• Michael R. Bloomberg, Mayor of the City of New York
  
• D/Cdr. Jeffrey L. Endean Ret.
  
• Robin Herbert, MD, Director, World Trade Center Medical Monitoring Program Data and Coordination Center
  
• Kerry Kelly, MD, Chief Medical Officer, New York City Fire Department
  
• James Melius MD, DrPH, Administrator, New York State Laborers’ Health and Safety Trust Fund
  
• Joan Reibman, MD, Director NYU/Bellevue Asthma Center
  
• Jeanne Mager Stellman, PhD, Mailman School of Public Health, Columbia University

Testimony of
MICHAEL R. BLOOMBERG
MAYOR
CITY OF NEW YORK
On
The Long-Term Health Impacts from September 11: A Review of Treatment, Diagnosis and Monitoring Effects
Wednesday, March 21, 2007

Senate Committee on Health, Education, Labor and Pensions
216 Hart Senate Office Building
Washington, DC

Click here for a PDF version

Chairman Kennedy, Ranking Member Enzi, Senator Clinton and distinguished members of the Committee: Good morning, and thank you Senator Kennedy, for holding this hearing.

I also want to thank Senator Enzi for bringing the Committee staff to New York last year for a briefing on this topic.

It has been just over 2,000 days since terrorists brazenly attacked New York. 2,000 days. Yet even now, we still do not – and cannot – know the full extent of the damage we suffered that terrible morning.

Tens of thousands of people took part in the rescue and recovery effort – including 45,000 workers and volunteers who came from all 50 states and are constituents of every member of this committee.

Many of these workers and other people who lived and worked near the World Trade Center now suffer from a range of physical and mental health problems…And there’s no telling what other illnesses may potentially develop in the future.

But there is one thing we do know: This nation must never walk away from these courageous men and women who answered the call without hesitation or who lived through this terrible ordeal.

Last September, I convened a panel of City experts who conducted a comprehensive assessment of what we know about who is sick… what their treatment options are… and what we are doing to stay on top of the science so that those who might become sick get the first-rate care they deserve.

By now, each of you should have received a copy of the panel’s report, which details the latest medical findings. A few points are especially significant:

?? More than 11,000 firefighters who responded on 9/11 experienced at least one new respiratory symptom within a week of the attacks – and more than 3,000 report that they continue to suffer from conditions including what is known as the “World Trade Center cough” and “Reactive Airways Disease.”

?? More than 6,500 rescue and recovery workers who were examined in a program at Mount Sinai Medical Center – about 7 out of every 10 – reported at least one new or worsened respiratory symptom while engaged in WTC response efforts. These symptoms have persisted in fully 59% of the workers.

?? And there are thousands of residents, commercial workers, and others have reported experiencing acute breathing problems, worsening asthma, posttraumatic stress disorder, and other mental illnesses which require sustained treatment.

The panel’s report contains 15 recommendations to address the substantial health impacts of 9/11 – but two major challenges have become clear:

?? Securing the sufficient long-term funding for our 9/11 monitoring, treatment, and research programs… and compensating all the victims of this tragedy fairly and quickly.

?? The Federal government’s support must play a crucial part in addressing both these issues.

Let me first talk about funding for our city’s 9/11 health programs.

The panel I convened estimated that the gross costs to treat those who are sick or could become sick as a result of 9/11 is $393 million per year. That estimate covers the entire potentially exposed population, including the thousands of rescue workers and others who came to New York City from all 50 states.

Over the past five years, the sick and the injured have been able to get help at three “Centers of Excellence” in the diagnosis and treatment of World Trade Center-related conditions. They are:

?? A free monitoring and treatment program run by the FDNY for firefighters and EMS workers who responded on 9/11 and took part in the rescue and recovery;

?? A free monitoring and treatment program for other first responders, workers, and volunteers at Mt. Sinai Medical Center, in partnership with approximately 15 affiliates across the country;

?? And a free evaluation and treatment program at Bellevue Hospital which the City opened last year for anyone with 9/11-related symptoms. It’s the only program available to residents and other non-responders and is virtually entirely funded by the City.

In addition, despite having never received any federal funding for this purpose, the NYPD has screened all 34,000 of its members who worked at the World Trade Center site.

All of these programs – along with the World Trade Center Health Registry – are producing valuable research, which has resulted in the publication of clinical guidelines for doctors so that we can best treat the illnesses we see now and what we may see in the future.

Yet all of these programs also could be discontinued unless they get sustained Federal support.

We estimate that sustaining and expanding these three indispensable programs… providing sufficient mental health services, supporting the NYP and supporting the research that’s critical to understanding what illnesses may emerge in the future – will cost about $150 million a year.

At the very least, the Federal government needs to cover those costs so that these essential needs can be met.

The 9/11 Heroes Health Improvement Act – which was introduced in January by Senators Kennedy and Clinton – would provide nearly $2 billion in monitoring and treatment grants between 2008 to 2012.

This bill needs to be passed – and quickly. Congress cannot turn its back on those who responded with courage and suffered through this terrible catastrophe.

After all, 9/11 wasn’t just a strike against New York–or Washington. It was an attack against all of America. It was an act of war. And our government has a clear responsibility to the casualties of that terrible morning.

Finally, let’s turn to compensation.

Persistent efforts were made after the attacks to obtain insurance to cover the rescue and recovery operations. However, no one was willing to provide it. In 2003, the Federal government set up a $1 billion World Trade Center Captive Insurance Company for the City and some 150 contractors to defend against damage claims.

The City and the contractors who heroically rushed to help are currently defending claims from more than 8,000 City employees and other workers arising out of the rescue, recovery, and clean-up operations at the World Trade Center.

Plaintiffs allege damages that we estimate may be in the billions of dollars. And it’s impossible to predict how many more lawsuits will be filed against us in the future. New Yorkers have always been proud of the way that the city came together after 9/11, but this drawn out and divisive litigation is undermining that unity.

What’s clear is that the process of determining compensation should be removed from the courts – and the best way to do that is by re-opening the September 11th Victim Compensation Fund.

The original fund was administered expertly and compassionately by Ken Feinberg – and provided a measure of relief to victims’ families, while avoiding protracted litigation, where there are no winners.

Now it’s imperative that Congress re-opens the fund to take care of those who were not eligible to benefit from it before it closed in December 2003. The mere fact that their injuries and illnesses have been slower to emerge should not disqualify them from getting the help they need.

It’s also crucial that the Federal government eliminates the potential liability that the City and its contractors continue to face in court.

Depending on the mechanism Congress chooses, the $1 billion available to the Captive Insurance Company could be made available for compensation.

Although we are open to other solutions, if the liability of the City and the contractors is eliminated, we could immediately transfer that $1 billion into the re-opened Victim Compensation Fund – making it the fund’s first, major installment.

Using federal resources to compensate claims – instead of litigating them – would mark an important step in healing the rifts that have surfaced since 9/11.

What’s more, it would send a clear message that if – God forbid – America suffers another terrorist attack, the private sector and our first responders could respond with the same kind of urgency and selflessness that we saw on 9/11, knowing that their government will always stand by them.

We saw an incredible demonstration of the American spirit in the wake of 9/11. It’s time we recapture that unity and determination for the sake of those who’ve already sacrificed so much – and the place to see that demonstrated is right now and right here in Congress.

Thank you for your time. I’ll be happy to answer any questions.

D/Cdr. JEFFREY L. ENDEAN Ret.
Succasunna, NJ

Click here for a PDF version

To: Chairman Kennedy, Ranking Member Enzi, Senator Clinton and other members of the HELP Committee.

I am Jeffrey L. Endean of Sucasunna, New Jersey. Former Division Commander with the Morris County Sheriff’s Office with 20 years assigned to the Special (Emergency) Services Division.

I would like to thank Senator Clinton and the members of the HELP Committee for the opportunity to testify today regarding the health care of 911 responders. There are many responders who would like to have had this opportunity and I wish to recognize them, and do my best to represent them honorably. On the morning of 11 September 2001 I responded with personnel under my command to carry out mutual aid to the N.J., NY Port Authoriry Police Dept. at the site of the attacks against America at the World Trade Center site.

The scene was very sad, to see my country ripped open, and just imagining the body count. The smoke was acrid and irritating, it was hard to see your hand in front of your face. The sound of the firefighters’ “mayday” alarms sounded like a million crickets. After the 11th I was assigned to the Port Authority as I am certified in Critical Incident Stress Management. My assignment was at the pile. The pile as it was called looked like a war zone or a peek into hell. The fire, smoke, smell of burning flesh. The devastation and parts of the skeleton of what was the WTC was surreal at best and terrifying at worst. Only someone who has seen such devastation and death can understand how this affects one. The faces of the responders told many sad stories. I worked along and watched out for personnel experiencing emotional issues. I would speak to them about their fears and feelings and guide them to a mental health professional if necessary. I kept this up as a volunteer responding after my shifts in Morris County until 22 November 2001. I retired 1 August 2002 after using sick time from 22 November 2001. During October 2001 I developed a chronic cough and was wheezing and just not feeling well. The coughing would be violent with my eyes bulging and not getting a breath. I was having difficulties breathing, wheezing and trouble sleeping. I was developing upper and lower respiratory infections on a regular basis. I received a letter from the PBA to contact Mt. Sinai Hospital for a screening. I did so post haste and in Jan 2003 had my first screening. The initial screening revealed scarring on my lungs, plural thickening of my lungs, wheezing, asthma and the chronic cough, and rhinitis. There was no treatment program available and I would later find that I had been misdiagnosed and treated for colds and allergies. My health continued to deteriorate, and the medical bills were mounting even though I had 80-20 medical insurance. They paid a set amount for services and I was stuck with ill health and mounting medical and prescription bills. I was called for a second screening in 2005 which revealed the same issues. I was placed into the new treatment program at Mt. Sinai. I was then in addition diagnosed with rad’s, gerd, asthma, chronic headaches, joint aches, and trouble sleeping and PTSD. I was assigned to Dr. Laura Bienenfeld who made diagnoses and initial treatment. She then referred me to specialists.

I was seen by the specialists at Mt. Sinai who corroborated the initial diagnosis with MRI, X Ray, camera up sinuses, down the throat, Endoscopy and visual. Dr. Genden ETN told me I was the 7,000th person he had seen and that particulate was encapsulated in the cells of my sinuses and my sinuses were like bloody sponges.

Specialist Dr. Christie learned from endoscopy that after a year of Nexium my esophageal erosion was not healing so dose was doubled. I also had a PET scan as it was believed a mass in my lung may have been cancerous. I awake to take three inhalers, one breathing pill, and other meds. I now need a nebulizer treatment three times per day and I still wheeze and cough and get severe headaches. My worker responders claim was accepted and all mentioned illnesses accepted in court. I am receiving good care, but will it remain? I am not getting well, just holding ground and will I lose ground? I am 57 and hope to live to 87 but I don’t know how long I will live.

I am now getting the proper tReatment from those who know the illnesses best. Their care has made the quality of life better. The WTC treatment program at Mt. Sinai is the most knowledgeable group of doctors in the world regarding the toxins and illnesses from a disaster like 911. No other doctors have ever seen and documented the symptoms and designed treatments and continue to innovate and adapt to the worsening illneses. To move this treatment away from Mt. Sinai would be a human disaster equal to 911 itself. The misdiagnoses and poor treatment would start all over again. We could not stop the attacks, death and continued casualties of 11 September. You have the ability to stop the human disaster. Creating a department or program by the government would be costly and cumbersome and it is not necessary. The Mt. Sinai program exists and to change it would result in the aforementioned human disaster. I ask the committee to take a long hard look at the success of the existing program and to subsidize it. This will save dollars and lives. This legacy of illness and suffering will continue for my lifetime and way beyond. The responders need to be taken care of. They ran down West Street not away from the attack. This was an atttack on America. President Bush termed it an act of War. Those who responded deserve nothing less than the best of care. FDR said “Any man who sheds his blood for his country deserves a fair deal.” This applies now in 2007 as it did then. I cannot believe that every Senator and Congress person does not champion this cause. America’s sons and daughters came to her aid as it is our duty. Now it’s the duty of our federal government to care for those who served.

Thank You
God Bless America
D/Cdr. Jeffrey L. Endean Ret.

TESTIMONY
Before
The United States Senate
Committee on Health, Education, Labor, and Pensions
Hearing on The Long-Term Health Impacts from September 11: A Review of Treatment, Diagnosis, and Monitoring Efforts
Washington, D. C.
March 21, 2007
Presented By

Robin Herbert, M.D.

Director, World Trade Center Medical Monitoring Program
Data and Coordination Center
Associate Professor, Department of Community and Preventive Medicine
Mount Sinai School of Medicine

Click here for a PDF version

Good morning.

Chairman Kennedy, Ranking Member Enzi, Senator Clinton and other esteemed members of the HELP Committee, I thank you for having invited me to present testimony before you today on the health consequences of 9/11 and on the urgent need to continue to provide proper medical services for the brave men and women who rose on that day to America’s defense, many of whom are now ill as a consequence of their heroism.

My name is Robin Herbert, MD. I am an Associate Professor in the Department of Community and Preventive Medicine of the Mount Sinai School of Medicine, and I serve as Director of the World Trade Center (WTC) Medical Monitoring Program Data and Coordination Center at Mount Sinai.

In the days, weeks, and months that followed September 11, 2001, thousands of hard-working Americans from all across this nation responded selflessly – without concern for their well-being – when the nation and the federal government called upon them to serve. Unfortunately, many of these workers and volunteers have become seriously ill as a result of their response work, and we have documented in many that their illness appears to be persistent. It is therefore critical that we take stock of how we, as a nation, are caring for World Trade Center responders, and for others who have fallen ill, or may become ill in the future as a result of 9/11. It is essential that we continue to provide aid and care for all those who were there for us – now and in the future. With your strong support – as a nation – I have no doubt we will.

Diversity of the WTC responder population
Well over 50,000 people worked or volunteered in the aftermath of the attacks in and around the World Trade Center, and at the Staten Island landfill. An extraordinarily broad range of skill sets and occupational groups was required to mount an effective response to the terrorist attacks. Those who rushed in to perform rescue, recovery, restoration of services, and essential clean up included both traditional first responders such as firefighters, paramedics, and law enforcement officers, as well as a large and very diverse population of heavy machinery operators, laborers, ironworkers and others from the building and construction trades, telecommunication workers, other utility workers, transportation workers, sanitation workers and other public and private sector workers and volunteers. This extraordinarily diverse group toiled in search and rescue efforts that extended for days, weeks, and months, and engaged in critical service restoration for one of America’s largest cities when it was in shock and on the brink of economic disaster. They sorted through the remains of the dead, and were witness, through many months, to horrors no one should ever have to face, or likely had ever faced, even if previously trained as responders. Even those not working directly on the pile – for example, responders who worked in manholes to restore communications, or to shut down gas lines to prevent explosions – sustained exposures both to airborne toxins and to the unexpected sight of human remains. Thus, when I use the term responders in my testimony, I will be referring to the large and diverse group of responders that performed rescue, recovery, restoration of services, and clean up in the service of our nation. In addition to tens of thousands of men and women from New York, New Jersey, and Connecticut, approximately 2,300 responders from every other state in the nation are currently registered in one of the WTC Medical Monitoring Programs. Particularly large numbers came from the states of Massachusetts, Ohio, California, Illinois, North Carolina, Georgia, and Florida. The health consequences of 9/11

The medical and mental health effects of the World Trade Center disaster have been well documented. I believe that there can no longer be any doubt that many people are sick, and that more will likely become ill in the future as a result of their work at Ground Zero.

In September 2006, we released a peer-reviewed paper in the medical journal Environmental Health Perspectives, detailing the findings from federally funded examinations of 9,442 WTC responders whom we and our partner institutions had examined between July 2002 and April 2004. I have appended this study for your review, and I would like to direct your attention to a few key findings:

• Among these 9,442 responders, 69% reported experiencing new or worsened respiratory symptoms while engaged in their efforts in or near Ground Zero.

• At the time of examination, up to 2 ½ years after the start of the rescue and recovery effort, 59% were still experiencing a new or worsened respiratory symptom, a finding which suggests that these conditions may be chronic and require ongoing treatment.

• One third of responders had abnormal breathing test results. One particular breathing test abnormality – decreased forced vital capacity – was found 5 times more frequently in WTC responders than in the general, non-smoking population of the United States. This is a most worrisome finding, that can be caused by a variety of conditions, including asthma with “air trapping,” and interstitial lung disease (or scarring disease of the lungs), the condition that has resulted in known fatalities among a few WTC responders.

• Findings from our program released in 2004 have attested to the fact that there also exist significant mental health consequences among WTC responders. All of these findings are consistent with other independent study findings. They are replicated also in the spectrum of disease that we have seen among patients treated in the Mount Sinai WTC Medical Treatment Program:

• 86% of treatment patients suffer from upper respiratory conditions, such as chronic sinusitis;

• 51% suffer from lower respiratory conditions, including asthma and WTC cough;

• 32% have gastrointestinal conditions;

• 29% have musculoskeletal conditions; and

• 38% have been diagnosed with mental health conditions, including post-traumatic stress disorder, anxiety or depression, in addition to their physical ailments.

It is important to note that most patients in the treatment program actually suffer from multiple WTC-related illnesses, complicating their case management and their access to benefits.

Lack of medical insurance among WTC Responders
More than 40% of the WTC responders in our treatment program are uninsured, and an additional 23% are underinsured, a situation that creates major barriers to access to medical services.

When I speak of the uninsured (those with no medical insurance) and the underinsured (those with insurance that may cover only in-patient care, or that may require payments of co-pays or have deductibles so high that our patients are functionally uninsured), I am talking about a wide range of responders. I am talking about poor workers: folks who cleaned buildings in the World Trade Center disaster area without, in many cases, adequate protection or training or insurance, often for fly-by-night operations that no longer exist. I am also speaking of construction workers, some of whom received insurance coverage for themselves and their families based on a certain number of days worked. But when these patients become too ill to work, or could no longer work as many days as they used to, their coverage often ended along with their paycheck. These difficulties are compounded for those responders who file for Workers’ Compensation for their needed medical care, because filing for Workers’ Compensation typically results in prolonged delays in accessing needed care due to case litigation and a complex bureaucratic maze. And there are others, countless tireless heroes, including thousands of volunteers as well, too numerous to detail here today. They put their lives on the line when they were needed, but now many of them find themselves in need. I invite all of you to speak with affected responders in our program, if indeed there is any doubt of their need.

The medical response to 9/11 – the critical need for Centers of Excellence
To provide medical services to the men and women who gave of themselves at Ground Zero, this nation has provided funding to establish and operate Centers of Excellence. These Centers bring together specialists from many fields of medicine who work together to provide state-of-the-art care for the complex diseases that we are seeing in the responders. The Centers also have the capacity to track patterns of disease and to provide information on new and emerging illnesses. The WTC Centers of Excellence were launched in late 2001 after initial reports were received of health problems in responders and volunteers. At that time the Congress provided resources for medical screening, and those funds became available in 2002. The WTC Worker and Volunteer Medical Screening Program was established as a regional and national consortium of Centers of Excellence that provided standardized, free, comprehensive screening examinations for WTC responders.

In July 2004, based on early findings from the screening programs, Congress authorized additional funding to establish an ongoing medical monitoring program for responders. This program too was organized as a network of Centers of Excellence. These Centers were selected by the National Institute for Occupational Health (NIOSH) through a fully competitive, peerreviewed

award process. This process established the World Trade Center Medical Monitoring Program which is funded through 2009. It provides baseline exams and well as follow up exams to WTC responders at 18 month intervals. NIOSH awarded funding to 2 sister programs of Centers of Excellence: one based at the Fire Department of New York (FDNY), and the other, a consortium of 5 Clinical Centers coordinated by a Data and Coordination Center at Mount Sinai Medical Center that serves all other responders.

Most recently, new federal funding for Treatment services which became available for the first time in 2006 has made possible a newly combined Medical Monitoring and Treatment Program. This program is again based in Centers of Excellence. It integrates all Monitoring and Treatment services and also supports a long needed expansion of services to provide care to a greater number of responders than ever before. This new federal funding builds on generous but limited private support that had previously enabled some provision of treatment services to responders.

The Centers of Excellence currently provide the following complex array of services to the WTC responders:

1) Regular, standardized, comprehensive physical and mental health examinations to identify possible WTC-related illness in all responders.

2) Treatment for concurrent WTC-related physical and mental health illnesses. This care requires the close coordination of specialists from many disciplines, including: occupational medicine, pulmonary medicine, psychiatry, thoracic surgery and rehabilitation medicine. This array and coordination of services is to be found only in Centers of Excellence such as those that Congress and NIOSH have established.

3) Social work assistance to responders who have lost their ability to work or sustained other disastrous economic effects because of their WTC response work. Social workers teach responders how to navigate the Workers’ Compensation system, access muchneeded medical and mental health treatment, and to plan for the long-term security and needs of their families. Our social workers provide essential services to the sickest of responders – those who, unfortunately, are too ill to return to work despite state of the art medical care. For these responders, who typically have lost their jobs, their self-esteem, their income, and their ability to meet their basic expenses (rent, mortgage, food), social workers work directly with them and their families to advocate for vital resources.

4) Outreach to responders to ensure that they are not lost to follow up by regular phone updates, mailings, and educational programs. This sustained outreach will grow in importance as responders retire and relocate throughout the nation.

5) Linkage of clinical monitoring and treatment findings to public health data analysis for identification of disease trends. This is essential because we remain very concerned about the potential for diseases of longer latency to emerge among WTC responders. We know that responders were at risk of exposures to a wide range of toxic chemicals, including cancer-causing agents - such as asbestos, benzene, dioxins, PCBs, and PAHs - and to substances that can cause ongoing respiratory problems, such as highly alkaline, fine particulate dust that can cause permanent scarring of the lungs. Thus, it is important that the model of health service delivery for these heroes is capable of identifying newly emerging disease patterns that may include interstitial lung diseases such as sarcoidosis and cancers. We have been faced, as a nation, with an unprecedented attack with unprecedented consequences. We therefore need health service models that are capable of meeting the needs created by this unprecedented event: models that can identify and treat the ill, AND that also can identify emerging diseases in a group that unwittingly sustained exposures with unknown effects.

6) Dissemination of information learned from disease surveillance to responders, the public, and health care providers.

Major accomplishments of the Centers are these:
1) The Centers coordinated by Mount Sinai have provided baseline examinations for over 20,000 WTC responders including law enforcement officers, construction workers, communications workers, transit workers, building cleaners, and other public and private sector workers and volunteers. Follow up examinations have been provided to over 7,440 WTC responders through the Mount Sinai Consortium.

2) The Mount Sinai Treatment Program alone has provided more than 14,000 medical and mental health treatment services to 3,700 responders.

3) The Mount Sinai Treatment Program alone has provided more than 7,700 non-mental health Social Work services primarily to assist the uninsured and the unemployed. They have successfully treated thousands of responders and returned many to active duty and productive lives.

4) The Centers have documented a very high incidence of both upper and lower respiratory disease in responders, much of which is persistent. They have documented a five-fold increase of certain abnormalities in pulmonary function testing.

5) They have documented high rates of mental health problems in responders, a proportion of which are persistent.

6) They are tracking the occurrence of rare diseases in responders such as pulmonary fibrosis and sarcoidosis. They have put into place an active surveillance system to monitor the appearance of cancer.

The two absolutely unique features of the Centers of Excellence are:
1) They have assembled a critical mass of medical expertise from many specialties – internal medicine, occupational medicine, pulmonary medicine, gastroenterology, and psychiatry, coupled with highly skilled social work units. This concentration of expertise enables the Centers to effectively treat the complex and multifactorial disorders of World Trade Center responders. Such sophisticated treatment is not possible in a private practice setting. Indeed, responders who have been seen outside the Centers have in some cases not been well managed medically and their medical care has not addressed the complexity of their problems.

2) The Centers of Excellence are linked to two Data and Coordination Centers (one at Mount Sinai and one at FDNY), which are staffed by public health specialists who are constantly monitoring patterns of disease and seeking new trends in illness. This highly sensitive system enables us to mount rapid responses to newly emerging problems, rapid responses that would not otherwise be possible. Additionally, the Data and Coordination Centers have developed unique expertise in conducting outreach and retention activities to ensure that no responder’s needs go untended, that contact with the most ill responders is not lost, and that public health and medical information learned from the activities of the Data and Coordination Centers are rapidly disseminated to the responders, the public, and other health care providers.

Concluding Comment
Our program of Centers of Excellence – the one that we, the legislative leaders, occupational medicine and other specialized medical experts, affected workers and their representatives, and health and safety experts have built together – has been designed and implemented to provide the greatest benefits and meet the demonstrated needs of our patient population. And our existing program of Centers of Excellence, and the lessons we have learned in the wake of September 11th, not only help to guide our ongoing response, but should be instrumental in helping guide future disaster response as well. By utilizing a Center-based approach, the program ensures quality, experienced and standardized care across the country. We ensure that responders receive the best medical services on an ongoing basis, regardless of where they live now or may live in the future. We ensure the ongoing critical update of clinical monitoring and treatment services, because of the program’s ability to identify disease trends by pooling information gleaned from almost 27,000 examinations and continually analyze that information. We ensure an ongoing public health response and education benefit, beyond the benefits to responders, health care providers, government agencies and policy-makers by informing future disaster preparedness and response.

As you are likely aware, federal funding for WTC-related treatment services is due to run out, likely before the end of this fiscal year. Federal support for the medical monitoring arm of our efforts, provided for the first five years of a 20 to 30 year needed initiative, may run out sooner than expected, because we are able to help more people now than we had initially anticipated. Today, you can choose to continue to help thousands of those affected by 9/11 as we are best able: through a coordinated, experienced, expanded model of Centers of Excellence. We can help prevent death and disability, and improve life for many of those who gave so much. By providing responders with expert medical and mental health services, we can help them to stay in their jobs or begin to work again. We can help give them back their lives. We can provide them with some hope for the future.

Five years following the attacks on the World Trade Center, thousands of the brave men and women who worked on the rescue, recovery, and clean up efforts are still suffering. Respiratory illness, psychological distress, and financial devastation have become a new way of life for many. Also suffering, of course, are many WTC area residents, office re-occupant employees and students, for whom no appropriate systematic response is yet in place. I hope that my comments today will serve as a reminder of the long-term and widespread impact of this disaster, and of the need to continue to build on the successful model which gives these men and women the care they deserve.

Thank you.

Testimony of

Dr. Kerry Kelly

Chief Medical Officer
New York City Fire Department
Long Term Health Impacts from September 11: A Review of Treatment, Diagnosis and Monitoring Efforts
March 21, 2007
U.S. Senate
Committee on Health, Education, Labor and Pensions

Click here for a PDF version

Good morning Senators Kennedy, Enzi and Clinton, and other Committee members. I am Dr. Kerry Kelly, the Chief Medical Officer for the New York City Fire Department (FDNY) Bureau of Health Services. Dr. David Prezant and I serve as Co- Directors of the FDNY’s World Trade Center Medical Monitoring and Treatment Program. Thank you for the opportunity to speak with you today about the health of our FDNY first responders following their exposures at the World Trade Center (WTC) site.

On September 11, 2001, FDNY first responders answered the call for help. Within a matter of minutes, with the collapse of the towers, 343 of our members perished, hundreds suffered acute traumatic injuries and thousands have required long-term treatment for respiratory and mental health conditions.

In the hours, days and months that followed, our members continued in rescue, recovery and fire suppression efforts, with a virtual job-wide exposure to the site, working amid the debris and dust from the collapse of the towers. More than 11,500 Firefighters and Fire Officers as well as 3,000 Emergency Medical Technicians (EMTs) and Paramedics participated in this work.

During that time, FDNY first responders experienced more exposure to the physical and emotional hazards at the WTC disaster site than any other group of workers. Attached to the written copies of my testimony, is a document that provides more detail about our findings and the health of our FDNY members and their exposures.

FDNY Medical Monitoring and Treatment Program
The FDNY’s WTC Medical Monitoring and Treatment Program is one of three Centers of Excellence for WTC Health that is identified in Mayor Bloomberg’s just2 published report on the health impacts of 9/11. The FDNY Center of Excellence was the first to provide monitoring and treatment for first responders. Since we have pre-9/11 data for all our members, it is the only Center of Excellence that can perform large-scale pre- and post-9/11 comparisons for any exposed group. It is the only Center of Excellence with a more than 90 percent participation rate. Our Center was the first to recognize and treat members with WTC health effects and provide published scientific data so that others could recognize the role of WTC exposure.

Physical Health Issues

For those working at the site, respiratory issues surfaced quickly. In recognition of these symptoms, FDNY initiated the WTC Medical Screening and Treatment Program in October of 2001, just four weeks after 9/11. From October 2001 through February 2002, we evaluated more than 10,000 of our FDNY first responders. Since that time, we have continued to screen both our active and retired members for a total of 14,250 FDNY personnel screened to date. This WTC Medical Monitoring Program has been federally funded through the CDC and NIOSH, and has been a joint, labor-management initiative. This FDNY program is dedicated to monitoring the health of our members, while the Mount Sinai Consortium and the Bellevue Center address the health issues of non-FDNY responders.

Our monitoring program works collaboratively, partnering with NIOSH. At this point, nearly 9,000 of our FDNY members have participated in a second round of FDNYadministered medical and mental health monitoring evaluations, and more than 1,300 have recently started a third round.

More than 3,000 of our members have sought respiratory treatment since 9/11. Most have been able to return to work, but more than 700 have developed permanent, disabling respiratory illnesses that have led to earlier-than-anticipated retirements among members of an otherwise generally healthy workforce. In the first five years after 9/11, we experienced a three- to five-fold increase in the number of members retiring with lung problems annually.

Since our Bureau of Health Services performs both pre-employment and annual medical examinations of all of our members, the WTC Medical Monitoring program has used the results of these exams to compare pre- and post-9/11 medical data. This objective information enables us to observe patterns and changes among members. A significantly higher number of Firefighters were found to be suffering from pulmonary disorders during the year after 9/11 than those suffering pulmonary disorders during the five-year period prior to 9/11. Furthermore, we have found that the drop in lung function is directly correlated to the person’s initial arrival time at the WTC site. On average, for symptomatic and asymptomatic FDNY responders, we found a 375 ml decline in pulmonary function for all of the 13,700 FDNY WTC first responders, and an additional 75 ml decline if the member was present when the towers collapsed. This pulmonary function decline was 12 times greater than the average annual decline experienced in the five years pre-9/11. However, over the past four years, pulmonary functions of many of our members have either leveled off or improved. For some, unfortunately, pulmonary functions have declined. More than 25 percent of those we tested with the highest exposure to WTC irritants showed persistent airway hyperactivity consistent with asthma or Reactive Airway Dysfunction (RADS). In addition, more than 25 percent of our full4 duty members participating in their follow-up medical monitoring evaluation continue to report respiratory symptoms.

The FDNY’s preliminary analysis has shown no clear increase in cancers since 9/11. Pre- and post-9/11, the Fire Department continues to see occasional, unusual cancers that require continued careful monitoring. Monitoring for future illnesses that may develop, and treatment for existing conditions, is imperative and, as I will discuss shortly, should be funded through Federal assistance.

Mental Health Issues

As our doctors and mental health professionals can attest, the need for mental health treatment was also apparent in the initial days after 9/11, as virtually our entire workforce faced the loss of colleagues, friends and family. Past disasters have taught us that first responders are often reluctant to seek out counseling services, frequently putting the needs of others first. Many times, recognition that they themselves need help may not happen for years after an event. Our goal was to reduce or eliminate any barrier to treatment so that members could easily be evaluated and treated in the communities where they live and firehouses and EMS stations were they work. We also developed enhanced educational programs for our members to address coping strategies and help identify early symptoms of stress, depression and substance abuse.

Nearly 14,000 FDNY members have sought mental health services through the FDNY Counseling Services Unit (CSU) since 9/11 for WTC-related conditions such as Post Traumatic Stress Disorder (PTSD), depression, grief, anxiety and substance abuse. Prior to 9/11, the CSU treated approximately 50 new cases a month. Since 9/11 and continuing to this date, CSU sees more than 260 cases at its six sites each month -- more than 3,500 clients annually. The continued stream of clients into CSU indicates that the need for mental health services remains strong.

Funding
Through the efforts of our Mayor and New York City’s Congressional delegation, and the continued support of our labor partners, we have secured funding to continue monitoring and treatment of our members. This funding is crucial to our monitoring and treatment programs, and we appreciate this Committee’s efforts to bring the needed attention to these issues and our funding needs. Additional funding is needed to provide for long-term monitoring because, in environmental-occupational medicine, there is often a significant time lag between exposures and emerging diseases. For example, the latency periods for most cancers are often at least 10 years or more. The actual effect of the dust and debris that rained down on our workforce on 9/11 may not be evident for years to come.

Additional funding is also required to continue enhanced diagnostic testing and focused treatment of FDNY first responders, addressing both physical and mental health problems related to World Trade Center exposures. Both our active FDNY members and our retirees face gaps in their medical coverage. Early diagnosis and aggressive treatment improves outcomes. This is only possible if burdensome out-of-pocket costs (co-payments, deductibles, caps, etc.) for treatment and medications are eliminated. For example, long-term medication needs for aerodigestive (upper and lower respiratory disease with or without gastroesophageal reflux dysfunction) and mental health illnesses require significant co-payments, taxing the resources of our members. In addition, most insurance plans do not adequately cover mental health treatment.

Conclusion
The 343 who perished at the World Trade Center are tragic reminders of the known risks that our first responders take on each and every call for help. For those who responded and survive, very real concerns for the unknown long-term health consequences remain. For members of this athletic and healthy workforce -- who face the loss of lung function, chronic sinus problems, gastric distress and mental health consequences -- the exposures at the WTC site have changed lives, shortened careers and forever changed the future of those who survived that tragedy. The commitment to longterm funding, for both monitoring and treatment, must be made now to allow the FDNY WTC Health Center of Excellence to plan for the future in order to protect and improve the health of our workforce (both active and retired) and to inform lesser exposed groups (and their healthcare providers) of the illnesses seen and the treatments that are most effective.

Continued funding for and operation of this Center of Excellence -- the FDNY WTC Medical Monitoring and Treatment Program -- is the most effective way to do this. Alternative fee-for-service plans will fail to provide effective treatment to large numbers of affected FDNY members, will not be cost-effective and cannot provide the standardized and comprehensive data analysis we need to inform the public, doctors, scientists and government officials, all of whom need this information. FDNY rescue workers (Firefighters and EMS personnel) answered the call for help on 9/11 and continue to do so every day. Now we need your continued help to maintain this Center of Excellence so that our members can best be served. Thank you for your past efforts, and your continued support of the FDNY and our members.

TESTIMONY
Before
The United States Senate
Committee on Health, Education, Labor, and Pensions
Hearing on The Long-Term Health Impacts from September 11: A Review of Treatment, Diagnosis, and Monitoring Efforts
Washington, DC
March 21, 2007
Presented by

James Melius MD, DrPH

Administrator, New York State Laborers’ Health and
Safety Trust Fund
Albany, NY

Click here for a PDF version

Honorable Chairman Kennedy, Ranking Member Enzi, Senator Clinton and other members of the Health, Education, Labor, and Pensions Committee. I greatly appreciate the opportunity to appear before you at this hearing.

I am James Melius, an occupational health physician and epidemiologist, who currently works as Administrator for the New York State Laborers’ Health and Safety Trust Fund, a labor-management organization focusing on health and safety issues for union construction laborers in New York State During my career, I spent over seven years working for the National Institute for Occupational Safety and Health (NIOSH) where I directed groups conducting epidemiological and medical studies. After that, I worked for seven years for the New York State Department of Health where, among other duties, I directed the development of a network of occupational health clinics around the state. I currently serve on the federal Advisory Board on Radiation and Worker Health which oversees part of the federal compensation program for former Department of Energy nuclear weapons production workers.

I have been involved in health issues for World Trade Center responders since shortly after September 11th. Over 3,000 of our union members were involved in response and clean-up activities at the site. One of my staff spent nearly every day at the site for the first few months helping to coordinate health and safety issues for our members who were working there. When the initial concerns were raised about potential health problems among responders at the site, I became involved in ensuring that our members participated in the various medical and mental health services that were being offered. For the past three years, I have served as the chair of the Steering Committee for the World Trade Center Medical Monitoring and Treatment Program. This committee includes representatives of responder groups and the involved medical centers (including the NYC Fire Department) who meet monthly to oversee the program and to ensure that the program is providing the necessary services to the many people in need of medical follow-up and treatment. I also serve as co-chair of the Labor Advisory Committee for the WTC Registry operated by the New York City Department of Health. These activities provide me with a good overview of the benefits of the current programs and the difficulties encountered by responders seeking to address their medical problems and other needs.

I believe that Dr. Kelly and Dr. Herbert have already presented the medical findings from their respective medical program for these responders. The pulmonary disease and other health problems among both fire fighters and other responders are quite striking and quite worrisome. Both programs have done an outstanding job in establishing their respective monitoring programs and in providing high quality medical examinations for many thousands of rescue workers and responders. These programs also recognized the problems that many of their participants were having paying for medical care for the conditions diagnosed in the medical monitoring programs and have made efforts to help the participants in obtaining necessary assistance. Given that one of the purposes of this hearing is to examine the need for more funding for treatment for people in this program, I believe that it may be helpful to examine the reasons why so many of the participants need assistance for paying for their medical treatment.

HEALTH INSURANCE COVERAGE
The people who worked in the initial response to the September 11th disaster and the later recovery activities represented many different types of workers. On the public safety side, there were fire fighters, police, and emergency medical services workers. The response and recovery activities also included construction trades workers, utility workers, sanitation workers, transit workers, cleaning workers, and NYC municipal workers from many agencies. Many other people just volunteered to work at the site especially in the first few days after September 11th. Despite the diversity of backgrounds and job duties, these different groups are showing very similar patterns of illness. The pulmonary changes found in fire fighters have also been demonstrated in the rescue and recovery workers being monitored in the Mount Sinai medical program. Most recently, an independent study conducted by medical researchers at Penn State University of NYC police officers responding to the WTC disaster reported similar respiratory findings among the group that they examined. The other types of medical and mental health problems documented among WTC responders also appear to be similar across all groups of responders.

However, given the diversity of this workforce, it is not surprising that their health insurance coverage might be quite variable. We are currently surveying the major union groups in New York whose members worked in the WTC response to evaluate their health insurance an disability coverage. We would be glad to provide that information to the committee when it is complete. However, I can provide a general overview. All city workers are covered through the city’s general health insurance plan which provides basic coverage including retirement coverage for long time workers. However, pharmaceutical coverage is provided through a different plan administered through each separate union. Construction trade workers are usually covered through their labormanagement health insurance fund which provides basic health insurance coverage and some pharmaceutical coverage. The pharmaceutical coverage is often quite limited with high deductibles and co-pays. These health plans require that the participant work a substantial number of days each quarter or year in order to maintain eligibility. An ill construction worker can easily lose their coverage by missing too many work days. Utility workers have general medical coverage including some pharmaceutical benefits. Cleaning workers (people who cleaned the residential and commercial buildings around the WTC) often worked for contractors who offered no health benefits at all. The majority of the people in the Mt. Sinai treatment program up to now have had no health insurance coverage or very limited coverage.

All health insurance plans exclude coverage for work-related injuries and illnesses. Even Medicare has an active program to identify and recover payments for work-related services. While it is recognized that there may be uncertainty about whether a condition being diagnosed is work-related or not, this consideration could easily lead to the denial of health insurance coverage for many people with WTC-related health conditions. New York State does have in place mechanisms for health insurance providers to be reimbursed for medical expense payments incurred for conditions that are ultimately determined to be eligible for workers’ compensation coverage. However, these mechanisms are administratively complicated and do not necessarily prevent the health insurer from denying reimbursement for WTC-related health expense.

Another problem with health insurance is the limitations on coverage of many of the health insurance plans that cover the participants. This is especially critical for pharmaceutical coverage. Treatment for many of the WTC-related conditions (asthma, mental health problems, etc.) requires substantial medication costs. These costs commonly range from $5000 to nearly $15,000 per year for participants. Many of the plans covering WTC participants have high deductibles or co-pays. Co-pays and deductibles can easily cost the participants with high medication costs several thousand dollars per year. These costs can severely strain the finances of a person with a moderate income especially if they have other health care costs and are missing significant time from their work due to illness. For those without any health insurance, the financial impact is even greater. Another potential problem is that many of these insurance programs have lifetime caps for each participant. Although these caps seem high ($500,000 to $1 million or more), they can easily be exceeded with a long term serious illness.

The medical and pharmaceutical costs for WTC-responders have also severely strained the health insurance plans for many of the responder groups, especially those providing pharmaceutical coverage. These funds are already stressed by the rapidly rising costs of health care. Those plans with a significant number of members who worked at the WTC response and clean-up have found that the overall medical and pharmaceutical costs for their plans have significantly increased due to the large number of participants with WTC-related medical costs. This has even led some to consider cutting back on their benefits for all members in order to absorb the costs for the WTC group.

WORKERS’ COMPENSATION COVERAGE
One alternative to health insurance coverage for WTC-related conditions is workers’ compensation insurance. Workers’ compensation is supposed to be a no fault insurance system to provide workers who are injured or become ill due to job-related factors with compensation for their wage loss as well as full coverage for the medical costs associated with the monitoring and treatment of their condition.

Similar to health insurance, the WTC program participants are covered by a variety of state, federal, and local programs with different eligibility requirements, benefits, and other provisions. Most private and city workers are covered under the New York State Workers’ Compensation system. New York City is self insured while most of the private employers obtain coverage through an outside insurance company. Uniformed services workers are, for the most part, not covered by the New York State Workers’ Compensation system but rather have a line of duty disability retirement system managed by New York City. A fire fighter, police officer, or other uniformed worker who can no longer perform their duties because of an injury or illness incurred while on duty can apply for a disability retirement which allows them to leave with significant retirement benefits. However, should a work-related illness first become apparent after retirement, no additional benefits (including medical care) are provided, and the medical benefits for even a recognized line of duty medical problem end when the person retires. Federal workers are covered under the compensation program for federal workers. Coverage for workers who came from out of state will depend on their employment arrangements with their private employer or agency. However, volunteers from New York or from out of state are all covered under a special program established by the New York Workers Compensation Board after 9/11.

The major difficulty with these compensation systems is the long delays in obtaining coverage. For example, the NYS Workers’ Compensation system is very bureaucratic. The insurer may challenge every step of the compensation process including even diagnostic medical testing. This challenge usually requires a hearing before a Workers’ Compensation Board (WCB) administrative judge to evaluate the case, and this hearing may often be delayed for months. Even once the case is established, the insurer can still challenge treatments recommended for that individual even for a medication that the individual may have been taking for many months for a chronic work-related condition. Thus, it may be many years before the case of a person with a WTC-related condition is fully recognized and adjudicated by the compensation system. Meanwhile, the claimant may not be receiving any medical or compensation benefits or may have had their benefits disrupted many times.

In order to alleviate some of the problems for WTC claimants, last year New York State implemented some new programs that were deigned to improve coverage for WTC responders by providing medical coverage and salary compensation for responders while their WCB cases were being evaluated. However, these provisions must be initiated by the insurer carrier, and there is uncertainty as to who would be responsible for reimbursing these costs if the claims are ultimately denied. To date, these provisions do not appear to be widely used. There was also legislation passed last year that allows more New York City workers to obtain disability retirement benefits for WTC-related conditions. Currently, there is an advisory task force in place that is examining how best to implement this legislation. Finally, there was a bill passed allowing people who worked at the WTC site to register for Workers’ Compensation benefits. Potential claimants were given a year to submit a registration form to the Board that makes them eligible to apply for benefits should they later develop a WTC-related health condition. Prior to that, claimants who later developed a WTC-related medical condition were not eligible to file claims because they were judged to have missed the filing deadline required by law. In addition, New York State has just passed broad workers’ compensation reform legislation that makes many changes in the current system. Once implemented, this legislation could help to alleviate some of the delays in the current system. However, it will be some time before all of these changes assist WTC claimants. Meanwhile, claimants continue to face long delays and many hurdles in obtaining workers’ compensation coverage for any conditions resulting from their WTC exposures. It is not clear that the recent changes in the system will adequately address these problems.

I would also add that depending on workers’ compensation and disability retirement systems to cover the medical costs for the monitoring and treatment program places the financial burden on the employers and insurance companies. New York City is self insured and thus would pay directly for all claims. The private employers involved will also have greater costs either by directly paying for claims if they are self insured or through higher premiums due to an increase in their experience rating.

COMPREHENSIVE SOLUTION
A comprehensive solution is needed to address the health needs of the 9/11 rescue and recovery workers. We cannot rely on a fragmented system utilizing private philanthropy, health insurance, line of duty disability retirement, and workers’ compensation to support the necessary medical monitoring and treatment for the thousands of people whose health may have been impacted by their WTC exposures. This fragmented approach will inevitably leave many of the ill and disabled rescue and recovery workers without needed medical treatment and will only worsen their health conditions. The delays and uncertainty about payments would discourage many of the ill rescue and recovery workers from seeking necessary care and discourage medical institutions from providing that care.

This is a critical time for the federally funded treatment programs. Their funding will soon run out, and federal officials are already proposing sending letters informing the participants that they must seek alternative arrangements for their care. Attempting to provide this care through some sort of voucher system as is currently being considered by the Department of Health and Human Services would also be disruptive. Discontinuing or disrupting this high quality, coordinated medical treatment would only exacerbate the health consequences of the 9/11 disaster. Most of the participants in the monitoring and treatment program have medical conditions (asthma, mental health problems, etc.) that should be responsive to medication and other treatments. Hopefully, many of these people will gradually recover and not become disabled due to their WTC-related medical conditions. To the extent, that we can prevent worsening of the medical conditions and prevent many of these people from becoming too disabled to work, we can not only help these individuals, but we can also lower the long term costs of providing care and assistance to this population.

Continued funding is also needed for the medical monitoring portion of this program. You have already heard about the benefits of the Centers of Excellence approach for providing and coordinating the medical monitoring and treatment of the 9/11 rescue and recover workers. We must be able to follow the health status of these participants, not only to provide better medical care but also to evaluate the possible occurrence of new WTC-related conditions. Neither workers’ compensation nor health insurance will support this type of comprehensive service. This program should also be extended to the residents and workers in the area around the WTC who were also exposed to the dust and smoke from the site. Too often in the past, we have neglected to properly monitor the health of groups exposed in extraordinary situations only to later spend millions of dollars trying to determine the extent to which their health has been impacted. Agent Orange exposure in Vietnam and the current compensation program for nuclear weapons workers are only two examples of this problem. We should learn the lessons from these past mistakes and make sure that we provide comprehensive medical monitoring for those potentially impacted by the WTC disaster.

Finally, we need to address the longer term compensation issues for the 9/11 rescue and recovery workers. This is a difficult issue due to the fragmented and adversarial nature of the current compensation systems and the potential costs for such a program. One proposal has been to restart the September 11th Victim Compensation Fund. This fund worked well for those immediately affected by the 9/11 disasters and would have the flexibility to take into account the differing benefits programs already available for anyone applying for compensation. However, other approaches to long term compensation should also be considered.

In summary, the current health insurance and workers’ compensation programs do not provide an adequate basis to ensure access to sufficient medical monitoring and treatment for 9/11 rescue and recovery workers. I would strongly urge you to take immediate steps to ensure that there is adequate federal funding for the current medical monitoring and treatment programs and to open up these programs or similar programs to the affected residents and to other affected workers. I would also urge you to develop legislation to provide individuals access to long term medical treatment for their WTC-related medical conditions and compensation for their losses.

I would be glad to answer any questions.

Statement of

Joan Reibman, MD

Associate Professor of Medicine and Environmental Medicine
Director NYU/Bellevue Asthma Center
Director of Bellevue Hospital WTC Environmental Health Center
Bellevue Hospital
New York University School of Medicine
The Long-Term Health Impacts from September 11: A Review of Treatment, Diagnosis and Monitoring Efforts
March 21, 2007
Before the Senate Health Education Labor and Pensions (HELP) Hearing

Click here for a PDF version

Thank you Chairman Kennedy, Ranking Member Enzi, and members of the Health Education Labor and Pensions committee:

My name is Joan Reibman, and I am an Associate Professor of Medicine and Environmental Medicine at New York University School of Medicine, and an Attending Physician at Bellevue Hospital, a public hospital on 27th Street in NYC. I am a specialist in pulmonary medicine, and for the past 15 years, I have directed the Bellevue Hospital Asthma Program. Most of my patients come from Lower Manhattan, which, though replete with office towers, is also a major residential community; almost 60,000 residents of diverse race and ethnicity backgrounds live south of Canal St. alone (US census data). The residents are economically diverse, some living in large public housing complexes, others in newly minted coops.

The destruction of the WTC towers resulted in the dissemination of dusts throughout Lower Manhattan. These dusts settled on streets, playgrounds, cars, and buildings. Dusts entered apartments through windows, building cracks, and ventilation systems. The WTC buildings continued to burn through December. Some residents hired professional cleaners to remove the dusts; many cleaned their own apartments. Thus individuals living in the communities of Lower Manhattan had potential for prolonged exposure to the initial dusts, to re-suspended dusts and to the fumes from the fires. As pulmonologists in a public hospital, we naturally asked whether the collapse of the buildings posed a health hazard for these residents. Although levels of dust particles and particle components were being measured, it seemed to us that the only way to measure the true impact was to monitor the residents.

With funds from the Centers from Disease Control, we collaborated with the New York State Department of Health to examine whether there was an increase in the rate of new respiratory symptoms. The study was designed, implemented and completed 16 months after 9/11/01 and the results have been reported in two publications (Reibman et al. The World Trade Center residents’ respiratory health study; new-onset respiratory symptoms and pulmonary function, Environ. Health Perspect. 2005; 113:40-411. Lin et al. Upper respiratory symptoms and other health effects among residents living near the world trade center site after September 11, 2001, Am. J. Epidemiol. 2005; 162:499-507). We surveyed residents in buildings within one mile of Ground Zero, and, for purposes of control, other lower-risk buildings approximately five miles from Ground Zero. Lung function testing, consisting of screening spirometry, was performed in a subgroup of individuals in the field. Analysis of the 2,812 residents in the exposed area revealed that approximately 60% of individuals in the exposed area compared to 20% in the control area reported new onset respiratory symptoms such as cough, wheezing, or shortness of breath, at any time following 9/11. The more important question, however, was whether these symptoms resolved over time, or persisted. To address this question, we examined whether symptoms persisted in the month preceding completion of the survey (8-16 months after 9/11) with a frequency of at least twice/week. Such new-onset and persistent symptoms as eye irritation, nasal irritation, sinus congestion, nose bleed, or headaches were present in 43% of the exposed residents, more than three times the number of exposed compared to control residents. New-onset persistent lower respiratory symptoms of any kind were present in 26.4% versus 7.5% of exposed and control residents respectively; a more than three fold increase in symptoms. This included an increase in new onset, persistent cough, daytime shortness of breath, and a 6.5-fold increase in wheeze (10.5 % of exposed residents versus 1.6% of control residents respectively). These respiratory symptoms resulted in an almost two-fold increase in unplanned medical visits and use of medications prescribed for asthma (controller and fast relief medications) in the exposed population compared to the control population.

There were some potential limitations to our studies. Because of the unexpected nature of the disaster, we had to rely on self-reported health information. One must keep in mind that during the time of the study, the postal service was not functioning in Lower Manhattan and often mail did not reach residents – we resorted to hand delivery. Residents were moving in and out of the buildings, were emotionally distraught, and were being bombarded with a variety of forms for housing services, clean-up services etc. Our response rate, though low, is comparable to that of the US Census and we confirmed our data, by targeting a few buildings in the exposed and control areas with more intense outreach that resulting in a better response rate (44%). The data from this group was similar to that from the overall study.

This study was one of the few studies, and particularly one of the few with a control population, to describe the incidence of respiratory symptoms among residents of Lower Manhattan after 9/11/01. It suggested that many residents had new onset symptoms in the immediate aftermath, with persistence of symptoms in the year after the event. Our findings are similar to those now described through the NYCDOHMH WTC Registry. Do these symptoms persist today, over five years after the attack and some three and a half years after our study? When it comes to residents and local office workers, we have little information. The NYCDOHMH WTC Registry, which was implemented after our study was completed, and closed in 2004, found a similar pattern of symptoms in residents and office workers, but did not address the issue of persistence. This question is now being addressed with a second study implemented by the NYCDOHMH WTC Registry and we look forward to the results, which will help shed light on this question.

While we await more survey information, we are cognizant of what we are seeing in our clinics. After 9/11, we began to treat residents who felt they had WTC-related illness in our Bellevue Hospital Asthma Clinic. We were then approached by the Beyond Ground Zero Network, a coalition of community organizations, and together began an unfunded program to treat residents. We were awarded an American Red Cross Liberty Disaster Relief Grant to set up a medical treatment program for WTC-related illness in residents and responders, which began functioning in September 2005. In September 2006, Mayor Bloomberg announced new initiatives to provide for evaluation and treatment of individuals with suspected World Trade Center-related illnesses and this city funding of $16 million over 5 years has allowed us to expand the program. To date, we have evaluated and are treating over 1000 individuals. In the past month alone, with minimal outreach, we received over 400 calls to enter the program. We have a wait list of hundreds. These requests are from local residents of diverse socioeconomic status, some of whom were evacuated, but others who were left in their apartments, with no place to go. We also receive calls from office workers, many of whom were caught in the initial dust cloud as the towers disintegrated and then later returned to work. And we have a large contingency of clean-up workers, the individuals who removed the layers of dusts that had infiltrated the surrounding commercial and office spaces in order to allow the city to function.

An individual has to have a physical symptom to enter our program; we are not a screening program for asymptomatic individuals. Most of our patients have symptoms that began after 9/11 and consist of upper respiratory symptoms such as sinus congestion (45%), or lower respiratory symptoms, such as cough (52%), shortness of breath (65%) or wheezing (36%), for which they are still seeking care, five years after 9/11. We have individuals like J.K., a former broker in government securities, who was working at 80 Pine Street, just east of the towers, and was caught in the dust cloud on 9/11. He returned to work 1 week later and soon after developed a persistent unremitting cough. He sought care by a variety of physicians and was told of recurrent bronchitis, pneumonia, and finally one year ago, was told that he had reactive airways dysfunction. Last year alone, he required 5 courses of prednisone – a steroid medication. Now, no longer working, and on chronic inhaled medications, on a good day, he can walk 5 blocks.

Or M. R. a 37 year old resident of Beekman Street, just east of the towers, who went 10 years without a sick day and trained for the marathon. He stayed in Lower Manhattan, having no place else to go, cleaned his dust-covered apartment and 1 year later, noted the onset of shortness of breath and wheezing. He now requires daily high dose inhaled steroids to control his symptoms.

Or J.F. a healthy man, a carpenter at the NY Stock exchange, caught in the dust cloud, who helped clean up the exchange, now with lung function that is 60% of normal. Whereas many of these individuals have symptoms that can be treated like asthma, others have a process in their lungs that we do not fully understand and may consist of a granulomatous disease of the lung like sarcoid, or fibrosis, which is a scarring in the lungs. And although we call ourselves a “treatment” program, many questions remain. We do not know how best to evaluate and monitor the symptoms. We do not know which medications work best. We do not know how long we will need to treat these individuals and if the symptoms will completely resolve. We do not understand the underlying mechanism or pathology of the symptoms. Only rare individuals, those with atypical presentations or a failure to respond to treatment, have had invasive tests, which may help reveal the underlying pathology. Finally, we do not know whether other diseases will emerge, the threat of cancers, particularly those of the blood or lymph nodes, remains a concern. We know that many residents and workers of downtown Manhattan were subjected to environmental insults on a large scale and many will require continued screening and treatment for years to come. Our unanswered questions suggest the continued need for epidemiologic, clinical and translational research studies to help answer these questions.

I thank Mayor Bloomberg and Members of Congress for their efforts to provide funding for monitoring and treatment and Members present for having this important hearing. We need continued support for treatment programs for residents, local workers, and individuals involved in rescue, recovery, and debris removal.

Joan Reibman, MD

Pertinent funding to Joan Reibman, MD.

2001-2002 CDC, World Trade Center Residents Respiratory Survey (Institutional P.I, Lin P.I.)

2001-2003 NIH, NIEHS, World Trade Center Residents Respiratory Impact Study: Physiologic/Pathologic characterization of residents with respiratory complaints (P.I.)

2004-2005 CDC, NIOSH WTC Worker and Volunteer Medical Monitoring Program (P.I.)

2005-2007 American Red Cross Liberty Disaster Relief Fund (P.I.)

2006-2011 New York City funding for Bellevue WTC Environmental Health Center

Testimony of

Jeanne Mager Stellman, PhD

Mailman School of Public Health
Columbia University
600 West 168th Street
New York, NY 10032

Click here for a PDF version

Before the Committee on Health, Education, Labor, and Pensions at a hearing entitled "The Long-Term Health Impacts from September 11:A Review of Treatment, Diagnosis and Monitoring Efforts."

March 21, 2007

My name is Jeanne Mager Stellman and I am a professor at the Mailman School of Public Health, Columbia University in New York City and director of the General Public Health program. My formal training is in physical chemistry, in which I hold a doctorate. I have spent the majority of my career in occupational and environmental health studies. I have recently been the principal investigator of a multimillion dollar contract with National Academy of Sciences to develop methodologies for evaluating exposure of veterans to herbicides in Vietnam. That work has resulted in a number of scientific publications, including an article and the cover in Nature, as well as an exhibit in the London Science Museum. Our methodology was strongly endorsed by the Institute of Medicine. The Institute of Medicine has recently convened a Committee for recommending ways in which to implement our methodology. Our long-term work on the health of American Legionnaires has been widely recognized and in 2005 Dr. Steven Stellman and I were awarded the Legion's Distinguished Service Medal, its highest honor.

I have been a Guggenheim Fellow and a recipient of one of the first Preventive Oncology Academic Awards given by the National Cancer Institute. I have been the principal investigator of many federally funded grants and have served on numerous peer review committees in both the United States and Canada. I am Editor-in-Chief of the 4th edition of the 4-volume Encyclopaedia of Occupational Health and Safety (ILO, Geneva 1998), an internationally recognized reference. I was Editor of the journal Women and Health from 1986-2004. I have written three books which have been translated into many languages, dozens of monographs, chapters and peer-reviewed articles.

With regard to the World Trade Center, I served on the EPA World Trade Center Expert Technical Review Panel, 2004 - 2006, that studied the environmental issues surrounding the destruction of the towers and the subsequent cleanup activities. Our task was to make recommendations with regard to community cleanup programs. During the past year I have been working on analysis of various aspects of the health data gathered by the clinical examinations in the WTC Medical Monitoring and Treatment Program and am the first author of a forthcoming paper on the mental health of the responders. I am thus intimately familiar with the scientific background and with the current health status of the responders.

I believe that my background and, in particular, my work with Vietnam veterans' exposures and health, and the related science policy issues, provides both expertise and perspective for understanding the complex psychological and chemical exposures of the World Trade Center responders.

The environmental effects of the 9/11 terrorist attack on the World Trade Center were cataclysmic. When the towers collapsed and were pulverized, thousands of tons of highly toxic and corrosive dust (particulate matter) were released into the atmosphere in a toxic plume that spread contaminants over lower Manhattan and neighboring areas. The fiery crashes of two fully fueled jetliners added some 90,000 liters of jet fuel at extremely high temperatures to the conflagration, creating a toxic plume containing a mixture of volatile organic compounds, acids, soot and metals. Pulverized dust was all that remained of the Twin Towers and it created a toxic mound six stories high. The rubble continued to smolder and burn for several months. A third building in the complex, WTC 7, also collapsed, thereby adding to the toxic mess and to the intense psychological trauma of the event.

The actual chemical nature of Ground Zero and the surrounding environs is very poorly characterized. An insufficient number of representative samples were drawn so that we only have an incomplete picture of the exposures. Yet some facts are clear. The rubble was highly alkaline and contained tons of corrosive cement dust. The rubble also contained tons of man-made mineral fibers, asbestos, and other building materials. Toxic chemicals, like polycyclic aromatic hydrocarbons (PAHs), polychlorinated biphenyls (PCBs) and polychlorinated furans and dioxins, were present and their composition varied from time to time and from place to place. Several excellent overviews of the devastation and conflagration exist and a few are listed in the rear of this testimony. (1-5)

The compounds and minerals that made up the WTC toxic plume were not benign. They have been the subject of much scientific inquiry and regulatory activity over the years. The toxic plume and the fumes emanating from the rubble contained a host of known and suspected carcinogens like dioxin, asbestos, the polycyclic aromatics and benzene. As the cleanup continued, diesel fuel emissions from the many construction vehicles added another toxic component and potential human carcinogen to the mix. The nature of the exposures changed with time, depending on whether or not there was rain, and the extent to which the fires were smoldering. Concentrations, of course, diminished as the cleanup progressed. Exposures were not limited to Ground Zero. Workers were involved in transporting the rubble and in adding it to the Staten Island landfill. Others were employed at the Office of the Chief Medical Examiner, and, of course, the Fire Department of New York, FDNY, contributed enormously and selflessly to the rescue and recovery effort.

From an environmental perspective, it is important to emphasize that many of the components of the WTC rescue, recovery and cleanup operations would individually have been considered serious occupational health hazards. The combination of so many toxic substances in such large quantities, and in the presence of so much particulate matter, will very likely exacerbate any individual chemical effects, making the sum of the components far more toxic. Although most of the dust was too coarse to be inhaled deep into the lungs, given the enormous mass of rubble, even the very small percentage of dust particles that were present and small enough to enter the small airways (respirable dust) represents a serious toxic load. Such small particles not only have the potential to damage the lungs themselves, but they also serve as excellent vehicles for transporting adsorbed chemicals into the lung and bloodstream. The larger particles that were breathed into the upper airways were highly alkaline. Exposure to the alkaline dust appears to have caused serious upper airways and throat problems, as well as gastrointestinal reflux, in a significant number of rescue workers.

In addition to the dust and chemical exposures, workers were exposed to extraordinarily stresssful working conditions. Among the group of workers who have been monitored by the WTC Medical Monitoring and Treatment Program (non-FDNY), more than 65% arrived at Ground Zero within the first 48 hours following the attack. By the end of the first week, about 70% of the overall workforce had arrived and by September 24, 2001, 90% of the rescue, recovery and cleanup crew was on the job. The great majority of them worked at Ground Zero operations for 3 months or more. Thus these workers were present for the extraordinarily traumatic -- and frightening -- early post-attack days and then they remained for the arduous and stressful working conditions that followed, with hours that were longer and work that was more intense that almost any other job in the United States.

The initial days at the site were fraught with danger and emotion. Workers handled nearly 20,000 human body parts. They discovered and transported bodies. They served in long bucket brigades to clear enough debris for construction vehicles to enter. Many worked around-the-clock, and then on workdays with extremely long shifts. They accomplished their tasks in a breathtakingly short period of time. Many of the rescue, recovery and cleanup workers also suffered the personal loss of friends, family or co-workers in the attack. Conditions such are these are an excellent breeding ground for a variety of stress-related psychological problems, like post-traumatic stress disorder, depression, panic disorder, generalized anxiety and other manifestations of a substantial stress response. These disorders can affect not only the workers themselves but also their spouses, children and other loved ones.

The average age of the non-FDNY responders was about 43 years. In the group currently being monitored, about one-third were in law enforcement and about the same percentage were construction workers. Utility workers and New York City employees drawn from a variety of agencies make up the remaining rescue, recovery and cleanup team now under surveillance in the monitoring and treatment. Many of these men and women had no training in rescue/recovery operations and we know that there were serious problems in providing workers with adequate protective gear or training for using it. Many of the workers had occupations that had already subjected them to a almost two decades of exposures to toxic and dangerous conditions, thereby possibly putting them at even greater risk by exacerbating existing disease potential.

The demographic makeup of the workforce is relevant to any consideration of both long- and short-term health effects. The rescue, recovery and cleanup workers were not an army of young recruits fresh from basic training, but were more mature, with some not in optimal physical condition. It is possible that a workforce with these characteristics may be placed at even greater risk for both short- and long-term health effects.

Studies of the WTC rescue, recovery and cleanup workers and of the FDNY firefighters are