the national institute for occupational safety and health was able to offer grants and cooperative agreements so that those doctors could begin now, many, many years later, their first work in trying to articulate characterize the issues that responders were facing as survivors. mr. pitts: another question. what are the consequences of letting the world trade center health program expire in september of 2015? how would it effect the operation of the centers of the excellent a-- of excellence across the country and the patients who use these facilities and services? dr. howard: certainly any of us that receive health care from a particular health plan, if we're notified that that plan no longer exists, creates great stress in our life. we have to adjust to new providers and other changes. our efforts to help those who may be part of our discontinued program, let's hope that does not happen, would have to

receive other providers of care and it would be our responsibility to make sure they did. the centers of excellence would not operate any more as a coordinated care operation for responders and survivors. mr. pitts: thank you. we're aware that special master sheila burnbahm administers the fund which is housed at the department of justice. is there coordination between the operations of the victims' compensation fund and the world trade center health program? dr. howard: yes, sir, there is. we have a data sharing and medical review agreements with the victims' compensation fund. we regularly meet with the staff. our staff is imbedded with their staff to assist in the medical

review. the victims' compensation fund has adopted our program requirements for their medical review. to date we have provided information to them on 18,262 of their v.c.f. claim ants. we continue to work -- claimants. we continue to work very closely with the victims' compensation fund. mr. pitts: how much higher is the federal employee compensation act rate compared to medicare parts a and b reimbursements for hospitals? dr. howard: the statute, the act sets the reimbursement rate according to the workers' compensation rates of the federal government. the feca rates. medicare rates are lower but maybe by 10% to 20% lower. so they are -- the feca rates are higher and our reimbursement rates for providers are higher than medicare.

mr. pitts: dr. howard, i can imagine that it is a logistical challenge to provide care for the responders and survivors who are scattered all across the country. what can you do to ensure that a physician in another part of the country, seeing only a few world trade center patients benefits from the clinical experience over the physicians in the new york metropolitan region, who have more experience treating these w.t.c.-related health conditions? dr. howard: the nationwide provider network that we have, which is currently seeing about 8,287 individuals, we have total coordination with that provider network. on the one hand, all of those individuals who do monitoring

for our survivors and responders that are in the nationwide program are trained, occupationally trained physicians, so that they are equivalent to the physicians that we have in our senters of excellence in new york and -- centers of excellence in new york and new jersey. we also provide them with additional training. we're working with medscape we also provide them with additional training. we're working with medscape right now to have online training available for all of our providers. we work is with -- we work with our contractor who has the nationwide provider network. and that physician, their medical director, sits in all of our groups and committees and we engage actively with those physicians. so i would say that for our relationship with the national -- the nationwide provider network,

those physicians republican on par with our physician -- are on par with the physicians. mr. pitts: good. thank you. my time is now expired. mr. green is recognized. mr. green: dr. howard, prior to the passage of the 9/11 health compensation act of 2010, you administered the c.d.c. grant program that funded medical monitoring and treatment services for 9/11 survivors and responders. that program was funded through discretionary dollars and there's always uncertainty about whether and what amount of discretionary funding would be appropriated for the grant program. can you describe how the creation of the world trade center health care program through this act has improved your ability to ensure that responders and survivors get the quality of medical services that they need? dr. howard: i would respond in two ways. one, on behalf of the members, it's very stressful to constantly be told on a year by year basis that your care may go away. your doctor and the institution, the facility that you go to,

may change. so it created a pervasive sense of stress. mind you, in our population, we have many thousands of individuals that suffer from ptsd. and some highly resistant ptsd. if they were here with me, they'd say how stressful year by year funding is to the program. from the administrative perspective, it's very difficult because we are always up to the last minute, thinking, should we start preparing for the program not to be funded? and that was certainly something that we did not want to happen. but it requires a long process of preparation. so we were never sure about that. mr. green: so the dedicated mandatory fundings helped you not only plan better but also the reaction from the patients. dr. howard: it's like night and day. when the act passed, i think all of us, members and us that were administrating the program,

breathed a sigh of relief that we had five years. we never had that before. mr. green: the 9/11 health compensation re-authorization that would permanently extend the program, could you explain how a permanent extension of the program would ensure that responders and survivors have that peace of mind? you talked about that medical monitoring and treatments that they've come to rely on will continue to meet their needs. dr. howard: as i say, i think that the assurance of having the same provider, especially for our patients that suffer from very serious mental and physical conditions, is a peace of mind that can only be bought from mandatory funding, without an end date. for us and the program, it really helps us do long-term strategic planning. it's very hard to do contracts when you can only provide a year or two or five years.

but being able to look beyond that five-year horizon is extremely helpful for the efficiency and the integrity of the program. mr. green: it seems the patients provide a great deal of understanding from the doctors and providers in the program. how do you think this affects the patient outcomes? dr. howard: without doubt. the providers that i first met in august of 2002, when i became first involved in this program are the very same providers that i see now in june of 2015. their dedication to this population has been worthy of note. mr. green: so the doctor-patient relationship is important, because of the continuation of the program. dr. howard: the trust that our members have to the providers that we are fortunate to have cannot be duplicated anywhere else. mr. green: do you think continuing the program is so important to ensuring the same level of knowledge and expertise?

dr. howard: very definitely. our providers have a wealth of clinical information that other providers would take them years to develop. mr. green: ok. thank you, mr. chairman. i yield back my time. mr. pitts: the chair thanks the gentleman. now recognize the vice chairman of the subcommittee, the gentleman from kentucky, mr. guthrie, five minutes, for questions. mr. guthrie: thank you, mr. chairman, thank you, dr. howard, for being here. i spent six years of my life in college and grad school and metro new york. i spent a lot of time at the u.s.o. off times square. it was all uniforms and public servants there, i always enjoyed talking to them there. you said something, i wasn't going to go this direction, but it's opened my eyes.

i live in bowling green, kentucky. we take care of our servants, if there's a fire, and someone in the fire house gets injured, we have systems in placing -- place, disability insurance and so forth. so i think a lot of us that aren't, you know, in new york continuously and the surrounding areas, like my friend here is, are the programs already in place. i know it's unique in the massness of it but why is it unique in terms of other injuries people might receive that requires its own system other than just the volume. could you hit the challenges? because you've opened my eyes to some things, but hit the challenge some of what you've already said but why this is this completely unique, why diseases are different if you're in a normal -- i don't know if normal is the right word but a somewhere standard situation that firefighters or other people would be in? dr. howard: i'd be happy to.

i think the best way to answer the question is by looking at some of the findings that we have gotten from the investment that the act has allowed us to make in research. looking at this population and the conditions. and i'll just mention a few issues. on the mental health issue. we have seen delayed onset of ptsd. that's not normally seen in other types of situations. that's something that we're seeing in this population. it's -- we've also seen a worsening of ptsd despite conventional treatments. i is a you a that they understand what people in scotland the torrent risk for him to learn a state they

understand that. that is the point i am making. the government -- and the that brings a significance and improvement of these positions within the united kingdom. and the run-up to the independence referendum i am not saying, how the country

occasionally protect the scottish media. in the scottish government right now it has powers and responsibilities. to give them the economy we have been decentralized government. i'm not saying david cameron is not a legitimate -- but the political reality he's got the same mandate. i don't think he would be acting

in a way to the detriment of the country. >> i'm charlie stephenson. send to open the door to what scottish foreign policy would be, what are your views ukraine iraq and syria. >> the scottish government supports the u.k. position on ukraine and russia with the international community's position and the sanctions against russia. and a voice of support for the international community. we support the efforts of the international community and one

of the severest threats i don't think they take a remarkably different position on international issues. we don't. we are part we are a participant . my party wasn't it government at this point in our nation's history. they take a different view that it was in iraq. there are some issues that we have taken a different view and

there will be issues in the future. the war in iraq, we were not in international community, it was the wrong direction to take. it will be a responsible voice on international issues. right here in the front row. >> should there be in the future an independent scotland i think one of the greatest concerns in the u.s. is how the defense structure would be disentangled. i wonder if you would speak about your vision for how defense would be handled as scotland were to be independent. >> is said in the referendum

very significant detail how an independent scotland -- and cooperate with the rest of the united kingdom and internationally. i would be happy to forward what we did about that. in independent scotland, and a. of near notwithstanding it was inevitably what there could be in an integrated way in the united kingdom. the defense that scotland to the bank of england is important to scotland is inconceivable in any

future constitutional arrangement that the united kingdom -- would be exclusively. this is the difference between the scottish government and the united kingdom. this is the future of the u.k. nuclear deterrent and does not support the trident. the agreement in principle, in part there is a practical concern that we have and the implication for conventional -- the trident nuclear deterrent. it has been significant reductions in the u.k. over the past 10 years, very current debate about the percentage of

gdp in the united kingdom. the more defense expenditure is taken up with trident on the conventional forces of the country, one example i use that i think the neglect of the convention -- as i said a moment ago, scotland's it is important that we have a large oil and fishing industry. the u.k. doesn't have any monitoring aircraft. the seven -- the russian submarines were patrolling, to

deal with that we had to draw -- some ideas, we need -- keep on defending the united kingdom and appropriately to international efforts everywhere. >> thank you. the carbohydrate -- hydrocarbon sources in the energy services. what are the areas that you see the potential sources of prosperity in the five years and how willing are you to accept new migrants, north africa to

participate? >> a good question. the oil and gas, countries that have natural resources, that said oil and gas continues to be a considerable source of revenue for scotland and the united kingdom for many years to come. we estimate it to be up to 24 billion -- in the north sea. it has a good and strong future ahead of it. it is a finite resource. scott lond we have some of your ups biggest potential for renewable energy. we are a leader when it comes to wind and energy and some of the

new technologies. that is a good area for scotland and want to be invested in. we're also lucky to have a number of sections in the economy that i would suggest the key strength of the british economy other than the economy would be life-sciences one of the things it is important to understand about the scottish economy oil and gas seems to be very important in the economy. it is not dependent on oil and gas.

one of the companies i talk about just announced an investment in scotland, the manufacture, just made a major investment in scotland. we have an advantage. one of the things is increasingly in scotland we have at universities than any other countries in the world in keeping with the university's that are working hand to glove to make sure we could maximize and take advantages. scotland welcomes innovation and

we welcome migrant workers do scotland. there are considerable numbers of polish people and other member states working and living in scotland. notwithstanding the debate. active in the u.k. consistent with the membership question, we connect it to the economy. we welcome immigration that can cope with the economy. we have an organization called power scotland. that is a public organization that helps companies looking for talent in some of our key sectors. we welcome the contribution.

>> in the back there? >> good morning. you are not received at the white house or by every member of the royal family? >> no. not in the slightest. showing towards what the government has been fantastic. also they are showing a genuine interest in scotland, the united kingdom has been first class. i have no complaints or rank or at all with my visit here this week. >> third row back. >> nelson cunningham -- the

family legend is at the cunningham's are from their share. i won't ask about the independence movement there. my question has to do with monetary issues. what currency would an independent scotland wish to have? >> the independence movement and issue is alive and well and prospering. the proposition on currency on an independent scotland would continue to use as the british pound, it is our currency, it would not continue to be our currency in the future. it is a hotly debated issue. i won't go into all of the ins and outs, many people will say

scotland and england would be interesting in what is happening with the euro. the problem come from parts of germany and everyone in between for one currency. that is not the position we have had in independent scotland. the economy in scotland and england are very closely aligned it leads to productivity levels. so should scotland continue to use the vintage pound it will be workable and very successful to do so. >> there won't be a new scottish mint? >> the banks -- if you go to

the united kingdom and scotland and looks exactly the same as the one you get in england. >> right here? >> thank you. i hail from the brookings institute. one area where people are looking within the united kingdom internationally it is an issue that you expect about seeing an open economy and society and especially in complex. there is scrutiny on scotland about the question you raise about separating the nation. with elections coming up at the end of this year the conflict

between russia and the ukraine the question you heard earlier it is how you have so much aggression coming of scotland and immigrants,. scotland is a migrant nation themselves. it is not just the scots, but many generations have moved about for hundreds of years. it is not just a language anymore. scotland how to resolve any of these conflicts. in the bigger issues with the u.k. itself, there are concerns in ireland and northern ireland about the future. and what is happening in scotland if they become independent. how do you address this issue?

in a modern context, dealing with the conflicts globally? >> the contributions kelling can make -- scotland can't make they should lead by example. to get to the heart of the question scotland is in the position of a territory on the borders of scotland the nation are well understood and agreed. the territorial limits of the nation of scotland's -- this is a more complex question. nationalism, offered a positive

-- for the rest of the world. the mission of what it means to be scottish in my view is whether or not --. if you choose to live in scotland and make scotland your home english the united states, pakistan, any other part of the world is scotland is your home if you worked there and make a contribution you are scottish and have as much right as i do to influence the country. the independence referendum migrants were living in scotland had a vote. they could vote in a referendum justice people who live in scotland who were born in england have the right to do that.

that approach to nationalism that is at the heart of the approach to the question. what does that do? it demonstrated this carefully with the complex question of governance and an entirely peaceful and democratic fashion. the issue of scottish independence has been an entity for 300 years, since scotland -- that has never gone away. in modern times not a single drop of blood has been shed in that debate on either side. that's a fantastic example for the rest of the world.

it's not for us to be in any other part of the world, they should do as we ought to do we should fly the flag to do it. >> a question about the effect on the northern ireland people. >> this was an issue that occasionally we talked about during the referendum campaign. i don't think that many people know that we have argued for scottish independence -- i don't want to diminish the periodically -- fortunately and thankfully we are forever part

of the united kingdom. and the constitution of future of the u.k., but they need to be successful. one of the features of this agreement i will be attending a meeting next week. that gives way to the british isles and how we can speak to the dialogue. we will be part of the british isles, we would have gone from an independent, that is a strong

representation that those kinds of regions can work in northern ireland. i am glad to see that continue. it should be above any. >> i work for every child matters. recently the united states congress has been considering welfare reform and the leadership has been open and looking at the u.k. as a model universal credit, and reforms by the conservative cameron government. what is your perspective on that and what do you see you should be worried about, unintended consequences of looking at that as a model? >> do it is my advice. you have to draw a distinction

between welfare reform in the u.k. and the practice of welfare reform. universal credit is bringing together on making sure and live

, i don't think these people did anything in the welfare system either. the people who have suffered in the last couple of years in the united kingdom have been people with disabilities and benefits have been significantly cut and ridiculously women on low wages they are taking the biggest hits. i would argue that you should shy away from some of the --. person in the back. i'm from google. your comments about being scotland being a model, the social media or the internet technology play a role that is different now?

it played a massive role in the independence of scotland. it helped to open up the debate for many more people. you had in the referendum, a population that wanted to get engaged because it was a big question and responsibility. you had that desire to be engaged in a way that they wouldn't be able to do in a way that wouldn't have been possible before.

the minority was bigger than it was. i don't think it did overall but that's the downside. it continues to have a transformational role. >> we have temper will more question. this is on the record.

the restoration of troubles the second -- on charles the second. this country, is there more that can be done to mobilize for the interest of scotland. the iris are very good in this country and mobilizing, can scotland do the same? i am very sorry you are banished from scotland. you are welcome back. anytime you like. i will greet you at the airport.

this is usually possible -- powerful. some of you might have been at that embassy. we have a population of 5 million. there are 10 million people in the scottish connection. we are working hard to mobilize and use the talents and skills and the network and capitalize -- we are working very hard to do that. it is called globals god's,sc --ots-to do that formally for the business community.

we can do much more. >> scotts of america rise up. is that it. please join me and thanking the prime minister. >> i would just ask you to keep your seats until she leaves the room. on the next washington journal congressman kevin yoder discusses the vote on the transportation authority will. and the trade debate in the

president's request for authorization to use military force against isis. washington journal is live every morning at 7:00 eastern and you can join the conversation with your phone calls and comments on facebook and twitter. this summer book tv will cover book festivals from around the country and top authors and books. nearly end of june watch for the annual roosevelt reading festival. in the middle of july, we are live at the harlem book fair the nation's flagship with officer -- authors and panel. in september, we are live from washington dc with the national book festival. that's a few of the events this summer on c-span two book tv. the united kingdom has planned a referendum on european union membership for 27 -- 2017.

members of the regional scottish parliament debated it and the implications for scotland should british voters decide to leave the eu. scotland, england and wales is one of the united kingdom's four constituent countries. here's part of the debate in ireland. it is one hour. >> the debate on the -- referendum, members who wish to take part in the debate --. >> scotland has an integral part of the european union, and gauge meant with european union and constitution will remain a

priority for this government. for the next -- the outcome of the general election has resulted in the published of the u.k. referendum bill. before the end of 2017. last year made clear in the run-up to the general election that a referendum is now reality and we must deal with it. the second reading of the draft referendum last week it meets the gold standard of the independence referendum in opposed to sunshine, and scotland published on the 20th of august 2014. this will make the positive case of the benefit of the eu membership and what it brings to scotland and the rest of the u.k.. why it is incumbent on us to

make the case for continued as a referendum approaches. this chamber has debated the importance of the eu membership on a number of on a number of occasions. the referendum now we must continue to state the case as it grows further. in making the positive case and make sure the facts, the unfounded fears and snares of those who want to see in eu from a narrow isolationists position. the prime minister was in brussels last week discussing the commitment to the eu. the argument was that membership as a country of 5 million people we understand we cannot the

2013. it is a massive -- a structural funds 2014 22020 the experience

of the eu is one which it which we can create a more equal society. that is the type of eu we must continue to develop. it has members who embrace and promote human rights or the convention rather than dismiss them or seek to refute them. it connects with humanitarian issues come with compassion, not facility. i welcome the social and cultural benefits, the might ration to scotland communities.

it is a huge benefit to scott's who moved elsewhere in the eu. we estimate 170,000 people born outside the ud -- the eu live outside scotland. immigration ask as a society. the migrants to the u.k. of around 20 billion times around 2000 one and 2011. this costs all of us. by being a productive member and are able to shape the policies to ensure we have next of an -- maximum benefits. it officers -- it offers no such opportunities -- the minister of foreign affairs interviewed and

we have to implement the directives from the discussion in brussels. when we are here today to vote the referendum bill. it fell short of expectations. the referendum has proved itself . the mp in this morning's debate advocated precisely that point. she is a conservative.

i am grateful and pleased to hear that information. complementing those from westminster as it still progresses. eu citizens can vote in parliamentary and government elections and are able to vote in the independence referendums we have chosen to make scotland their home and extending a vote to them in the referendum. they should have a voice in the issues of the country good i don't understand to grant the citizens, ireland is like this. the polls have shown that people in scotland have a favorable --

the government provision in the bill if each passes votes -- that statutory requirement is not unique. it is used in some states such as canada,. what can happen in that instance? >> if you look at the opinion polls as well as long as there are no health and safety issues that conservatives i will try to continue. the issue of the double majority

during the independence referendum last year. >> people have their own issues currently. this is about a national referendum and independence referendum is the point about our future and the european union. i think the provisions, up to this point i don't see the double majority. on timing, it is imperative that the render -- that the referendum in 2016 and maybe 2017, that is something that you disagree with we can get consensus with. the scottish government has never argued that the eu passes

was set in eu agenda. this have been distance from the citizens and reconnecting with those institutions, assuming ways we can contribute. it is more proportionate and consistent and targeted. it is done by implementing management. and by facing the issues, to prioritize economic and social issues and concerns of its citizens. they address international issues. more energy security and to the single market for to tackle climate change competitiveness of the eu and collective action.

this would require they let -- that a living wage be paid and encourage member states to combat. and doing things in a better and smarter way. also i continued improvement agenda changing the way the eu works. existing structures can accommodate this. the uk's relationship with europe is clear what they actually want and what is required. david cameron seems neither to be clear. a word of warning, we shouldn't pass the negotiations between the u.k. and other member states in terms of one is and losers. everyone should gain from it. compromise in my view is not a concession. if we remain concerned about the

rhetoric in some quarters which creates the impression that eu membership is not present and wall and become beneficial if we achieved big enough reforms. it's not hard to articulate the benefits we are to gain from that -- membership. the real danger there we will focus the debate on a narrow agenda and the success or otherwise of the prime minister's negotiations. this will be a bigger picture of the eu. it is the overall position which will be the decision and must conduct the debate of membership with the bigger picture in mind. including -- i believe the best way to -- is to tell the individual stories of people and businesses that can be benefited right now. the members of this parliament can help make a positive case for eu membership's and to those

. i moved to motion and my name. >> speaker, nine minutes. >> thank you. it's not that long since we had a debate but this one takes part . we now have a majority and we will have an announcement about 2017. u.k. parliament has a second reading of the bill today and i do except and there needs to be a debate. we do have a majority in the early days of the government. we support changing the u.k. -- and soon to be in the referendum so we want a firm and well conducted debate.

it has interest in knowledge that endorses -- we support the scottish parliament which in -- includes the eu and the u.k.. it also raises concerns about the referendum. the eu wants to shift it to its own space. it will dominate the public debate. this is not guaranteed. those of us who support it must win that argument. we are at a danger in scotland, and many come to this debate to understand. we can be naive.

there are many positive reasons to debate the eu by the cabinet secretary. i will talk more about this at this afternoon. the eu is not working for scotland. to the campaign on the direction of the eu. those concerns will be addressed in this debate. the eu is a social, and education union. by, contributed to, or aggravated by their exposure. that's the determination made by the physician. we don't make it in the program. that's an independent view that the physician has. then they submit it to us and we make sure that all of the supporting information is there and then we certify it. if the supporting information isn't there, we have a question, we go back and forth unless -- untlil we're all absolutely

sure, including the determining physician and us, that this is a case to be certified. certification then means that you get your cancer covered for health care. mrs. ellmers: having the concentration on cancer leads me to the next question, which is do you anticipate adding other possible diseases outside of the cancer realm? dr. howard: we have received to date seven petitions for requests adding conditions. two of those were cancer. the original cancer petition chairman pitts referred to, 001, and then soon after that we had a petition with regard to prostate cancer and then five others. with the five others, we did not find sufficient scientific evidence to support their addition. we get quite a few requests for adding conditions. it's hard to estimate whether -- what conditions we would add in the future. but we evaluate each of those requests on their scientific

basis. mrs. ellmers: in regard to autoimmune diseases, i understand that you have made a determination that those would with the five others we did not find sufficient scientific evidence to support their additions. we get quite a few requests for adding conditions. hard to estimate what conditions we went out and the future. we evaluate each of those requests on their scientific racist. >> in regard to autoimmune diseases i understand that you have made a determination that those would not be identified are added. can you expand on that? we>> we received a petition to add a large number of autoimmune diseases to our list.

including the study that stimulated the petition by fdny. we found that it was insufficient at this time. it does not mean that -- this is why we are emphasizing so much the importance of research funding in this program. the additional work that is going on by other cce's and our world trade center health registry to look into that issue. it does not mean that forever it will not be added, but at this time we are not adding. ms. ellmers: thank you, dr. howard. i appreciate the information. i'm glad this is considered an ongoing process into the future. we do not know what the future holds for god bless all of the first responders who are here. i yield back. >> now that all the members of

the subcommittee has had an opportunity to ask questions we can ask for consent. i ask that ms. clark begin five minutes for questioning. ms. clark: thank you very much. we've been joined by congressman nadler of new york. the original sponsor of the act. i wanted to yield some time. mr. nadler: thank you. as someone who, along with mr. king was one of the three original sponsors of the bill, we struggled for years to pass it. the history has proven the necessity of this bill. i want to thank dr. howard for his service. i'm glad the famine has -- the chairman has called the hearing. judging from the comments, there seems to be bipartisan support for extending the bill.

i want to urge that that be done. i thank the chairman of the committee again. extension of this bill is essential because the diseases won't go away. this is for both the first responders and survivors in the community and so i urge the extension of the bill and thank ms. clarke for yielding and i yield back to her. ms. clarke: thank you. dr. howard, just following up on a couple of the questions that mrs. ellmers asked about the conditions, for the record what is the process by which you can add new conditions to the program? dr. howard: well, first of all the administrator has the ability to add a condition on his or her own motion. the other very common route that we have seen so far is the public can petition the administrator to add a condition. as i said, we received seven

petitions so far. two of those we added the condition, the first one being cancer, the second one being a particular type of cancer, prostate cancer. the other five we have found insufficient evidence for. ms. clarke: i understand the statute outlines specific timing requirements to respond to those petitions. could you describe that for us? dr. howard: the administrator has 60 days to respond to a petition unless the administrator refers the petition to our scientific and technical advisory committee and then the time frame is 180 days system of for instance in terms of the first petition on cancer, we referred this to our science and technical advisory committee, they had 180 days to make their decision. ms. clarke: do you have any concerns with the statutory time frame to respond to petitions? dr. howard: one of the things the g.a.o. report pointed out in their review of our cancer petition and our addition of

cancer was that there was no external peer review of our science that we used to justify the addition of cancer. and i think

some of the things that we've learned already the issues about asthma, mental health persistent post traumatic stress syndrome, etcetera, have come largely from the world trade center health registry studies. >> so you think it is important we continue our work. >> it is absolutely vital. >> thank you very much, dr. howard. i yield back. thank you, mr. chairman. i thank the ranking member. >> chair and they have produced almost 60 papers in this area. they follow the same people over periods of time, they, every so many years, they study them to figure out what their experience is. so their research is vital to

this program. ms. clarke: do we have a sense of any of their findings so far? dr. howard: all their findings are not only on their website but also on ours. i think some of the things we i think some of the things we have learned already, the issues about asthma, mental health, persistent ptsd, etc., have come largely from the world trade center health registry studies. ms. clarke: you think it's important that we consider that work? dr. howard: i think it's vital. ms. clarke: thank you, dr. howard. i yield back. mr. pitts: the chair thanks the gentlelady that concludes questions from members who are present. i'm sure we will have follow-up questions from members, we'll send you those in writing and ask that you respond. thank you. that concludes our first panel. we'll take a three-minute recess as the staff sets up the witness table for the next panel. committee stands in recess.

mr. pitts: return of recess having expired, we will reconvene. i asked the guests to take their seats. please take your seats. the committee will reconvene. i asked the guests to take their seats and i will introduce the second panel. we have three witnesses on the second panel. i will introduce them in the order in which they will present testimony. first we have dr. iris udasin from or robert wood johnson

medical school. we had david former retired firefighter. and we have former police detective. thank you for your testimony. your written testimony will be made part of the record. you will each be given five minutes to summarize. there are a series of lights on the table. you will see green first, and then yellow. when read appears, we ask that you conclude your testimony. dr. udasin, you are recognized for five minutes to summarize your testimony. dr. udasin: my name is iris udasin i serve as rutgers' director of center

from seeing people jumping off tall buildings to their death or finding charred remains. our designation as a center of excellence has allowed us to provide quality of care for responders by centering all their care in the convenient location with staff members sensitive to their needs coordinating treatment from start to finish. the combination of program wide knowledge gained over 12 years of care delivery, in addition to

my personal knowledge in new jersey, has allowed us to understand this cohort of patients using medical and pharmaceutical resources wisely to accomplish the following objectives which i will illustrate with specific patient examples. coordination of care for complex cases, diagnosis and treatment of patients considering physical and mental health aspects of disease. use of state-of-the-art diagnostic techniques for early diagnosis and treatment, use of knowledge gained in our treatment of patients to allow for early intervention allowing patients to stay at work. i'm proud to share this panel with david, a retired police officer who performed many months of search-and-rescue work at the site. david presented with swelling in his neck in 2006, a nationally -- eventually diagnosed as cancer of the throat. an unusual cancer in healthy and

he was referred for a chest x-ray foster a natural group larger in january. this was evaluated by a radiologist who was an expert in

interpreting lung cat scan. concern about the suspicious nature of the nodule..the patient was referred to our surgeon, who removed lung cancer. the patient is back at work. he's overseas looking for people who have cheated the government paying taxes. finally, rutgers university and nyu have combined to do research finding markers for sleep apnea associated with environmental exposure. this expertise has allowed for early diagnosis and treatment of obstructive sleep apnea enabling us to get people to work safely. my fourth patient as a pilot for a law-enforcement agency with a history of sinusitis, which are risk factors for sleep apnea p thanks to early diagnosis, this patient has been treated for his

conditions and is fully qualified under federal standards to operate his aircraft. he asked how he could think before his treatment and i said he should continue to catch terrorists. in summary, all of our patients are honored and treated by skilled clinicians. we believe we are continuing to acquire the knowledge to provide early diagnosis and treatment of emergency responders who were exposed to toxic agents and psychosocial stressors. we are striving to continue to achieve excellence in treating our patients, as well as preparation for providing the best medical care for any emergency responders who were exposed to a multitude of unpredictable exposures. thank you for the extra time. mr. pitts: the chair thanks the gentlelady and now recognizes david. five minutes for your summary.

david: thank you, sir. the first thing i would like to do is thank you for having the hearing. it is very important, by the amount of people that are here today. it's an honor and a privilege to be here and address you.. there's a lot of things i would like to say. most important is to enter a question you posed to dr. howard. what happens if? dr. howard was wonderful in his answers. i think i'm going to be a little more blunt -- people are going to die. the men and women that are sick that are being taken care of now , i've only been cancer free a little over a year. i could easily -- if it wasn't for this lady, i would not be here at all. to end this program, people are going to die. it's just -- it's a fact, it is unquestionable, that is what is

going to happen. i was born and raised in mr. pallone's district and lived in his district once i retired. i moved a few years ago and i live in congressman lynch's district. i have both sides of the aisle covered. this is not something that should have any political fighting. this should be an absolute bipartisan, 435-0-type tbill. this is a no-brainer as far as i'm concerned. the other, the last point i would like to meet because i'm trying to keep this brief. i would not be here sitting here if it was not for the doctors and dr. udasin and her other colleagues' knowledge, skills abilities, research, they have

become the experts in what is ailing us. not just me, but all the people part of the program. you cannot go to your regular doctor -- they do not have the knowledge. what has happened to us that is the most important thing is that we can have a quality of life to go forward. i'm going to leave it at that. i will be happy to answer any of your questions. >> subcommittee, ranking member

green, and numbers of the subcommittee on health for inviting me to appear before you. i live in bayside, new york. i'm 52 years old, a wife, mother and grandmother. with me are my husband and my son. i'm a proud former new york city police detective. i retired from the department after 18.5 years of service. my career came to an end as a result of a problem from the world trade center site. i was working in brooklyn, new york when my fellow officers and i learned of the terrorist attacks, we rushed to lower manhattan by boat. when we arrived, the towers had collapsed. the air was thick with dust and smoke.

my fellow officers and i worked all day and into the night. we evacuated people from around the site. we directed them away from the disaster. there was so much dust i was not given protection for my eyes, throat or lungs. i had to wash the debris from my eyes and throat with a hose. my fellow officers and i could not stop doing what we had to do. the first night i left the world trade center around 10:00 p.m. after 12 hours. five hours later i reported back to the site at 4:00 a.m. on september 12. i removed debris by using buckets and shovels. at no time was i provided with respiratory perfection. if i was not crying over what i was seeing tears streamed down my face from the dust. i spent weeks at the site shoveling, clearing away debris, searching for survivors and later sifting for body parts.

we worked side-by-side and hand-in-hand with iron workers construction workers firefighters, police officers removing debris together. we were searching and removing wreckage of the world trade center. we were working on top of the burning and hot rebel. the fires never stopped burning. and call, we were told, was not a concern. all of us are working 24/7. the work was tough, it was dangerous. there was never a time when i thought about quitting or leaving. i thought of thousands of victims. if our work brought the removal and recovery efforts closer to the end we were glad to contribute. i live with the consequences of 9/11 every day. i've been diagnosed with interstitial lung disease -- with fibrosis in my lungs. the information in my lungs interferes with my breathing and

destroys the tissues that get oxygen to my blood. my lungs are permanently scarred. i cannot move around my home or take the stairs without wheezing or gasping for breath. i started morning connecting to a

provides medical structure by coordinating doctors and medication

it is very important for the level of care you give. was it possible to provide this level of care before congress established the world trade center health program? dr. udasin: it was not possible to obtain this degree of care. initially, we had in 2000, the end of 2002 and 2003, we just had the monitoring program. it was very frustrating because you could find something wrong with the person and we really did not have the resources to make sure they got to see the correct person. i'm grateful for the zadroga act funding so we can do that. mr. petz: thank you.

can you talk about your care before and after the creation of the centers of excellence in the zadroga act? in your view, is it better coordinated? mr. howley: i was thinking of a story when you just asked the doctor a question. i'm probably one of her original patients going back to the monitoring program in 2003. the first time i went there my blood pressure was basically somewhere off her chart. my sinuses were completely blown out. i had constant infections. i have acid reflux. she basically refused to let me leave her office unless i went straight to my doctor to get treated for blood pressure. i'm 6'3" and she is about 5'1".

i believed her that she was not going to let me out of the office. there is a big difference. and she is just wonderful. i have not really dealt -- i've only dealt with one other of the doctors at her office. i have never been any other office. i cannot speak about any of them. the doctors are generally -- i just tremendous. as she was saying, when the cancers kept coming back for me, it has reoccurred 4 times for me. she can make those phone calls now. and cap me to the right -- when she says tuesday, she's not kidding you. mr. pitts: would you respond to that as a patient in the health program. are you satisfied with the care you have succeeded -- received?

ms. burnette: i'm very satisfied. in 2004 i started blacking out at work. nobody knew why. with regular doctors, i was being sent for tests. in the program they sent me to one doctor, who sends me to another doctor to make sure everything is covered. they schedule everything for

it was for surgeons that were qualified to do what i needed to get done. mr. green: i understand you receive treatments through mount sinai. can you explain what treatment. ms. burnette: they did an open lung biopsy. it explained how they needed to treat it and what doctors i needed to see. mr. pitts: -- mr. green:? they are treating the whole person ms. burnette: i have a primary doctor and they send me two different doctors for the different diseases i have.

mr. green: do you think your condition would be worse? ms. burnette: i believe it would be terribly worse. i was not able to hold a conversation without the program providing me with the medications i needed. mr. green: dr. udasin, why does this cohort of patients need to specialized care provided at the centers of excellence? dr. udasin: we have people with rare conditions like david that need specialist help. we have been able to use our best university resources to get people that have seen many abnormalities on things like cat scans to get patients like the gentleman i mentioned to have the cancer removed. really

have someone who looks at the whole person and actually treats all the illnesses that you are subject to. thank you. mr. pitts: the chair recognizes

the gentleman from new jersey. >> thank you. dr., can you explain in a little more detail your center of excellence and what that means? how many there are in the metropolitan region. what qualifies your organization as being a center of excellence? dr. udasin: thank you. we are part of the non-fdny of responder program. the fdny has a separate center. we are one of the new york-new jersey consortium which includes centers at mount sinai, and why you -- nyu, stony brook, queens college and rutgers. mr. lance: int&xy ñrw3ó73 manhattan,

long island and queens. dr. udasin: right. ñ?ñ?we serve as a center of excellence in new jersey. what makes us different, our physicians are board-certified in primary care specialties internal medicine, and occupational medicine. double bird -- double board-certified, almost all of our physicians have had at least two certifications. rutgers has an environmental center of excellence in our same building. we do extensive work on exposure and health effects. we have a lot of experience with exposure and illness.

we have a pulmonary doctor that comes into our practice and sees patients with us. we have mental health people that come into our practice and see patients. across the street from us, we had our surgeons, are gastroenterologists and a number of other specialists that we need in the rutgers center. mr. lance: our state legislature has permitted the combination. dr. udasin: in any event i have registered nurses helping us take care of patients, making

sure people know how to use their medications. it is important that we have people making sure not only medications are used, but they are used correctly. than i have my mental health, my administrative which tracy heads. that group of people is performing audits to make sure everybody else is doing everything correctly. )fñ?ñ?we are using our pharmacy correctly. we do our best to keep costs down. all our providers and people are prescriptions, everybody is certified appropriate to do this. our patient actually get their medications when they get to the pharmacy. that's part of coordination of care i want to make sure we have

funding. i want the money to be there to treat our patients. mr. lance: thank you for your superb public service. what position did you play in basketball when you play basketball? ms. burnette: point guard. mr. lance: i was five foot eight, i never played basketball. mr. chairman, i have a letter from 38 members=zñ?ñ? of new york and new jersey delegations requesting early passage of the bill. i requested be submitted for the record. mr. pitts: the gentleman seeks unanimous consent to put in the record. without objection, so ordered. mr. lance: thank you. mr. pitts: the chair recognizes

the ranking member of the full committee, mr. pallone. five minutes. mr. pallone: dr. udasin, i wanted to try to have you explain the importance of the records center and all of the centers that are part of this world trade program in terms of research. there is an extensive research component. i want to emphasize if you can how you are developing diagnosis and treatment of disorders -- how thatúñ?ñ?ñ research and uniqueness of the senate makes that possible. can you describe how they rutgers centers involved

improving the ability to diagnose and treat health conditions, and the benefits of that research. dr. udasin: answering the rutgers only and nyu researchfçñ?ñ. between our laboratory toxicology -- one of our sleep experts presented this at the recent american graphic society meeting. certain markers were developed that certain people can be predicted possibly to have sleep apnea. this is really important. these are inflammatory markers. these people, they say we are

exposed to all kinds of toxins that can cause inflammation. we've been able to find people sooner, get them treated and to think about sleep apnea and the environment. traditionally sleep apnea was thought of as something you had to be a beast to get. when you have patients that are not quite playing point guard but are in awfully good shape that have sleep apnea, we are able to -- as i said, because of our occupational expertise --

there was somebody who recently died on the new jersey turnpike because a best ever fell asleep. we have a lot of patients who drive commercial vehicles, operate planes, operate the subway. operate all kinds of heavy equipment. it is really good that we are able to treat them and keep them safe and awake. i feel like that is one thing our research has accomplished. which is not only applicable to our patients but it is applicable to other people with environmental exposures. mr. pallone: i appreciate that. the other thing, how we can expect an increase among the population of these 9/11-related conditions. as time goes on, we find more cancers, more disorders, people get older wkc?k

exist before and have to be, and that now are finding fewer research or others that are related to 9/11 that we did not know about before. dr. udasin: i want to say that certain kinds of malignancies has a very short latency period s. you would expect to see something like that within a couple years after exposure to toxins. other toxins, like asbestos, have longer latency period. they might be seen later on and at a different time. if i could use a few mittens -- a few minutes to answer a question you asked earlier about mistakes made by providers outside of the program. if i could add that we have found in the program that people who has been undertreated by local providers for various

cancers, for severe lung conditions like pulmonary fibrosis. i want to say, even if that was not the question you asked i want to say that we have been able to improve the health care by tuning, getting better diagnostic services to our patients than they were able to get for some of the local people. mr. pallone: thank you very much. mr. pitts: the chair thanks the gentleman. that concludes the questions of the members. they will have follow-up questions and writing. we will submit those to you as you please respond properly. i remind members they have until

thursday, june 25. thank you for sharing your experience and for your excellent testimony. the committee will take this legislation up and act on it. you have performed a public service by being here. thank you. the subcommittee is adjourned. >> scott wong is the senior staff writer for "the hill," covering the issue on capitol hill -- gop-of him on the cusp of a fast-track victory. tell us where we are in the process. what is it all about. scott: the first of 4 trade votes. it kicks off the process. this has to do with trade

preferences, it would allow african nations to export goods to the u.s. duty-free. the more controversial bills will be taken up tomorrow friday. it is the first of 4. it kind of gets the ball rolling for completion. >> are there different things to democrat and republicans in the house? scott: the two bills coming up tomorrow are taa which has to do with providing benefits to workers.

that is seen ahead of tpa the so-called fast-track bill that would give president obama greater trade authority to get some of these big trade deals done. in particular, one with 11 pacific rim nations. taa will be a critical component of getting the fast track build on. what they have been negotiating the last few days, will any of these derail taa which is critical to getting tpa done. host: assuming all the members are present and voting, they would need 218 to pass the measure. as we speak here, the

president's labor secretary's and chief of staff are lobbying democrats to pass these measures. what is the message from the administration. scott: the bills are critical for president obama's economic agenda. they will help create jobs, help with exports and imports and of course, we are seeing equal effort on the opposing side. we are seeing the head of the afl-cio who has been with house democrats in the past hour trying to rally the opposition to the trade package. you are seeing outside groups spending hundreds of thousands of dollars in advertisements

trying to force democrats to back away from any sort of support for this trade measure. we are really seeing a flurry of activity. it is getting into the final hours before big votes. host: tell us about numbers. what is your sense about how many democrats are going to support this? scott: the numbers have been all over the map. 20 democrats have pledged their support to supporting the trade package. that will be difficult. republicans do not believe that they had enough support within their own conferencez

what we are hearing from gop leadership and other web sources is that republicans will need anywhere from between 190-200 votes. they will be aided by 20-30 democratic votes. that will be on the tpa, fast-track package p developer before that, taa dealing with workers, workers aid, that would be created mostly by democrats. that's a priority of democrats who have insisted. democrats will be, will -- we have not seen it yet but democrats should be supporting the taa bill. we will see more republicans

supporting the tpa bill. host: to be clear for viewers and listeners, those will come up tomorrow. scott: right. today is a trade preferences bill. it gets the process going. speaker john boehner is rolling the dice. he's gambling that his side has the momentum right now. i think there's also a concern among leadership, among even the white house that the longer you postpone these votes, if you push it into next week, there is a risk of starting to lose the momentum. you get opponents a greater opportunity to rally against these measures, to spend money in congressional districts in terms of television ads. i think speaker john boehner is making a calculation. the white house is making a calculation that they need to strike now.

they feel the momentum is on their side. host: where is the senate and the process? scott: most of the package has passed the senate. they are taking up senate-passed bills. there is a concern this week that if you tweak some of the senate passed bills with amendments that democrats have demanded you'd have to send part of the package back to the senate. that raises more uncertainty that further delays the process if the house can pass this, it gets 42 president's -- it gets forwarded to the president's desk. host: read more at thehill.com. follow the tweets @scottwongdc.

>> coming up, a conversation about race and justice.

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trade authority bill. representative are lee of california discusses the house debate on the trade authority bill and the request for authorization to use military force against isis. host: today, the house of representatives will vote on several trade measures including adjustment assistance and trade promotion authority. vote counts are not clear yet. the president and the white house has been lobbying hard, including attending the congressional baseball game. that opens the way for the president to negotiate the partnership trade agreement. how do you feel of about the trade agreement and of free trade and this process for the