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United States Government Accountability Office:
GAO:  

Testimony Before the Committee on Homeland Security, House of 
Representatives: 

SEPTEMBER 11: Problems Remain in Planning for and Providing Health 
Screening and Monitoring Services for Responders:  

Statement of Cynthia A. Bascetta: 
Director, Health Care:  

For Release on Delivery: 
Expected at 10:00 a.m. EDT: 
Thursday, September 20, 2007:  

GAO Highlights: 

Highlights of GAO-07-1253T, a testimony before the Committee on 
Homeland Security, House of Representatives.  

Why GAO Did This Study: 

Six years after the attack on the World Trade Center (WTC), concerns 
persist about health effects experienced by WTC responders and the 
availability of health care services for those affected. Several 
federally funded programs provide screening, monitoring, or treatment 
services to responders. GAO has previously reported on the progress 
made and implementation problems faced by these WTC health programs, as 
well as lessons learned from the WTC disaster.  

This testimony is based on previous GAO work, primarily September 11: 
HHS Needs to Ensure the Availability of Health Screening and Monitoring 
for All Responders (GAO-07-892, July 23, 2007). This testimony 
discusses (1) status of services provided by the Department of Health 
and Human Services’ (HHS) WTC Federal Responder Screening Program, (2) 
efforts by the Centers for Disease Control and Prevention’s National 
Institute for Occupational Safety and Health (NIOSH) to provide 
services for nonfederal responders residing outside the New York City 
(NYC) area, and (3) lessons learned from WTC health programs.  

For the July 2007 report, GAO reviewed program documents and 
interviewed HHS officials, grantees, and others. In August and 
September 2007, GAO updated selected information in preparing this 
testimony.  

What GAO Found: 

In July 2007, following a reexamination of the status of the WTC health 
programs, GAO recommended that the Secretary of HHS take expeditious 
action to ensure that health screening and monitoring services are 
available to all people who responded to the WTC attack, regardless of 
who their employer was or where they reside. As of September 2007 the 
department has not responded to this recommendation.  

As GAO reported in July 2007, HHS’s WTC Federal Responder Screening 
Program has had difficulties ensuring the uninterrupted availability of 
screening services for federal responders. From January 2007 to May 
2007, the program stopped scheduling screening examinations because 
there was a change in the program’s administration and certain 
interagency agreements were not established in time to keep the program 
fully operational. From April 2006 to March 2007, the program stopped 
scheduling and paying for specialty diagnostic services associated with 
screening. NIOSH, the administrator of the program, has been 
considering expanding the program to include monitoring—that is, follow-
up physical and mental health examinations—but has not done so. If 
federal responders do not receive monitoring, health conditions that 
arise later may not be diagnosed and treated, and knowledge of the 
health effects of the WTC disaster may be incomplete.  

NIOSH has not ensured the availability of screening and monitoring 
services for nonfederal responders residing outside the NYC area, 
although it recently took steps toward expanding the availability of 
these services. In late 2002, NIOSH arranged for a network of 
occupational health clinics to provide screening services. This effort 
ended in July 2004, and until June 2005 NIOSH did not fund screening or 
monitoring services for nonfederal responders outside the NYC area. In 
June 2005, NIOSH funded the Mount Sinai School of Medicine Data and 
Coordination Center (DCC) to provide screening and monitoring services; 
however, DCC had difficulty establishing a nationwide network of 
providers and contracted with only 10 clinics in seven states. In 2006, 
NIOSH began to explore other options for providing these services, and 
in May 2007 it took steps toward expanding the provider network. 
However, as of September 2007 these efforts are incomplete. 

Lessons have been learned from the WTC health programs that could 
assist in the event of a future disaster. Lessons include the need to 
quickly identify and contact responders and others affected by a 
disaster, the value of a centrally coordinated approach for assessing 
individuals’ health, and the importance of addressing both physical and 
mental health effects. Consideration of these lessons by federal 
agencies is important in planning for the response to future 
disasters.  

To view the full product, including the scope and methodology, click on 
[hyperlink, http://www.GAO-07-1253T]. For more information, contact 
Cynthia A. Bascetta at (202) 512-7114 or bascettac@gao.gov. 

[End of section] 

Mr. Chairman and Members of the Committee: 

I am pleased to be here today to discuss our work on the implementation 
of federally funded health programs for individuals affected by the 
September 11, 2001, attack on the World Trade Center (WTC), as well as 
lessons learned from responses to that disaster[Footnote 1]. Tens of 
thousands of people served as responders in the aftermath of the WTC 
disaster, including New York City Fire Department (FDNY) personnel, 
federal government personnel, and other government and private-sector 
workers and volunteers from New York and elsewhere. By responders we 
are referring to anyone involved in rescue, recovery, or cleanup 
activities at or near the vicinity of the WTC or the Staten Island site 
[Footnote 2]. These responders were exposed to numerous physical 
hazards, environmental toxins, and psychological trauma. Six years 
after the destruction of the WTC buildings, concerns remain about the 
physical and mental health effects of the disaster, the long-term 
nature of some of these health effects, and the availability of health 
care services for those affected. 

Following the WTC attack, federal funding was provided to government 
agencies and private organizations to establish programs for screening, 
monitoring, or treating responders for illnesses and conditions related 
to the WTC disaster; these programs are referred to in this testimony 
as the WTC health programs[Footnote 3,4]. The Department of Health and 
Human Services (HHS) funded the programs as separate efforts serving 
different categories of responders—for example, firefighters, other 
workers and volunteers, or federal responders—and has responsibility 
for coordinating program efforts. Officials involved in the 
administration and implementation of the WTC health programs have 
derived lessons from their experiences that could improve the design of 
such programs in the future. 

We have previously reported on the implementation of these programs and 
their progress in providing services to responders,[Footnote 5] who 
reside in all 50 states and the District of Columbia. In 2005 and 2006, 
we reported that one of the WTC health programs, HHS’s WTC Federal 
Responder Screening Program, which was established to provide one-time 
screening examinations for responders who were federal employees when 
they responded to the WTC attack, had accomplished little.[Footnote 6] 
HHS established the program in June 2003, suspended it in March 2004, 
and resumed it in December 2005. In September 2006, we reported that 
the program was registering and screening federal responders and that a 
total of 907 federal workers had received screening 
examinations.[Footnote7] We also reported that the National Institute 
for Occupational Safety and Health (NIOSH), the component of HHS’s 
Centers for Disease Control and Prevention (CDC) responsible for 
administering most of the WTC health programs, had begun to take steps 
to provide access to screening, monitoring, and treatment services for 
nonfederal responders who resided outside the New York City (NYC) 
metropolitan area[Footnote 8]. 

In September 2006 we also testified that CDC had begun, but not 
completed, the process of allocating funding from a $75 million 
appropriation made in fiscal year 2006 for WTC health programs for 
responders[ 9,10]. This was the first appropriation specifically 
available for treatment for responders. We reported that in August 2006 
CDC had awarded $1.5 million from this appropriation to the FDNY WTC 
Medical Monitoring and Treatment Program and almost $1.1 million to the 
New York/New Jersey (NY/NJ) WTC Consortium for treatment-related 
activities. We also reported that CDC officials told us they could not 
predict how long the funding from the appropriation would support four 
WTC health programs that provide treatment services.  

My testimony today is primarily based on our report issued in July 
2007[Footnote 11]. As you requested, I will discuss (1) the status of 
services provided by the WTC Federal Responder Screening Program, (2) 
NIOSH’s efforts to provide services for nonfederal responders residing 
outside the NYC metropolitan area, (3) NIOSH’s awards to grantees for 
treatment services, and (4) lessons learned from WTC health programs.  

To assess the status of services provided by the WTC Federal Responder 
Screening Program, we obtained and reviewed program data and documents 
from HHS, including applicable interagency agreements. We interviewed 
officials from the HHS entities involved in administering and 
implementing the program: NIOSH and two HHS offices, the Federal 
Occupational Health Services (FOH)[Footnote12] and the Office of the 
Assistant Secretary for Preparedness and Response (ASPR)[Footnote 13]. 
To assess NIOSH’s efforts to provide services for nonfederal responders 
residing outside the NYC metropolitan area, we obtained documents and 
interviewed officials from NIOSH. We also interviewed officials of 
organizations that worked with NIOSH to provide or facilitate services 
for nonfederal responders residing outside the NYC metropolitan area, 
including the Mount Sinai School of Medicine in NYC and the Association 
of Occupational and Environmental Clinics (AOEC)—a network of 
university-affiliated and other private occupational health clinics 
across the United States and in Canada. To assess NIOSH’s awards to 
grantees for treatment services, we obtained documents and interviewed 
officials from NIOSH. We also interviewed officials from two WTC health 
program grantees [Footnote 14] from which the majority of responders 
receive medical services: the NY/NJ WTC Consortium[Footnote 15] and the 
FDNY WTC program. In addition, we interviewed officials from the 
American Red Cross, which has funded treatment services for responders. 
In our review of the WTC health programs, we relied primarily on 
information provided by agency officials and contained in government 
publications. We compared the information with information in other 
supporting documents, when available, to determine its consistency and 
reasonableness. We determined that the information we obtained was 
sufficiently reliable for our purposes. To identify lessons learned, we 
relied on previous work, for which we conducted interviews with HHS 
officials, WTC health program officials, and experts in public 
health[Footnote 16]. We also reviewed our previous work on the safety 
and health of workers who responded to Hurricane Katrina[Footnote 17]. 
We performed the work for the July 2007 report from November 2006 
through July 2007—and updated selected information in August and 
September 2007. We performed the work to identify lessons learned from 
July 2005 through September 2005 and updated this information in 
February 2006. All work was conducted in accordance with generally 
accepted government auditing standards.  

In brief, we reported in July 2007 that HHS’s WTC Federal Responder 
Screening Program had had difficulties ensuring the uninterrupted 
availability of screening services for federal responders and that 
NIOSH, the administrator of the program, was considering expanding the 
program to include monitoring but had not done so. We also reported 
that NIOSH had not ensured the availability of screening and monitoring 
services for nonfederal responders residing outside the NYC 
metropolitan area, although it had recently taken steps toward 
expanding the availability of these services. As a result of our 
assessment of these programs, we recommended that the Secretary of HHS 
expeditiously take action to ensure that screening and monitoring 
services are available for all responders, including federal responders 
and nonfederal responders residing outside of the NYC metropolitan 
area. As of September 2007 the department has not responded to this 
recommendation. We also reported that NIOSH had awarded and set aside 
treatment funds totaling $51 million from its $75 million appropriation 
for four NYC-area programs. Finally, important lessons have been 
learned from the WTC health programs that could assist in the event of 
a future disaster. These include the need to quickly identify and 
contact responders and others affected by a disaster, the value of a 
centrally coordinated approach for assessing individuals’ health, and 
the importance of addressing both physical and mental health effects. 

Background: 

The tens of thousands of individuals[Footnote 18] who responded to the 
September 11, 2001, attack on the WTC experienced the emotional trauma 
of the disaster and were exposed to a noxious mixture of dust, debris, 
smoke, and potentially toxic contaminants, such as pulverized concrete, 
fibrous glass, particulate matter, and asbestos. A wide variety of 
health effects have been experienced by responders to the WTC attack, 
and several federally funded programs have been created to address the 
health needs of these individuals.  

Health Effects:  

Numerous studies have documented the physical and mental health effects 
of the WTC attacks.19 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 suggested that exposed firefighters on average experienced a 
decline in lung function equivalent to that which would be produced by 
12 years of aging[Footnote 20]. A recently published study found a 
significantly higher risk of newly diagnosed asthma among responders 
that was associated with increased exposure to the WTC disaster 
site[Footnote 21]. 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 alcohol and tobacco use have also 
been reported.  

Some health effects experienced by responders have persisted or 
worsened over time, leading many responders to begin seeking treatment 
years after September 11, 2001. Clinicians involved in screening, 
monitoring, and treating responders have found that many responders’ 
conditions—both physical and psychological—have not resolved and have 
developed into chronic disorders that require long-term monitoring. For 
example, findings from a study conducted by clinicians at the NY/NJ WTC 
Consortium show that at the time of examination, up to 2.5 years after 
the start of the rescue and recovery effort, 59 percent of responders 
enrolled in the program were still experiencing new or worsened 
respiratory symptoms[Footnote 22]. Experts studying the mental health 
of responders found that about 2 years after the WTC attack, responders 
had higher rates of PTSD and other psychological conditions compared to 
others in similar jobs who were not WTC responders and others in the 
general population[Footnote 23]. Clinicians also anticipate that other 
health effects, such as immunological disorders and cancers, may emerge 
over time. 

Overview of WTC Health Programs: 

There are six key programs that currently receive federal funding to 
provide voluntary health screening, monitoring, or treatment at no cost 
to responders[Footnote 24]. The six WTC health programs, shown in table 
1, are (1) the FDNY WTC Medical Monitoring and Treatment Program; (2) 
the NY/NJ WTC Consortium, which comprises five clinical centers in the 
NY/NJ area;[Footnote 25] (3) the WTC Federal Responder Screening 
Program; (4) the WTC Health Registry; (5) Project COPE; and (6) the 
Police Organization Providing Peer Assistance (POPPA) program[Footnote 
26]. The programs vary in aspects such as the HHS administering agency 
or component responsible for administering the funding; the 
implementing agency, component, or organization responsible for 
providing program services; eligibility requirements; and services. 

Table 1: Key Federally Funded WTC Health Programs, June 2007: 

Program: FDNY WTC Medical Monitoring and Treatment Program; 
HHS administering agency or component: NIOSH; 
Implementing agency, component, or organization: 
FDNY Bureau of Health Services; 
Eligible population: Firefighters and emergency medical service 
technicians; 
Services provided: Initial screening; Follow-up medical monitoring; 
Treatment of WTC-related physical and mental health conditions. 

Program: NY/NJ WTC Consortium; 
HHS administering agency or component: NIOSH; 
Implementing agency, component, or organization: Five clinical 
centers, one of which, the Mount Sinai-Irving J. Selikoff Center for 
Occupational and Environmental Medicine, also serves as the 
consortium's Data and Coordination Center (DCC); 
Eligible population: All responders, excluding FDNY firefighters and 
emergency medical 
service technicians and current federal employees[A]; 
Services provided: Initial screening; Follow-up medical monitoring; 
Treatment of WTC-related physical and mental health conditions. 

Program: WTC Federal Responder Screening Program; 
HHS administering agency or component: NIOSH[B]; 
Implementing agency, component, or organization: FOH; 
Eligible population: Current federal employees who responded to the WTC 
attack in an official capacity; 
Services provided: One-time screening; Referrals to employee assistance 
programs and specialty diagnostic services[C]. 

Program: WTC Health Registry; 
HHS administering agency or component: Agency for Toxic Substances and 
Disease Registry (ATSDR); 
Implementing agency, component, or organization: NYC Department of 
Health and Mental Hygiene; 
Eligible population: Responders and people living or attending school 
in the area of the WTC or working or present in the vicinity on 
September 11, 2001; 
Services provided: Long-term monitoring through periodic surveys. 

Program: Project COPE; 
HHS administering agency or component: NIOSH; 
Implementing agency, component, or organization: Collaboration between 
the NYC Police Foundation and Columbia University Medical Center; 
Eligible population: New York City Police Department (NYPD) uniformed 
and civilian employees and their family members; 
Services provided: Hotline, mental health counseling, and referral 
services; some services provided by Columbia University clinical staff 
and some by other clinicians. 

Program: POPPA program; 
HHS administering agency or component: NIOSH; 
Implementing agency, component, or organization: POPPA program; 
Eligible population: NYPD uniformed employees; 
Services provided: Hotline, mental health counseling, and referral 
services; some services provided by trained NYPD officers and some by 
mental health professionals. 

Source: GAO analysis of information from NIOSH, ATSDR, FOH, FDNY, the 
NY/NJ WTC Consortium, the NYC Department of Health and Mental Hygiene, 
the POPPA program, and Project COPE. 

Note: Some of these federally funded programs have also received funds 
from the American Red Cross and other private organizations. 

[A] In February 2006, ASPR and NIOSH reached an agreement to have 
former federal employees screened by the NY/NJ WTC Consortium. 

[B] Until December 26, 2006, ASPR was the administrator. 

[C] FOH can refer an individual with mental health symptoms to an 
employee assistance program for a telephone assessment. If appropriate, 
the individual can then be referred to a program counselor for up to 
six in-person sessions. The specialty diagnostic services are provided 
by ear, nose, and throat doctors; pulmonologists; and cardiologists. 

[End of table] 

The WTC health programs that are providing screening and monitoring are 
tracking thousands of individuals who were affected by the WTC 
disaster. As of June 2007, the FDNY WTC program had screened about 
14,500 responders and had conducted follow-up examinations for about 
13,500 of these responders, while the NY/NJ WTC Consortium had screened 
about 20,000 responders and had conducted follow-up examinations for 
about 8,000 of these responders. Some of the responders include 
nonfederal responders residing outside the NYC metropolitan area. As of 
June 2007, the WTC Federal Responder Screening Program had screened 
1,305 federal responders and referred 281 responders for employee 
assistance program services or specialty diagnostic services. In 
addition, the WTC Health Registry, a monitoring program that consists 
of periodic surveys of self-reported health status and related studies 
but does not provide in-person screening or monitoring, collected 
baseline health data from over 71,000 people who enrolled in the 
Registry.[Footnote 27] In the winter of 2006, the Registry began its 
first adult follow-up survey, and as of June 2007 over 36,000 
individuals had completed the follow-up survey. 

In addition to providing medical examinations, FDNY's WTC program and 
the NY/NJ WTC Consortium have collected information for use in 
scientific research to better understand the health effects of the WTC 
attack and other disasters. The WTC Health Registry is also collecting 
information to assess the long-term public health consequences of the 
disaster. 

Federal Funding and Coordination of WTC Health Programs: 

Beginning in October 2001 and continuing through 2003, FDNY's WTC 
program, the NY/NJ WTC Consortium, the WTC Federal Responder Screening 
Program, and the WTC Health Registry received federal funding to 
provide services to responders. This funding primarily came from 
appropriations to the Department of Homeland Security's Federal 
Emergency Management Agency (FEMA),[Footnote 28] as part of the 
approximately $8.8 billion that the Congress appropriated to FEMA for 
response and recovery activities after the WTC disaster.[Footnote 29] 
FEMA entered into interagency agreements with HHS agencies to 
distribute the funding to the programs. For example, FEMA entered into 
an agreement with NIOSH to distribute $90 million appropriated in 2003 
that was available for monitoring.[Footnote 30] FEMA also entered into 
an agreement with ASPR for ASPR to administer the WTC Federal Responder 
Screening Program. A $75 million appropriation to CDC in fiscal year 
2006 for purposes related to the WTC attack resulted in additional 
funding for the monitoring activities of the FDNY WTC program, NY/NJ 
WTC Consortium, and the Registry.[Footnote 31] The $75 million 
appropriation to CDC in fiscal year 2006 also provided funds that were 
awarded to the FDNY WTC program, the NY/NJ WTC Consortium, Project 
COPE, and the POPPA program for treatment services for responders. An 
emergency supplemental appropriation to CDC in May 2007 included an 
additional $50 million to carry out the same activities provided for in 
the $75 million appropriation made in fiscal year 2006.[Footnote 32] 
The President's proposed fiscal year 2008 budget for HHS includes $25 
million for treatment of WTC-related illnesses for responders. 

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, and in September 2006 the Secretary established a WTC Task 
Force to advise him on federal policies and funding issues related to 
responders' health conditions. The chair of the task force is HHS's 
Assistant Secretary for Health, and the vice chair is the Director of 
NIOSH. The task force reported to the Secretary of HHS in early April 
2007. 

WTC Federal Responder Screening Program Has Had Difficulties Ensuring 
the Availability of Screening Services, and NIOSH Has Considered 
Expanding the Program to Include Monitoring: 

HHS's WTC Federal Responder Screening Program has had difficulties 
ensuring the uninterrupted availability of services for federal 
responders. First, the provision of screening examinations has been 
intermittent. (See fig. 1.) After resuming screening examinations in 
December 2005[Footnote 33] and conducting them for about a year, HHS 
again placed the program on hold and suspended scheduling of screening 
examinations for responders from January 2007 to May 2007. This 
interruption in service occurred because there was a change in the 
administration of the WTC Federal Responder Screening Program, and 
certain interagency agreements were not established in time to keep the 
program fully operational. In late December 2006, ASPR and NIOSH signed 
an interagency agreement giving NIOSH $2.1 million to administer the 
WTC Federal Responder Screening Program.[Footnote 34] Subsequently, 
NIOSH and FOH needed to sign a new interagency agreement to allow FOH 
to continue to be reimbursed for providing screening examinations. It 
took several months for the agreement between NIOSH and FOH to be 
negotiated and approved, and scheduling of screening examinations did 
not resume until May 2007.[Footnote 35] 

Figure 1: Timeline of Key Actions Related to the WTC Federal Responder 
Screening Program: 

[See PDF for image] 

Note: The WTC Federal Responder Screening Program serves current 
federal employees who responded to the WTC attack in an official 
capacity. In February 2006, ASPR and NIOSH reached an agreement to have 
former federal employees screened by the NY/NJ WTC Consortium. 

[A] In December 2006 the Office of Public Health and Emergency 
Preparedness became ASPR. We refer to that office as ASPR throughout 
this figure, regardless of the time period being discussed. 

[B] In providing referrals for specialty diagnostic services, FOH 
schedules and pays for the diagnostic services. 

[C] After HHS placed the program on hold, FOH completed examinations 
that had already been scheduled. 

[End of figure] 

Second, the program's provision of specialty diagnostic services has 
also been intermittent. After initial screening examinations, 
responders often need further diagnostic services by ear, nose, and 
throat doctors; cardiologists; and pulmonologists; and FOH had been 
referring responders to these specialists and paying for the services. 
However, the program stopped scheduling and paying for these specialty 
diagnostic services in April 2006 because the program's contract with a 
new provider network did not cover these services.[Footnote 36] In 
March 2007, FOH modified its contract with the provider network and 
resumed scheduling and paying for specialty diagnostic services for 
federal responders. 

In July 2007 we reported that NIOSH was considering expanding the WTC 
Federal Responder Screening Program to include monitoring examinations-
-follow-up physical and mental health examinations--and was assessing 
options for funding and delivering these services. If federal 
responders do not receive this type of monitoring, health conditions 
that arise later may not be diagnosed and treated, and knowledge of the 
health effects of the WTC disaster may be incomplete. In February 2007, 
NIOSH sent a letter to FEMA, which provides the funding for the 
program, asking whether the funding could be used to support monitoring 
in addition to the one-time screening currently offered. A NIOSH 
official told us that as of August 2007 the agency had not received a 
response from FEMA. NIOSH officials told us that if FEMA did not agree 
to pay for monitoring of federal responders, NIOSH would consider using 
other funding. According to a NIOSH official, if FEMA or NIOSH agrees 
to pay for monitoring of federal responders, this service would be 
provided by FOH or one of the other WTC health programs. 

NIOSH Has Not Ensured the Availability of Services for Nonfederal 
Responders Residing outside the NYC Metropolitan Area: 

NIOSH has not ensured the availability of screening and monitoring 
services for nonfederal responders residing outside the NYC 
metropolitan area, although it recently took steps toward expanding the 
availability of these services. Initially, NIOSH made two efforts to 
provide screening and monitoring services for these responders, the 
exact number of which is unknown.[Footnote 37] The first effort began 
in late 2002 when NIOSH awarded a contract for about $306,000 to the 
Mount Sinai School of Medicine to provide screening services for 
nonfederal responders residing outside the NYC metropolitan area and 
directed it to establish a subcontract with AOEC.[Footnote 38] AOEC 
then subcontracted with 32 of its member clinics across the country to 
provide screening services. From February 2003 to July 2004, the 32 
AOEC member clinics screened 588 nonfederal responders nationwide. AOEC 
experienced challenges in providing these screening services. For 
example, many nonfederal responders did not enroll in the program 
because they did not live near an AOEC clinic, and the administration 
of the program required substantial coordination among AOEC, AOEC 
member clinics, and Mount Sinai. 

Mount Sinai's subcontract with AOEC ended in July 2004, and from August 
2004 until June 2005 NIOSH did not fund any organization to provide 
services to nonfederal responders outside the NYC metropolitan 
area.[Footnote 39] During this period, NIOSH focused on providing 
screening and monitoring services for nonfederal responders in the NYC 
metropolitan area. In June 2005, NIOSH began its second effort by 
awarding $776,000 to the Mount Sinai School of Medicine Data and 
Coordination Center (DCC) to provide both screening and monitoring 
services for nonfederal responders residing outside the NYC 
metropolitan area. In June 2006, NIOSH awarded an additional $788,000 
to DCC to provide screening and monitoring services for these 
responders. NIOSH officials told us that they assigned DCC the task of 
providing screening and monitoring services to nonfederal responders 
outside the NYC metropolitan area because the task was consistent with 
DCC's responsibilities for the NY/NJ WTC Consortium, which include data 
monitoring and coordination. DCC, however, had difficulty establishing 
a network of providers that could serve nonfederal responders residing 
throughout the country--ultimately contracting with only 10 clinics in 
seven states to provide screening and monitoring services.[Footnote 40] 
DCC officials said that as of June 2007 the 10 clinics were monitoring 
180 responders. 

In early 2006, NIOSH began exploring how to establish a national 
program that would expand the network of providers to provide screening 
and monitoring services, as well as treatment services, for nonfederal 
responders residing outside the NYC metropolitan area.[Footnote 41] 
According to NIOSH, there have been several challenges involved in 
expanding a network of providers to screen and monitor nonfederal 
responders nationwide. These include establishing contracts with 
clinics that have the occupational health expertise to provide services 
nationwide, establishing patient data transfer systems that comply with 
applicable privacy laws, navigating the institutional review 
board[Footnote 42] process for a large provider network, and 
establishing payment systems with clinics participating in a national 
network of providers. On March 15, 2007, NIOSH issued a formal request 
for information from organizations that have an interest in and the 
capability of developing a national program for responders residing 
outside the NYC metropolitan area.[Footnote 43] In this request, NIOSH 
described the scope of a national program as offering screening, 
monitoring, and treatment services to about 3,000 nonfederal responders 
through a national network of occupational health facilities. NIOSH 
also specified that the program's facilities should be located within 
reasonable driving distance to responders and that participating 
facilities must provide copies of examination records to DCC. In May 
2007, NIOSH approved a request from DCC to redirect about $125,000 from 
the June 2006 award to establish a contract with a company to provide 
screening and monitoring services for nonfederal responders residing 
outside the NYC metropolitan area. Subsequently, DCC contracted with 
QTC Management, Inc.,[Footnote 44] one of the four organizations that 
had responded to NIOSH's request for information. DCC's contract with 
QTC does not include treatment services, and NIOSH officials are still 
exploring how to provide and pay for treatment services for nonfederal 
responders residing outside the NYC metropolitan area.[Footnote 45] QTC 
has a network of providers in all 50 states and the District of 
Columbia and can use internal medicine and occupational medicine 
doctors in its network to provide these services. In addition, DCC and 
QTC have agreed that QTC will identify and subcontract with providers 
outside of its network to screen and monitor nonfederal responders who 
do not reside within 25 miles of a QTC provider.[Footnote 46] In June 
2007, NIOSH awarded $800,600 to DCC for coordinating the provision of 
screening and monitoring examinations, and QTC will receive a portion 
of this award from DCC to provide about 1,000 screening and monitoring 
examinations through May 2008. According to a NIOSH official, QTC's 
providers have begun conducting screening examinations, and by the end 
of August 2007, 18 nonfederal responders had completed screening 
examinations, and 33 others had been scheduled. 

NIOSH Awarded Funding for Treatment Services to Four WTC Health 
Programs: 

In fall 2006, NIOSH awarded and set aside funds totaling $51 million 
from its $75 million appropriation for four WTC health programs in the 
NYC metropolitan area to provide treatment services to responders 
enrolled in these programs. Of the $51 million, NIOSH awarded about $44 
million for outpatient services to the FDNY WTC program, the NY/NJ WTC 
Consortium, Project COPE, and the POPPA program. NIOSH made the largest 
awards to the two programs from which almost all responders receive 
medical services, the FDNY WTC program and NY/NJ WTC Consortium (see 
table 2). In July 2007 we reported that officials from the FDNY WTC 
program and the NY/NJ WTC Consortium expected that their awards for 
outpatient treatment would be spent by the end of fiscal year 
2007.[Footnote 47],[Footnote 48] In addition to the $44 million it 
awarded for outpatient services, NIOSH set aside about $7 million for 
the FDNY WTC program and NY/NJ WTC Consortium to pay for responders' 
WTC-related inpatient hospital care as needed.[Footnote 49] 

Table 2: NIOSH Awards to WTC Health Programs for Providing Treatment 
Services, 2006 (Dollars in millions): 

WTC health program: NY/NJ WTC Consortium; 
Amount of award[A]: $20.8; 
Date of award: October 26, 2006. 

WTC health program: FDNY WTC Medical Monitoring and Treatment Program; 
Amount of award[A]: 18.7; 
Date of award: October 26, 2006. 

WTC health program: Project COPE; 
Amount of award[A]: 3.0[B]; 
Date of award: September 19, 2006. 

WTC health program: POPPA program; 
Amount of award[A]: 1.5[C]; 
Date of award: September 19, 2006. 

WTC health program: Total amount of awards; 
Amount of award[A]: $44.0.  

Source: NIOSH. 

[A] Amount is rounded to the nearest $0.1 million. 

[B] NIOSH will provide $1 million annually to Project COPE beginning in 
September 2006 through September 2008, for a total award of $3 million. 

[C] NIOSH will provide $500,000 annually to the POPPA program beginning 
in September 2006 through September 2008, for a total award of $1.5 
million. 

[End of table] 

The FDNY WTC program and NY/NJ WTC Consortium used their awards from 
NIOSH to continue providing treatment services to responders and to 
expand the scope of available treatment services. Before NIOSH made its 
awards for treatment services, the treatment services provided by the 
two programs were supported by funding from private philanthropies and 
other organizations. According to officials of the NY/NJ WTC 
Consortium, this funding was sufficient to provide only outpatient care 
and partial coverage for prescription medications. The two programs 
used NIOSH's awards to continue to provide outpatient services to 
responders, such as treatment for gastrointestinal reflux disease, 
upper and lower respiratory disorders, and mental health conditions. 
They also expanded the scope of their programs by offering responders 
full coverage for their prescription medications for the first time. A 
NIOSH official told us that some of the commonly experienced WTC 
conditions, such as upper airway conditions, gastrointestinal 
disorders, and mental health disorders, are frequently treated with 
medications that can be costly and may be prescribed for an extended 
period of time. According to an FDNY WTC program official, prescription 
medications are now the largest component of the program's treatment 
budget. 

The FDNY WTC program and NY/NJ WTC Consortium also expanded the scope 
of their programs by paying for inpatient hospital care for the first 
time, using funds from the $7 million that NIOSH had set aside for this 
purpose. According to a NIOSH official, NIOSH pays for hospitalizations 
that have been approved by the medical directors of the FDNY WTC 
program and NY/NJ WTC Consortium through awards to the programs from 
the funds NIOSH set aside for this purpose. By August 31, 2007, federal 
funds had been used to support 34 hospitalizations of responders, 28 of 
which were referred by the NY/NJ WTC Consortium's Mount Sinai clinic, 5 
by the FDNY WTC program, and 1 by the NY/NJ WTC Consortium's CUNY 
Queens College program. Responders have received inpatient hospital 
care to treat, for example, asthma, pulmonary fibrosis,[Footnote 50] 
and severe cases of depression or PTSD. According to a NIOSH official, 
one responder is now a candidate for lung transplantation and if this 
procedure is performed, it will be covered by federal funds. If funds 
set aside for hospital care are not completely used by the end of 
fiscal year 2007, he said they could be carried over into fiscal year 
2008 for this purpose or used for outpatient services. 

After receiving NIOSH's funding for treatment services in fall 2006, 
the NY/NJ WTC Consortium ended its efforts to obtain reimbursement from 
health insurance held by responders with coverage.[Footnote 51] 
Consortium officials told us that efforts to bill insurance companies 
involved a heavy administrative burden and were frequently 
unsuccessful, in part because the insurance carriers typically denied 
coverage for work-related health conditions on the grounds that such 
conditions should be covered by state workers' compensation programs. 
However, according to officials from the NY/NJ WTC Consortium, 
responders trying to obtain workers' compensation coverage routinely 
experienced administrative hurdles and significant delays, some lasting 
several years. Moreover, according to these program officials, the 
majority of responders enrolled in the program either had limited or no 
health insurance coverage. According to a labor official, responders 
who carried out cleanup services after the WTC attack often did not 
have health insurance, and responders who were construction workers 
often lost their health insurance when they became too ill to work the 
number of days each quarter or year required to maintain eligibility 
for insurance coverage. 

According to a NIOSH official, although the agency had not received 
authorization as of August 30, 2007, to use the $50 million emergency 
supplemental appropriation made to CDC in May 2007, NIOSH was 
formulating plans for use of these funds to support the WTC treatment 
programs in fiscal year 2008. 

Lessons from WTC Health Programs Could Assist with Response to Future 
Disasters: 

Officials involved in the WTC health programs implemented by government 
agencies or private organizations--as well as officials from the 
federal administering agencies--derived lessons from their experiences 
that could help with the design of such programs in the future. Lessons 
include the need to quickly identify and contact responders and others 
affected by a disaster, the value of a centrally coordinated approach 
for assessing individuals' health, and the importance of addressing 
both physical and mental health effects. 

Officials involved in WTC monitoring efforts discussed with us the 
importance of quickly identifying and contacting responders and others 
affected by a disaster.[Footnote 52] They said that potential 
monitoring program participants could become more difficult to locate 
as time passed.[Footnote 53] 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. Our work on Hurricane 
Katrina found that no one was assigned responsibility for collecting 
data on the total number of response and recovery workers deployed to 
the Gulf and no agency collected it.[Footnote 54],[Footnote 55] 

Furthermore, officials from the WTC health programs 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 agency roles so important 
aspects of disaster response efforts are not overlooked. For example, 
as we reported in March 2007,[Footnote 56] federal agencies involved in 
the response to the Hurricane Katrina disaster disagreed over which 
agency should fund the medical monitoring of responders. We recommended 
that the relevant federal agencies involved clearly define their roles 
and resolve this disagreement so that the need may be met in future 
disasters. In general, there has been no systematic monitoring of the 
health of responders to Hurricane Katrina. 

Officials also told us that efforts to address health effects should be 
comprehensive--encompassing responders' physical and mental health. 
Officials from the NY/NJ WTC Consortium told us that the initial 
planning for their program had focused primarily on screening 
participants' physical health and that they originally budgeted only 
for basic mental health screening. Subsequently, they recognized a need 
for more in-depth 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 in-person 
psychiatric screening, and, when necessary, provide more extensive 
evaluations. Our work on Hurricane Katrina found problems with the 
provision of mental health services during the response to the 
disaster. Not all responders who needed mental health services received 
them. For example, it was difficult to get mental health counselors to 
go to the base camps where workers lived during the response and to get 
counselors to provide services during off-hours to workers who did not 
have standard work schedules. 

Concluding Observations: 

Screening and monitoring the health of the people who responded to the 
September 11, 2001, attack on the World Trade Center are critical for 
identifying health effects already experienced by responders or those 
that may emerge in the future. In addition, collecting and analyzing 
information produced by screening and monitoring responders can give 
health care providers information that could help them better diagnose 
and treat responders and others who experience similar health effects. 

While some groups of responders are eligible for screening and follow-
up physical and mental health examinations through the federally funded 
WTC health programs, other groups of responders are not eligible for 
comparable services or may not always find these services available. 
Federal responders have been eligible only for the initial screening 
examination provided through the WTC Federal Responder Screening 
Program. NIOSH, the administrator of the program, has been considering 
expanding the program to include monitoring but has not done so. In 
addition, many responders who reside outside the NYC metropolitan area 
have not been able to obtain screening and monitoring services because 
available services are too distant. Moreover, HHS has repeatedly 
interrupted the programs it established for federal responders and 
nonfederal responders outside of NYC, resulting in periods when no 
services were available to them. 

HHS continues to fund and coordinate the WTC health programs and has 
key federal responsibility for ensuring the availability of services to 
responders. HHS and its agencies have recently taken steps to move 
toward providing screening and monitoring services to federal 
responders and to nonfederal responders living outside of the NYC area. 
However, these efforts are not complete, and the stop-and-start history 
of the department's efforts to serve these groups does not provide 
assurance that the latest efforts to extend screening and monitoring 
services to these responders will be successful and will be sustained 
over time. Therefore we recommended in July 2007 that the Secretary of 
HHS take expeditious action to ensure that health screening and 
monitoring services are available to all people who responded to the 
attack on the WTC, regardless of who their employer was or where they 
reside. As of September 2007 the department has not responded to this 
recommendation. 

Finally, important lessons have been learned from the WTC disaster. 
These include the need to quickly identify and contact responders and 
others affected by a disaster, the value of a centrally coordinated 
approach for assessing individuals' health, and the importance of 
addressing both physical and mental health effects. Consideration of 
these lessons by federal agencies is important in planning for the 
response to future disasters. 

Mr. Chairman, this completes my prepared remarks. I would be happy to 
respond to any questions you or other members of the committee may have 
at this time. 

Contacts and Acknowledgments: 

For further information about this testimony, please contact Cynthia A. 
Bascetta at (202) 512-7114 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; 
Hernan Bozzolo; Frederick Caison; Anne Dievler; and Roseanne Price made 
key contributions to this statement. 

[End of section] 

Appendix I: Abbreviations: 

AOEC: Association of Occupational and Environmental Clinics: 
ASPR: Office of the Assistant Secretary for Preparedness and Response: 
ATSDR: Agency for Toxic Substances and Disease Registry: 
CDC: Centers for Disease Control and Prevention: 
DCC: Data and Coordination Center: 
FDNY: New York City Fire Department: 
FEMA: Federal Emergency Management Agency: 
FOH: Federal Occupational Health Services: 
HHS: Department of Health and Human Services: 
NIOSH: National Institute for Occupational Safety and Health: 
NYC: New York City 
NY/NJ: New York/New Jersey: 
NYPD: New York City Police Department: 
POPPA: Police Organization Providing Peer Assistance: 
PTSD: post-traumatic stress disorder: 
WTC World Trade Center:  

[End of section] 

Related GAO Products: 

September 11: HHS Needs to Ensure the Availability of Health Screening 
and Monitoring for All Responders. GAO-07-892. Washington, D.C.: July 
23, 2007. 

Disaster Preparedness: Better Planning Would Improve OSHA's Efforts to 
Protect Workers' Safety and Health in Disasters. GAO-07-193. 
Washington, D.C.: March 28, 2007. 

September 11: HHS Has Screened Additional Federal Responders for World 
Trade Center Health Effects, but Plans for Awarding Funds for Treatment 
Are Incomplete. GAO-06-1092T. Washington, D.C.: September 8, 2006. 

September 11: Monitoring of World Trade Center Health Effects Has 
Progressed, but Program for Federal Responders Lags Behind. 
GAO-06-481T. Washington, D.C.: February 28, 2006. 

September 11: Monitoring of World Trade Center Health Effects Has 
Progressed, but Not for Federal Responders. GAO-05-1020T. Washington, 
D.C.: September 10, 2005. 

September 11: Health Effects in the Aftermath of the World Trade Center 
Attack. GAO-04-1068T. Washington, D.C.: September 8, 2004. 

[End of section] 

FOOTNOTES 

[1] A list of abbreviations used in this testimony is in app. I. 

[2] The Staten Island site is the landfill that is the off-site 
location of the WTC recovery operation. 

[3] In this testimony, "screening" refers to initial physical and 
mental health examinations of affected individuals. "Monitoring" refers 
to tracking the health of individuals over time, either through 
periodic surveys or through follow-up physical and mental health 
examinations.  

[4] One of the WTC health programs, the WTC Health Registry, also 
includes people living or attending school in the area of the WTC or 
working or present in the vicinity on September 11, 2001. 

[5] See, for example, GAO, September 11: HHS Has Screened Additional 
Federal Responders for World Trade Center Health Effects, but Plans for 
Awarding Funds for Treatment Are Incomplete, GAO-06-1092T (Washington, 
D.C.: Sept. 8, 2006). A list of related GAO products is included at the 
end of this testimony. 

[6] See GAO, September 11: Monitoring of World Trade Center Health 
Effects Has Progressed, but Not for Federal Responders, GAO-05-1020T 
(Washington, D.C.: Sept. 10, 2005), and September 11: Monitoring of 
World Trade Center Health Effects Has Progressed, but Program for 
Federal Responders Lags Behind, GAO-06-481T (Washington, D.C.: Feb. 28, 
2006). 

[7] See GAO-06-1092T. 

[8] In general, the WTC health programs provide services in the NYC 
metropolitan area.  

[9] Department of Defense Appropriations Act, 2006, Pub. L. No. 109-
148, § 5011(b), 119 Stat. 2680, 2814 (2005). 

[10] See GAO-06-1092T. 

[11] See GAO, September 11: HHS Needs to Ensure the Availability of 
Health Screening and Monitoring for All Responders, GAO-07-892 
(Washington, D.C.: July 23, 2007). 

[12] FOH is a service unit within HHS's Program Support Center that 
provides occupational health services to federal government departments 
and agencies located throughout the United States. 

[13] ASPR coordinates and directs HHS's emergency preparedness and 
response program. In December 2006 the Office of Public Health and 
Emergency Preparedness became ASPR. We refer to that office as ASPR 
throughout this testimony, regardless of the time period discussed. 

[14] NIOSH provides funds to the programs through cooperative 
agreements, but refers to award recipients as grantees. Therefore, in 
this testimony we use the term grantee when referring to NIOSH's award 
recipients. 

[15] In previous reports we have also referred to this program as the 
worker and volunteer WTC program.  

[16] See GAO-05-1020T and GAO-06-481T. 

[17] See GAO, Disaster Preparedness: Better Planning Would Improve 
OSHA's Efforts to Protect Workers' Safety and Health in Disasters, GAO-
07-193 (Washington, D.C.: Mar. 28, 2007). 

[18] There is not a definitive count of the number of people who served 
as responders. Estimates have ranged from about 40,000 to about 
91,000.  

[19] See, for example, Centers for Disease Control and Prevention, 
"Mental Health Status of World Trade Center Rescue and Recovery Workers 
and Volunteers--New York City, July 2002-August 2004," Morbidity and 
Mortality Weekly Report, vol. 53 (2004); "Physical Health Status of 
World Trade Center Rescue and Recovery Workers and Volunteers--New York 
City, July 2002-August 2004," Morbidity and Mortality Weekly Report, 
vol. 53 (2004); and "Surveillance for World Trade Center Disaster 
Health Effects among Survivors of Collapsed and Damaged Buildings," 
Morbidity and Mortality Weekly Report, vol. 55 (2006). See also G. I. 
Banauch et al., "Pulmonary Function after Exposure to the World Trade 
Center in the New York City Fire Department," American Journal of 
Respiratory and Critical Care Medicine, vol. 174, no. 3 (2006); G. 
Izbicki et al., "World Trade Center 'Sarcoid Like' Granulomatous 
Pulmonary Disease in New York City Fire Department Rescue Workers," 
Chest, vol. 131 (2007); and K. Wheeler et al., "Asthma Diagnosed after 
September 11, 2001 among Rescue and Recovery Workers: Findings from the 
World Trade Center Health Registry," Environmental Health Perspectives, 
http://dx.doi.org/10.1289/ehp.10248 (downloaded Aug. 27, 2007). 

[20] Banauch et al., "Pulmonary Function."  

[21] Wheeler et al., "Asthma Diagnosed." 

[22] R. Herbert et al., "The World Trade Center Disaster and the Health 
of Workers: Five-Year Assessment of a Unique Medical Screening 
Program," Environmental Health Perspectives, vol. 114, no. 12 (2006). 

[23] For example, see R. Gross et al., "Posttraumatic Stress Disorder 
and Other Psychological Sequelae among World Trade Center Clean Up and 
Recovery Workers," Annals of the New York Academy of Sciences, vol. 
1071 (2006) and M. Perrin et al., "Differences in PTSD Prevalence and 
Associated Risk Factors among World Trade Center Disaster Rescue and 
Recovery Workers," American Journal of Psychiatry, vol. 64 (2007).  

[24] In addition to these programs, a New York State responder 
screening program received federal funding for screening New York State 
employees and National Guard personnel who responded to the WTC attack 
in an official capacity. This program ended its screening examinations 
in November 2003.  

[25] The NY/NJ WTC Consortium consists of five clinical centers 
operated by (1) Mount Sinai-Irving J. Selikoff Center for Occupational 
and Environmental Medicine; (2) Long Island Occupational and 
Environmental Health Center at SUNY, Stony Brook; (3) New York 
University School of Medicine/Bellevue Hospital Center; (4) Center for 
the Biology of Natural Systems, at CUNY, Queens College; and (5) 
University of Medicine and Dentistry of New Jersey Robert Wood Johnson 
Medical School, Environmental and Occupational Health Sciences 
Institute. Mount Sinai's clinical center, which is the largest of the 
five centers, also receives federal funding to operate a data and 
coordination center to coordinate the work of the five clinical centers 
and conduct outreach and education, quality assurance, and data 
management for the NY/NJ WTC Consortium. 

[26] Project COPE and the POPPA program provide mental health services 
to members of the New York City Police Department (NYPD) and operate 
independently of the NYPD. 

[27] The WTC Health Registry also provides information on where 
participants can seek health care.  

[28] FEMA is the agency responsible for coordinating federal disaster 
response efforts under the National Response Plan.  

[29] See Consolidated Appropriations Resolution, 2003, Pub. L. No. 108-
7, 117 Stat. 11, 517; 2002 Supplemental Appropriations Act for Further 
Recovery from and Response to Terrorist Attacks on the United States, 
Pub. L. No. 107-206, 116 Stat. 820, 894; Department of Defense and 
Emergency Supplemental Appropriations for Recovery from and Response to 
Terrorist Attacks on the United States Act, 2002, Pub. L. No. 107-117, 
115 Stat. 2230, 2338; and 2001 Emergency Supplemental Appropriations 
Act for Recovery from and Response to Terrorist Attacks on the United 
States, Pub. L. No. 107-38, 115 Stat. 220-221. 

[30] Pub. L. No. 108-7, 117 Stat. 517.  

[31] The statute required CDC, in expending such funds, to give first 
priority to specified existing programs that administer baseline and 
follow-up screening; clinical examinations; or long-term medical health 
monitoring, analysis, or treatment for emergency services personnel or 
rescue and recovery personnel. It required CDC to give secondary 
priority to similar programs coordinated by other entities working with 
the State of New York and NYC. Pub. L. No. 109-148, § 5011(b), 119 
Stat. 2814.  

[32] U.S. Troop Readiness, Veterans' Care, Katrina Recovery, and Iraq 
Accountability Appropriations Act, 2007, Pub. L. No. 110-28, ch. 5, 121 
Stat. 112, 166 (2007).  

[33] The program previously suspended examinations from March 2004 to 
December 2005. See GAO-06-481T. 

[34] The agreement was a modification of ASPR's February 2006 
interagency agreement with NIOSH that covers screenings for former 
federal employees.  

[35] Before an agreement between NIOSH and FOH could be signed, the 
agreement between ASPR and NIOSH required several technical 
corrections. The revised ASPR-NIOSH agreement extended the availability 
of funding for the WTC Federal Responder Screening Program to April 30, 
2008.  

[36] In April 2006, FOH contracted with a new provider network to 
provide various services for all federal employees, such as 
immunizations and vision tests. The contract with the new provider 
network did not cover specialty diagnostic services by ear, nose, and 
throat doctors; cardiologists; and pulmonologists. Although the 
previous provider network had provided these services, the new provider 
network and the HHS contract officer interpreted the statement of work 
in the new contract as not including these specialty diagnostic 
services. 

[37] According to the NYC Department of Health and Mental Hygiene, 
about 7,000 nonfederal and federal responders residing outside the NYC 
metropolitan area have enrolled in the WTC Health Registry. 

[38] Around that time, NIOSH was providing screening services for 
nonfederal responders in the NYC metropolitan area through the NY/NJ 
WTC Consortium and the FDNY WTC program. Nonfederal responders residing 
outside the NYC metropolitan area were able to travel at their own 
expense to the NYC metropolitan area to obtain screening services 
through the NY/NJ WTC Consortium.  

[39] In early 2004, AOEC applied to NIOSH to use its national network 
of member clinics to provide screening and monitoring for nonfederal 
responders residing outside the NYC metropolitan area, but NIOSH 
rejected AOEC's application for several reasons, including that the 
application did not adequately address how to coordinate and implement 
a monitoring program with complex data collection and reporting 
requirements. 

[40] Contracts were originally established with 11 clinics in eight 
states, but 1 clinic discontinued its participation in the program 
after conducting one examination. The 10 active clinics are located in 
seven states: Arkansas, California, Illinois, Maryland, Massachusetts, 
New York, and Ohio. Of the 10 active clinics, 7 are AOEC member 
clinics.  

[41] According to NIOSH and DCC officials, efforts to provide 
monitoring services to federal responders residing outside the NYC 
metropolitan area may be included in the national program.  

[42] Institutional review boards are groups that have been formally 
designated to review and monitor biomedical research involving human 
subjects, such as research based on data collected from screening and 
monitoring examinations. 

[43] Department of Health and Human Services, Sources Sought Notice: 
National Medical Monitoring and Treatment Program for World Trade 
Center (WTC) Rescue, Recovery, and Restoration Responders and 
Volunteers, SSA-WTC-001 (Mar. 15, 2007).  

[44] QTC is a private provider of government-outsourced occupational 
health and disability examination services. 

[45] Some nonfederal responders residing outside the NYC metropolitan 
area may have access to privately funded treatment services. In June 
2005 the American Red Cross funded AOEC to provide treatment services 
for these responders. As of June 2007, AOEC had contracted with 40 of 
its member clinics located in 27 states and the District of Columbia to 
provide these services. An American Red Cross official told us in 
September 2007 that funding for AOEC to provide treatment services 
would continue through June 2008.  

[46] As of June 2007, DCC identified 1,151 nonfederal responders 
residing outside the NYC metropolitan area who requested screening and 
monitoring services and were too ill or lacked financial resources to 
travel to NYC or any of DCC's 10 contracted clinics. 

[47] In August 2007 a NIOSH official told us that NIOSH did not expect 
that all of these funds would be spent by September 30, 2007. 

[48] In addition to funding from NIOSH, the FDNY WTC program and the 
NY/NJ WTC Consortium received funding in 2006 from the American Red 
Cross to provide treatment services. In September 2007 an official from 
the American Red Cross told us that it was the organization's 
understanding that most of the clinics in the NY/NJ WTC Consortium had 
expended the American Red Cross funds but that one of the Consortium's 
clinics was expected to request a no-cost 6-month extension up to the 
end of calendar year 2007. The American Red Cross had already granted a 
similar extension for the same period to the FDNY WTC program.  

[49] Of the $24 million remaining from the $75 million appropriation to 
CDC, NIOSH used about $15 million to support monitoring and other WTC-
related health services conducted by the FDNY WTC program and NY/NJ WTC 
Consortium. ATSDR awarded $9 million to the WTC Health Registry to 
continue its collection of health data.  

[50] Pulmonary fibrosis is a condition characterized by the formation 
of scar tissue in the lungs following the inflammation of lung tissue.  

[51] The NY/NJ WTC Consortium now offers treatment services at no cost 
to responders; however, prior to fall 2006 the program attempted when 
possible to obtain reimbursement for its services from health insurance 
carriers and to obtain applicable copayments from responders. 

[52] See, for example, GAO-06-481T. 

[53] The extent of the challenge of locating potential participants 
varied among WTC health programs, depending on the population involved. 
For example, FDNY had contact information for all potential 
participants in its monitoring program because they were employed by 
FDNY during or after the disaster. In contrast, the NY/NJ WTC 
Consortium and the WTC Health Registry had to expend considerable 
effort to identify people who were eligible to participate and inform 
them about the programs. 

[54] See GAO-07-193.  

[55] Ten federal agencies, however, estimated the number of federal 
workers each deployed to the Gulf, and six of the ten also tracked the 
number of workers employed by their contractors. 

[56] See GAO-07-193. 

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