Testimony 

Before the Subcommittee on National Security, 

Emerging Threats, and International Relations, 

Committee on Government Reform, House of 

Representatives 

United States Government Accountability Office

GAO 

For Release on Delivery 

Expected at 10:00 a.m. EDT 

Wednesday, September 8, 2004 SEPTEMBER 11 

Health Effects in the 

Aftermath of the World 

Trade Center Attack 

Statement of Janet Heinrich 

Director, Health Care—Public Health Issues 

GAO-04-1068T 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

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

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Janet Heinrich 

at (202) 512-7119. 

Highlights of GAO-04-1068T, a testimony 

before the Subcommittee on National 

Security, Emerging Threats, and 

International Relations, Committee on 

Government Reform, House of 

Representatives 

September 8, 2004

SEPTEMBER 11

Health Effects in the Aftermath of the 

World Trade Center Attack 

In the aftermath of the September 11 attack on the World Trade Center, a 

wide variety of physical and mental health effects have been reported in the 

scientific literature. The primary health effects include various injuries, 

respiratory conditions, and mental health effects. In the immediate aftermath 

of the attack, the primary injuries were inhalation and musculoskeletal 

injuries. During the 10-month cleanup period, despite the dangerous work 

site, responders reported few injuries that resulted in lost workdays. A range 

of respiratory conditions have also been reported, including wheezing, 

shortness of breath, sinusitis, asthma, and a new syndrome called WTC 

cough, which consists of persistent cough accompanied by severe 

respiratory symptoms. Almost all the firefighters who responded to the 

attack experienced respiratory effects, and hundreds had to end their 

firefighting careers due to WTC-related respiratory illness. Unlike the 

physical health effects, the mental health effects were not limited to people 

in the WTC area but were also experienced nationwide. Because most of the 

information about mental health effects comes from questionnaire or survey 

data, what is reported in most cases are symptoms associated with a 

psychiatric disorder, rather than a clinical diagnosis of disorder. The most 

commonly reported mental health effects include symptoms associated with 

depression, stress, anxiety, and posttraumatic stress disorder (PTSD)—a 

disorder that can develop after experiencing or witnessing a traumatic event 

and includes such symptoms as intrusive memories and distressing 

dreams—as well as behavioral effects such as increased use of alcohol and 

tobacco and difficulty coping with daily responsibilities. 

Six programs were established to monitor and understand the health effects 

of the attack, and these programs vary in terms of which people are eligible 

to participate, methods for collecting information about the health effects, 

options for treatment referral, and number of years people will be 

monitored. Although five of the programs focus on various responder 

populations, the largest program—the WTC Health Registry—is open not 

only to responders but also to people living or attending school in the 

vicinity of the WTC site, or working or present in the vicinity on September 

11. The monitoring programs vary in their methods for identifying those who 

may require treatment, and although none of these programs are funded to 

provide treatment, they provide varying options for treatment referral. Under 

current plans, HHS funding for the programs will not extend beyond 2009. 

Some long-term health effects, such as lung cancer, may not appear until 

several decades after a person has been exposed to a harmful agent. 

GAO provided a draft of this testimony to DHS, EPA, HHS, and the 

Department of Labor. In its written comments, HHS noted that the testimony 

does not include significant discussion of ways in which mental health 

symptoms have changed over time. The evidence GAO examined did not 

support a full discussion of changes in mental or physical health effects over 

time. 

When the World Trade Center 

(WTC) buildings collapsed on 

September 11, 2001, nearly 3,000 

people died and an estimated 

250,000 to 400,000 people who 

were visiting, living, working, and 

attending school nearby, or 

responding to the attack, were 

exposed to a mixture of dust, 

debris, smoke, and various 

chemicals. In the months to follow, 

thousands of people who returned 

to the area to live and work, as well 

as responders who were involved 

in the search for remains and site 

cleanup, were also exposed. In 

addition, people in New York City 

and across the country were 

exposed to the emotional trauma of

a terrorist attack on American soil. 

Concerns have been raised about 

the short- and long-term physical 

and mental health effects of the 

attack. Various government 

agencies and private organizations 

established efforts to monitor and 

understand these health effects. 

GAO was asked to describe the 

health effects that have been 

observed in the aftermath of the 

WTC attack and the efforts that are 

in place to monitor and understand 

those health effects. GAO searched 

bibliographic databases such as 

Medline to determine the pertinent 

scientific literature, reviewed that 

literature, and interviewed and 

reviewed documents from 

government officials, health 

professionals, and officials of labor 

groups. 
Page 1 GAO-04-1068T 

Mr. Chairman and Members of the Subcommittee: 

I appreciate the opportunity to be here today as you discuss the health 

effects of the September 11, 2001, terrorist attack on the World Trade 

Center (WTC).1

 When the WTC buildings collapsed on that day, nearly 

3,000 people died and an estimated 250,000 to 400,000 people were 

immediately exposed to a mixture of dust, debris, smoke, and various 

chemicals.2

 These people included those living, working, and attending 

school in the vicinity as well as the thousands of emergency response 

workers who rushed to the scene. Also exposed to these substances were 

the thousands of responders3

 who were involved in some capacity in the 

rescue operations, search for remains, and site cleanup in the days, weeks, 

and months to follow and the thousands of residents, commuters, and 

students who returned to the area to live and work while the cleanup 

continued.4

 In addition, people in New York City (NYC) and across the 

country were exposed to the emotional trauma of a terrorist attack 

intended to instill fear and anxiety in the American population. 

Concerns have been raised about the short- and long-term physical and 

mental health effects of the attack. Experts have stressed the importance 

of understanding the health effects related to the attacks and ensuring that 

these effects are investigated and that people needing treatment are 

identified. Under challenging circumstances due to the unprecedented 

nature of the events and the need for rapid response, various government 

 1

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

2

New York City Department of Health and Mental Hygiene and U.S. Department of Health 

and Human Services, Agency for Toxic Substances and Disease Registry, Protocol for the 

World Trade Center Health Registry (New York, 2003). 

3

For purposes of this testimony, the term responders refers to anyone involved in rescue, 

recovery, and cleanup efforts at or in the vicinity of the WTC site and Staten Island Fresh 

Kills landfill (the off-site location of the WTC recovery operation), including firefighters, 

law enforcement officers, emergency medical technicians and paramedics, morticians, 

health care professionals, construction workers, ironworkers, carpenters, heavy equipment 

operators, mechanics, truck drivers, engineers, laborers, telecommunications workers, and 

various federal, state, and local agency employees who assisted with rescue, recovery, and 

cleanup activities. 

4

For more information on exposures to these substances, see, for example, U.S. 

Environmental Protection Agency, Exposure and Human Health Evaluation of Airborne 

Pollution from the World Trade Center Disaster (External Review Draft) (Washington, 

D.C., 2002), and J.D. Pleil et al., “Air Levels of Carcinogenic Polycyclic Aromatic 

Hydrocarbons after the World Trade Center Disaster,” Proceedings of the National 

Academy of Sciences of the United States of America, vol. 101, no. 32 (2004). 
Page 2 GAO-04-1068T 

agencies and private-sector organizations established several efforts to 

monitor and understand the health effects resulting from the attack. You 

asked us to examine these efforts. 

In this testimony, we describe (1) health effects that have been observed 

in the aftermath of the WTC attack and (2) efforts that are in place to 

monitor and understand those health effects. My colleague’s testimony 

addresses workers’ compensation for people who were injured while 

working during the attack or its aftermath.5

To describe the health effects of the WTC attack and the efforts to monitor 

and understand them, we reviewed the scientific literature related to 

efforts to identify, track, or treat the physical and mental health effects of 

the September 11 attack6

 and interviewed and reviewed documents from 

federal, state, and local agency officials, as well as medical and public 

health professionals and officials of labor groups. We searched 19 

bibliographic databases such as Medline to determine the pertinent 

literature. The studies of health effects vary in study design, measures 

used, survey instruments, time periods, and populations studied, and thus 

in many cases the reported results cannot be directly compared. The 

federal, state, and local officials we interviewed were from the U.S. 

Departments of Defense (DOD), Education, Health and Human Services 

(HHS), Homeland Security (DHS), Justice (DOJ), Labor (DOL), and 

Veterans Affairs (VA); the Environmental Protection Agency (EPA); the 

New York State Department of Health; the New York State Office of 

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

Hygiene. The medical and public health professionals we interviewed were 

affiliated with the Association of Occupational and Environmental Clinics, 

the City University of New York’s Queens College, the New York City Fire 

Department’s (FDNY) Bureau of Health Services, the Greater New York 

Hospital Association, the Johns Hopkins Bloomberg School of Public 

Health, the Mailman School of Public Health at Columbia University, the 

Mount Sinai-Irving J. Selikoff Clinical Center for Occupational and 

Environmental Medicine, the New York Academy of Medicine, the New 

York University School of Medicine’s Child Study Center, and the National 

Child Traumatic Stress Network. We also interviewed representatives of 

 5

GAO, September 11: Federal Assistance for New York Workers’ Compensation Costs, 

GAO-04-1013T (Washington, D.C.: Sept. 8, 2004). 

6

See the bibliography for a list of the scientific literature that we relied on in producing this 

testimony. 
Page 3 GAO-04-1068T 

labor groups, including the American Federation of State, County and 

Municipal Employees District Council 37; the Communications Workers of 

America; the New York State American Federation of Labor-Congress of 

Industrial Organizations; and the Uniformed Firefighters Association. 

We relied primarily on data from published, peer-reviewed articles and 

government reports and did not independently verify the data contained in 

the scientific literature or documents obtained from agency officials and 

medical professionals. However, we did review the methods used in the 

studies and discussed any questions we had about the studies with their 

authors. We determined that the data reported from these studies were 

sufficiently reliable for our objectives. We conducted our work from 

March 2004 through September 2004 in accordance with generally 

accepted government auditing standards. 

In summary, in the aftermath of the September 11 attack on the World 

Trade Center, a wide variety of physical and mental health effects have 

been reported in the scientific literature. The primary health effects 

include various injuries, respiratory conditions, and mental health effects. 

In the immediate aftermath of the attack, the primary injuries were 

inhalation and musculoskeletal injuries. During the 10-month cleanup 

period, despite the dangerous nature of the work site, responders reported 

few injuries that resulted in lost workdays. A range of respiratory 

conditions have also been reported, including wheezing, shortness of 

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

consists of persistent cough accompanied by severe respiratory 

symptoms. Almost all the firefighters who responded to the attack 

experienced respiratory effects, and hundreds had to end their firefighting 

careers due to WTC-related respiratory illness. Whereas the physical 

health effects were limited to people in the WTC area, the mental health 

effects, although more pronounced in the NYC area, were experienced 

nationwide. Because most of the information about mental health effects 

comes from questionnaire or survey data, what is reported in most cases 

are symptoms associated with a psychiatric disorder, rather than a clinical 

diagnosis of the disorder itself. The most commonly reported mental 

health effects include symptoms associated with depression, stress, 

anxiety, and posttraumatic stress disorder (PTSD)—an often debilitating 

and potentially chronic disorder that can develop after experiencing or 

witnessing a traumatic event and includes such symptoms as intrusive 

memories and distressing dreams—as well as behavioral effects such as 

increased use of alcohol and tobacco and difficulty coping with daily 

responsibilities. 
Page 4 GAO-04-1068T 

Six programs have been established by federal, state, and local 

government agencies and private organizations to monitor and understand 

the health effects of the attack. These programs vary in terms of which 

people are eligible to participate, methods for collecting information about 

the health effects, options for treatment referral, and number of years 

people will be monitored. Although five of the monitoring programs focus 

on various responder populations, the largest program—the WTC Health 

Registry—is open not only to responders—that is, those involved in the 

rescue, recovery, and cleanup efforts—but also to people living or 

attending school in the vicinity of the WTC site, or working or present in 

the vicinity on September 11. The monitoring programs vary in their 

methods for identifying those who may require treatment, and although 

none of these programs are funded to provide treatment, they provide 

varying options for treatment referral. Under current plans, HHS funding 

for the programs will not extend beyond 2009. Some long-term health 

effects, such as lung cancer, may not appear until several decades after a 

person has been exposed to a harmful agent. 

We provided a draft of this testimony to DHS, DOL, EPA, and HHS. In its 

written comments, HHS noted that the testimony does not include 

significant discussion of ways in which mental health symptoms have 

changed over time. The evidence we examined did not support a full 

discussion of changes in mental or physical health effects over time. HHS 

and the other agencies also provided technical comments, which we 

incorporated as appropriate. 

Although people across the country were exposed through the media to 

the emotional trauma of the WTC attack, the residents, office workers, and 

others living, working, or attending school in the WTC area and the WTC 

responders not only experienced the traumatic event in person but also 

were exposed to a complex mixture of potentially toxic contaminants in 

the air and on the ground, such as pulverized concrete, fibrous glass, 

particulate matter, and asbestos. Almost 3,000 people, including some who 

were trapped above the impact zone and others who entered the buildings 

to assist in the evacuation, were killed in the attack.7

 The majority of the 

estimated 16,400 to 18,800 people who were in the WTC complex that 

 7

National Commission on Terrorist Attacks upon the United States, The 9/11 Commission 

Report (Washington, D.C., 2004). 

Background 
Page 5 GAO-04-1068T 

morning were able to evacuate, however, with minor or no injuries.8 An 

estimated 40,000 responders were at or in the vicinity of the WTC site or 

the Staten Island Fresh Kills landfill, participating in rescue, recovery, and 

cleanup efforts9

; conducting environmental and occupational health 

assessments; providing crisis counseling and other treatment; providing 

security; and assisting with the criminal investigation. 

The responders included personnel from many agencies at the federal, 

state, and local levels, as well as from organizations in the private sector, 

and various other workers and volunteers. The agencies and organizations 

include HHS’s Agency for Toxic Substances and Disease Registry 

(ATSDR), HHS’s Centers for Disease Control and Prevention (CDC), the 

Department of Energy, EPA, DOJ’s Federal Bureau of Investigation (FBI), 

DHS’s Federal Emergency Management Agency (FEMA), HHS’s National 

Institute for Occupational Safety and Health (NIOSH), HHS’s National 

Institute of Environmental Health Sciences (NIEHS), the Department of 

the Interior’s National Park Service, DOL’s Occupational Safety and Health 

Administration (OSHA), HHS’s Public Health Service Commissioned 

Corps, HHS’s Substance Abuse and Mental Health Services Administration 

(SAMHSA), DOD’s U.S. Coast Guard, DOJ’s U.S. Marshals Service, the 

New York State Department of Environmental Conservation, the New 

York State Emergency Management Office, the New York State National 

Guard, the New York State Office of Mental Health, the New York State 

Department of Health, the Metropolitan Transportation Authority’s New 

York City Transit, FDNY and emergency medical services (EMS), the New 

York City Department of Health and Mental Hygiene, the New York City 

Police Department (NYPD), the New York City Department of Design and 

Construction, the New York City Department of Environmental 

Protection, the New York City Department of Sanitation, the New York 

City Office of Emergency Management, the American Red Cross, and the 

Salvation Army. 

Recognizing a need to monitor and understand the full health effects of the 

WTC collapse, officials from various organizations secured federal funding 

 8

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

9

Department of Health and Human Services, “HHS Awards $81 Million for Five-Year Health 

Screening of World Trade Center Rescue, Recovery Workers,” Department of Health and 

Human Services, http://www.hhs.gov/news/press/2004pres/20040318.html (accessed 

Aug. 9, 2004). 
Page 6 GAO-04-1068T 

to establish programs to monitor the health of affected people.10 FDNY 

sought federal support in order to provide comprehensive medical 

evaluations to its firefighters, and established its WTC Medical Monitoring 

Program (referred to here as the FDNY program). The Mount Sinai Clinical 

Center for Occupational and Environmental Medicine also sought federal 

support in the weeks following the attack to develop its WTC Worker and 

Volunteer Medical Monitoring Program (referred to here as the Mount 

Sinai program).11 Through its Federal Occupational Health (FOH) services, 

HHS initiated a WTC responder screening program for federal workers 

(referred to here as the FOH program) involved in WTC rescue, recovery, 

and cleanup activities. Similarly, the New York State Department of Health 

established the medical monitoring program for New York State 

responders (referred to here as the NYS program) engaged in emergency 

activities related to the September 11 attack. In addition, two registries 

were established to compile lists of exposed persons and collect 

information through interviews and surveys in order to provide a basis for 

understanding the health effects of the attack. The New York City 

Department of Health and Mental Hygiene contacted ATSDR in February 

2002 to develop the WTC Health Registry. ATSDR provided technical 

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

and worked with FEMA to obtain funds for the WTC Health Registry for 

responders and people living or attending school in the vicinity of the WTC 

site, or working or present in the vicinity on September 11. Separately, 

Johns Hopkins received a grant from NIEHS to create another registry 

 10FEMA provided funds appropriated for disaster relief and emergency response to the 

September 11, 2001, terrorist attacks to HHS through interagency agreements to support 

monitoring efforts. See Consolidated Appropriations Resolution, 2003, Pub. L. No. 108-7, 

117 Stat. 11, 517; see also 2002 Supplemental Appropriations Act for Further Recovery from 

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

894; Department of Defense and Emergency Supplemental Appropriations for Recovery 

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

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

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

220-1. 

11Initial medical screenings of responders conducted by this program were supported by 

funds appropriated to CDC for disease control, research, and training. See Department of 

Defense and Emergency Supplemental Appropriations for Recovery from and Response to 

Terrorist Attacks on the United States Act, 2002, 115 Stat. at 2313. 
Page 7 GAO-04-1068T 

(referred to here as the Johns Hopkins registry) of WTC site workers who 

were involved in cleanup efforts.12

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

and reported across a wide range of people in the aftermath of the 

September 11 attacks. The health effects include various injuries, 

respiratory conditions, reproductive health effects, and mental health 

effects. Unlike the physical health effects, the mental health effects of the 

September 11 attacks were not limited to responders and people who were 

in the WTC area but were also experienced by people across the nation. 

Because most of the information about mental health effects comes from 

questionnaire or survey data, what is reported in most cases are symptoms 

associated or consistent with a disorder, such as PTSD, rather than a 

clinical diagnosis of a disorder. The most commonly reported mental 

health effects were symptoms associated with PTSD, depression, stress, 

and anxiety, as well as behavioral effects such as increases in substance 

use and difficulties coping with daily responsibilities. 

Although the total number of people injured during the WTC attack is 

unknown, data on hospital visits show that thousands of people were 

treated in its immediate aftermath for injuries, including inhalation 

injuries, musculoskeletal injuries, burns, and eye injuries. Unpublished 

data collected by the Greater New York Hospital Association from 

September 11 through September 28, 2001, showed 6,232 emergency room 

visits and 477 hospitalizations related to the attack in 103 hospitals in New 

York State and 1,018 emergency room visits and 84 hospitalizations related 

to the attack in nearby New Jersey hospitals. These numbers do not 

include injured people who may have been treated in more distant New 

York State, New Jersey, and Connecticut hospitals, in triage stations,13 or 

by private physicians, and those who did not seek professional treatment. 

More detailed information on injuries is available from the four hospitals 

closest to the WTC and a fifth hospital that served as a burn referral 

 12The grant was funded by an appropriation to NIEHS to support research, worker training, 

and education activities. See Department of Defense and Emergency Supplemental 

Appropriations for Recovery from and Response to Terrorist Attacks on the United States 

Act, 2002, 115 Stat. at 2337. 

13Triage stations are temporary facilities set up in the aftermath of a disaster where medical 

assessments of patients are performed to determine their relative priority for treatment, 

based on the severity of illness or injury. 

Varied Physical and 

Mental Health Effects 

Have Been Observed 

and Reported across a 

Wide Range of People 

Injuries 
Page 8 GAO-04-1068T 

center. According to the New York City Department of Health and Mental 

Hygiene, between September 11 and September 13, 2001, these hospitals 

treated 790 people, 2 of whom later died, for injuries related to the attack 

(CDC, 2002c). The most common of these injuries were musculoskeletal 

injuries—such as fractures, sprains, and crush injuries—and inhalation 

injuries. The majority of people with injuries were treated and released, 

although about 18 percent required hospitalization.14

In addition, thousands of responders were treated for injuries, a small 

proportion of which were classified as serious, during the 10-month 

cleanup period. The disaster site was considered to be extremely 

dangerous, yet no additional life was lost after September 11. Using data 

from five Disaster Medical Assistance Teams (DMAT) temporary medical 

facilities15 and the four hospitals closest to the WTC site, researchers 

documented 5,222 visits by rescue workers to DMAT facilities and 

emergency rooms in the first month of the cleanup period (Berrios-Torres 

et al., 2003). During this month, musculoskeletal injuries were the leading 

cause of rescue worker visits and hospitalizations. Other injuries included 

burns and eye injuries. According to OSHA, despite logging more than 

3.7 million work hours over the 10-month cleanup period, WTC site 

workers reported only 57 injuries that OSHA classified as serious because 

they resulted in lost workdays, yielding a lost workday injury rate of 

3.1 injuries per 100 workers per year. This rate is lower than that seen in 

the type of construction deemed by OSHA to be the most similar to the 

WTC cleanup, specialty construction, which has a lost workday injury rate 

of 4.3. 

A range of respiratory health effects, including a new syndrome called 

WTC cough and chronic diseases such as asthma, were observed among 

people exposed to the WTC collapse and its aftermath. Many of the 

programs examining respiratory health effects are ongoing and have 

published only preliminary results. Nevertheless, the studies present a 

 14In an assessment of the cardiovascular effects of the WTC attack in eight hospitals in 

NYC, no significant increases in hospitalization for cardiac events immediately following 

the attack were found (Chi et al., 2003). 

15The DMAT facilities were set up around the disaster site by FEMA’s National Disaster 

Medical System, which was activated on September 11. The DMATs maintained a 24-hour 

presence at the WTC site for 2 months after the disaster. In addition to the DMATs, the 

National Disaster Medical System also includes teams of morticians, veterinarians, nurses, 

pharmacists, and management personnel. 

Respiratory Health Effects 
Page 9 GAO-04-1068T 

consistent collection of conditions among those people who were involved 

in rescue, recovery, and cleanup as well as those who lived and worked in 

the WTC vicinity. The most commonly reported conditions include cough, 

wheezing, shortness of breath, sinusitis, and asthma. Many of the findings 

on respiratory effects published to date have focused on firefighters, and 

FDNY medical staff first described WTC cough, which consists of 

persistent cough accompanied by severe respiratory symptoms,16 often in 

conjunction with sinusitis, asthma, and gastroesophageal reflux disease 

(GERD).17 Several studies report on other WTC responders, such as the 

police, ironworkers, and cleanup workers, and a few studies report on the 

respiratory effects among people living and working in lower Manhattan. 

Almost all of the FDNY firefighters who had responded to the attack 

experienced respiratory effects, and hundreds had to end their firefighting 

careers due to WTC-related respiratory illness. Within 48 hours of the 

attack, FDNY found that about 90 percent of its 10,116 firefighters and 

EMS workers who were evaluated at the WTC site reported an acute 

cough. The FDNY Bureau of Health Services also noted wheezing, 

sinusitis, sore throats, asthma, and GERD among firefighters who had 

been on the scene. During the first 6 months after the attack, FDNY 

observed that of the 9,914 firefighters who were present at the WTC site 

within 7 days of the collapse, 332 firefighters had WTC cough (Prezant et 

al., 2002). Eighty-seven percent of the firefighters with WTC cough 

reported symptoms of GERD. According to the FDNY Bureau of Health 

Services, symptoms of GERD are typically reported by less than 25 percent 

of patients with chronic cough. Some FDNY firefighters exhibited WTC 

cough that was severe enough for them to require at least 4 weeks of 

medical leave. Despite treatment of all symptoms, 173 of the 

332 firefighters and one EMS technician with WTC cough showed only 

partial improvement. FDNY also found that the risk of reactive airway 

dysfunction syndrome, or irritant-induced asthma, and WTC cough was 

associated with intensity of the exposure, defined as the time of arrival at 

the site (Banauch et al., 2003). In addition, FDNY reports that one 

firefighter who worked 16-hour days for 13 days and did not use 

 16Severe respiratory symptoms are defined by the FDNY Bureau of Health Services as 

symptoms that are severe enough to require at least 4 consecutive weeks of medical leave. 

17GERD occurs when the lower esophageal sphincter does not close properly and stomach 

contents leak back, or reflux, into the esophagus. When refluxed stomach acid touches the 

lining of the esophagus, it causes a burning sensation in the chest or throat called 

heartburn. 

FDNY Firefighters 
Page 10 GAO-04-1068T 

respiratory protection during the first 7 to 10 days was diagnosed with a 

rare form of pneumonia that results from acute high dust exposure (Rom 

et al., 2002). According to an official from the FDNY Bureau of Health 

Services, because one of the criteria for being a firefighter is having no 

respiratory illness, about 380 firefighters were no longer able to serve as 

firefighters as of March 2004 as a consequence of respiratory illnesses they 

developed after WTC exposure. 

Studies and screenings conducted among other responders—carpenters, 

cleanup workers, federal civilian employees, heavy equipment operators, 

ironworkers, mechanics, National Guard members, police officers, 

telecommunications technicians, truck drivers, and U.S. Army military 

personnel—have found respiratory health effects similar to those seen in 

FDNY firefighters. Some of the responders with existing respiratory 

conditions reported that symptoms worsened, and others reported that 

they developed new respiratory symptoms on or after September 11. The 

most commonly reported symptom was cough. For example, about 

63 percent of officers from NYPD’s Emergency Services Unit who were 

evaluated about 1 to 4 months after September 11 reported having a cough 

(Salzman et al., 2004). Other symptoms observed among responders 

included chest tightness, nasal congestion, shortness of breath, sore 

throat, and wheezing. Unpublished results from respiratory health 

assessments of WTC site workers—including truck drivers, heavy 

equipment operators, mechanics, laborers, and carpenters—conducted by 

Johns Hopkins in December 2001 show that among those who reported no 

previous history of lower respiratory symptoms, 34 percent reported 

developing a cough and 19 percent reported wheezing. While some 

responders reported that symptoms improved or resolved a few months 

after the attack, others reported that they continued to experience 

symptoms. For example, initial results from screenings of 250 participants 

in Mount Sinai’s monitoring program show that 46 percent of these 

responders were still experiencing at least one pulmonary symptom and 

52 percent were still experiencing an ear, nose, or throat symptom 9 

months after the attack (Herbert and Levin, 2003). 

Surveys conducted among people living or working in lower Manhattan 

show that these people experienced respiratory health effects similar to 

those experienced by responders, such as nose or throat irritation and 

cough. For example, a door-to-door survey conducted by the New York 

City Department of Health and Mental Hygiene in three residential areas in 

lower Manhattan between October 25 and November 2, 2001, showed that 

the most frequently reported symptoms were nose or throat irritation 

(about 66 percent) and cough (about 47 percent) (CDC, 2002a). A NIOSH 

Other WTC Responders 

People Living or Working in 

Lower Manhattan 
Page 11 GAO-04-1068T 

survey of federal employees working near the WTC site found that 

56 percent of respondents reported having a cough (Trout et al., 2002). 

Other symptoms observed among those living or working in lower 

Manhattan include chest tightness, head or sinus congestion, shortness of 

breath, and wheezing. Some people reported that the WTC collapse and its 

aftermath exacerbated existing respiratory conditions, such as asthma, 

and others reported symptoms that developed after September 11, 2001. 

For example, a review of medical charts of children with existing asthma 

from a lower Manhattan clinic found that after September 11 there was a 

significant increase in asthma-related clinic visits among children who 

lived within 5 miles of the WTC site (Szema et al., 2004). Unpublished 

preliminary findings from a New York State Department of Health survey 

of NYC residents found that almost three-fourths of respondents living 

near the WTC site experienced new upper respiratory symptoms after 

September 11. 

For all measures of reproductive health studied except birth weight for 

gestational age,18 no differences were found between infants born to 

women who were in or near the WTC on September 11 and infants of 

those who were not. The Mount Sinai School of Medicine conducted a 

study of the 187 pregnant women19 who were either in or near the WTC on 

September 11. This study found no significant differences in average 

gestational duration at birth or average birth weight between infants of the 

women who were in or near the WTC on September 11 during their 

pregnancy and infants of the 2,367 women in the study’s comparison 

group, who were not (Berkowitz et al., 2003). Additionally, no significant 

differences in frequency of preterm births (less than 37 weeks of 

gestation) or in incidence of low birth weight (less than 2,500 grams) were 

observed. Nor was an association observed between symptoms of 

posttraumatic stress in the mother and frequency of preterm birth, low 

birth weight, or small-for-gestational-age20 infants. However, 8.2 percent of 

 18Gestation is the period between conception and birth of a baby, and gestational age is 

duration of gestation. 

19Of the 187 women, 3 miscarried and 2 were unavailable for follow-up, leaving 182 women 

with live births. The last delivery occurred in June 2002. 

20The term “small for gestational age” (SGA) means a fetus or infant is smaller in size than 

is expected for the baby’s sex, genetic heritage, and duration of gestation. Birth weight 

below the population tenth percentile, taking into account gestational age, is the most 

widely used definition of SGA. 

Reproductive Health 

Effects 
Page 12 GAO-04-1068T 

infants born to women who were in or near the WTC on September 11 

were born with a birth weight below the tenth percentile for gestational 

age, compared to 3.8 percent of infants born to women in the study’s 

control group. This difference was still statistically significant after 

variables such as maternal age, race/ethnicity, sex of the infant, and 

maternal smoking history were taken into account.21 Because small-forgestational-age infants are at risk for developmental problems, the Mount 

Sinai program includes a follow-up study in which researchers plan to 

obtain physical measurements of growth and perform assessments of early 

cognitive development. 

In the weeks and months after the WTC attack, people living, working, or 

attending school in NYC and responders involved in the rescue, recovery, 

and cleanup reported symptoms associated with PTSD, as did people 

across the nation. PTSD is an often debilitating and potentially chronic 

disorder that can develop after experiencing or witnessing a traumatic 

event. It includes such symptoms as difficulty sleeping, irritability or 

anger, detachment or estrangement, poor concentration, distressing 

dreams, intrusive memories and images, and avoidance of reminders of the 

trauma. 

People living or working near the WTC site reported a higher rate of 

symptoms associated with PTSD than did those living or working farther 

from the site. For example, researchers found that about 7.5 percent of 

Manhattan residents reported symptoms consistent with PTSD 5 to 

8 weeks after the attack, with 20 percent of those living in close proximity 

to the WTC reporting symptoms (Galea et al., 2002a). Similarly, NIOSH 

surveys found that reports of symptoms consistent with PTSD were 

significantly higher among school staff in the WTC vicinity than among 

school staff working at least 6 miles from the WTC site (CDC, 2002a). 

 21Additionally, an unpublished study conducted by the Mailman School of Public Health at 

Columbia University found no differences in birth weight, length, head circumference, or 

Apgar scores (the Apgar is a test performed at 1 and 5 minutes after birth to determine the 

physical condition of the newborn). However, in this study, the gestational duration 

observed among pregnant women who lived or worked near the WTC during the 2 weeks 

after September 11 was shorter than that of those who did not (274.3 versus 275.9 days). 

Though this difference was statistically significant, its clinical significance is unclear. 

Researchers planned to assess cognitive and motor functions of the infants at a 1-year 

follow-up visit. 

Symptoms Associated with 

PTSD 
Page 13 GAO-04-1068T 

Some groups of people, such as children and responders, were found to 

have experienced traumatic reactions to the attack. For example, a 

citywide survey of a representative sample of NYC fourth to twelfth 

graders 6 months after the attack found that over 10 percent reported 

having symptoms consistent with PTSD. The researchers who conducted 

this survey noted that these symptoms were five times more prevalent 

than pre-September 11 rates reported for other communities (Hoven et al., 

2002). Responders, many of whom lost colleagues, were also affected. 

Initial findings from the Mount Sinai program show that about 22 percent 

of a sample of 250 WTC responders reported symptoms consistent with 

PTSD (Herbert and Levin, 2003). 

People across the nation also reported symptoms associated with PTSD. A 

nationwide survey comparing reactions in NYC to those across the 

country using a nationally representative sample of U.S. adults found that 

the prevalence of symptoms associated with PTSD 1 to 2 months after the 

attack was significantly higher in the NYC metropolitan area (11.2 percent) 

than in other major metropolitan areas (3.6 percent) and the rest of the 

country (4 percent) (Schlenger et al., 2002). Another nationally 

representative sample in a nationwide survey of U.S. adults shows that 

17 percent of the U.S. population outside of NYC reported symptoms 

associated with PTSD 2 months after the attack (Silver et al., 2002). 

Although no baseline data are available on the prevalence of symptoms 

related to PTSD, typically about 3.6 percent of U.S. adults have a 

psychiatric diagnosis of PTSD during the course of a year.22

People living, working, and attending school in NYC and WTC responders, 

as well as people across the nation, reported symptoms associated with 

depression, stress, and anxiety. For example, in NYC, researchers found 

that about 9.7 percent of Manhattan residents surveyed 5 to 8 weeks after 

the attack reported symptoms consistent with depression (Galea et al., 

2002a). Nine hospitals in NYC reported that from September 11 to 

September 24, 2001, the predominant symptoms related to the WTC attack 

were those associated with anxiety, stress, and depression (Greater New 

York Hospital Association, 2001). Data from these hospitals show that 

anxiety declined over the month following the attack but increased again 

 22Department of Veterans Affairs, “What Is Posttraumatic Stress Disorder? A National 

Center for PTSD Fact Sheet,” www.ncptsd.org/facts/general/fs_what_is_ptsd.html, updated 

May 14, 2003 (accessed Aug. 16, 2004). 

Symptoms Associated with 

Depression, Stress, and 

Anxiety 
Page 14 GAO-04-1068T 

around the time that the first case of anthrax in NYC was announced in 

mid-October 2001. A NIOSH survey of people working in schools near the 

WTC site also reported symptoms of depression (CDC, 2002a). Among the 

responders, initial screenings from the Mount Sinai program show that 

nearly 37 percent of 250 program participants reported symptoms 

associated with anxiety, insomnia, and depression (Herbert and Levin, 

2003). In addition, a nationwide survey conducted 3 to 5 days after the 

attack in a nationally representative sample of U.S. adults found that 44 

percent of those surveyed reported one or more substantial symptoms of 

stress, including having difficulty concentrating, feeling irritable, feeling 

upset when something reminds the person of the attack, having disturbing 

thoughts or dreams, and having trouble sleeping (Schuster et al., 2001). 

The behavioral effects in the aftermath of the WTC attack included 

increased use of substances such as alcohol, tobacco, and marijuana. 

Increased use of alcohol and tobacco was identified through surveys of the 

general population conducted by the states of Connecticut, New Jersey, 

and New York in the 3 months following the attack (CDC, 2002b). In 

Manhattan, researchers found that almost 29 percent of people who 

responded to a survey administered 5 to 8 weeks after September 11 

reported increased use of cigarettes, alcohol, or marijuana after the attack 

(Vlahov et al., 2002). According to these researchers, this increase in 

substance use was still evident 6 months after September 11 (Vlahov et al., 

2004a,b). 

The behavioral effects also included difficulty coping with daily 

responsibilities. Some NYC children and adolescents, family members, and 

other adults, including members of the response community, are still 

having difficulty coping 3 years after September 11. For example, an 

ongoing SAMHSA-supported youth mental health program in NYC is 

treating 220 children and adolescents who are having problems coping, 

such as having difficulties functioning in school. In addition, researchers 

affiliated with the New York University School of Medicine’s Child Study 

Center’s bereavement program for families of uniformed personnel killed 

in responding to the WTC attacks noted that the psychological and 

emotional reactions of children and adolescents directly affected by the 

attacks have diminished somewhat over time but that some children 

continue to be affected by the emotional state and coping difficulties of 

their parents. Of particular concern to these researchers are the widowed 

mothers, who are experiencing sustained distress at twice the level 

typically found in the general population and are having difficulty coping 

with their daily responsibilities, such as single parenthood, almost 3 years 

Behavioral Effects 
Page 15 GAO-04-1068T 

later. Some responders, such as members of FDNY, also report having 

difficulty coping in the aftermath of September 11. 

The programs established to monitor and understand the health effects of 

the attack vary in terms of which people are eligible to participate, 

methods for collecting information about the health effects, options for 

treatment referral, and number of years people will be monitored. (See 

table 1.) FEMA provided funding for most of these programs through 

interagency agreements with HHS. These programs are not centrally 

coordinated, but some of them are collaborating with each other. 

Programs Established 

to Monitor and 

Understand Health 

Effects Vary in 

Eligibility 

Requirements, 

Methods, Treatment 

Referrals, and 

Duration 
Page 16 GAO-04-1068T 

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

 Administrator 

Eligible 

Populations Participation 

Monitoring 

Methods 

Treatment 

Referral 

Intended Duration and 

Federal Fundinga

WTC Health 

Registry 

NYC 

Department of 

Health and 

Mental Hygiene 

Between 250,000 

and 400,000 

responders and 

people living or 

attending school 

in the area of the 

WTC or working 

or being present 

in the vicinity on 

September 11 

As of 9/2004, 

60,483 people 

were enrolledb

Telephonebased health 

interview; plan 

to re-interview 

subset of 

population in 

2005 

Provides 

information on 

where 

treatment can 

be sought; 

refers 

participants to 

LIFENETc

 for 

mental health 

services 

Agency for Toxic 

Substances and 

Disease Registry 

intends to fund through 

fiscal year 2008 

 — $20 million total 

Environmental 

Protection Agency 

allocated in fiscal year 

2004 

 — $1.5 million total 

FDNY WTC 

Medical 

Monitoring 

Program

(FDNY program) 

FDNY Bureau 

of Health 

Services 

(FDNY-BHS) 

About 11,000 

firefighters and 

3,500 emergency 

medical service 

(EMS) 

technicians 

As of 4/2004, 

11,770 

firefighters and 

EMS technicians 

were enrolled 

Medical 

examination 

and 

questionnaire; 

three follow-up 

examinations 

planned 

Refers to 

FDNY-BHS 

National Institute for 

Occupational Safety 

and Health (NIOSH) 

intends to fund through 

6/2009 

 — $25 million total 

National Center for 

Environmental Health 

funded initial monitoring

 — $4.8 million total 

WTC Worker and 

Volunteer 

Medical 

Monitoring 

Program

(Mount Sinai 

program) 

Mount Sinai’s 

Irving J. 

Selikoff Clinical 

Center for 

Occupational 

and 

Environmental 

Medicined

About 12,000 

responderse

 

As of 8/2004, 

about 11,793 

people were 

enrolled 

Medical 

examination 

and 

questionnaire; 

three follow-up 

examinations 

planned 

Refers to 

privately 

funded 

program 

available for 

responders 

NIOSH intends to fund 

through 7/2009 

 — $56 million total 

NIOSH funded initial 

monitoringf 

— $15.8 million total 

The medical 

monitoring 

program for 

New York State 

workers

(NYS program) 

New York State 

Department of 

Health 

About 9,800 

New York State 

employees and 

National Guard 

personnel 

As of 10/2003, 

1,677 employees 

received medical 

evaluations 

Medical 

examination 

and 

questionnaire; 

follow-up on 

subset of 300 

employees 

planned 

Instructs 

participants to 

see their 

primary care 

physician or 

the state’s 

occupational 

health unit 

National Center for 

Environmental Health 

funded through fiscal 

year 2003 

 — $2.4 million total 

WTC cleanup 

and recovery 

worker registry

(Johns Hopkins 

registry) 

Johns Hopkins 

Bloomberg 

School of 

Public Health 

About 12,000 

members from 

three unionsg and 

the NYC 

Department of 

Sanitation 

As of 6/2003, 

1,337 workers 

responded to the 

mailed 

questionnaire 

Mail-in health 

survey 

Provides 

participants 

with brochures 

about health 

services; refers 

uninsured to 

Columbia 

University for 

mental health 

services 

National Institute of 

Environmental Health 

Sciences (NIEHS) 

funded through fiscal 

year 2003h 

— $1.2 millioni total 
Page 17 GAO-04-1068T 

 Administrator 

Eligible 

Populations Participation 

Monitoring 

Methods 

Treatment 

Referral 

Intended Duration and 

Federal Fundinga

WTC responder 

screening 

program for 

federal workersj

(FOH program) 

Department of 

Health and 

Human 

Services’ 

(HHS) Federal 

Occupational 

Health services 

About 10,000 

federal workers 

responding to 

WTC 

As of 3/2004, 

412 exams were 

completed and 

reviewed 

Medical 

examination 

and 

questionnaire 

Instructs 

participants to 

see their 

primary care 

physician 

HHS intends to fund 

through 12/2005 

 — $3.7 million total 

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

Health. 

Note: Programs are ordered according to participation level. 

a

Except as noted, FEMA provided funds to the agencies listed below through interagency agreements 

with HHS to support efforts to monitor the health effects of the WTC attack. 

b

The WTC Heath Registry officials told us that they have generated a list of 185,000 potential 

participants gathered from various sources, including employers and registration via the Web or 

telephone. Registry officials told us that the registry will continue to interview and enroll people who 

are on this list after the registration period ends. 

c

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

Office of Mental Health. 

d

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

e

People eligible to participate in the Mount Sinai program are those who worked primarily at or 

immediately adjacent to the WTC site, either during or after the disaster, including firefighters from 

outside NYC, police officers from NYC and surrounding communities, emergency rescue workers 

from a variety of organizations (including emergency medical technicians and paramedics), building 

and construction trade workers from the NYC metropolitan area and throughout the nation, members 

of the press and news media, health care workers, food service workers, structural and other 

engineers, and a variety of other public- and private-sector workers, and people who worked in the 

immediate vicinity of the WTC site restoring essential services, such as telephone services, 

electricity, and transportation, or performing services necessary to reopen buildings in the area, 

including cleaning and assessing the structural integrity of nearby buildings. The program excluded 

federal employees, FDNY firefighters, and, initially, New York State employees, who were all eligible 

for other programs. New York State responders were initially screened in the NYS program. The NYS 

program plans to follow 300 of these responders. All New York State responders are now eligible to 

participate in the Mount Sinai program. 

f

Initial medical monitoring conducted through this program was supported by funds appropriated to 

CDC. 

g

The International Brotherhood of Teamsters, the International Union of Operating Engineers, and the 

Laborers International Union of North America. 

h

Funds appropriated to NIEHS to support research, worker training, and education activities 

supported this grant. 

i

Includes funding for other activities, including Johns Hopkins’ WTC Cleanup and Recovery Worker 

Health Assessment and community outreach. 

j

HHS officials told us that HHS is making modifications to the program and no screenings are taking 

place. 
Page 18 GAO-04-1068T 

The six programs that have been created to monitor people who were 

exposed to the WTC attack and its aftermath vary in terms of populations 

eligible to participate. Although five of the programs focus on various 

responder populations, the largest program—the WTC Health Registry—is 

open not only to responders but also to people living or attending school 

in the vicinity of the WTC site, or working or present in the vicinity on 

September 11. Specifically, people eligible for participation in the WTC 

Health Registry include anyone who was in a building, on the street, or on 

the subway south of Chambers Street on September 11; residents and staff 

of or students enrolled in schools (prekindergarten through twelfth grade) 

or day care centers south of Canal Street on September 11; and those 

involved in rescue, recovery, cleanup, or other activities at the WTC site 

and/or WTC recovery operations on Staten Island anytime between 

September 11, 2001, and June 30, 2002. (See figure 1.) An estimated 

250,000 to 400,000 people are eligible for the WTC Health Registry23; 

however, the registry was planned with the expectation that 100,000 to 

200,000 people would enroll. Together the FDNY program and the Mount 

Sinai program cover more than half of the estimated 40,000 WTC 

responders.24 The FDNY program is open to all 11,000 FDNY firefighters 

and all 3,500 FDNY EMS technicians, including firefighters and technicians 

who were not exposed. Some 12,000 other responders are eligible to 

participate in the Mount Sinai program. Responders who were government 

employees are eligible for participation in programs such as the FOH 

program, which is open to the estimated 10,000 federal workers who 

responded to the WTC attacks, and the NYS program, which was open to 

about 9,800 New York State employees and New York National Guard 

personnel who were directed to respond to the WTC disaster. In addition, 

approximately 12,000 members from three NYC unions and the NYC 

Department of Sanitation, whether they were responders or not, were 

eligible to participate in the Johns Hopkins registry. 

 23New York City Department of Health and Mental Hygiene and Department of Health and 

Human Services, Agency for Toxic Substances and Disease Registry, Protocol for the World 

Trade Center Health Registry (New York, 2003). 

24Officials involved in the monitoring efforts acknowledge the potential for duplication 

across programs—for example, a responder could be enrolled in the Mount Sinai program, 

the Johns Hopkins registry, and the WTC Health Registry—but they have not determined 

the extent of duplication. 

Program Eligibility 
Page 19 GAO-04-1068T 

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

WTC Site 

Concerns have been raised by community and labor representatives 

regarding the eligibility requirements for some of these programs, and 

while changes have been made to accommodate some of these concerns, 

others remain unresolved, particularly with respect to the WTC Health 

Registry. For example, the eligibility criteria for participation in the Mount 

Sinai program were initially more restrictive, covering responders who 

Canal St.

Chambers St.

Wall Street

Rector

Manhattan

Bridge

Brooklyn

Bridge

Brooklyn Hudson

River

East

River

Source: GAO adaptation based on WTC Health Registry Eligibility Map provided by New York City Department of Health and 

Mental Hygiene.

Broadway

WTC

Site

To

Staten 

Island N
Page 20 GAO-04-1068T 

had been at the site at least 24 hours between September 11 and 14, 2001. 

After discussions with labor representatives and CDC officials, the 

program expanded its eligibility criteria to include additional responders 

who may not have been there on those days but were there later in 

September. In contrast, community and labor representatives have been 

unsuccessful in their attempts to expand the eligibility criteria of the WTC 

Health Registry. These representatives have noted that the geographic 

boundaries used by the registry exclude office workers below Chambers 

Street who were not at work on September 11 but returned to work in the 

following weeks; office workers, including several groups of city 

employees, working between Chambers and Canal Streets; and Brooklyn 

residents who may have been exposed to the cloud of dust and smoke. 

Registry officials told us that they understand the desire to be included but 

they believe coverage is adequate to provide a basis for understanding the 

health effects of the WTC attack. 

The monitoring programs vary in their methods for identifying those who 

may require treatment, and although none of these programs are funded to 

provide treatment, they provide varying options for treatment referral. 

Some programs refer participants to affiliated treatment programs, 

whereas others provide information on where participants can seek care. 

The FDNY program offers a comprehensive medical evaluation that 

includes collection of blood and urine for analysis, a pulmonary function 

test, a chest X-ray, a renal toxicity evaluation, a cardiogram, a hepatitis C 

test, and hearing and vision tests, as well as self-administered 

questionnaires on exposures and physical and mental health. Funds for the 

monitoring program do not cover treatment services. However, FDNY 

members who require treatment after being screened can obtain treatment 

and counseling services from the FDNY Bureau of Health Services and the 

FDNY Counseling Services Unit as a benefit of their employment. 

Similarly, under the Mount Sinai program, people receive a comprehensive 

physical examination that includes blood and urine analysis, a chest X-ray, 

a pulmonary function test, and complete self-administered as well as 

nurse-administered questionnaires on exposure, clinical history, and 

mental health.25 If a person requires follow-up medical care or mental 

health services but is unable to pay for the services, he or she can be 

 25In addition, a standardized evaluation of nasal passages and upper airways is performed 

on a subgroup of 1,000 participants. 

Monitoring Methods and 

Options for Treatment 

Referral 
Page 21 GAO-04-1068T 

referred for care to other Mount Sinai programs such as the Health for 

Heroes program, which is supported through philanthropic donations. 

The FOH and NYS programs also consist of medical evaluations of 

participants and self-administered health and exposure questionnaires. 

The FOH program conducted about 400 medical evaluations of federal 

workers. These evaluations included a physical examination, a pulmonary 

function test, a chest X-ray, and blood tests. Under the NYS program, the 

New York State Department of Civil Service Employee Health Service 

clinics or affiliated clinics conducted medical evaluations that included a 

physical examination and a pulmonary evaluation of almost 1,700 state 

workers. The questionnaires for both programs are more limited than the 

FDNY or Mount Sinai questionnaires; for example, they have fewer mental 

health questions. Under the FOH and NYS programs, workers who require 

care have been told to follow up with their primary care physicians under 

their own insurance. 

Unlike most of the other monitoring programs, the WTC Health Registry 

and the Johns Hopkins registry do not include a medical evaluation, and 

neither effort is affiliated with a treatment facility or program. Instead, the 

programs collect information from participants solely through 

questionnaires and provide information on where participants can seek 

care. The WTC Health Registry questionnaire is generally administered 

over the telephone. The program provides all participants with a resource 

guide of occupational, respiratory, environmental, and mental health 

facilities in New York State, New Jersey, and Connecticut where people 

can seek treatment. Some of the services provided by these facilities 

require health insurance, whereas others are free of charge. If in the 

course of a telephone questionnaire, a person’s responses to the mental 

health questions suggest that he or she may need to speak with a mental 

health professional, the person is given the option of being connected 

directly to a LIFENET counselor. The LIFENET counselor provides the 

person with information on where to go and whom to call for help with 

problems related to the WTC disaster. For the Johns Hopkins registry, the 

participants complete a mail-in questionnaire on physical and mental 

health. Responders who report mental health symptoms and agree to be 

recontacted may receive follow-up calls to refer them to mental health 

services. The referral process is facilitated by Columbia University’s 

Resiliency Program, which provides free, short-term mental health 

services to affected people. The Johns Hopkins registry also provides 

participants with brochures about health services and programs they may 

find useful, including information about the Mount Sinai program. 
Page 22 GAO-04-1068T 

The duration of the monitoring programs may not be long enough to fully 

capture critical information on health effects. Under current plans, HHS 

funding for the programs will not extend beyond 2009. For example, 

ATSDR entered into a cooperative agreement with the New York City 

Department of Health and Mental Hygiene in fiscal year 2003 with the 

intent to continue support of the WTC Health Registry for 5 years of its 

planned 20-year duration. Similarly, NIOSH awarded 5-year grants in July 

2004 to continue the FDNY and Mount Sinai programs, which had begun in 

2001 and 2002, respectively. Health experts involved in the monitoring 

programs, however, cite the need for long-term monitoring of affected 

groups because some possible health effects, such as cancer, do not 

appear until several decades after a person has been exposed to a harmful 

agent.26 They also emphasize that monitoring is important for identifying 

and assessing the occurrence of newly identified conditions, such as WTC 

cough, and chronic conditions, such as asthma. 

Although the monitoring programs began as separate efforts, some of the 

programs are collaborating with each other. In addition, there are other 

kinds of collaborative efforts, including those in which programs receive 

advice from various outside partners. 

The WTC Responder Health Consortium is an example of collaboration 

between monitoring programs. It was established by NIOSH in March 2004 

to coordinate the existing health monitoring of WTC responders initiated 

by the FDNY and Mount Sinai programs and to facilitate data sharing. It 

awarded $81 million in 5-year grants to six institutions to become clinical 

centers for WTC health monitoring. FDNY and Mount Sinai serve as 

coordinating centers under the consortium, and the other four institutions 

are coordinated with Mount Sinai.27 Together, these institutions will 

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

27These four institutions are the Long Island Occupational and Environmental Health 

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

Queens College, and the University of Medicine and Dentistry of New Jersey’s Robert 

Wood Johnson Medical School. 

Duration and Funding 

Collaboration 
Page 23 GAO-04-1068T 

provide follow-up health evaluations to a total of about 12,000 NYC 

firefighters and EMS technicians and up to 12,000 other WTC responders.28

Collaboration efforts have also been fostered between the monitoring 

programs and outside partners and researchers. For example, the WTC 

Registry has a Scientific Advisory Group that includes representatives 

from the Mount Sinai School of Medicine, FDNY, the Johns Hopkins 

University, Columbia University, Hunter College, New York Academy of 

Medicine, New York University, the New York State Department of Health, 

and the New Jersey Department of Health. The group has assisted the New 

York City Department of Health and Mental Hygiene and ASTDR in 

development of the WTC Registry protocol, selection of the eligible 

population, and analysis methods. It has been meeting with WTC officials 

quarterly since early 2002 to advise on such issues as data collection, study 

options, and guidelines for research studies to be done using the registry. 

In addition, EPA convened an expert review panel in March 2004 to obtain 

greater input on ongoing efforts to monitor the health effects of workers 

and residents affected by the WTC collapse. The panel consists of 

representatives from federal and NYC agencies involved in air monitoring; 

from WTC health effects monitoring programs; and from academic 

institutions and the affected community. The goals of the panel include 

identification of unmet public health needs, gaps in exposure data, gaps in 

efforts to understand the health effects of the WTC attack, and ways in 

which the WTC Health Registry could be enhanced to allow better tracking 

of workers and residents. 

A multitude of physical and mental health effects have been reported in 

the years since the terrorist attack on the World Trade Center on 

September 11, 2001, but the full health impact of the attack is unknown. 

Concern about potential long-term effects on people affected by the attack 

remains. The monitoring programs may not be in operation long enough to 

adequately capture information about new conditions, chronic conditions, 

and diseases whose onset may occur decades after exposure to a harmful 

agent, such as many cancers. Nevertheless, these programs are providing a 

more complete picture of the health impact of such events, and as they 

 28NYPD also applied to be in the consortium to provide monitoring for its officers who were 

responders to the WTC disaster, but was not able to secure funding to support its 

monitoring activities. However, NYPD responders are eligible for enrollment in the Mount 

Sinai program. 

Concluding 

Observations 
Page 24 GAO-04-1068T 

proceed they are also providing the opportunity to identify people needing 

treatment. 

We provided a draft of this testimony to DHS, DOL, EPA, and HHS. HHS 

provided written comments, in which it noted that the testimony does not 

include significant discussion on the ways in which mental health 

symptoms have changed over time. We relied primarily on data from 

published, peer-reviewed articles and government reports, and some of the 

researchers we spoke with emphasized that their studies are ongoing and 

they expect to publish further results. In the absence of these results, the 

evidence we examined did not support a full discussion of changes in 

mental or physical health effects over time. HHS and the other agencies 

also provided technical comments, which we incorporated as appropriate. 

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

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

have at this time. 

For further information about this testimony, please contact Janet 

Heinrich at (202) 512-7119. Michele Orza, Angela Choy, Alice London, 

Nkeruka Okonmah, and Roseanne Price made key contributions to this 

statement. 

Agency Comments 

Contact and Staff 

Acknowledgments 
Page 25 GAO-04-1068T 

ATSDR Agency for Toxic Substances and Disease Registry 

CDC Centers for Disease Control and Prevention 

DOD Department of Defense 

DHS Department of Homeland Security 

DOJ Department of Justice 

DOL Department of Labor 

DMAT Disaster Medical Assistance Teams 

EMS emergency medical services 

EPA Environmental Protection Agency 

FBI Federal Bureau of Investigation 

FEMA Federal Emergency Management Agency 

FOH Federal Occupational Health 

FDNY New York City Fire Department 

GERD gastroesophageal reflux disease 

HHS Department of Health and Human Services 

NIEHS National Institute of Environmental Health Sciences 

NIOSH National Institute for Occupational Safety and Health 

NYC New York City 

NYPD New York City Police Department 

OSHA Occupational Safety and Health Administration 

PTSD posttraumatic stress disorder 

SGA small for gestational age 

SAMHSA Substance Abuse and Mental Health Services 

 Administration 

VA Department of Veterans Affairs 

WTC World Trade Center 

Appendix I: Abbreviations 
Page 26 GAO-04-1068T 

Banauch, G.I., et al. “Persistent Hyperreactivity and Reactive Airway 

Dysfunction in Firefighters at the World Trade Center.” American Journal 

of Respiratory and Critical Care Medicine, 168, no. 1 (2003): 54-62. 

Berkowitz, G.S., et al. “The World Trade Center Disaster and Intrauterine 

Growth Restriction.” (Letter) Journal of the American Medical 

Association, 290, no. 5 (2003): 595-96. 

Berrios-Torres, S.I., et al. “World Trade Center Rescue Worker Injury and 

Illness Surveillance, New York, 2001.” American Journal of Preventive 

Medicine, 25, no. 2 (2003): 79-87. 

Boscarino, J.A., et al. “Mental Health Service and Medication Use in New 

York City after the September 11, 2001, Terrorist Attack.” Psychiatric 

Services, 55, no. 3 (2004): 274-83. 

Boscarino, J.A., et al. “Psychiatric Medication Use among Manhattan 

Residents Following the World Trade Center Disaster.” Journal of 

Traumatic Stress, 16, no. 3 (2003): 301-6. 

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.” Special Issue, Morbidity and Mortality 

Weekly Report, 51 (2002a): 1-13. 

Centers for Disease Control and Prevention. “Psychological and Emotional 

Effects of the September 11 Attacks on the World Trade Center—

Connecticut, New Jersey, and New York, 2001.” Morbidity and Mortality 

Weekly Report, 51, no. 35 (2002b): 784-85. 

Centers for Disease Control and Prevention. “Rapid Assessment of Injuries 

among Survivors of the Terrorist Attack on the World Trade Center—New 

York City, September 2001.” Morbidity and Mortality Weekly Report, 51, 

no. 1 (2002c): 1-5. 

Chi, J.S., et al. “Hospital Admissions for Cardiac Events in New York City 

after September 11, 2001.” American Journal of Cardiology, 92, no. 1 

(2003): 61-63. 

Cushman, J.G., et al. “Two New York City Hospitals’ Surgical Response to 

the September 11, 2001, Terrorist Attack in New York City.” Journal of 

Trauma, 54, no. 1 (2003): 147-55. 

Bibliography 
Page 27 GAO-04-1068T 

DeLisi, L.E., et al. “A Survey of New Yorkers after the Sept. 11, 2001, 

Terrorist Attacks.” American Journal of Psychiatry, 160, no. 4 (2003): 

780-83. 

Deren, S., et al. “Impact of the September 11th Attacks in New York City 

on Drug Users: A Preliminary Assessment.” Journal of Urban Health: 

Bulletin of the New York Academy of Medicine, 79, no. 3 (2002): 409-12. 

Edelman, P., et al. “Biomonitoring of Chemical Exposure among New York 

City Firefighters Responding to the World Trade Center Fire and 

Collapse.” Environmental Health Perspectives, 111, no. 16 (2003): 1906-11. 

Fairbrother, G., et al. “Posttraumatic Stress Reactions in New York City 

Children after the September 11, 2001, Terrorist Attacks.” Ambulatory 

Pediatrics, 3, no. 6. (2003): 304-11. 

Feldman, D.M., et al. “Symptoms, Respirator Use, and Pulmonary Function 

Changes among New York City Firefighters Responding to the World 

Trade Center Disaster.” Chest, 125, no. 4 (2004): 1256-64. 

Galea, S., et al. “Posttraumatic Stress Disorder in Manhattan, New York 

City, after the September 11th Terrorist Attacks.” Journal of Urban 

Health: Bulletin of the New York Academy of Medicine, 79, no. 3 (2002a): 

340-53. 

Galea, S., et al. “Psychological Sequelae of the September 11 Terrorist 

Attacks in New York City.” New England Journal of Medicine, 346, no. 

13 (2002b): 982-87. 

Galea, S., et al. “Trends of Probable Post-Traumatic Stress Disorder in 

New York City after the September 11 Terrorist Attacks.” American 

Journal of Epidemiology, 158, no. 6 (2003): 514-24. 

Greater New York Hospital Association. GNYHA Survey on the 

Utilization of Hospital-Based Psychiatric Services Following the Attack 

on the World Trade Center: A Final Report. New York, 2001. 

Herbert, R., and S. Levin. World Trade Center Worker and Volunteer 

Medical Screening Program. Report of Initial Findings to the National 

Institute for Occupational Safety and Health of the Centers for Disease 

Control and Prevention. New York, 2003. 
Page 28 GAO-04-1068T 

Hoven, C.W., et al. “Mental Health of New York City Public School 

Children after 9/11: An Epidemiologic Investigation.” In S. Coates et al. 

(eds.), September 11: Trauma and Human Bonds. Hillsdale, NJ: Analytic 

Press, 2003. 

Landrigan, P.J., et al. “Health and Environmental Consequences of the 

World Trade Center Disaster.” Environmental Health Perspectives, 112, 

no. 6 (2004): 731-39. 

Levin, S., et al. “Health Effects of World Trade Center Site Workers.” 

American Journal of Industrial Medicine, 42, no. 6 (2002): 545-47. 

Levy, B.S., and V.W. Sidel (eds.). Terrorism and Public Health. New York: 

Oxford University Press, 2003. 

Lippy, B.E. “Safety and Health of Heavy Equipment Operators at Ground 

Zero.” American Journal of Industrial Medicine, 42, no. 6 (2002): 539-42. 

Malievskaya, E., et al. “Assessing the Health of Immigrant Workers near 

Ground Zero: Preliminary Results of the World Trade Center Day Laborer 

Medical Monitoring Project.” American Journal of Industrial Medicine, 

42, no. 6 (2002): 548-49. 

Martyny, J., et al. “Respiratory Protection.” New England Journal of 

Medicine, 347, no. 11 (2002): 824-30. 

Niles, B.L., et al. “Posttraumatic Stress Disorder Symptomatology in 

Vietnam Veterans before and after September 11.” Journal of Nervous and 

Mental Disease, 191, no. 10 (2003): 682-84. 

Prezant, D.J., et al. “Cough and Bronchial Responsiveness in Firefighters at 

the World Trade Center Site.” New England Journal of Medicine, 347, 

no. 11 (2002): 806-15. 

Rom, W.N., et al. “Acute Eosinophilic Pneumonia in a New York City 

Firefighter Exposed to World Trade Center Dust.” American Journal of 

Respiratory and Critical Care Medicine, 166, no. 6 (2002): 797-800. 

Rosenheck, R.A., and A. Fontana. “Post-September 11 Admission 

Symptoms and Treatment Response among Veterans with Posttraumatic 

Stress Disorder.” Psychiatric Services, 54, no. 12 (2003): 1610-17. 
Page 29 GAO-04-1068T 

Salzman, S.H., et al. “Early Respiratory Abnormalities in Emergency 

Services Police Officers at the World Trade Center Site.” Journal of 

Occupational and Environmental Medicine, 46, no. 2 (2004): 113-22. 

Schlenger, W.E., et al. “Psychological Reactions to Terrorist Attacks: 

Findings from the National Study of Americans’ Reactions to September 

11.” Journal of the American Medical Association, 288, no. 5 (2002): 

581-88. 

Schuster, M.A., et al. “A National Survey of Stress Reactions after the 

September 11, 2001, Terrorist Attacks.” New England Journal of 

Medicine, 345, no. 20 (2001): 1507-12. 

Silver, R.C., et al. “Nationwide Longitudinal Study of Psychological 

Responses to September 11.” Journal of the American Medical 

Association, 288, no. 10 (2002): 1235-44. 

Simeon, D., et al. “Peritraumatic Reactions Associated with the World 

Trade Center Disaster.” American Journal of Psychiatry, 160, no. 

9 (2003): 1702-5. 

Skloot, G., et al. “Respiratory Symptoms and Physiologic Assessment of 

Ironworkers at the World Trade Center Disaster Site.” Chest, 125, no. 4 

(2004): 1248-55. 

Spadafora, R. “Firefighter Safety and Health Issues at the World Trade 

Center Site.” American Journal of Industrial Medicine, 42, no. 6 (2002): 

532-38. 

Szema, A.M., et al. “Clinical Deterioration in Pediatric Asthmatic Patients 

after September 11, 2001.” Journal of Allergy and Clinical Immunology, 

113, no. 3 (2004): 420-26. 

Thiel de Bocanegra, H., and E. Brickman. “Mental Health Impact of the 

World Trade Center Attacks on Displaced Chinese Workers.” Journal of 

Traumatic Stress, 17, no. 1 (2004): 55-62. 

Trout, D., et al. “Health Effects and Occupational Exposures among Office 

Workers near the World Trade Center Disaster Site.” Journal of 

Occupational and Environmental Medicine, 44, no. 7 (2002): 601-5. 
Page 30 GAO-04-1068T 

Vlahov, D., et al. “Increased Use of Cigarettes, Alcohol, and Marijuana 

among Manhattan, New York, Residents after the September 11th Terrorist 

Attacks.” American Journal of Epidemiology, 155, no. 11 (2002): 988-96. 

Vlahov, D., et al. “Consumption of Cigarettes, Alcohol, and Marijuana 

among New York City Residents Six Months after the September 11 

Terrorist Attacks.” American Journal of Drug and Alcohol Abuse, 30, 

no. 2 (2004a): 385-407. 

Vlahov, D., et al. “Sustained Increased Consumption of Cigarettes, Alcohol, 

and Marijuana among Manhattan Residents after September 11, 2001.” 

American Journal of Public Health, 94, no. 2 (2004b): 253-4. 

Wallingford, K.M., and E.M. Snyder. “Occupational Exposures during the 

World Trade Center Disaster Response.” Toxicology and Industrial 

Health, 17, no. 5-10 (2001): 247-53. 

Warren, T., et al. “Factors Influencing Experienced Distress and Attitude 

toward Trauma by Emergency Medicine Practitioners.” Journal of 

Clinical Psychology in Medical Settings, 10, no. 4 (2003): 293-96. 

(290361) 
This is a work of the U.S. government and is not subject to copyright protection in the 

United States. It may be reproduced and distributed in its entirety without further 

permission from GAO. However, because this work may contain copyrighted images or 

other material, permission from the copyright holder may be necessary if you wish to 

reproduce this material separately. 
The Government Accountability Office, the audit, evaluation and 

investigative arm of Congress, exists to support Congress in meeting its 

constitutional responsibilities and to help improve the performance and 

accountability of the federal government for the American people. GAO 

examines the use of public funds; evaluates federal programs and policies; 

and provides analyses, recommendations, and other assistance to help 

Congress make informed oversight, policy, and funding decisions. GAO’s 

commitment to good government is reflected in its core values of 

accountability, integrity, and reliability. 

The fastest and easiest way to obtain copies of GAO documents at no cost 

is through GAO’s Web site (www.gao.gov). Each weekday, GAO posts 

newly released reports, testimony, and correspondence on its Web site. To 

have GAO e-mail you a list of newly posted products every afternoon, go 

to www.gao.gov and select “Subscribe to Updates.” 

The first copy of each printed report is free. Additional copies are $2 each. 

A check or money order should be made out to the Superintendent of 

Documents. GAO also accepts VISA and Mastercard. Orders for 100 or 

more copies mailed to a single address are discounted 25 percent. Orders 

should be sent to: 

U.S. Government Accountability Office 

441 G Street NW, Room LM 

Washington, D.C. 20548 

To order by Phone: Voice: (202) 512-6000 

TDD: (202) 512-2537 

Fax: (202) 512-6061 

Contact: 

Web site: www.gao.gov/fraudnet/fraudnet.htm 

E-mail: fraudnet@gao.gov

Automated answering system: (800) 424-5454 or (202) 512-7470 

Gloria Jarmon, Managing Director, JarmonG@gao.gov(202) 512-4400 

U.S. Government Accountability Office, 441 G Street NW, Room 7125 

Washington, D.C. 20548 

Jeff Nelligan, Managing Director, NelliganJ@gao.gov (202) 512-4800 

U.S. Government Accountability Office, 441 G Street NW, Room 7149 

Washington, D.C. 20548 

GAO’s Mission 

Obtaining Copies of 

GAO Reports and 

Testimony 

Order by Mail or Phone 

To Report Fraud, 

Waste, and Abuse in 

Federal Programs 

Congressional 

Relations 

Public Affairs 

PRINTED ON RECYCLED PAPER