eral responsibility, some of it may be a State responsibility, some of it may be a local responsibility. In any instance, however, it needs to be a process that is seamless and does not make you sick just going through the process. And nothing should delay that process from happening.

I would like to know as it relates to the long term health effects exposures, what is the best treatment for those suffering from respiratory problems? What is the best treatment? What do we know? Dr. LEVIN. Well, there is a standard of care for irritant-induced asthma and sinusitis. It usually involves inhaled steroids, either nasal steroids or the kind of steroids that asthmatics use. And, of course, Mr. Graham here talked about his rescue pump. These are broncho-dilators, things that open the airways when they are shutdown. And there are a number of other anti-inflammatory medications that are taken either by inhalation or by mouth that can be effective.

When sinuses become acutely infected, one is on antibiotics; even a person who has asthma who develops a bronchitis, winds up on antibiotics. But the basic standard of care for these conditions is well established.

Mr. SHAYS. Dr. Freiden, if you need to go, why do you not leave. Thank you.

I'm sorry.

Dr. LEVIN. There is a well established standard of care which involves the use of these anti-inflammatory medications.

Mr. SHAYS. Is it expensive?

Dr. LEVIN. Is it expensive? Yes.

Mr. SHAYS. Yes.

Dr. LEVIN. Unfortunately, these inhalers are quite expensive. Mr. SHAYS. No, but the whole process of dealing with someone with this type of ailment?

Dr. LEVIN. The evaluation expenses?

Mr. SHAYS. The evaluations, the treatment?

Dr. LEVIN. And the treatment is expensive.

Mr. SHAYS. Describe to me what expensive means?

Dr. LEVIN. Well, each one of these inhalers runs between $60 to $80 for a single unit. A person who has active asthma, you know, will go through several of these in the course of a month.

Mr. SHAYS. Dr. Herbert, you can answer the questions, too.

Dr. HERBERT. Actually, some of the inhalers are even more. I

mean

Mr. SHAYS. But I am asking about the whole treatment. Forget just this little element of it. I want to know are we talking thousands of dollars a month, are we talking thousands of dollars a year? The total treatment, the total care. I want to grasp something about the magnitude of the cost.

Yes, Dr. Weiden.

Dr. WEIDEN. So they are involved in screening, I am involvement in treatment.

Mr. SHAYS. OK.

Dr. HERBERT. We also do treatment

Dr. WEIDEN. So that their agenda is not treatment of all people who come to them.

Mr. SHAYS. Yes, sir.

Dr. WEIDEN. My agenda is treatment of all people who come to them. And I can just tell you that on average I will treat these patients for well over a year. I will see them at least once a month frequently, two or three times a month. I will order testing that will come up to maybe $2,000 to $5,000 for any individual case. And I would guess that the respiratory component will cost between $200 and $400 a month. And in addition with regard to prevention, one of the surprising things that we found is that these patients also have severe heartburn. And that treating the heartburn, which is also quite expensive, then markedly improves the respiratory symptoms that respiratory patients have. So I think there is an advantage to having all of this done in one place with physicians who see a high volume of these patients, and it allows us to be more efficient.

Mr. SHAYS. Let me ask you, is there anything that any of you want to want to record?

First, may I just ask, is there any Member that just has a question that needs to be put on the record, any Member here? If not, anything that any of you would like to put on the record before we go to panel two?

Yes, sir?

Dr. WEIDEN. One of the things that has been obliquely mentioned but is not really been the focus of the testimony is post-traumatic stress disorder. I am not an expert in this, but it is my assessment that a large proportion of the patients who I treat for respiratory illness have post-traumatic stress disorder. And I believe that as many permanent disabilities will occur on this basis as on a respiratory basis, and it has already occurred within the fire department that the number of suicides related to the World Trade Center has far exceeded any other cause of mortality after the initial collapse.

Mr. SHAYS. Anyone else like to put anything on the record?
Yes?

Dr. HERBERT. We, in fact, have treated hundreds of responders. And one of the concerns I have is that in addition to treating the respiratory conditions and the mental health conditions, our patients are a group who have tremendous psycho-social needs because many of them are disabled. They need social services as well as physician care. And I would hope that would be thought about in any plans for treatment.

Mr. SHAYS. Yes?

Mr. NADLER. Dr. Levin, one question. On a long term basis based on what you have seen of respiratory ailments and all the other things that you've seen, would you expect to see a high incident in all these people of long latency diseases that come out 15 years from now, cancers and so forth?

Dr. LEVIN. We do not know, but there are certain groups among the people that we have screened that we worry about a great deal. That includes the people who were cleaning those buildings day in and day out, disturbing settled dust without respiratory protection, without training. And there were some people who were on that pile, right where the plumes of smoke were coming out containing high concentrations of carcinogenic agents, without respiratory pro

tection who may, in fact, may be at significantly increased risk for

cancer.

Mr. NADLER. You are talking about the people who were cleaning buildings afterwards?

Dr. LEVIN. Cleaning buildings after the collapse of those towers, who were provided with no respiratory protection, no training, who did this disturbance of settled dust day in and day out and in enclosed spaces and really may have sustained enough exposure

Mr. NADLER. Are you talking about the people who were cleaning in the EPA clean up, or you are not referring to that?

Dr. LEVIN. Not necessarily that specific group. I do not know their levels of protection.

Mr. NADLER. OK.

Dr. LEVIN. I know that building after building, office buildings and residential buildings, were cleaned by largely immigrant workers who were provided

Mr. NADLER. Through private contractors.

Dr. LEVIN. Through private contractors.

Mr. NADLER. That is inside and out?

Dr. LEVIN. Inside and out, and the issue for them may in fact be one of concern about cancer down the road.

Mr. NADLER. And OSHA, nobody enforced standards or protection on these workers?

Dr. LEVIN. Not to my knowledge.

Mr. NADLER. Thank you.

Mr. SHAYS. Thank you.

Any other closing comments from anybody? Yes, Mr. Graham? Mr. GRAHAM. With your statement before about OSHA, OSHA did lose their office and they did mobilize quite quickly with no office, no communications and no equipment. So, I just wanted to put that in.

Mr. SHAYS. Thank you.

I think, Mrs. Maloney has a comment.

Mrs. MALONEY. A brief question to Mr. Rapp, Mr. Graham and Mr. Willis, all of whom are suffering from health problems related to September 11. I would like to know possibly in writing, since our time may be running out, who is paying your medical bills? How are you managing financially? Did you apply to the Victims Fund, the special fund that is managed by Mr. Feinberg? Did they respond to your concerns? And what is the current status of your workmans compensation plan? Are you having trouble or has that been resolved?

Mr. SHAYS. Let us do this; we will supply you a letter with those questions. You will make sure our committee has that. And if you could respond to it, it would be very helpful.

Do you have a general response in terms of that question that you would like to respond to before we go?

Mr. GRAHAM. Well, generally my union's paying. Thank God I am still working.

Mr. SHAYS. You say your union is paying?

Mr. GRAHAM. My union benefits, my coverage through the union is paying for that. And

Mrs. MALONEY. But if you terminate because of health reasons, there will be no health coverage?

Mr. GRAHAM. Right. I have to work so many hours to earn my benefit hours. So if I do not work, there is no benefit. And I have applied for victim's compensation. And my workmans comp has been denied, whatever.

Mr. SHAYS. OK. Denied.

Mrs. MALONEY. Denied? Unbelievable.

Mr. SHAYS. Contested?

Mr. GRAHAM. Contested at least.

Mr. SHAYS. OK. Well, we got our work cut out for us, do we not? Thank you all very much. You have been a wonderful panel. I appreciate your patience.

Mr. OWENS. One of the members of the audience, you know her written testimony, she could not testify.

Mr. SHAYS. Yes. If we could have the name of the individual and their address and we will submit it into the record. And we will note for the record who that is.

Mr. OWENS. Ms. Heidi Mount.

Mr. SHAYS. Without objection, that will be submitted into the record.

[The prepared statment of Ms. Mount follows:]

from Fride Nirunt

On behalf of my husband Kevin, I would like to enter the following testimony. He is unable to be here today due to his medical conditions. Kevin suffers from chronic asthma, Hepatitis C, chronic sinusitis, a collapsed left eardrum and depression. These injuries are the end result of having worked without the benefit of protective gear during the 9/11 clean-up and recovery effort. Although we can safely blame terrorists for the loss of the thousands of lives taken that day, I hold the city, state and federal officials responsible for the life my husband is now forced to live.

On 9/11, Kevin was a member of the Operating Engineers Union and worked as a tractor operator for the NYC Department of Sanitation, non-uniformed division. He began working for the city twenty-three years ago when he accepted a position as a heavy equipment operator at the Staten Island landfill. Soon after the catastrophic collapse of the two towers, Kevin was called upon to work at the World Trade Center. Never before had he witnessed such devastation and he vowed to work to the very best of his ability as a tribute to those who perished. This was a promise he would never forget.

As he surveyed the damage and the huge amount of debris which spread for blocks, Kevin knew it would take some time just to clear a safe path to Ground Zero. He also knew the air was not healthy. He asked a supervisor for a respirator and was told there were none available. He was instructed to “find” a paper dust mask Kevin thought it was odd that respirators were not available when so many other workers were in full haz mat gear. But he knew this was an emergency situation of unprecedented magnitude and that it would probably take a day or two before supplies would be readily available to all workers. He was confident that the Mayor of New York, the Department of Sanitation and the International Union of Operating Engineers would do everything in their power to protect the workers from harm.

Within two weeks, the operation was extended to the Staten Island landfill. Kevin and his co-workers returned to their regular work place. Kevin's earlier expectation of protective gear becoming readily available after a few days at Ground Zero never came to be. He continued to work with nothing more than a paper dust mask. He was however, optimistic that once he returned to the landfill, which was his "home-turf," he would receive the necessary protective gear. He was at that point, coughing regularly and complaining of burning in his airway. He was also experiencing headaches.

According to Kevin, the environmental conditions were much worse at the landfill than at Ground Zero. The amount of dust and smoke created by the acceptance of almost a million tons of debris created a major health problem. At the height of the operation, up to nine hundred tons of steel and debris were accepted on a daily basis. Despite numerous requests for a respirator and despite the fact that there was a huge tent on the site, which was stacked with full haz mat gear, Kevin was not issued a respirator until late October, six weeks after the attack. But it was too late. Kevin was already sick.

Kevin's state of health continued to deteriorate. His respiratory condition worsened and I would lay awake at night and listen to him struggle to exhale with every breath he took. He started experiencing flu like symptoms and would sleep from the minute he got home