at the Mount Sinai clinical center, as well as to 

hire three administrators and a medical assistant. Officials from the 

clinical center told us that this waiting time had developed because 

additional people were seeking monitoring due to media reports about 

illnesses diagnosed in responders and because the proportion of 

responders who needed to be referred for treatment had increased. 

In addition to having awarded about $4.5 million, CDC plans to award an 

additional $4.5 million in September 2006. In spring 2006, CDC invited 

Project COPE and the POPPA program, two programs that provide mental 

health services to members of the NYPD, to apply for funding through a 

peer review process. In their applications, the POPPA program requested 

CDC Has Awarded about 

$4.5 Million of the 

$75 Million Appropriated 

 45The registry subsequently applied for an additional $1 million to support its operations 

through April 2007. 

46The official told us that CDC was able to make these awards so quickly after receiving the

applications because agency officials had been discussing the programs’ needs for 

treatment funds with program officials for several months and the programs had provided 

draft applications a week before submitting the final applications. 

Page 17 GAO-06-1092T 
$1.5 million over 3 years, and Project COPE requested funding of 

$3 million over 3 years. CDC received their applications in June and July,

respectively, and plans to implement the application review process in 

time to be in a position to make awards in September 2006. 

CDC does not plan to award additional funds from the $75 million to the 

FDNY WTC and worker and volunteer WTC programs until it makes 

certain decisions about the coverage of treatment services. These 

decisions include determining which medical conditions will be covered;47

developing a prescription drug formulary, that is, the list of drugs that will 

be covered; and determining the extent to which inpatient care will be 

covered. CDC officials said that they expected to make the coverage

decisions in late 2006 and that they would obtain input from the American 

Red Cross and the programs. 

A CDC official told us that making decisions about which prescription 

drugs to cover could be the greatest challenge CDC and the programs face,

because of the potentially high cost of drugs needed to treat responders. 

An FDNY WTC program official said that prescription drug costs are a 

looming financial problem for the FDNY WTC program. The CDC official 

told us that the most common diagnoses of WTC responders—

gastroesophageal reflux disease, obstructive pulmonary disease, and 

mental health conditions—frequently are treated with prolonged and

expensive drug therapy. For example, medications for respiratory therapy

can cost $1,000 a month and may continue for a year. The FDNY WTC 

program official estimated that 100 percent coverage of prescriptions for 

firefighters and emergency medical technicians could cost $10 million to 

$18 million per year and potentially consume all of the funding that CDC 

would provide to the program. Clinicians at the worker and volunteer 

WTC clinical center at Mount Sinai stated that spending on prescription 

drugs at their center was increasing by $5,000 to $10,000 each month and 

amounted to $60,000 in July 2006. 

Another coverage decision that CDC faces is to determine the extent to 

which inpatient care will be covered. Currently, the FDNY WTC and 

worker and volunteer WTC programs provide only outpatient care, but 

CDC Is Waiting to Award 

Additional Funds for 

Treatment Until It Makes 

Decisions about Coverage 

 47The medical conditions that now receive treatment funded by the American Red Cross 

provided the baseline for conditions that will be included. CDC will determine whether any 

additional conditions will be included and will continue to assess whether all appropriate

conditions are included over time. 

Page 18 GAO-06-1092T 
officials involved with these programs believe that the treatment funds 

from the $75 million should cover some inpatient care, such as when a 

responder’s WTC-linked asthma becomes exacerbated to an extent that 

requires hospitalization.

CDC officials told us that they plan to reach decisions about treatment 

coverage in fall 2006. They also plan to invite the FDNY WTC and worker 

and volunteer WTC programs to submit applications for treatment funding 

in the fall. If the applications are submitted by December 2006, CDC 

officials expect to be able to review them in time to provide funding to the 

programs by February 2007. 

CDC is also in the process of resolving issues related to providing access 

to screening, monitoring, and treatment services for WTC responders, 

including former federal workers, who reside outside the New York 

metropolitan area. CDC is negotiating with AOEC about possibly using 

AOEC clinics around the country to provide these services. CDC officials 

told us they intend that monitoring and treatment services available to 

responders around the country would be comparable to services provided 

by the worker and volunteer WTC program. 

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

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

have at this time. 

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; Fred 

Caison; Anne Dievler; Keyla Lee; and Roseanne Price made key 

contributions to this statement. 

Contact and 

Acknowledgments 

Page 19 GAO-06-1092T 
Page 20 GAO-06-1092T 

Appendix I: Abbreviations 

AOEC Association of Occupational and Environmental Clinics 

ATSDR Agency for Toxic Substances and Disease Registry 

CDC Centers for Disease Control and Prevention 

EAP employee assistance program 

FDNY New York City Fire Department 

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

FEMA Federal Emergency Management Agency 

FOH Federal Occupational Health Services 

HHS Department of Health and Human Services 

NIOSH National Institute for Occupational Safety and Health 

NYPD New York City Police Department 

OPHEP Office of Public Health Emergency Preparedness

POPPA Police Organization Providing Peer Assistance 

WTC World Trade Center 

(290562) 
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