September 11: Monitoring of World Trade Center Health Effects Has Progressed, but Not for Federal Responders
Published: 2005-09-10T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: After the 2001 attack on the World Trade Center (WTC), nearly 3,000 people died and an estimated 250,000 to 400,000 people who lived, worked, or attended school in the vicinity were affected. An estimated 40,000 people who responded to the disaster--including New York City Fire Department (FDNY) personnel and other government and private-sector workers and volunteers--were exposed to numerous physical and mental health hazards. Concerns remain about the long-term health effects of the attack and about the nation's capacity to plan for and respond to both short- and long-term health effects in the event of a future attack or other disaster. Several federally funded programs have monitored the physical and mental health effects of the WTC attack. These monitoring programs include one-time screening programs and programs that also conduct follow-up monitoring. GAO was asked to assess the progress of these programs. GAO examined (1) federally funded programs implemented by state and local government agencies or private institutions, (2) federally administered programs to monitor the health of federal workers who responded to the disaster in an official capacity, and (3) lessons learned from WTC monitoring programs. GAO reviewed program documents and interviewed federal, state, and local officials and others involved in WTC monitoring programs.
section_title: What GAO Found
paragraphs: Three federally funded monitoring programs implemented by state and local governments or private organizations after the WTC attack have provided initial medical examinations--and in some cases follow-up examinations--to thousands of affected responders to screen for health problems. For example, the FDNY medical monitoring program completed initial screening for over 15,000 firefighters and emergency medical service personnel, and the worker and volunteer program screened over 14,000 other responders. The New York State responder screening program screened about 1,700 state responders before ending its examinations in 2003. Most state responders have not been informed that they are now eligible to participate in the worker and volunteer program, and New York State responders could miss the opportunity for continued monitoring. These monitoring programs and the WTC Health Registry have collected information that program officials believe researchers could use to help better understand the health consequences of the attack and improve treatment. Program officials expressed concern, however, that current federal funding arrangements for long-term monitoring may be too short to allow for identification of all future health effects. In contrast to the progress made by other federally funded programs, the Department of Health and Human Services' (HHS) program to screen federal workers who were sent by their agencies to respond to the WTC disaster has accomplished little and is on hold. The program--which started about one year later than other WTC monitoring programs--completed screening of 394 of the estimated 10,000 federal workers who responded in an official capacity to the disaster, but HHS officials suspended examinations and the program has not screened anyone since March 2004. The program's limited activity and the exclusion of federal workers from other monitoring programs because of the assumption that they could receive screening examinations through the HHS program may have resulted in many federal responders losing the opportunity to identify and seek treatment for their WTC-related health problems. Officials involved in WTC health monitoring programs cited lessons from their experiences that could help others who may be responsible for designing and implementing health monitoring efforts that follow other disasters, such as Hurricane Katrina. These include the need to quickly identify and contact people affected by a disaster; to monitor for mental health effects, as well as physical injuries and illnesses; and to anticipate when designing disaster-related monitoring efforts that there will likely be many people who require referrals for follow-up care and that handling the referral process may require substantial effort. HHS and New York State officials provided comments on the facts contained in this testimony and GAO made changes as appropriate.

section_title: Letter
paragraphs: Thank you for inviting me to participate in today’s hearing to discuss  issues related to the health effects that people continue to experience in  the aftermath of the September 11, 2001, terrorist attack on the World  Trade Center (WTC). After the collapse of the WTC buildings, nearly 3,000  people died, and an estimated 250,000 to 400,000 people who lived,  worked, or attended school in the vicinity were affected. An estimated  40,000 people responded to the disaster, including New York City Fire  Department (FDNY) personnel and other government and private-sector  workers and volunteers from New York and other locations across the  nation. These responders, as they took part in various rescue, recovery,  and cleanup activities in the days, weeks, and months following the attack,  were exposed to numerous physical hazards and environmental toxins due  to the destruction caused by the attack. The magnitude and unprecedented  nature of this event also exposed responders and many other people to  considerable psychological trauma.
Four years after the destruction of the WTC buildings, concerns remain  about the long-term physical and mental health effects of the attack.  Several recent studies of responders report that many of them have high  rates of physical and mental health symptoms, of which respiratory  problems are the most persistent physical effects. While the nature and  severity of a future terrorist attack cannot be predicted, our prior work on  the health effects of the WTC attack, the 2001 anthrax attacks, and  bioterrorism preparedness, as well as reports by other organizations,  highlight the importance of ensuring the nation’s capacity to plan for and  respond to the short- and long-term health consequences likely to result in  the event of a future attack or other disaster, such as the destruction  recently caused by Hurricane Katrina.
As we testified in September 2004, in the aftermath of the WTC attack, five  key federally funded programs were implemented to assess the short-term,  and in some cases long-term, effects on people’s physical and mental  health. These programs include the FDNY WTC Medical Monitoring  Program, WTC Medical Monitoring Program (worker and volunteer  program), New York State responder screening program, WTC Health  Registry, and the Department of Health and Human Services’ (HHS) WTC  Federal Responder Screening Program. You asked us to provide  information on the progress of these monitoring programs. My testimony  today will focus on (1) progress made by federally funded programs that  are implemented by state and local government agencies or private  organizations and were established to monitor the health of people in the  aftermath of the attack, (2) progress made by federally administered  programs established to monitor the health of federal workers who  responded to the disaster in an official capacity, and (3) lessons from WTC  monitoring programs that could assist those who may be responsible for  future disaster-related health monitoring efforts.
To conduct this work, we obtained and reviewed program documents  dating from the beginning of the programs, including grantee progress  reports, budget documents, clinical protocols, health screening and other  assessment tools, and selected peer-reviewed articles based on  information collected by WTC monitoring programs. We also interviewed  federal, state, and local officials and others involved in administering WTC  monitoring programs, including officials from HHS and the Department of  Homeland Security (DHS); New York State Department of Health; New  York City Department of Health and Mental Hygiene; and FDNY. Within  HHS, we interviewed officials from the Agency for Toxic Substances and  Disease Registry (ATSDR); the Centers for Disease Control and  Prevention’s (CDC) National Center for Environmental Health and  National Institute for Occupational Safety and Health (NIOSH); Federal  Occupational Health Services (FOH); and the Office of Public Health  Emergency Preparedness (OPHEP). We also obtained information from  the Department of Defense (DOD) and the Department of Justice (DOJ).  We interviewed medical professionals affiliated with the New York  University School of Medicine, FDNY’s Bureau of Health Services, Long  Island Occupational and Environmental Health Center, Mount Sinai-Irving  J. Selikoff Center for Occupational and Environmental Medicine, Mount  Sinai School of Medicine Department of Psychiatry, and the University of  Medicine and Dentistry of New Jersey’s Robert Wood Johnson Medical  School. We relied on data provided by agency officials and contained in  government publications and did not independently verify the data we  obtained. In our judgment the reliability of the information we obtained  was adequate for our purposes. HHS and New York State officials  provided comments on the facts contained in this statement, and we made  changes as appropriate. We conducted our work from July 2005 through  September 2005 in accordance with generally accepted government  auditing standards.
In summary, three federally funded programs implemented by state and  local governments or private organizations in the aftermath of the WTC  attack have provided initial medical examinations—and in some cases  follow-up examinations—to thousands of affected responders to screen  for health problems. For example, the FDNY program completed initial  screening for over 15,000 firefighters and emergency medical service  personnel, and the worker and volunteer program has screened over  14,000 other responders. The New York State program screened about  1,700 state responders before ending its screening examinations; in  general, it has not informed state responders that they are now eligible to  receive continued monitoring from the worker and volunteer program.  These three programs and the WTC Health Registry have collected  information that monitoring program officials believe could be used by  researchers to help better understand the health consequences of the  attack and improve treatment, such as by identifying which types of  treatment are effective for specific conditions. Officials of programs that  plan to conduct long-term health monitoring are concerned that current  federal funding arrangements may be too short to allow for identification  of all the health effects that participants may eventually experience.
In contrast to the progress made by federally funded programs  implemented by state and local governments or private organizations, the  program that HHS implemented to screen federal workers who were sent  by their agencies to respond to the WTC disaster has accomplished little.  The program—which started later than other WTC monitoring programs— completed screening of 394 of the estimated 10,000 federal workers who  responded in an official capacity to the disaster and were not eligible for  any other WTC health monitoring program. HHS placed the program on  hold in January 2004, when it stopped scheduling new examinations. It has  not screened anyone since March 2004. We identified two federal agencies  that, in the aftermath of the WTC attack, have implemented programs to  assess the health of their own employees who responded to the disaster.
Officials involved in WTC health monitoring programs cited lessons from  their experiences that could help others who may be responsible for  designing and implementing disaster-related health monitoring efforts in  the future. These include the need to quickly identify and contact people  affected by a disaster; to monitor for mental health effects, as well as the  more obvious physical injuries and illnesses; and, when developing health  monitoring efforts in the wake of disasters, to anticipate that there will  likely be many people who require referrals for further diagnostic and  treatment services and that handling the referral process may require a  substantial level of effort.
subsections: section_title: Background
paragraphs: When the WTC buildings collapsed on September 11, 2001, an estimated  250,000 to 400,000 people were immediately exposed to a noxious mixture  of dust, debris, smoke, and potentially toxic contaminants in the air and on  the ground, such as pulverized concrete, fibrous glass, particulate matter,  and asbestos. Those affected included people residing, working, or  attending school in the vicinity of the WTC and thousands of emergency  response workers. Also affected were the estimated 40,000 responders  who were involved in some capacity in the days, weeks, and months that  followed, including personnel from many government agencies and private  organizations as well as other workers and volunteers.
A wide variety of physical and mental health effects have been observed  and reported among people who were involved in rescue, recovery, and  cleanup operations and among those who lived and worked in the vicinity  of the WTC. Physical health effects included injuries and respiratory  conditions, such as sinusitis, asthma, and a new syndrome called WTC  cough, which consists of persistent coughing accompanied by severe  respiratory symptoms. Almost all firefighters who responded to the attack  experienced respiratory effects, including WTC cough, and hundreds had  to end their firefighting careers due to WTC-related respiratory illnesses.  The most commonly reported mental health effects among responders and  others were symptoms associated with posttraumatic stress disorder—an  often debilitating disorder that can develop after a person experiences or  witnesses a traumatic event, and which may not develop for months or  years after the event. Behavioral effects such as alcohol and tobacco use  and difficulty coping with daily responsibilities were also reported.
Several federally funded programs monitor the health of people who were  exposed to the WTC attack and its aftermath. The monitoring programs  vary in such aspects as eligibility requirements, methods used for  collecting information about people’s health, and approaches for offering  referrals. Of the four programs that offer medical examinations to WTC  responders, the only one that is open to federal workers who responded to  the disaster in an official capacity is the one implemented by HHS. (See  table 1.) None of the monitoring programs receives federal funds to  provide clinical treatment for health problems that are identified.
The majority of federal funding for these monitoring programs was  provided by DHS’s Federal Emergency Management Agency (FEMA), as  part of the approximately $8.8 billion in federal assistance that the  Congress appropriated to FEMA for response and recovery activities after  the WTC disaster. One fiscal year 2003 appropriation specifically  authorized FEMA to use a portion of its WTC-related funding for screening  and long-term monitoring of emergency services and rescue and recovery  personnel. Generally, however, FEMA may fund only short-term care  after a disaster, such as emergency medical services, and not ongoing  clinical treatment.
FEMA entered into interagency agreements with HHS to fund most of  these health monitoring programs. HHS is the designated lead agency for  the public health and medical support function under the National  Response Plan and is responsible for coordinating the medical resources  of all federal departments and agencies. HHS’s Office of Public Health  Emergency Preparedness (OPHEP) coordinates and directs HHS’s  emergency preparedness and response program.
section_title: Health Monitoring Programs Implemented by State and Local Governments or Private Organizations Have Made Progress
paragraphs: Three federally funded programs implemented by state and local  governments or private organizations—the FDNY WTC Medical  Monitoring Program, WTC Medical Monitoring Program (worker and  volunteer program), and New York State responder screening program— have made progress in monitoring the physical and mental health of  people affected by the WTC attack. Federal employees who responded to  the WTC disaster in an official capacity were not eligible for these  programs because it was expected that another program would be  developed for them. The New York State program stopped providing  examinations in November 2003, and state workers are now eligible for  initial or continued monitoring through the worker and volunteer program.  In general, the state program has not informed state responders that they  are eligible for the worker and volunteer program. All three programs and  the WTC Health Registry have collected information that could contribute  to better understanding of the health consequences of the attack and  improve health care for affected individuals. Officials from the FDNY,  worker and volunteer, and WTC Health Registry programs are concerned  that federal funding for their programs could end before sufficient  monitoring occurs to identify all long-term health problems related to the  WTC disaster.
subsections: section_title: Three WTC Monitoring Programs Provided Medical Examinations to Identify Responders’ Health Problems
paragraphs: Three federally funded programs implemented by state and local  governments or private organizations have provided medical examinations  to identify physical and mental health problems after the WTC attack. (See  table 2.) Two of these programs—the FDNY WTC Medical Monitoring  Program and the worker and volunteer program—are tracking the health  of WTC rescue, recovery, and cleanup workers and volunteers over time.  The third program, the New York State responder screening program,  offered one-time screening examinations to state employees, including  National Guard personnel, who participated in WTC rescue, recovery, and  cleanup work. Federal employees who responded to the WTC disaster in  an official capacity were not eligible for any of these programs because it  was expected that another program would be developed for them.
The FDNY program completed initial screening for over 15,000 firefighters  and emergency medical service personnel, and the worker and volunteer  program completed initial screening for over 14,000 other responders. In  both programs, screenings include physical examinations, pulmonary  function tests, blood and urine analysis, a chest X-ray, and questionnaires  on exposures and mental health issues. Both programs have begun to  conduct follow-up examinations of participants and continue to accept  new enrollees who desire initial screening. Current plans are to conduct a  total of three follow-up examinations for each participant by 2009. As part  of their federally funded activities, both programs provide referrals for  participants who require treatment. FDNY employees and retirees can  obtain treatment and counseling services from the FDNY Bureau of Health  Services and the FDNY Counseling Services Unit, or they can use their  health insurance to obtain treatment and counseling services elsewhere.  The worker and volunteer program also provides referrals for its  participants, including referrals to programs funded by the American Red  Cross and other nonprofit organizations.
The New York State program screened about 1,700 of the estimated 9,800  state workers and National Guard personnel who responded to the WTC  disaster. Officials sent letters to these responders to inform them about  the program and their eligibility for it. For each participant, the screening  included a health and exposure questionnaire and physical and pulmonary  examinations. Participants who required further evaluation or treatment  after screening were told to follow up with their personal physician or a  specialist. The program stopped screening participants in November 2003,  in part because the number of responders requesting examinations was  dwindling, and no follow-up examinations are planned.
In February 2005, worker and volunteer program officials began to allow  New York State responders to participate in that monitoring program. The  officials determined that the worker and volunteer program would have  sufficient funding to accommodate state workers who want to join the  program. The state program has not notified the approximately 1,700  workers it has screened that they are now eligible for continued  monitoring from the worker and volunteer program. Program officials  relayed this development only to those state responders who inquired  about screening or monitoring examinations following the decision to  permit state responders to participate in the worker and volunteer  program. Worker and volunteer program officials told us that, through  August 2005, no state workers who responded to the WTC disaster in an  official capacity had received examinations from the worker and volunteer  program. According to worker and volunteer program officials, any state  worker screened by the state program would need a new baseline  examination through the worker and volunteer program because the  screening data collected by the state program differ from the data  collected in the worker and volunteer program. For example, the worker  and volunteer program offers a breathing test not provided by the state  program.
section_title: Programs Provide Data for WTC-Related Health Research
paragraphs: In addition to providing medical examinations, these three programs—the  FDNY program, the worker and volunteer program, and the New York  State program—have collected information for use in scientific research to  better understand the health consequences of the WTC attack and other  disasters. A fourth program, the WTC Health Registry, includes health and  exposure information obtained through interviews with participants; it is  designed to track participants’ health for 20 years and to provide data on  the long-term health consequences of the disaster (see table 2). Physicians  who evaluate and treat WTC responders told us they expect that research  on health effects from the disaster will not only help researchers  understand the health consequences, but also provide information on  appropriate treatment options for affected individuals.
Both the FDNY program and the worker and volunteer program have been  the basis for published research articles on the health of WTC responders.  For example, the FDNY program reported on the injuries and illnesses  experienced by firefighters and emergency medical service workers after  responding to the attack. In addition, the worker and volunteer program  published information on the physical and mental health of responders in  2004. Officials from both programs plan to publish additional findings as  they track participants’ health over time. Although the New York State  program has stopped offering examinations, program officials are  continuing to analyze data from the program with plans for eventual  publication.
The WTC Health Registry program has collected health information  through interviews with responders, people living or attending school in  the vicinity of the WTC site, and people working or present in the vicinity  on September 11, 2001. The registry completed enrollment and conducted  interviews with over 71,000 participants by November 2004. Officials  updated contact information for all participants in 2005, and they plan to  conduct a follow-up health survey of participants in early 2006. Registry  officials would like to conduct subsequent follow-up surveys periodically  through about 2023—20 years after the program began in 2003—but have  not yet secured funding for long-term monitoring.
The registry is designed to provide a basis for research to evaluate the  long-term health consequences of the disaster. It includes contact  information for people affected by the WTC attack, information on  individuals’ experiences and exposures during the disaster, and  information on their health. In November 2004, registry officials published  preliminary results on the health status of registry participants, and  officials expect to submit several research papers for publication within  the next year. In addition, in May 2005, registry officials published  guidelines for allowing registry information to be used in scientific  research, and they have since approved three proposals for external  research projects that use registry information. These proposals include  two studies of building evacuations and a study of psychological  responses to terrorism.
section_title: Program Officials Are Concerned That Current Federal Funding Arrangements Will End before Needed Monitoring Is Complete
paragraphs: Officials from the FDNY, worker and volunteer, and WTC Health Registry  programs are concerned that current federal funding arrangements for  programs designed to track participants’ health over time may be too short  to allow for identification of all the health effects that may eventually  develop. ATSDR plans to fund the WTC Health Registry through April  2008, and NIOSH plans to fund the FDNY program and the worker and  volunteer program through mid-2009. ATSDR’s 5-year cooperative  agreement with the New York City Department of Health and Mental  Hygiene to support the WTC Health Registry went into effect April 30,  2003, and extends through April 29, 2008. Similarly, NIOSH awarded 5-year  grants in July 2004 to continue the FDNY and worker and volunteer  programs, which had begun in 2001 and 2002, respectively. Health experts  involved in these monitoring programs, however, cite the need for long- term monitoring of affected groups because some possible health effects,  such as cancer, may not appear until decades after a person has been  exposed to a harmful agent. They also told us that monitoring is important  for identifying and assessing the occurrence of newly identified  conditions, such as WTC cough, and chronic conditions, such as asthma.
section_title: HHS’s Program for Screening Federal Responders Has Accomplished Little and Is on Hold
paragraphs: HHS’s OPHEP established the WTC Federal Responder Screening Program  to provide medical screening examinations for an estimated 10,000 federal  workers who responded to the WTC disaster in an official capacity and  were not eligible for any other medical monitoring program. OPHEP did  not develop a comprehensive list of federal responders who were eligible  for the program. The program began in June 2003—about a year later than  other monitoring programs—and completed screenings for 394 workers.  No examinations have occurred since March 2004, because officials placed  the program on hold, temporarily suspending new examinations. The  program is still on hold, and OPHEP officials are taking actions intended  to lead to restarting the program. We identified two federal agencies that  established screening programs for their own personnel who responded to  the disaster.
subsections: section_title: HHS Program Screened Few Federal Workers and Has Been on Hold for over 1 Year
paragraphs: HHS’s WTC Federal Responder Screening Program was established to  provide free voluntary medical screening examinations for an estimated  10,000 federal workers whom their agencies sent to respond to the WTC  disaster from September 11, 2001, through September 10, 2002, and who  were not eligible for any other monitoring program. FEMA provided $3.74  million through an interagency agreement with HHS’s OPHEP for the  purpose of developing and implementing the program. OPHEP entered  into an agreement with HHS’s FOH to schedule and conduct the screening  examinations.
The launching of the federal responder screening program lagged behind  the implementation of other federally funded monitoring programs for  WTC responders. For example, the medical screening program for New  York State employees and the worker and volunteer program started  conducting screening examinations in May 2002 and July 2002,  respectively. However, OPHEP did not launch its program until June 2003.  (Figure 1 highlights key actions in developing and implementing the  program.)
OPHEP did not develop a plan for identifying all federal agencies and their  personnel that responded to the WTC disaster or for contacting all federal  personnel eligible for the screening program. Although OPHEP and FEMA  developed a partial list of federal responders—consisting primarily of HHS  and FEMA personnel—OPHEP did not have a comprehensive list of  agencies and personnel, and so could not inform all eligible federal  responders about the WTC screening program. The program’s principal  action to communicate with the federal responders was to place program  information and registration forms on FEMA’s National Disaster Medical  System (NDMS) Web site.
The screening program had operated for about 6 months when OPHEP  officials decided in January 2004 to place it on hold by temporarily  suspending examinations. FOH officials told us that they completed 394  screening examinations from June 2003 through March 2004, with most  completed by the end of September 2003. According to FOH, a total of  $177,967 was spent on examinations. As of September 7, 2005, the  program remained on hold, with 37 people on the waiting list for  examinations, and OPHEP has not set a date for resuming the  examination process.
OPHEP officials told us that three operational issues contributed to the  decision to suspend the program. First, OPHEP could not inform all  eligible federal responders about the program because it lacked a  comprehensive list of eligible federal responders. Second, there were  concerns about what actions FOH clinicians could take when screening  examinations identified problems. Based on the examinations that had  been completed before the program was placed on hold, FOH clinicians  determined that many participants needed additional diagnostic testing  and follow-up care, primarily in the areas of respiratory functioning and  mental health. However, under the existing interagency agreement there  was no provision for providing follow-up care and no direction for  clinicians on how to handle the provision of further diagnostic tests,  treatment, or referrals. FOH officials told us that they were concerned  about continuing to provide screening examinations without the ability to  provide participants with additional needed services. Third, although the  screening program had been established to provide examinations to all  federal responders regardless of their current federal employment status,  HHS officials told us that the department determined that FOH does not  have the authority to provide examinations to people who are no longer in  federal service. OPHEP officials told us in September 2005 that they were  exploring avenues for providing examinations to federal responders who  were no longer federal employees.
OPHEP has begun to take action to prepare for offering examinations  again. In April 2005, program officials enlisted the assistance of ATSDR— which had successfully developed the WTC Health Registry—to help  develop the needed lists of federal agencies and personnel for the federal  responder program. OPHEP executed an agreement with ATSDR that  allocated about $491,000 from the program’s remaining allocation from  FEMA to ATSDR. Under this agreement, which is scheduled to run  through April 2006, ATSDR is working with the contractor it used to  develop the WTC Health Registry to develop a new registration Web site,  develop and implement a comprehensive recruitment and enrollment plan  for current and former federal workers, and establish a database  containing the names of federal responders. On September 1, 2005,  OPHEP sent a letter to 51 federal agencies requesting them to provide  ATSDR’s contractor with contact information on the employees they sent  to respond to the WTC disaster.
In July 2005, OPHEP and FOH executed a new agreement so that when the  program begins examining responders again, FOH clinicians will be able to  make referrals for follow-up care. For example, they will be able to refer  participants with mental health symptoms to an FOH employee assistance  program for a telephone assessment. If appropriate, the participant will be  referred to an employee assistance program counselor for up to six in- person sessions. If the assessment indicates that longer treatment is  necessary, the participant instead will be advised to use health insurance  to obtain care or to contact a local Department of Labor Office of Workers’  Compensation to file a claim, receive further evaluation, and possibly  obtain compensation for mental health services. The new agreement  between OPHEP and FOH also will allow FOH clinicians to order  additional clinical tests, such as special pulmonary and breathing tests.
section_title: Two Federal Agencies Established Their Own Screening Programs
paragraphs: We identified two federal agencies that established medical screening  programs to assess the health of the personnel they had sent to respond to  the WTC disaster. One agency, the Army, established two screening  programs—one specifically for Army Corps of Engineers personnel and  one that also included other Army responders. The Army Corps of  Engineers established a voluntary program to assess the health of 356  employees it had sent to respond to the disaster. The program, initiated in  November 2001, consists of sending employees an initial medical  screening questionnaire covering physical health issues. If questionnaire  results indicate symptoms or concerns that need further evaluation, the  employee is offered a medical examination. As of August 2004, 92 Corps  of Engineers employees had participated in the program, with 40 receiving  follow-up examinations. The Army’s Center for Health Promotion and  Preventive Medicine initiated a program—the World Trade Center Support  Health Assessment Survey—in January 2002. It was designed as a  voluntary medical screening for Army military and civilian personnel,  including contractors. From January 2002 through September 2003,  questionnaires were sent to 256 employees. According to DOD, 162  employees completed and returned their questionnaires. In addition, the  U.S. Marshals Service, within the Department of Justice, modified an  existing agreement with FOH in 2003 for FOH to screen approximately 200  U.S. Marshals Service employees assigned to the WTC or Pentagon  recovery sites. The one-time assessment includes a screening  questionnaire and a medical examination. FOH officials said that as of  August 2005, 88 of the 200 U.S. Marshals Service employees had requested  and obtained examinations.
section_title: Lessons from WTC Health Monitoring Programs Could Assist Future Monitoring Efforts
paragraphs: Officials involved in the WTC health monitoring programs implemented by  state and local governments or private organizations—including officials  from the federal administering agencies—derived lessons from their  experiences that could help officials design such programs in the future.  They include the need to quickly identify and contact people affected by a  disaster, the value of a centrally coordinated approach for assessing  individuals’ health, the importance of monitoring both physical and mental  health, and the need to plan for providing referrals for treatment when  screening examinations identify health problems.
Officials involved in the monitoring programs emphasized the importance  of quickly identifying and contacting people affected by a disaster. They  said that potential monitoring program participants can become more  difficult to locate as time passes. In addition, potential participants’  ability to recall the events of a disaster may decrease over time, making it  more difficult to collect accurate information about their experiences and  health. However, the time it takes to design, fund, approve, and implement  monitoring programs can lead to delays in contacting the people who were  affected. For example, the WTC Health Registry received funding in July  2002 but did not begin collecting data until September 2003—2 years after  the disaster. From July 2002 through September 2003, the program’s  activities included developing the registry protocol, testing the  questionnaire, and obtaining approval from institutional review boards and  the federal Office of Management and Budget. This delayed the collection  of information from participants. To prevent similar delays during the  response to future disasters, ATSDR officials are developing a  questionnaire, known as the Rapid Response Registry, to allow officials to  identify and locate potentially affected individuals immediately after a  disaster and collect basic preliminary information, such as their current  contact information and their location during the disaster. ATSDR  officials expect that using this instrument would reduce delays in  collecting time-sensitive information while officials take the time  necessary to develop a monitoring program for disaster-related health  effects.
Furthermore, officials told us that health monitoring for future disasters  could benefit from additional centrally coordinated planning. Such  planning could facilitate the collection of compatible data among  monitoring efforts, to the extent that this is appropriate. Collecting  compatible data could allow information from different programs to be  integrated and contribute to improved data analysis and more useful  research. In addition, centrally coordinated planning could help officials  determine whether separate programs are necessary to serve different  groups of people. For example, worker and volunteer program officials  indicated that it might have been possible for that program to serve federal  workers who responded to the disaster in an official capacity, which might  have eliminated the need to organize and administer a separate program  for them.
Officials also stated that screening and monitoring programs should be  comprehensive, encompassing both physical and mental health  evaluations. Worker and volunteer medical monitoring program officials  told us that the initial planning for the program had focused primarily on  screening participants’ physical health, and that they did not originally  budget for extensive mental health screening. Subsequently, they  recognized a need for more extensive mental health screening, including  greater participation of mental health professionals, but the program’s  federal funding was not sufficient to cover such screening. By  collaborating with the Mount Sinai School of Medicine Department of  Psychiatry, program officials were able to obtain philanthropic funding to  develop a more comprehensive mental health questionnaire, provide on- site psychiatric screening, and, when necessary, provide more extensive  evaluations.
Many participants in the monitoring programs required additional testing  or needed treatment for health problems that were identified during  screening examinations. Officials told us that finding treatment sources for  such participants is an important, but challenging, part of the programs’  responsibility. For example, officials from the worker and volunteer  program stated that identifying providers available to treat participants  became a major part of their operations, and was especially difficult when  participants lacked health insurance. The officials said that planning for  future monitoring programs should include a determination of how best to  help participants obtain needed treatment.
section_title: Concluding Observations
paragraphs: Federally funded programs implemented by state and local governments  or private organizations to monitor the health effects of the WTC attack on  thousands of people who responded to the disaster have made progress.  However, the program HHS established to screen the federal employees  whose agencies sent them to the WTC after the attack has accomplished  little, completing screenings of fewer than 400 of the thousands of federal  responders. Moreover, no examinations have occurred for over a year.  Because of this program’s limited activity, and the inability of federal  workers to participate in other monitoring programs because of the  assumption that they would have the opportunity to receive screening  examinations through the HHS program, many federal responders may not  have had an opportunity to identify and seek treatment for health  problems related to the WTC disaster. For state responders, the  opportunity for continued monitoring could be lost if they are not  informed that they are now eligible to participate in the worker and  volunteer program.
Based on their experiences, officials involved in the monitoring programs  have made a number of useful observations that will apply to future  terrorist attacks and natural disasters such as Hurricane Katrina. For  example, screening for mental as well as physical health problems in New  Orleans and along the Gulf Coast will be critical to the recovery of  survivors of Hurricane Katrina and the responders to the disaster. The  federal, state, and local government officials who are responsible for  planning and implementing health monitoring activities in the aftermath of  disasters could improve their effectiveness by incorporating the lessons  learned from the World Trade Center experience.
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: Contact and Acknowledgments
paragraphs: For further information about this testimony, please contact Cynthia A.  Bascetta at (202) 512-7101 or bascettac@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on the  last page of this statement. Helene F. Toiv, Assistant Director; George H.  Bogart; Alice L. London; Roseanne Price; and William R. Simerl made key  contributions to this statement.
section_title: Appendix I: Abbreviations
section_title: Appendix II: Government Agencies That Sent Responders Following the World Trade Center Attack
paragraphs: Through our work, we identified the following agencies that sent  employees to respond to the World Trade Center attack of September 11,  2001.
subsections: section_title: Federal Agencies
section_title: New York State Agencies
section_title: New York City Agencies
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