September 11: Improvements Still Needed in Availability of Health Screening and Monitoring Services for Responders outside the New York City Area
Published: 2008-01-22T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Six years after the attack on the World Trade Center (WTC), concerns persist about health effects experienced by WTC responders and the availability of health care services for those affected. Several federally funded programs provide screening, monitoring, or treatment services to responders. GAO has previously reported on the progress made and implementation problems faced by these WTC health programs. This testimony is based primarily on GAO's testimony, September 11: Improvements Needed in Availability of Health Screening and Monitoring Services for Responders ( GAO-07-1229T , Sept. 10, 2007), which updated GAO's report, September 11: HHS Needs to Ensure the Availability of Health Screening and Monitoring for All Responders ( GAO-07-892 , July 23, 2007). In this testimony, GAO discusses efforts by the Centers for Disease Control and Prevention's National Institute for Occupational Safety and Health (NIOSH) to provide services for nonfederal responders residing outside the New York City (NYC) area. For the July 2007 report, GAO reviewed program documents and interviewed Department of Health and Human Services (HHS) officials, grantees, and others. GAO updated selected information in August and September 2007 and conducted work for this statement in January 2008.
section_title: What GAO Found
paragraphs: In July 2007, following a reexamination of the status of the WTC health programs, GAO recommended that the Secretary of HHS take expeditious action to ensure that health screening and monitoring services are available to all people who responded to the WTC attack, regardless of where they reside. As of January 2008, the department has not responded to this recommendation. As GAO testified in September 2007, NIOSH has not ensured the availability of screening and monitoring services for nonfederal responders residing outside the NYC area, although it has taken steps toward expanding the availability of these services. In late 2002, NIOSH arranged for a network of occupational health clinics to provide screening services. This effort ended in July 2004, and until June 2005 NIOSH did not fund screening or monitoring services for nonfederal responders outside the NYC area. In June 2005, NIOSH funded the Mount Sinai School of Medicine Data and Coordination Center (DCC) to provide screening and monitoring services; however, DCC had difficulty establishing a nationwide network of providers and contracted with only 10 clinics in seven states. In 2006, NIOSH began to explore other options for providing these services, and in 2007 it took steps toward expanding the provider network.

section_title: Letter
paragraphs: I am pleased to be here today to discuss our work on the implementation  of federally funded health programs for individuals affected by the  September 11, 2001, attack on the World Trade Center (WTC). Tens of  thousands of people served as responders in the aftermath of the WTC  disaster, including New York City Fire Department (FDNY) personnel,  federal government personnel, and thousands who came to New York City  (NYC) from around the country. By responders we are referring to anyone  involved in rescue, recovery, or cleanup activities at or near the vicinity of  the WTC or the Staten Island site. These responders were exposed to  numerous physical hazards, environmental toxins, and psychological  trauma. Six years after the destruction of the WTC buildings, concerns  remain about the physical and mental health effects of the disaster, the  long-term nature of some of these health effects, and the availability of  health care services for those affected.
Following the WTC attack, federal funding was provided to government  agencies and private organizations to establish programs for screening,  monitoring, or treating responders for illnesses and conditions related to  the WTC disaster; these programs are referred to in this testimony as the  WTC health programs. The Department of Health and Human Services  (HHS) funded the programs as separate efforts serving different categories  of responders—for example, firefighters, other workers and volunteers, or  federal responders—and has responsibility for coordinating program  efforts.
We have previously reported on the implementation of these programs and  their progress in providing services to responders, who reside in all 50  states and the District of Columbia. We also previously reported that one  of the WTC health programs, HHS’s WTC Federal Responder Screening  Program, which was established to provide onetime screening  examinations for responders who were federal employees when they  responded to the WTC attack, has had difficulties ensuring the  uninterrupted availability of services. HHS established the program in  June 2003, suspended it in March 2004, resumed it in December 2005,  suspended it again in January 2007, and resumed it in May 2007. We also  reported that the National Institute for Occupational Safety and Health  (NIOSH), the component of HHS’s Centers for Disease Control and  Prevention responsible for administering most of the WTC health  programs, had begun to take steps to provide access to screening,  monitoring, and treatment services for nonfederal responders who resided  outside the NYC metropolitan area.
My testimony today is based primarily on testimony we issued in  September 2007, which in turn was based on a report we issued in July  2007. As you requested, I will discuss the status of NIOSH’s efforts to  provide services for nonfederal responders residing outside the NYC  metropolitan area.
To assess the status of NIOSH’s efforts to provide services for nonfederal  responders residing outside the NYC metropolitan area, we obtained  documents and interviewed officials from NIOSH. We also interviewed  officials of organizations that worked with NIOSH to provide or facilitate  services for nonfederal responders residing outside the NYC metropolitan  area, including the Mount Sinai School of Medicine in NYC and the  Association of Occupational and Environmental Clinics (AOEC)—a  network of university-affiliated and other private occupational health  clinics across the United States and in Canada. In our review of the WTC  health programs, we relied primarily on information provided by agency  officials and contained in government publications. We compared the  information with information in other supporting documents, when  available, to determine its consistency and reasonableness. We determined  that the information we obtained was sufficiently reliable for our  purposes. We conducted our earlier work from November 2006 through  July 2007, updated selected information in August and September 2007,  and conducted work for this statement in January 2008. We conducted this  performance audit in accordance with generally accepted government  auditing standards. Those standards require that we plan and perform the  audit to obtain sufficient, appropriate evidence to provide a reasonable  basis for our findings and conclusions based on our audit objectives. We  believe that the evidence obtained provides a reasonable basis for our  findings and conclusions based on our audit objectives.
In brief, as we testified in September 2007, NIOSH has not ensured the  availability of screening and monitoring services for nonfederal  responders residing outside the NYC metropolitan area, although it has  taken steps toward expanding the availability of these services. As a result  of our assessment of the WTC health programs, we recommended in our  July 2007 report that the Secretary of HHS expeditiously take action to  ensure that screening and monitoring services are available for all  responders, including federal responders and nonfederal responders  residing outside of the NYC metropolitan area. As of January 2008, the  department has not responded to this recommendation.
subsections: section_title: Background
paragraphs: The tens of thousands of individuals who responded to the September 11,  2001, attack on the WTC experienced the emotional trauma of the disaster  and were exposed to a noxious mixture of dust, debris, smoke, and  potentially toxic contaminants, such as pulverized concrete, fibrous glass,  particulate matter, and asbestos. A wide variety of health effects have  been experienced by responders to the WTC attack, including 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. Commonly reported mental health effects  among responders and other affected individuals included symptoms  associated with post-traumatic stress disorder, depression, and anxiety.  Behavioral health effects such as alcohol and tobacco use have also been  reported.
There are six key programs that currently receive federal funding to  provide voluntary health screening, monitoring, or treatment at no cost to  responders. The six WTC health programs, shown in table 1, are (1) the  FDNY WTC Medical Monitoring and Treatment Program; (2) the New  York/New Jersey (NY/NJ) WTC Consortium, which comprises five  clinical centers in the NY/NJ area; (3) the WTC Federal Responder  Screening Program; (4) the WTC Health Registry; (5) Project COPE; and  (6) the Police Organization Providing Peer Assistance (POPPA) program.  The programs vary in aspects such as the HHS administering agency or  component responsible for administering the funding; the implementing  agency, component, or organization responsible for providing program  services; eligibility requirements; and services.
The WTC health programs that are providing screening and monitoring are  tracking thousands of individuals who were affected by the WTC disaster.  As of June 2007, the FDNY WTC program had screened about 14,500  responders and had conducted follow-up examinations for about 13,500 of  these responders, while the NY/NJ WTC Consortium had screened about  20,000 responders and had conducted follow-up examinations for about  8,000 of these responders. Some of the responders include nonfederal  responders residing outside the NYC metropolitan area. As of June 2007,  the WTC Federal Responder Screening Program had screened 1,305  federal responders and referred 281 responders for employee assistance  program services or specialty diagnostic services. In addition, the WTC  Health Registry, a monitoring program that consists of periodic surveys of  self-reported health status and related studies but does not provide in- person screening or monitoring, collected baseline health data from over  71,000 people who enrolled in the registry. In the winter of 2006, the  registry began its first adult follow-up survey, and as of June 2007 over  36,000 individuals had completed the follow-up survey.
In addition to providing medical examinations, FDNY’s WTC program and  the NY/NJ WTC Consortium have collected information for use in  scientific research to better understand the health effects of the WTC  attack and other disasters. The WTC Health Registry is also collecting  information to assess the long-term public health consequences of the  disaster.
In February 2006, the Secretary of HHS designated the Director of NIOSH  to take the lead in ensuring that the WTC health programs are well  coordinated, and in September 2006 the Secretary established the WTC  Task Force to advise him on federal policies and funding issues related to  responders’ health conditions. The chair of the task force is HHS’s  Assistant Secretary for Health, and the vice chair is the Director of NIOSH.
section_title: NIOSH Has Not Ensured the Availability of Services for Nonfederal Responders Residing outside the NYC Metropolitan Area
paragraphs: NIOSH has not ensured the availability of screening and monitoring  services for nonfederal responders residing outside the NYC metropolitan  area, although it has taken steps toward expanding the availability of these  services. Initially, NIOSH made two efforts to provide screening and  monitoring services for these responders, the exact number of whom is  unknown. The first effort began in late 2002 when NIOSH awarded a  contract for about $306,000 to the Mount Sinai School of Medicine to  provide screening services for nonfederal responders residing outside the  NYC metropolitan area and directed it to establish a subcontract with  AOEC. AOEC then subcontracted with 32 of its member clinics across the  country to provide screening services. From February 2003 to July 2004,  the 32 AOEC member clinics screened 588 nonfederal responders  nationwide. AOEC experienced challenges in providing these screening  services. For example, many nonfederal responders did not enroll in the  program because they did not live near an AOEC clinic, and the  administration of the program required substantial coordination among  AOEC, AOEC member clinics, and Mount Sinai.
Mount Sinai’s subcontract with AOEC ended in July 2004, and from August  2004 until June 2005 NIOSH did not fund any organization to provide  services to nonfederal responders outside the NYC metropolitan area.  During this period, NIOSH focused on providing screening and monitoring  services for nonfederal responders in the NYC metropolitan area. In June  2005, NIOSH began its second effort by awarding $776,000 to the Mount  Sinai School of Medicine Data and Coordination Center (DCC) to provide  both screening and monitoring services for nonfederal responders residing  outside the NYC metropolitan area. In June 2006, NIOSH awarded an  additional $788,000 to DCC to provide screening and monitoring services  for these responders. NIOSH officials told us that they assigned DCC the  task of providing screening and monitoring services to nonfederal  responders outside the NYC metropolitan area because the task was  consistent with DCC’s responsibilities for the NY/NJ WTC Consortium,  which include data monitoring and coordination. DCC, however, had  difficulty establishing a network of providers that could serve nonfederal  responders residing throughout the country—ultimately contracting with  only 10 clinics in seven states to provide screening and monitoring  services. DCC officials said that as of June 2007 the 10 clinics were  monitoring 180 responders.
In early 2006, NIOSH began exploring how to establish a national program  that would expand the network of providers to provide screening and  monitoring services, as well as treatment services, for nonfederal  responders residing outside the NYC metropolitan area. According to  NIOSH, there have been several challenges involved in expanding a  network of providers to screen and monitor nonfederal responders  nationwide. These include establishing contracts with clinics that have the  occupational health expertise to provide services nationwide, establishing  patient data transfer systems that comply with applicable privacy laws,  navigating the institutional review board process for a large provider  network, and establishing payment systems with clinics participating in a  national network of providers. On March 15, 2007, NIOSH issued a formal  request for information from organizations that have an interest in and the  capability of developing a national program for responders residing  outside the NYC metropolitan area. In this request, NIOSH described the  scope of a national program as offering screening, monitoring, and  treatment services to about 3,000 nonfederal responders through a  national network of occupational health facilities. NIOSH also specified  that the program’s facilities should be located within reasonable driving  distance to responders and that participating facilities must provide copies  of examination records to DCC. In May 2007, NIOSH approved a request  from DCC to redirect about $125,000 from the June 2006 award to  establish a contract with a company to provide screening and monitoring  services for nonfederal responders residing outside the NYC metropolitan  area. Subsequently, DCC contracted with QTC Management, Inc., one of  the four organizations that had responded to NIOSH’s request for  information. DCC’s contract with QTC does not include treatment  services, and NIOSH officials are still exploring how to provide and pay for  treatment services for nonfederal responders residing outside the NYC  metropolitan area. QTC has a network of providers in all 50 states and the  District of Columbia and can use internal medicine and occupational  medicine doctors in its network to provide these services. In addition,  DCC and QTC have agreed that QTC will identify and subcontract with  providers outside of its network to screen and monitor nonfederal  responders who do not reside within 25 miles of a QTC provider. In June  2007, NIOSH awarded $800,600 to DCC for coordinating the provision of  screening and monitoring examinations, and QTC was to receive a portion  of this award from DCC to provide about 1,000 screening and monitoring  examinations through May 2008. According to a NIOSH official, QTC’s  providers began conducting screening examinations in summer 2007.
section_title: Concluding Observations
paragraphs: Screening and monitoring the health of the people who responded to the  September 11, 2001, attack on the World Trade Center are critical for  identifying health effects already experienced by responders or those that  may emerge in the future. In addition, collecting and analyzing information  produced by screening and monitoring responders can give health care  providers information that could help them better diagnose and treat  responders and others who experience similar health effects.
While many responders have been able to obtain screening and follow-up  physical and mental health examinations through the federally funded  WTC health programs, other responders may not always find these  services available. Specifically, many responders who reside outside the  NYC metropolitan area have not been able to obtain screening and  monitoring services because available services are too distant. Moreover,  HHS has repeatedly interrupted its efforts to provide services outside the  NYC area, resulting in periods when no such services were available.
HHS continues to fund and coordinate the WTC health programs and has  key federal responsibility for ensuring the availability of services to  responders. HHS and its agencies have taken steps to move toward  providing screening and monitoring services to nonfederal responders  living outside of the NYC area. However, these efforts are not complete,  and the stop-and-start history of the department’s efforts to serve these  responders does not provide assurance that the latest efforts to extend  screening and monitoring services to them will be successful and will be  sustained over time. Therefore we recommended in July 2007 that the  Secretary of HHS take expeditious action to ensure that health screening  and monitoring services are available to all people who responded to the  attack on the WTC, regardless of where they reside. As of January 2008,  the department has not responded to this recommendation.
Mr. Chairman, this completes my prepared remarks. I would be happy to  respond to any questions you or other members of the subcommittee may  have at this time.
section_title: Contacts and Acknowledgments
paragraphs: For further information about this testimony, please contact Cynthia A.  Bascetta at (202) 512-7114 or bascettac@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on the  last page of this statement. Helene F. Toiv, Assistant Director; Hernan  Bozzolo; Frederick Caison; Anne Dievler; Anne Hopewell; and Roseanne  Price made key contributions to this statement.
section_title: Appendix I: Abbreviations
section_title: Related GAO Products
paragraphs: September 11: Improvements Needed in Availability of Health Screening  and Monitoring Services for Responders. GAO-07-1229T. Washington,  D.C.: September 10, 2007.
September 11: HHS Needs to Ensure the Availability of Health Screening  and Monitoring for All Responders. GAO-07-892. Washington, D.C.:   July 23, 2007.
September 11: HHS Has Screened Additional Federal Responders for  World Trade Center Health Effects, but Plans for Awarding Funds for  Treatment Are Incomplete. GAO-06-1092T. Washington, D.C.: September 8,  2006.
September 11: Monitoring of World Trade Center Health Effects Has  Progressed, but Program for Federal Responders Lags Behind.  GAO-06-481T. Washington, D.C.: February 28, 2006.
September 11: Monitoring of World Trade Center Health Effects Has  Progressed, but Not for Federal Responders. GAO-05-1020T. Washington,  D.C.: September 10, 2005.
September 11: Health Effects in the Aftermath of the World Trade Center  Attack. GAO-04-1068T. Washington, D.C.: September 8, 2004.
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