Statement by
John Howard, M.D., M.P.H.
National Institute for Occupational Safety and Health
Centers for DIsease Control and Prevention
U.S. Deparment of Health and Human Services

Assessing 9/11 Health Effects
before the
The Subcommittee on National Security, Emerging Threats, and International Relations Committee on Government Reform
United States House of Representatives

September 8, 2004

Mr. Chairman and members of the Subcommittee, my name is John Howard, and I am the Director of the National Institute for Occupational Safety and Health (NIOSH), part of the Centers for Disease Control and Prevention (CDC) within the Department of Health and Human Services (HHS). CDC's mission is to promote health and quality of life by preventing and controlling disease, injury and disability. NIOSH is a research institute within CDC that is responsible for conducting research and making recommendations to identify and prevent work-related illness and injury. I am pleased to appear before you today to provide testimony on behalf of CDC and our sister agency, the Agency for Toxic Substances and Disease Registry (ATSDR).

CDC supplied extensive emergency assistance during the initial months following September 11th, providing technical assistance to the Federal Emergency Management Administration (FEMA) and to New York to better characterize acute exposures and to make recommendations for the development of a comprehensive protection program for the rescue workers.

My testimony will focus on the most recent CDC efforts to respond to the needs of workers and volunteers regarding the potential short-and long-term health effects of their exposures to the World Trade Center (WTC) site. I will report on the status of efforts to assess health effects from the September 11th attack on the WTC and the programs in place for monitoring health and providing assistance to victims.

Mr. Chairman, I would like to express my appreciation to you and to the members of the subcommittee for holding this hearing. HHS shares your concern for the community and for the workers who responded so courageously in our country's time of great need.

Assessing Health Status of WTC Responders

Since September 11, 2001, CDC has continually provided technical assistance and financial grant awards to local, state, and federal organizations to assess the health impact of the WTC disaster. Immediately following the attack, CDC provided much needed medical evaluation for the brave men and women who worked day and night in the rescue and recovery at Ground Zero. In collaboration with an informal network of occupational medicine specialists, CDC helped to facilitate the production of a guidance document to assist community-based physicians in the medical evaluation of patients exposed to this disaster; ultimately providing the groundwork for the creation of a comprehensive medical screening program. In addition, in 2001, CDC conducted a series of health hazard evaluations to examine the physical and mental health concerns of those working at or near Ground Zero. The results of these health hazard evaluations were reported to you during the Subcommittee hearing in October 2003.

Also reported to you during the previous hearing were the activities of the National Institutes of Environmental Health Sciences (NIEHS), at HHS' National Institutes of Health, which has provided over $8.5 million since September 11 for a multi-faceted array of studies on the health consequences of the attacks. NIEHS grantees have identified the composition and structure of dust particles from the collapse of the buildings, and have determined particle size and the degree of penetration into the airways of those who were exposed. Researchers have also created a public database that includes both pre- and post-September 11 air quality data (http:wtc.hs.Columbia.edu).

Other NIEHS-funded researchers have conducted clinical and epidemiological studies to investigate respiratory abnormalities and post-traumatic stress syndrome in WTC-exposed population such as firefighters, ironworkers and community residents. Scientists have also identified the symptoms and duration of the "World Trade Center Cough", and determined that some dust particles from the attacks were small enough to penetrate into lung airways, producing caustic effects on the respiratory system. Other researchers have evaluated birth outcomes and conducted follow-up studies on the impact of prenatal hazardous exposures during the WTC attack. NIEHS grantees have sponsored town-hall style meetings to inform the public about study results and future planned studies and address residents' comments related to health consequences of the attacks.

Baseline Medical Screening

In 2002, CDC's National Center for Environmental Health granted $4.8 million to the New York City Fire Department and $2.4 million to the New York State Department of Health to conduct baseline medical evaluations of firefighters and New York State employees, respectively, who responded to the WTC site in the course of their jobs.

To assess the health status of the emergency services and rescue and recovery personnel who were not otherwise covered by the New York City Fire Department and New York State Health Department baseline medical screening programs, CDC awarded $11.8 million to Mt. Sinai School of Medicine's Center for Occupational and Environmental Medicine to establish the WTC Worker and Volunteer Medical Screening Program. In 2003, CDC supplemented this program with an additional $4 million. As of August 4, 2004, 11,793 workers and volunteers have been screened.

Mt. Sinai established the Screening Program by organizing a consortium of occupational health clinics to provide screening services to workers and volunteers living throughout the New York City metropolitan area and subcontracted with a national network of occupational health clinics for those workers and volunteers who responded from as far away as California and Washington State. In consultation with occupational health experts from NIOSH, Mt. Sinai developed the comprehensive medical screening program which began in July 2002, and included medical and exposure assessment questionnaires, comprehensive physical examinations, lung function assessments, chest x-rays, routine blood and urine tests, and mental health screening. The program also provided necessary clinical referrals and occupational health education for workers and volunteers. Participants were recruited through a series of outreach efforts that included community and union meetings and mailings and articles distributed through the media.

NIOSH scientists, in collaboration with Mt. Sinai, analyzed a subset of the 11,793 program participants. The study analyzed data from 1,138 participants seen at Mount Sinai between July 2002 and December 2002. These findings will be published on Friday, September 10th, in two articles in the CDC Morbidity and Mortality Weekly Report (MMWR). The articles describe the respiratory symptoms and include the first published report on mental health findings for these WTC rescue and recovery workers and volunteers.

In addition to these efforts, HHS's Office of Public Health Emergency Preparedness is coordinating a screening program that parallels Mt. Sinai's. This program screens Federal responders who are not covered by the programs offered by the New York City Fire Department, New York State Health Department, or Mt. Sinai.

Long-term Medical Monitoring

In 2003, Congress directed and provided $90 million to FEMA to work with NIOSH to support long-term follow-up medical monitoring for the WTC rescue and recovery workers and volunteers, including current and retired New York City firefighters.

In anticipation of receipt of these funds, in May 2003, NIOSH held a public meeting in New York City to gather input regarding the content and structure of this program. The meeting was attended by individuals representing the medical community, city and state health departments, labor unions, employers, and other federal research agencies such as the Environmental Protection Agency and the National Institutes of Health (NIH). Participants identified a number of significant health concerns among the exposed workers, particularly, respiratory and mental health. CDC collected additional comments from NIH and mental health experts to develop strategies for assessing and monitoring workers to address long-term public health concerns and to learn valuable lessons about complex psychobiological impacts and long-term recovery.

Based on the information gathered, in March 2004, CDC awarded eight grants for a total of approximately $81 million to provide New York City firefighters ($25 million) and other rescue and recovery workers (approximately $56.5 million) and volunteers with medical monitoring examinations over the next five years. The other $9 million from Congress funded the expansion of the baseline screenings (as discussed previously) and CDC/NIOSH operational costs. The grants provide for long-term monitoring at six clinical centers: the New York City Fire Department, State University of New York - Stony Brook, the Mt. Sinai School of Medicine, the New York University School of Medicine, the City University of New York's Queens College, and the University of Medicine and Dentistry of New Jersey's Robert Wood Johnson Medical School. The New York City Fire Department and the Mt. Sinai School of Medicine were provided funding to establish coordinating data centers. This will facilitate communication among clinical centers and assure quality control. Periodic analysis of the monitoring results will provide the information necessary to identify priorities and allow for the adaptation of monitoring protocols to accommodate the changing needs of the population and new medical innovations over time.

A steering committee was established to make decisions regarding the structure and content of the monitoring programs; thus, enabling the creation of a single coordinated examination protocol for all rescue workers enrolled in the program. Commencing this past April, the steering committee, composed of the principal investigators and labor representatives, has met one to two times per month and made major decisions regarding the structure and content of the program. In addition, the committee established multiple working groups composed of national experts who have provided technical advice on the recommended content and structure of the follow-up examinations.

The clinical centers are currently providing baseline examinations (as stated earlier, as of August 4, 2004, 11,793 workers and volunteers have been screened). Follow-up examinations will begin in October 2004 after appropriate hospital review committees have approved the clinical protocol. The creation of this coordinated program will allow for improved communication and information sharing across all of the diverse occupations involved in the WTC rescue, recovery, and restoration efforts.

Assessing Health Impacts on Workers and the Community

In addition to its activities to assess and address the health impacts on rescue and recovery workers and volunteers, CDC and ATSDR are working to identify the health effects of 9/11 on the people who were living, working or attending school in the vicinity of the WTC site.

World Trade Center Health Registry (WTCHR)

ATSDR, in collaboration with the New York City Department of Health and Mental Hygiene, has established a registry to identify and track the long term health effects of tens of thousands of workers and community members who were the most directly exposed to smoke, dust, and debris resulting from the World Trade Center collapse. The World Trade Center Health Registry (WTCHR) was launched September 5, 2003, thus beginning data collection. Extensive public outreach and media campaigns followed, focusing on reaching possible participants throughout the New York metropolitan area and other areas where affected individuals may now reside. Registrants will be interviewed periodically over a period of 20 years or more through the use of a comprehensive and confidential health survey concerning their physical and mental health. Participation in the health registry is voluntary and stringent safeguards are in place to protect the confidentiality of all information collected. Fostering a cross federal agency effort, both FEMA and EPA have provided funding to ATSDR for various aspects of the development, launch and maintenance of the Registry.

One year following the launch, more than 59,000 people have been interviewed and enrolled, establishing the WTCHR as the largest health registry of its kind in the United States. Registrants include rescue and recovery workers, office workers, residents and school children from each of the 50 states. Official enrollment for the Registry ended on August 31, 2004. The Registry will be maintained over time by the New York City Department of Health and Mental Hygiene.

The WTC Health Registry will provide an important picture of the health consequences of the events of September 11th. Registry information will be used to identify trends in physical or mental health resulting from the exposure of nearby residents, school children and workers to WTC dust, smoke and debris. In addition, it will serve as a resource for future investigations, including epidemiological and other research studies, concerning the health consequences of exposed persons from all walks of life. These investigations and studies will act as a significant base for developing and disseminating important prevention and public policy information for use in the unfortunate event of future disasters. By assembling a broad range of data and information into a single database, the Registry also facilitates coordinated follow-up.

The New York City Department of Health and Mental Hygiene and ATSDR will communicate information concerning physical or mental health impacts to the public and to health care providers so those affected can make informed decisions about their health care. Information is posted quarterly and available on the WTC Health Registry Website (www.wtcregistry.org). For the first time, the upcoming quarterly update in October will present health outcome data collected and analyzed via the Registry.


Although there is certainly much more to learn from the tragedy of 9/11, CDC and ATSDR have succeeded in providing valuable assistance to the American people in time of need. Over the years since the WTC collapse, we have networked and collaborated with numerous researchers and health professionals across the country to develop and implement medical monitoring programs and to disseminate pertinent information to assist the exposed workers and volunteers as well as the community-at-large. Our medical monitoring programs and the Health Registry will continue to describe the physical and mental health effects over time, some of which may not yet be discovered, and help to direct resources to those in need throughout the entire United States. Furthermore, our data will provide evidence to further guide public health response in the unfortunate event of future disasters. CDC and ATSDR are committed to the health and welfare of the brave men and women who worked so tirelessly to serve the people of the United States and to all of those who were exposed to the potentially harmful agents emitted as a result of this tragic moment in history.

Thank you for your attention. I am pleased to answer any questions.

Last Revised: September 15, 2004