Testimony
	New York City Department of Health & Mental Hygiene Office of Communications

Good Afternoon. I am Dr. Isaac Weisfuse, Deputy Commissioner for Disease Control at the New York City Department of Health and Mental Hygiene (DOHMH). I am accompanied today by Dr. Jessica Leighton, Assistant Commissioner for Environmental Disease Prevention, Division of Environmental Health, and Pauline Thomas, M.D., Assistant Commissioner for Surveillance, Division of Epidemiology. Although public health emergency preparedness involves every division within the Department of Health and Mental Hygiene, overall responsibility for planning and coordination falls within my division at DOHMH.

Emergency response capabilities of the New York City Department of Health (NYCDOH) evolved in the late 1990s along with the growing understanding of the role of public health in emergency situations. From the creation of the Mayor's Office of Emergency Management (OEM) in 1996, the City Health Department was a core participant in citywide emergency preparedness activities, including staffing the OEM incident command center and actively participating in the citywide emergency planning and in simulated exercises and drills. We had established an incident command system (ICS) structure including standing committees comprising senior agency personnel who were meeting monthly prior to 9/11.

These efforts served the City well during the events of September 11^th and the anthrax attacks that followed. Despite the loss of telephone services and electronic mail capability, and the forced evacuation and relocation of DOH's Emergency Operations Center (EOC) from 125 Worth Street to the Public Health Laboratory building at 455 1st Avenue, we activated the EOC within 30 minutes of the attack, and successfully mobilized emergency response teams for 24-hour-a-day coverage.

The City Departments of Health and of Mental Health, Mental Retardation and Alcoholism Services, which have since merged into the Department of Health and Mental Hygiene, played a multifaceted role in the response to the terrorist attack - a role that shifted over time. Initially, it consisted of providing care and triage for injured persons, shelter to displaced persons, assessing the threat to routine health services, assessing hospital staffing and resource needs, and performing a rapid epidemiological assessment of injuries. Within a day after the attack, priorities shifted to providing respiratory protection for workers, worker-injury surveillance and injury prevention, surveillance for bioterrorism, ensuring food and water safety, monitoring rodent and vector control, coordinating environmental sampling and providing mental health and crisis counseling. As you know, we have testified many times about our activities. Today I will focus on some of the steps we have taken, and continue to take, to monitor the health effects of 9/11, and to improve and strengthen our ability to respond to any future emergency, including bioterrorism.

The unprecedented nature of the World Trade Center collapse presented unique challenges. The release of potential contaminants during and after the collapse was of primary public health concern from the beginning. Environmental monitoring requires complex and highly technical expertise, and involves a large number of disciplines and government agencies, including those agencies that set standards and guidelines, such as the federal Environmental Protection Agency (EPA) and Agency for Toxic Substances and Disease Registry (ATSDR); those that establish and operate air monitors, such as the New York State Department of Environmental Conservation (NYSDEC) and the New York City Department of Environmental Protection (NYCDEP); and those agencies responsible for worker safety, such as the Occupational Safety and Health Administration (OSHA). The World Trade Center incident required extraordinary collaboration between all of these agencies.

Beginning September 11, Hazardous Materials units of different City, State and federal agencies were at the WTC site to assess the existence of potential contaminants. Most environmental sampling is done by environmental and occupational agencies, and DOHMH does only very limited environmental sampling. Because there were multiple agencies conducting or planning environmental sampling, coordination between the agencies was crucial to develop an efficient, technically sound, and comprehensive effort to monitor environmental hazards. Although communication was difficult because of unavailability of telephone service, staff from the NYCDOH, NYCDEP, EPA, NYSDOH, NYSDEC, the Consolidated Edison power company, and the Port Authority of New York and New Jersey, and researchers from Mount Sinai Medical Center, met on September 12 to determine how to coordinate both worker-protection concerns and environmental sampling efforts. Thereafter, daily interagency conferences grew to include representatives of other agencies and organizations -- OSHA, the National Institute for Occupational Safety and Health (NIOSH), the National Institute of Environmental Health Sciences (NIEHS), the New York State Department of Laboratories, Bechtel Corporation, the New York City Office of Safety and Health, and Public Employee Safety and Health. These meetings were supplemented by frequent smaller meetings among various members of this large group as necessary to address specific issues or technical problems - often on the floor at our increasingly crowded temporary headquarters at the Public Health Laboratory. In addition, NYCDOH, NYCDEP, and many of the environmental agencies were represented at the twice-daily meeting at the Command Center at Pier 92.

One of the most important needs that was highlighted by the WTC disaster is the need for a comprehensive, computerized environmental tracking system that can be used for both routine and emergency environmental health tracking. Such a tracking system requires that we have national standards for sample collection, laboratory analysis, data submission or transfer, data analysis, and data presentation or display. It also requires that we have information on background levels in different environments and health-based standards we can use to compare levels that have been identified. Without such a system in place, the gathering, analysis, interpretation, and communication of these results is difficult.

As part of our emergency planning for possible future events, we are working to develop such a tracking system that can gather, combine and interpret inter-agency and other data. To do this, we are creating an inventory of existing environmental monitoring data collectors to see what data they collect, the methodology used to collect it, and how the data are stored. Next, we will be working with the environmental agencies to develop standardized procedures for data collectors to report specific sampling information (such as chemical, sample type, date and time, etc). Sampling data will also be coded for geographic location. It is planned that all environmental data collected during emergencies by participating agencies will be electronically transmitted and stored in a computerized database. This database will allow DOHMH and other agencies to quickly and easily combine, analyze, and share environmental information. These data will be available in written reports, charts and maps, and will be made available to the public promptly.

Another area that needs further development is the compilation of environmental health standards and background levels for chemicals of concern. Standards and criteria are needed for comparing environmental sampling results. We need to rely on agencies such as the EPA to develop national standards so that they can be consistent throughout the country. Background levels in the impacted areas or monitoring results in non-impacted areas are also important for comparison values to determine if the levels are truly elevated above normal levels.

The DOHMH has also dedicated other resources to enhance its Emergency Environmental Response Section to plan for and respond to the health impacts of a biological, chemical or radiological incident. This section will be able to provide on-site technical response, including limited environmental sampling for perimeter control; technical expertise on radiological and hazardous materials, interpretation and reporting of environmental sampling results; environmental risk assessments; re-occupancy criteria; recommendations for decontamination procedures; site and community sanitation, pest and vector control services; assessment of community impact and needs; veterinary public health services, and public and provider education on environmental emergency issues.

With a grant from the ATSDR, we have also established The World Trade Center Health Registry, a critically-important effort to evaluate the implications for physical and mental health that may have resulted from exposure to the 9/11 disaster. The registry is a comprehensive, strictly confidential, health survey to assess possible long-term health effects in different groups, including those who were in close proximity to the site and those who were exposed as recovery and clean-up workers, residents, and school children, in the ensuing weeks as the fires burned. We intend to track the health of enrolled persons for up to 20 years. The registry is not an attempt to identify and monitor every exposed person, but, rather, a systematic evaluation that will allow us to reach conclusions about the health effects of 9/11, both for those who participate and as well for persons who were exposed at various levels, but do not participate. The Registry is not a substitute for the clinical studies that are being conducted by Mount Sinai, the New York City Fire Department, and New York University, among others. However, it will provide the only comprehensive information that will be available to put those clinical studies in perspective. We are pleased with the level of participation. To date, we have enrolled more than 28,000 people, including more than 10,000 responders and more than 5,000 residents, as well as more than 10,000 persons who work in lower Manhattan.

At the time of 9/11, no automatic system for post-disaster population-based health assessment existed. The process of obtaining the necessary funding and approvals meant that DOHMH could not begin this unprecedented health assessment for some time following the event. This experience highlighted the need for a national rapid response registry that can be immediately deployed following a disaster. The ATSDR agrees, and is developing such a registry that can be implemented expeditiously in the event of any future disasters.

I would also like to discuss the issue of public communication and the 9/11 experience. Prior to 9/11, the New York City Health Department gained considerable crisis communication experience from the media storm that accompanied the appearance of the West Nile virus in 1999. We learned the importance of getting news out quickly, of aggressive community outreach, and of communicating clearly about what we know and what we don't know. However, putting crisis and risk communication theory into practice is harder than it may seem.

In the wake of the World Trade Center attacks, the usual difficulties of communicating timely and accurate health-related information were magnified by the communications problems; the number of agencies involved in monitoring, assessing and responding to the environmental concerns; and the sheer number of people who were directly affected and the variety of exposure experiences, as well as the heightened anxiety of Lower Manhattan residents who were displaced from their homes, workplaces and schools. Nevertheless, the City Health Department moved quickly to provide the best available health-related information to the public. Within hours of 9/1l, DOH produced health advisories, fact sheets and press releases, which were distributed widely. We established an emergency public health hotline number and distributed it to media outlets, with DOH employees answering the phones 24 hours a day. The multilingual LifeNet Hotline for mental health counseling was publicized on September 12. We produced advisories and collaborated with NYCDEP to produce information on safe reoccupation of buildings and homes. In addition to placing information on our website and distributing it through "blast faxes," we fielded staff to distribute information door-to-door in Lower Manhattan, and sent representatives to address countless community meetings and neighborhood forums.

Understandably, residents and workers were anxious and often skeptical. While the data suggested a low likelihood of long-term illnesses, it was easy to confuse the health related messages and the highly technical air quality assessments that applied to workers and first responders on the "pile" with those which applied to those who lived or worked in the surrounding areas. It was especially difficult to understand the health messages in the context of long-term significant health risks versus short-term symptoms and respiratory discomfort.

We did our best to overcome these difficulties, and we continue to strive for improvement in our public communications. Because of the lessons learned from 9/11, as well as from the anthrax incidents that followed, and more recent concerns about SARS, crisis communication has become an integral and important part of our emergency preparedness planning process. While it is impossible to predict what the next big crisis might be, we now have a draft plan, we regularly update contact lists, and we have drafted template press releases and messages for likely and less-likely scenarios. This information will be available to each member of the agency's emergency command structure. We have also created an emergency team structure to better coordinate communication activities, to provide staff with predetermined roles, and to prevent staff burnout. The team structure will require cross-training of staff to assure a more ready and coordinated communications response. We are much more ready for any future crisis, and we continue to be open to further improvement of our public and communications strategies.

Since the spring of 2002, the DOHMH has received approximately $48 million from the federal Centers for Disease Control and Prevention (CDC) to strengthen its ability to respond to potential biological, chemical, and nuclear attacks. An additional $13 million was made available to DOHMH through the City's allocation from the Homeland Security grant last September. We have used these funds to support a staff infrastructure devoted to emergency preparedness, and to enhance systems and equipment to create an Emergency Preparedness capability that has become a national model. We have improved disease surveillance and detection - partly through the enhancement of the cutting edge "syndromic surveillance system" that collects data gleaned from 911 calls, emergency department logs, pharmaceutical sales and workplace absentee reports to detect clusters of symptoms that may represent infectious disease outbreak. We have improved our coordination between the public health sector and its emergency response partners, and tested our model through live exercises. We have created the capacity to quickly field clinics that could provide medication to the entire NYC population quickly. We have enhanced communication and collaboration among DOHMH, the city's hospitals, health care workers, and other government agencies to ensure rapid multi-agency coordination. We have upgraded our laboratory testing capacity. And perhaps most importantly, we have worked to raise the skill levels and training of our own staff, and worked closely with New York City's health care providers to raise the clinical skill levels that are needed to detect or respond to bioterrorism attacks. For example, we have developed comprehensive guidelines for hospitals and other acute care medical facilities for use when evaluating patients and establishing infection control and appropriate triage and isolation of patients, to lessen the possibility that an undiagnosed disease would be transmitted in hospital settings. It is a strong, well-trained and motivated public health workforce, rather than fancy technology or equipment, which is key to our preparedness efforts.

DOHMH also received almost $17 million since March of 2002 for the programmatic coordination of the Bioterrorism Hospital Preparedness Program in New York City, over 90 percent of which is being distributed to New York City hospitals to support their bioterrorism and emergency preparedness efforts.

However, there is still much more to be done and federal funding still falls far short of the need. On the basis of both past experience and relevant data, experts assert that New York City shoulders at least half the total national risk for future chemical, biological, radiological, nuclear, and explosive (CBRNE) terrorist attacks. Unfortunately, the City has borne over half the impact of the terrorist attacks on the nation since 9/11, including two of the four terrorist-highjacked planes, and four of the seven anthrax-laden letters sent in the fall of 2001. Most intelligence reports including a place of reference mention NYC, indicating that future attacks will likely target New York City. With a population of 8.1 million, and a daytime city population estimated at 11 million, the City is the largest and most densely populated metropolitan area, with the busiest daily commuter rail and subway systems (NYC has 7.1 million weekday riders) and the most air traffic, in the nation.

Clearly, New York City bears a disproportionate risk of high?impact/high?casualty terrorist events, yet has consistently been shortchanged by federal funding by any measure of assessment. In fiscal year 2003, CDC per capita funding for public health emergency preparedness to NYC was $2.59, versus $2.99 nationally; and NYC, with the highest risk of any jurisdiction in the country, ranked 45th out of 54 states and municipalities in per capita funding. Even if the per capita funding inequity were to be rectified, NYC's allotment would still fall far short if measured against any distribution based on risk factors, whether calculated on the basis of terrorism event data or expert assessment. NYC is similarly underfunded with respect to HRSA hospital preparedness support, receiving only $1.59 per capita versus $1.71 nationally, and again ranking 45th out of 54. The City urges Congress to distribute bioterrorism hospital preparedness funds and state and local capacity funds employing a formula that considers both population density and risk and we would welcome the City Council's support to obtain equitable funding for the City.

Thank you for your interest. Dr. Leighton and I will be happy to respond to your questions.

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