When a disaster or emergency overwhelms state and local response capabilities, the federal government can provide assistance with response and recovery efforts. FEMA, the federal agency responsible for coordinating federal disaster response efforts, collaborates with HHS on health issues related to disasters. Following the September 11, 2001, attack on the WTC, FEMA provided funding to HHS to establish certain WTC health programs. HHS’s disaster response and recovery activities operate within an administrative and legal framework that helps to define federal agency roles and responsibilities and gives HHS certain authorities. Following the attack on the WTC, the Congress appropriated approximately $8.8 billion to FEMA, over several years, for response and recovery activities. FEMA entered into interagency agreements with HHS agencies, such as NIOSH, ASPR, and ATSDR, to distribute funding to government and private organizations to implement health screening and monitoring programs for responders and other affected groups. In fiscal year 2006, the Congress appropriated $75 million to CDC that was available for monitoring and treatment services for certain WTC responders. The Congress made additional appropriations to CDC available for the same purpose in fiscal years 2007 and 2008. Federal funds appropriated or awarded for the WTC health programs from October 2001 through December 2007 have totaled about $369.2 million. There are four key WTC health programs that currently receive federal funding to provide voluntary health screening, monitoring, or treatment services to responders at no cost for illnesses and conditions related to the WTC disaster. The four programs are the FDNY WTC Medical Monitoring and Treatment Program; the NY/NJ WTC Consortium, which comprises five clinical centers in the NY/NJ area; HHS’s WTC Federal Responder Screening Program; and the WTC Health Registry. Unlike the other key programs, the WTC Health Registry does not provide in-person screening or monitoring services. Instead it uses periodic surveys of self-reported health status to collect health information on responders, as well as people who resided, worked, attended school, or were present in the vicinity of the WTC. (See app. I for more information about these key WTC health programs.) HHS funded the WTC health programs to serve different categories of responders (e.g., firefighters, federal responders, and other workers and volunteers). The programs also varied in their geographic coverage. For example, the FDNY WTC Program and the NY/NJ WTC Consortium primarily serve, respectively, firefighters and other workers and volunteers who reside in the NYC area or travel to that area for services. HHS’s WTC Federal Responder Screening Program provides screening services to federal responders nationwide through its network of FOH clinics. In addition, beginning in late 2002, NIOSH funded services for nonfederal responders residing outside the NYC metropolitan area. Table 1 provides information on the numbers of responders who have received various health services. NIOSH is the HHS administering agency for all the WTC health programs, except the WTC Health Registry, and in February 2006 the Secretary of HHS designated the Director of NIOSH to take the lead in ensuring that the WTC health programs are well coordinated. Information collected by the WTC health programs and other researchers has helped to identify the physical and mental health effects of the WTC disaster. 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. One study conducted by researchers affiliated with the FDNY WTC Program found that exposed firefighters on average experienced a decline in lung function equivalent to that which would be produced by 12 years of aging. A study conducted by WTC Health Registry researchers found that responders’ risk of newly diagnosed asthma increased with greater exposure to the WTC disaster site, as indicated by arriving at the site at an earlier date or working there for a longer duration. The Mount Sinai School of Medicine clinical center of the NY/NJ WTC Consortium found that about half of the participants in its screening program met the threshold criteria for being referred for a clinical mental health evaluation. Commonly reported mental health effects among responders and other affected individuals included symptoms associated with post-traumatic stress disorder (PTSD), depression, and anxiety. Behavioral health effects such as increased alcohol and tobacco use were also reported. In previous reports we noted limitations of the WTC health programs and problems with their implementation. For example, we reported that federal responders were eligible only for screening services and did not receive monitoring services as other responders did. We also reported on the service interruptions in the WTC Federal Responder Screening Program. HHS established the program in June 2003, suspended it in March 2004, resumed it in December 2005, suspended it again in January 2007, and resumed it in May 2007. Similarly, NIOSH’s services for nonfederal responders residing outside the NYC area were not continuously available for all responders. In addition, some of the screening and monitoring programs initially faced difficulties referring responders for treatment. Throughout the history of these programs, program officials have raised concerns about whether the duration of federal funding would be adequate. HHS’s disaster response activities, including efforts to address the health of responders, operate within an administrative and legal framework. In response to the attacks on September 11, 2001, the Congress enacted the Homeland Security Act of 2002, which established DHS and required the department to consolidate existing federal government response plans into a single coordinated national response plan. In December 2004, DHS issued the National Response Plan (NRP), which detailed missions, policies, structures, and responsibilities of federal agencies for coordinating resource and programmatic support to states, localities, and other entities. The NRP was to be invoked when the President issued a major disaster or emergency declaration under the Stafford Act. The NRP was first invoked in August 2005 in response to Hurricane Katrina and was subsequently updated in May 2006. In January 2008, DHS issued the NRF to supersede the NRP. The NRF is intended to provide a coordinated approach to disaster and emergency response and short-term recovery. FEMA is responsible for assigning work and providing funding to other federal agencies for performing operations included in the NRF. To execute this responsibility, FEMA uses mission assignments, which are interagency agreements with other federal agencies intended to meet immediate and short-term needs. When a disaster or emergency is declared under the authority of the Stafford Act and FEMA issues a mission assignment, a federal agency has 60 days after the declaration to complete tasks described in the mission assignment, unless time is extended by FEMA due to unusual or extenuating circumstances. Under the NRF, HHS is the primary agency for coordinating the federal government’s public health and medical response, and the Department of Labor’s Occupational Safety and Health Administration (OSHA) is the lead agency for responding to worker safety and health concerns, with HHS as a cooperating agency. HHS’s responsibilities for public health and medical response are described in the NRF’s Public Health and Medical Services Annex, also known as Emergency Support Function #8 (ESF#8). Under ESF#8, HHS can deploy its public health and medical personnel, including civilian volunteers, to the affected area. In addition, HHS can request an appropriate organization supporting ESF#8, such as the Environmental Protection Agency or the American Red Cross, to activate and deploy its public health and medical personnel. HHS can also assist state, tribal, and local officials in establishing a registry of potentially exposed individuals and conducting long-term monitoring for potential health effects. HHS’s ASPR coordinates ESF#8 actions. OSHA’s and HHS’s responsibilities for worker safety and health are described in the NRF’s Worker Safety and Health Support Annex. Under the Worker Safety and Health Support Annex, OSHA, in coordination with HHS, is responsible for providing technical assistance, advice, and support for medical surveillance and monitoring and for evaluating the need for longer-term medical monitoring of response and recovery workers. OSHA and NIOSH have established an interagency agreement that broadly describes NIOSH’s role in carrying out the Worker Safety and Health Support Annex. However, NIOSH would receive funding specifically to carry out activities related to the Worker Safety and Health Support Annex only if, after a disaster, FEMA issued a mission assignment to OSHA for such activities and OSHA in turn assigned activities to NIOSH. In addition to the NRF, there are certain statutes that are relevant to HHS’s responsibilities concerning responder health. According to the Pandemic and All-Hazards Preparedness Act, HHS is the lead federal agency for public health and medical responses to emergencies and disasters. The act specifies that ASPR must carry out certain functions during a response, including registering federal public health and medical personnel who are deployed under the authority of the Secretary of HHS. These personnel include members of the National Disaster Medical System (NDMS). Section 709 of the Security and Accountability for Every Port Act of 2006 (also known as the SAFE Port Act) provides that the President, acting through HHS, may establish and implement a program to provide screening and monitoring services for certain individuals affected by a presidentially declared disaster, including responders. The act specifies that such a program may include collecting exposure data, developing and disseminating information and educational materials, performing baseline and follow-up clinical and mental health evaluations, establishing and maintaining an exposure registry, studying short- and long-term health effects through epidemiologic and other health studies, and providing assistance to individuals in determining eligibility for health coverage and identifying appropriate health services. The act also authorizes the President, acting through HHS, to establish cooperative agreements with a medical institution, including a local health department or a consortium of medical institutions, to carry out this program.