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. A wide variety of physical and mental health effects have been observed and reported across a wide range of people in the aftermath of the September 11 attacks. The health effects include various injuries, respiratory conditions, reproductive health effects, and mental health effects. Unlike the physical health effects, the mental health effects of the September 11 attacks were not limited to responders and people who were in the WTC area but were also experienced by people across the nation. Because most of the information about mental health effects comes from questionnaire or survey data, what is reported in most cases are symptoms associated or consistent with a disorder, such as PTSD, rather than a clinical diagnosis of a disorder. The most commonly reported mental health effects were symptoms associated with PTSD, depression, stress, and anxiety, as well as behavioral effects such as increases in substance use and difficulties coping with daily responsibilities. Although the total number of people injured during the WTC attack is unknown, data on hospital visits show that thousands of people were treated in its immediate aftermath for injuries, including inhalation injuries, musculoskeletal injuries, burns, and eye injuries. Unpublished data collected by the Greater New York Hospital Association from September 11 through September 28, 2001, showed 6,232 emergency room visits and 477 hospitalizations related to the attack in 103 hospitals in New York State and 1,018 emergency room visits and 84 hospitalizations related to the attack in nearby New Jersey hospitals. These numbers do not include injured people who may have been treated in more distant New York State, New Jersey, and Connecticut hospitals, in triage stations, 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. 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. 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. Studies and screenings conducted among other responders—carpenters, cleanup workers, federal civilian employees, heavy equipment operators, ironworkers, mechanics, National Guard members, police officers, telecommunications technicians, truck drivers, and U.S. Army military personnel—have found respiratory health effects similar to those seen in FDNY firefighters. Some of the responders with existing respiratory conditions reported that symptoms worsened, and others reported that they developed new respiratory symptoms on or after September 11. The most commonly reported symptom was cough. For example, about 63 percent of officers from NYPD’s Emergency Services Unit who were evaluated about 1 to 4 months after September 11 reported having a cough (Salzman et al., 2004). Other symptoms observed among responders included chest tightness, nasal congestion, shortness of breath, sore throat, and wheezing. Unpublished results from respiratory health assessments of WTC site workers—including truck drivers, heavy equipment operators, mechanics, laborers, and carpenters—conducted by Johns Hopkins in December 2001 show that among those who reported no previous history of lower respiratory symptoms, 34 percent reported developing a cough and 19 percent reported wheezing. While some responders reported that symptoms improved or resolved a few months after the attack, others reported that they continued to experience symptoms. For example, initial results from screenings of 250 participants in Mount Sinai’s monitoring program show that 46 percent of these responders were still experiencing at least one pulmonary symptom and 52 percent were still experiencing an ear, nose, or throat symptom 9 months after the attack (Herbert and Levin, 2003). Surveys conducted among people living or working in lower Manhattan show that these people experienced respiratory health effects similar to those experienced by responders, such as nose or throat irritation and cough. For example, a door-to-door survey conducted by the New York City Department of Health and Mental Hygiene in three residential areas in lower Manhattan between October 25 and November 2, 2001, showed that the most frequently reported symptoms were nose or throat irritation (about 66 percent) and cough (about 47 percent) (CDC, 2002a). A NIOSH survey of federal employees working near the WTC site found that 56 percent of respondents reported having a cough (Trout et al., 2002). Other symptoms observed among those living or working in lower Manhattan include chest tightness, head or sinus congestion, shortness of breath, and wheezing. Some people reported that the WTC collapse and its aftermath exacerbated existing respiratory conditions, such as asthma, and others reported symptoms that developed after September 11, 2001. For example, a review of medical charts of children with existing asthma from a lower Manhattan clinic found that after September 11 there was a significant increase in asthma-related clinic visits among children who lived within 5 miles of the WTC site (Szema et al., 2004). Unpublished preliminary findings from a New York State Department of Health survey of NYC residents found that almost three-fourths of respondents living near the WTC site experienced new upper respiratory symptoms after September 11. For all measures of reproductive health studied except birth weight for gestational age, 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. 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. 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). 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. 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. 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. 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. 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. 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. 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. 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. 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Summary: 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. 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.