Public Testimony

	New York City Department of Health & Mental Hygiene Bureau of Intergovernmental Affairs

Testimony of
Thomas R. Frieden, M.D., M.P.H.
Commissioner
New York City Department of Health and Mental Hygiene

Before the
Subcommittee on National Security, Emerging Threats and International Relations
Committee on Government Reform
U.S. House of Representatives

Progress Since 9/11: Protecting Public Health and Safety of the Responders and Residents

September 8, 2006
10:30 AM
New York City

Good morning, Chairman Shays, Congresswoman Maloney, and members of the Government Reform Committee. I am Dr. Thomas Frieden, Commissioner of the New York City Department of Health and Mental Hygiene (DOHMH). I am pleased to be here today.

The collapse of the Towers on 9/11 was an unprecedented urban environmental disaster. In the days and months that followed, millions of people were affected emotionally, physically, and financially. While we don’t know all that we would like to know, we do know that many people have experienced respiratory symptoms and psychological distress including post-traumatic stress disorder (PTSD). We share a commitment with others in this room to do whatever we can to understand health problems better and to link those who are in need of care to effective services.

The attack exposed tens of thousands of rescue and recovery workers, area residents, office workers, school children, and pedestrians to environmental contaminants and to extreme psychological stress. This large and diverse population had a wide variety of individual experiences and exposures, and health impacts will vary. Outreach to affected individuals involves many city, state and federal agencies, as well as private organizations, medical providers and institutions in many states across many care systems. We are pleased that Dr. John Howard, Director of the National Institute for Occupational Safety and Health (NIOSH), has been appointed to coordinate this important work at the federal level.

We are also grateful for the tireless work of the New York City Congressional delegation and Mayor Bloomberg in securing funding to support the medical and mental health monitoring and treatment programs for WTC responders at the NYC Fire Department, the various centers coordinated by the Mt. Sinai Medical Center and the programs provided for police officers. These programs provide valuable screening and treatment to thousands of rescue and recovery workers and they must be continued. DOHMH has partnered with, and looks forward to continued collaboration with, the medical monitoring programs and other medical and academic institutions as well as labor and community groups to address health concerns related to the WTC disaster. We also appreciate the funding provided for the DOHMH World Trade Center Health Registry, which will help us understand and respond to the long-term health effects of the WTC disaster. However, it is essential that the federal government continue and expand support for health monitoring and treatment programs, including extension of the WTC Health Registry, and provide additional funding for continued health and mental health services. The City also supports legislation to re-open the Federal Victims Compensation Fund, which was established to provide support for the families of those who died in the attack and for the individuals who were physically injured in its aftermath. This legislation would extend the deadline for filing a claim with the fund and therefore provide support for those who may have become ill more recently as a result of the events of September 11, 2001.

In the past year, the DOHMH led an initiative to update and disseminate clinical guidelines on how to treat adults exposed to the World Trade Center disaster who present with physical or mental health conditions. The guidelines update previously-released DOHMH guidelines on depression, post-traumatic stress disorder, and substance abuse disorders, as well as guidelines on the diagnosis and treatment of respiratory, gastrointestinal, and sinus diseases previously developed by Mt. Sinai and FDNY physicians.

These guidelines, updated in collaboration with medical experts from the WTC Medical Monitoring and Treatment Programs, the New York City Fire Department, the NYU/Bellevue treatment program and other clinical and mental health specialists, incorporate the latest available published information on physical health care, as well as new national guidelines on treatment of chronic cough. Their aim is to help physicians and other health professionals recognize and effectively treat conditions that are possibly WTC-related. They outline appropriate diagnostic and treatment approaches and they prompt health care providers to assess for possible association to WTC exposures. They received broad expert peer review, as well as repeated input from our labor and community advisors, and are being widely disseminated through the NYC DOHMH's City Health Information (CHI) publication and website. So that they will be available to health care providers outside the NYC area, the guidelines are also being posted on the U.S. Department of Health and Human Services web sites. We expect to update the guidelines periodically based on published scientific data.

Earlier this week, the Mayor announced that the City is funding a series of initiatives that will augment medical and mental health screening and treatment programs, including establishing a new WTC Environmental Health Center at Bellevue Hospital, the expansion of the World Trade Center Unit at DOHMH, and the creation of a Mayoral review panel to ensure maximum coordination among City agencies and assess the sufficiency of state and federal resources to address ongoing needs.

The center at the Bellevue Hospital, in collaboration with NYU Medical Center, will focus on medical coverage gaps and provide evaluation and treatment for anyone exposed to the WTC attacks including people experiencing symptoms that are not covered by the existing WTC medical screening programs. This will include Lower Manhattan, Brooklyn and residents of all the boroughs, privately contracted workers, school children, and commercial building inhabitants. It will make available comprehensive medical and mental health assessments and specialty treatment to a broader range of people with suspected WTC-related health problems. DOHMH will evaluate and monitor the screening findings as part of its active surveillance efforts.

The initiatives also include an expanded unit at the Health Department to increase monitoring for potential WTC-related health conditions; increase communication with affected individuals, treating physicians, and the public; and expand risk reduction, linkage to care, and mental health services for persons who continue to suffer after 9/11. To better understand health problems potentially associated with the WTC attack, this unit will track and investigate, to the extent possible, a range of health conditions, and routinely share that information with health care providers and the public. We will collaborate with expert academic partners in this endeavor to systematically look for patterns of lung diseases, cancers and deaths, using data matches between the WTC Health Registry, death records, and cancer registries, as well as to conduct investigations of specific conditions.

The DOHMH will also target risk reduction efforts to WTC-affected adults, including provision of information on environmental triggers for asthma, and will establish and promote a clearinghouse for information of interest to persons concerned about WTC health effects, health care providers, and the public.

The City will also provide for additional mental health services for people who were exposed to the WTC disaster, and who continue to suffer the psychological effects of 9/11, including uniformed services workers and their families, rescue, recovery, and clean-up workers and volunteers, commercial building inhabitants and Lower Manhattan residents and others.

The New York City Health Department is participating in a series of other important collaborative projects. DOHMH, National Institute for Occupational Safety and Health (NIOSH), and others are working together to develop uniform and transparent autopsy guidelines to evaluate fatalities that may be connected with the WTC disaster.

The DOHMH World Trade Center Health Registry, which was conceived immediately after 9/11, is the main platform to enable us to better understand possible WTC-related illnesses and also a major means of assessing for gaps in treatment needs. In the months that followed 9/1l, we worked with the federal Agency for Toxic Substances and Disease Registry to establish and secure funding for the Registry, which was designed to follow and systematically document the health status of persons most directly exposed to WTC conditions through periodic monitoring of registrants for 20 years. More than 71,000 individuals who were highly exposed to the WTC disaster, including first responders, other City agency and private recovery workers, individuals who were working in office buildings on the morning of the attacks, and school children in Lower Manhattan, voluntarily enrolled in the WTCHR, making it the largest effort ever in the United States to systematically monitor the health of persons exposed to a large-scale disaster. Initial funding came from EPA and FEMA, and additional funding recently appropriated by Congress will help maintain the Registry for the near future. However, it is essential that the federal government keep faith with the 71,000 registrants and commit to continued, stable, and sufficient financial support for the 20-year life of the Registry.

Since its establishment, the Registry has maintained a frequently-updated Resource Guide of 9/11-related resources and services to help enrollees and the public locate specialized care and learn about additional services in New York City and the surrounding areas. Enrollees are informed through periodic newsletters reporting Registry findings, research findings from other WTC-related studies, and important WTC-related news in general. The Registry also receives several hundred calls per month with WTC-related health questions from WTCHR enrollees and the general public. Staff provides referral information to callers about specialized medical and mental health services, including LIFENET, a free, confidential, crisis intervention, referral and information service available to all persons in the U.S. through a toll-free line.

Baseline interviews with 71,327 registrants were completed over a period of about 13 months, and we reported preliminary findings immediately upon completion of data collection in November 2004. Nearly half of adult enrollees in the survey reported new or worsened sinus or nasal problems after 9/11. Shortness of breath, wheezing, persistent cough, and throat irritation were also common respiratory complaints. One in four enrollees reported new or worsened reflux symptoms. Two to three years after the event, registrants also reported higher levels of psychological distress than the citywide average.

In April of 2006, we published an in-depth analysis of physical and mental health conditions among more than 8,000 registrants who were survivors of the collapsed or damaged buildings on 9/11. Fifty-seven percent of the building survivors in the survey reported new or worsening respiratory symptoms, and almost all reported having witnessed events with a strong potential to cause psychological trauma. Presence on 9/11 in the dust or debris cloud caused by the Towers' collapse was the strongest factor associated with reported physical and mental health effects. Survivors caught in the dust cloud were twice as likely as those not caught in the cloud to report newly-diagnosed asthma. This study adds to the growing body of literature suggesting that exposure to the dust cloud on 9/11 in particular was a major risk factor for respiratory illness.

Using data from the baseline interviews, the Registry is currently assessing physical and mental health outcomes among other key subgroups, including children, adult residents of lower Manhattan, WTC tower survivors, and rescue, recovery, and clean-up workers.

We are also ascertaining cancer incidence and mortality among enrollees and will be conducting a follow-up study of birth outcomes among enrollees who were pregnant on 9/11. Currently, there is an absence of scientific evidence linking WTC exposures with cancer. Most cancers have a long latency period, so we would not yet expect to see an increase in cancer from exposure to potential carcinogens.

The Registry also serves as a unique resource for health researchers around the country. If protocols are approved by a review committee research projects may go forward, and researchers, through DOHMH, may contact enrollees to offer them the opportunity to participate in research. More than 90 percent of enrollees opted to receive information about external studies. Since the Registry’s establishment, three studies by external researchers have been approved. By supporting and facilitating other research efforts, the Registry is an important resource to answer critical questions regarding the health impacts of 9/11.

The first biennial follow-up survey of the health of 71,000 Registry enrollees is beginning this month. This survey will provide critical information on the prevalence, persistence, and extent of resolution of health symptoms reported in the baseline survey, and it will help us determine if new symptoms or conditions have emerged. The survey includes questions on general health status, disability, mental health, and medical conditions, including asthma, persistent cough, and other lung disorders. Participants will be asked about bereavement, social support, and access to health care and medical treatment for potential WTC-related illnesses. The survey will also address the use of respirators and masks following 9/11, as well as home and office cleaning practices. An important goal for the follow-up survey is not only to identify persistent or new illnesses that may be WTC related, but also to identify and help address gaps in medical treatment among participants. Collecting follow-up information on 71,000 participants is expected to take at least nine months. We will release initial key findings as soon as possible upon the completion of the survey, as we did with our baseline survey, and we will also conduct additional investigations based on the updated data.

The WTC Health Registry is the largest health registry project in the United States. We have learned a great deal since its inception in 2003, and we continue to learn how to strengthen and improve its activities. We work closely with our labor and community advisors to maximize their input into the Registry's work, including design of the follow-up survey and the development of clinical guidelines. In May, we held a public meeting to share findings and other information with NYC residents and Registry enrollees. The meeting's attendance and enthusiastic response has encouraged us to plan for similar meetings in the future.

In closing, I would like to reiterate that while there is much we still do not know, there is much we are doing to better understand and better address health conditions, to share information with doctors, patients, and the public, and to facilitate appropriate medical care for those who are ill. The response involves many levels of government and private institutions. It will also require a long-term commitment of federal and state resources. Working together, we can make sure that all those who experience illness from the attacks on 9/11 have access to appropriate medical evaluation and treatment.

Thank you for your support in these efforts.

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