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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Through our work, we identified the following agencies that sent employees to respond to the World Trade Center attack of September 11, 2001. 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Summary: 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. 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.