	Background

Although people across the country were exposed through the media to  the emotional trauma of the WTC attack, the residents, office workers, and  others living, working, or attending school in the WTC area and the WTC  responders not only experienced the traumatic event in person but also  were exposed to a complex mixture of potentially toxic contaminants in  the air and on the ground, such as pulverized concrete, fibrous glass,  particulate matter, and asbestos. Varied Physical and Mental Health Effects Have Been Observed and Reported across a Wide Range of People

A wide variety of physical and mental health effects have been observed  and reported across a wide range of people in the aftermath of the  September 11 attacks. The health effects include various injuries,  respiratory conditions, reproductive health effects, and mental health  effects. Unlike the physical health effects, the mental health effects of the  September 11 attacks were not limited to responders and people who were  in the WTC area but were also experienced by people across the nation. Because most of the information about mental health effects comes from  questionnaire or survey data, what is reported in most cases are symptoms  associated or consistent with a disorder, such as PTSD, rather than a  clinical diagnosis of a disorder. The most commonly reported mental  health effects were symptoms associated with PTSD, depression, stress,  and anxiety, as well as behavioral effects such as increases in substance  use and difficulties coping with daily responsibilities. In addition, thousands of responders were treated for injuries, a small  proportion of which were classified as serious, during the 10-month  cleanup period. Respiratory Health Effects

A range of respiratory health effects, including a new syndrome called  WTC cough and chronic diseases such as asthma, were observed among  people exposed to the WTC collapse and its aftermath. The most commonly reported conditions include cough,  wheezing, shortness of breath, sinusitis, and asthma. FDNY Firefighters

Almost all of the FDNY firefighters who had responded to the attack  experienced respiratory effects, and hundreds had to end their firefighting  careers due to WTC-related respiratory illness. PTSD is an often debilitating and potentially chronic  disorder that can develop after experiencing or witnessing a traumatic  event. Programs Established to Monitor and Understand Health Effects Vary in Eligibility Requirements, Methods, Treatment Referrals, and Duration

The programs established to monitor and understand the health effects of  the attack vary in terms of which people are eligible to participate,  methods for collecting information about the health effects, options for  treatment referral, and number of years people will be monitored. Program Eligibility

The six programs that have been created to monitor people who were  exposed to the WTC attack and its aftermath vary in terms of populations  eligible to participate. Although five of the programs focus on various  responder populations, the largest program—the WTC Health Registry—is  open not only to responders but also to people living or attending school  in the vicinity of the WTC site, or working or present in the vicinity on  September 11. Monitoring Methods and Options for Treatment Referral

The monitoring programs vary in their methods for identifying those who  may require treatment, and although none of these programs are funded to  provide treatment, they provide varying options for treatment referral. Under current plans, HHS  funding for the programs will not extend beyond 2009. Health experts involved in the monitoring  programs, however, cite the need for long-term monitoring of affected  groups because some possible health effects, such as cancer, do not  appear until several decades after a person has been exposed to a harmful  agent. Agency Comments

We provided a draft of this testimony to DHS, DOL, EPA, and HHS. HHS  provided written comments, in which it noted that the testimony does not  include significant discussion on the ways in which mental health  symptoms have changed over time. In the absence of these results, the  evidence we examined did not support a full discussion of changes in  mental or physical health effects over time. “Posttraumatic Stress Reactions in New York City  Children after the September 11, 2001, Terrorist Attacks.” Ambulatory  Pediatrics, 3, no.
Why GAO Did This Study

When the World Trade Center (WTC) buildings collapsed on September 11, 2001, nearly 3,000 people died and an estimated 250,000 to 400,000 people who were visiting, living, working, and attending school nearby, or responding to the attack, were exposed to a mixture of dust, debris, smoke, and various chemicals. In the months to follow, thousands of people who returned to the area to live and work, as well as responders who were involved in the search for remains and site cleanup, were also exposed. In addition, people in New York City and across the country were exposed to the emotional trauma of a terrorist attack on American soil. Concerns have been raised about the short- and long-term physical and mental health effects of the attack. Various government agencies and private organizations established efforts to monitor and understand these health effects. GAO was asked to describe the health effects that have been observed in the aftermath of the WTC attack and the efforts that are in place to monitor and understand those health effects. GAO searched bibliographic databases such as Medline to determine the pertinent scientific literature, reviewed that literature, and interviewed and reviewed documents from government officials, health professionals, and officials of labor groups.

What GAO Found

In the aftermath of the September 11 attack on the World Trade Center, a wide variety of physical and mental health effects have been reported in the scientific literature. The primary health effects include various injuries, respiratory conditions, and mental health effects. In the immediate aftermath of the attack, the primary injuries were inhalation and musculoskeletal injuries. During the 10-month cleanup period, despite the dangerous work site, responders reported few injuries that resulted in lost workdays. A range of respiratory conditions have also been reported, including wheezing, shortness of breath, sinusitis, asthma, and a new syndrome called WTC cough, which consists of persistent cough accompanied by severe respiratory symptoms. Almost all the firefighters who responded to the attack experienced respiratory effects, and hundreds had to end their firefighting careers due to WTC-related respiratory illness. Unlike the physical health effects, the mental health effects were not limited to people in the WTC area but were also experienced nationwide. Because most of the information about mental health effects comes from questionnaire or survey data, what is reported in most cases are symptoms associated with a psychiatric disorder, rather than a clinical diagnosis of disorder. The most commonly reported mental health effects include symptoms associated with depression, stress, anxiety, and posttraumatic stress disorder (PTSD)--a disorder that can develop after experiencing or witnessing a traumatic event and includes such symptoms as intrusive memories and distressing dreams--as well as behavioral effects such as increased use of alcohol and tobacco and difficulty coping with daily responsibilities. Six programs were established to monitor and understand the health effects of the attack, and these programs vary in terms of which people are eligible to participate, methods for collecting information about the health effects, options for treatment referral, and number of years people will be monitored. Although five of the programs focus on various responder populations, the largest program--the WTC Health Registry--is open not only to responders but also to people living or attending school in the vicinity of the WTC site, or working or present in the vicinity on September 11. The monitoring programs vary in their methods for identifying those who may require treatment, and although none of these programs are funded to provide treatment, they provide varying options for treatment referral. Under current plans, HHS funding for the programs will not extend beyond 2009. Some long-term health effects, such as lung cancer, may not appear until several decades after a person has been exposed to a harmful agent. GAO provided a draft of this testimony to DHS, EPA, HHS, and the Department of Labor. In its written comments, HHS noted that the testimony does not include significant discussion of ways in which mental health symptoms have changed over time. The evidence GAO examined did not support a full discussion of changes in mental or physical health effects over time.