September 11: Health Effects in the Aftermath of the World Trade Center Attack
Published: 2004-09-08T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: 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.
section_title: What GAO Found
paragraphs: 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.

section_title: Letter
paragraphs: 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). 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. 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 responders 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. 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  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.
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 attack 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  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.
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.
subsections: section_title: Background
paragraphs: 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. The majority of the  estimated 16,400 to 18,800 people who were in the WTC complex that  morning were able to evacuate, however, with minor or no injuries. 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 efforts; 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  to establish programs to monitor the health of affected people. 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). 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  (referred to here as the Johns Hopkins registry) of WTC site workers who  were involved in cleanup efforts.
section_title: Varied Physical and Mental Health Effects Have Been Observed and Reported across a Wide Range of People
paragraphs: 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.
subsections: section_title: Injuries
paragraphs: 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, 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  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.
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  facilities 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.
section_title: Respiratory Health Effects
paragraphs: 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  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, often in  conjunction with sinusitis, asthma, and gastroesophageal reflux disease  (GERD). 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.
subsections: section_title: FDNY Firefighters
paragraphs: 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  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.
section_title: Other WTC Responders
paragraphs: 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).
section_title: People Living or Working in Lower Manhattan
paragraphs: 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  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.
section_title: Reproductive Health Effects
paragraphs: For all measures of reproductive health studied except birth weight for  gestational age, 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 women 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-age infants. However, 8.2 percent of  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. Because small-for- gestational-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.
section_title: Symptoms Associated with PTSD
paragraphs: 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).
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.
section_title: Symptoms Associated with Depression, Stress, and Anxiety
paragraphs: 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  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).
section_title: Behavioral Effects
paragraphs: 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  later. Some responders, such as members of FDNY, also report having  difficulty coping in the aftermath of September 11.
section_title: Programs Established to Monitor and Understand Health Effects Vary in Eligibility Requirements, Methods, Treatment Referrals, and Duration
paragraphs: 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.
subsections: section_title: Program Eligibility
paragraphs: 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 Registry;  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. 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.
R e c t o r 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  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.
section_title: Monitoring Methods and Options for Treatment Referral
paragraphs: 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. 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  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.
section_title: Duration and Funding
paragraphs: 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. 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.
section_title: Collaboration
paragraphs: 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. Together, these institutions will  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.
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.
section_title: Concluding Observations
paragraphs: 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  proceed they are also providing the opportunity to identify people needing  treatment.
section_title: Agency Comments
paragraphs: 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.
section_title: Contact and Staff Acknowledgments
paragraphs: 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.
section_title: Appendix I: Abbreviations
section_title: Bibliography
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