Note: This article was originally posted in September 2006, noting the 5th anniversary of the 9/11 terrorist attacks.
Five years ago, the nation recoiled in horror as two planes crashed into the World Trade Center towers in New York City on Sept. 11, claiming the lives of more than 3,000 people. After the towers collapsed, firefighters, policemen and other emergency responders and volunteers rushed to Ground Zero to rescue anyone who still was alive beneath the rubble. Once rescue efforts became recovery and cleanup efforts, workers continued to toil at the site.
But the calamity continues today. From the moment the towers collapsed, a toxic cloud filled with asbestos particles, shards of fiberglass and other toxins shrouded Ground Zero. Consequently, many of the responders and volunteers some say as many as 40,000 who spent days or even months at the World Trade Center site have reported a slew of irreversible and chronic illnesses ranging from upper and lower respiratory ailments to gastro-esophageal reflux disease, post-traumatic stress disorder and cancer.
At least four responders firefighter Stephen Johnson, police officer James Godbee, detective James Zadroga and emergency medical services paramedic Debbie Reeve have died, allegedly as a result of exposure to World Trade Center dust particles. More than 12,000 people have been monitored in the two primary medical services for Ground Zero workers, one run by the New York Fire Department (FDNY), the other by the World Trade Center Monitoring Program based at Mount Sinai Medical Center in New York City.
In FDNY, more than 600 firefighters were forced into retirement because they were deemed permanently disabled, allegedly from exposure to Ground Zero hazards.
The tragedy of the World Trade Center collapse not only is centered on the victims that died on 9/11, but also on the notion that these responders and contractors are getting sicker by the minute. According to Dr. Jacqueline Moline, principal investigator of the World Trade Center Monitoring and Treatment Program at Mount Sinai Medical Center, doctors were seeing as early as October 2001 that first responders were having health problems related to the World Trade Center dust.
As more first responders are diagnosed with illnesses related to 9/11 dust, lessons are emerging for occupational and environmental health professionals who might one day face a similar disaster. While officials at OSHA and EPA appear to be unwilling to comment on the lessons those agencies learned as a result of 9/11 perhaps fearing they will be assigned blame for the illnesses now befalling responders and contractors at the World Trade Center site workers at Ground Zero have learned to live with these lessons everyday.
Lesson One: Get the Facts Straight
John Feal, an operating engineer contracted to work at the site on Sept. 12, is a textbook example of how respiratory protection was essential for the workers on site a lesson learned the hard way, since respirators were scarce commodities in the early days of the cleanup.
In addition to suffering a painful and disabling injury when a 6,000-pound steel beam crushed his left foot as he was working on the site on Sept. 17, Feal also incurred sarcoidosis, a disease that scars lung tissue, and is bedeviled by acid reflux, a painful form of heartburn. He only worked at the site for 5 and 1/2 days, he says.
According to Feal, he was never ordered to wear any type of respiratory protection the entire time he was there. "Not once did anyone tell me to wear a mask, so I never wore one," he says. "Now I can't go back to work because I am too sick and I won't know if I'll be able to pay my rent next month."
Feal, like many other emergency responders, points the finger at EPA and former EPA Administrator Christine Todd Whitman for assuring 9/11 responders and the rest of New York the air was safe to breathe, an assurance later revealed by the EPA Inspector General's report in August 2003 to be unfounded.
"When the EPA made a Sept. 18 announcement that the air was 'safe' to breathe, it did not have sufficient data and analyses to make such a blanket statement," the report noted.
Feal believes Whitman misled many workers about the dangers at Ground Zero, causing them to work at the site without masks. "There is no reason for her to make such a statement without having proper evidence that the air was safe," Feal says. "I never smoked in my life. I am an Army veteran. I used to wrestle. For this to happen to me, in my mind ... I thought I was invincible."
Lesson Two: Provide PPE and Training
Appropriate half- or full-faced air-purifying respirators weren't made available to workers in adequate numbers until several weeks after the attack, says David Newman, an industrial hygienist from the New York Committee for Occupational Safety and Health (NYCOSH). When the respirators finally became available for use, several problems emerged.
According to Newman, there already was a short history of people not wearing respirators even though they were available, creating a culture of casualness among the workers. "You had Christie Whitman from the EPA and other officials stating that the air was safe to breathe, which undermines the success of any effort to get workers to wear respirators," Newman says.
In addition, the nature of the respirators themselves was an impediment, Newman says. Not only can they be uncomfortable to wear especially when not fit-tested, which was the case at Ground Zero but the design itself didn't allow people to communicate with one another, important if a first responder has to warn others of potential dangers in the work area.
Moline says one of the lessons learned by both first responders and government agencies is the importance of training first responders on how to properly use respirators. "People were wearing respirators on their chins. They didn't know what to do with them," Moline says.
She says many of the rescue workers were not as well-trained as the firefighters, yet they were doing the same job. "We need to be aware that these people had exposures that they weren't trained for," she adds.
Lesson Three: Don't Suspend Enforcement
Joel Shufro, NYCOSH's executive director, points to what he calls OSHA's failure to enforce the respiratory protection standard and other regulations as another lapse in worker protections at Ground Zero one that will continue as other national emergencies occur, Shufro says.
OSHA suspended enforcement of occupational safety and health regulations at the World Trade Center site, causing a concern for Shufro and others that lingers today. (Amid continuing complaints that local and federal officials were not doing enough to protect workers in the area adjacent to the World Trade Center, OSHA's Region Two office did begin a local emphasis program in Lower Manhattan in February 2002.)
"We have a Freedom of Information Act request on [OSHA's] decision to not enforce respiratory protection and we are still waiting on that," Shufro says. "But based on what happened at Ground Zero, it's pretty much a guarantee [enforcement of workplace safety and health standards will be suspended] during a national emergency of this nature and we are going to see workers getting injured, sick and killed in the future."
In fact, in the National Emergency Management Plan (NEMP) released in 2004, OSHA clarified that in the future, the agency will not enforce safety rules, but will instead provide technical assistance during large-scale emergencies.
A major part of OSHA's assistance role during the emergency phase of nationally significant incidents includes the assessment and the management of the risks faced by first responders and recovery workers. That role was played out most recently during the response to the Gulf Coast hurricanes of 2005.
According to the NEMP, the OSHA regional administrator in whose region the incident occurs may seek to regain OSHA's traditional enforcement authority, but this shift must be based on the incident's unique set of conditions and risks and only after consultation with the OSHA administrator.
Lesson Four: Worry About the Worker, Not Liability
The New York City government also has been heavily criticized for its alleged role in failing to address the safety and health risks for workers and volunteers at Ground Zero.
"Rather than deal with the problem, they took the minimal approach and the consequences were that there were large numbers of people who were exposed who could have been protected," Shufro explains. According to Shufro and Newman, the city seemed much more interested in protecting itself from liability than protecting public health. The city's Department of Health also has failed to issue treatment guidelines for physicians, they say.
"Unfortunately, we see more Ground Zero workers clinically diagnosed with respiratory and other medical problems and the city has been retrenching and posturing to make sure to make no statements that would increase their liability," Newman says.
Lesson Five: Don't Allow Politics to Sabotage Response
Newman and Suzanne Mattei, New York City director of the Sierra Club, claim that while federal agencies and the city of New York carry much of the responsibility for failing to protect emergency response workers, they were simply following orders issued by the White House, succumbing to tremendous pressure to reopen Wall Street as soon as possible.
Everyone wanted life to return to normal as soon as possible, but the consequences one day could be deadly for workers and residents who returned while toxins still contaminated the air and buildings near Ground Zero.
Mattei surmises that since the White House Council on Environmental Quality suppressed all health warnings, EPA took the position that the air was safe to breathe and OSHA took the position that the cleanup of Ground Zero was a safety and health success story.
"By them assuring that everything was safe, it is as if they were saying that these people who are sick don't exist," Mattei says. "And if you can't admit that they're sick, how are they going to get help and get better?"
At least 27 studies published by medical researchers from FDNY, Mount Sinai and other medical centers and associations state the opposite. They all detail how the toxins emitted following the collapse of the World Trade Center were the culprits in damaging the lungs of many, if not all, of the first responders who were there working for days and months.
A study published in the August issue of the American Thoracic Society's journal the American Journal of Respiratory and Critical Care Medicine found that the firefighters who spent time at Ground Zero suffered a decrease in lung function capability equal to 12 years of age-related decline.
Mattei says she fears response efforts in the future will continue to be shaped by political considerations rather than by public health, medical and scientific considerations, as they would put first responders at great risk.
"My concern is emergency responders are a type of people who put other people's safety in front of their own; therefore if we don't protect them, who will?"
Lesson Six: Emergencies Impact More People than First Responders
The people working on the pile at the World Trade Center aren't the only ones who have developed health problems in the wake of 9/11. Robert Gulack, an attorney working for the Securities and Exchange Commission (SEC), was at World Trade Center Building 7 when the planes hit. He was safely evacuated when the towers came down and had no exposure to the debris.
A month later, though, SEC announced it had taken office space at the Woolworth building, located a block and a half away from Ground Zero. Within 2 days, Gulack says he fell sick. After several bouts of pneumonia and chronic bronchitis, tests showed he had permanent low-level lung damage.
According to Gulack, EPA had claimed that no office worker in the Ground Zero neighborhood was hurt by the blown debris, and as a result, the agency is reluctant to decontaminate office buildings and residences around Ground Zero.
"The important thing about my story is that it shows that somebody who was in fine health can get permanent lung damage simply by working at an office that was not properly decontaminated," he says.
The New York City Department of Health also was not cooperative in work areas in the Ground Zero neighborhood, Newman says. He claims the department either ignored the issue of potential exposures to office workers and residences around Ground Zero or told them to clean the debris themselves. "This was widely inappropriate, ineffective and dangerous," Newman says.
Lesson Seven: No Excuses
In addition to theories about government agencies being pressured by the White House to not alarm workers and the rest of the New York population, other failures in protecting first responders and others working in the immediate area come from not having an adequate disaster plan.
But Mattei claims this should not be an excuse. "If we keep saying that we're not ready, when are we going to be ready?" She asks. "That's the nature of an emergency, that it's unexpected."
One of the problems in not having a proper plan when unprecedented disasters emerge is the first responder population is narrowly defined, says Newman. "We are seeing with the last few incidents [9/11 and the hurricanes in the Gulf Coast] that statutory provisions don't take into account the limited number of trained personnel that are available," he says. "We have a failure to adequately assess who it is that we need to respond to, but also who it is that does respond."
During the World Trade Center rescue and recovery efforts, workers and volunteers responded by the thousands, and most of them had not received any training or had any experience in wearing respiratory protection, according to Newman.
In addition, many of these workers were not tracked by their employers. For example, thousands of transit workers were sent to work at Ground Zero, but it's not clear that the New York City Transit Authority could even produce a list of people they sent to work there.
Lesson Eight: The Importance of Site Control
Having a list of responders on site in these types of situations is crucial, both for site management at the time of the crisis and for any public health concerns that might crop up later, says NIOSH Director John Howard, director of Mount Sinai's Medical Monitoring Program, which will debut its treatment arm in October.
"In a big disaster, when there are lots of people rushing to help, someone should probably keep a list of who was sent and who was at the site," he says. "No one can assume that there will be a healthy aftermath and it is important to find these people so that we can offer treatment and care."
Howard acknowledges a lot of money has been spent in making people aware of the problem and trying to find them, as many responders have scattered across the country since 2001. Because of this, Howard says it's almost impossible to figure out the magnitude of the problem.
Bill Romaka, sergeant of arms safety and health officer with the Uniformed Firefighters Association an organization working with FDNY to secure money for treatment to firefighters who have gotten sick agrees that not having enough meaningful data is a big problem, despite the fact that FDNY has been conducting medical evaluations since before 9/11.
"So many firefighters since 2001 have retired and moved away, even out of state," Romaka says. "If they aren't tracked down, it's hard [to get enough] data to make any type of conclusions."
For this purpose, the New York City Health Department established the World Trade Center Health Registry in 2003, inviting people who worked at Ground Zero or worked around the area to report their health conditions.
According to Dr. Lorna Thorpe, deputy commissioner of the Department of Epidemiology at the New York City Department of Health and Mental Hygiene, more than 71,000 people who worked either on the pile or in the Ground Zero area have provided information, which she says has revealed "there is substantial evidence that many people had new or exacerbated respiratory health symptoms and conditions after 9/11."
In the midst of conducting a follow-up survey to the initial 2003-2004 survey, the new results will point to the extent to which symptoms were resolved or continued to persist, Thorpe says.
Lesson Nine: Protect Workers
It is instructive to look at the management of the World Trade Center site in comparison to the Pentagon site, according to Mattei. One is a lesson in what not to do, the other in how such emergencies should be handled.
"At the Pentagon site, [the workers] abided by HAZMAT rules and the site was tightly controlled," she says. "You weren't on that pile unless you had proper safety gear on."
Howard points out one of the mistakes made at Ground Zero was to maintain the site as a rescue operation for 9 months.
"Although it's overpowering to rescue your brothers and sisters, it's over on the fourth or fifth day," he explains. "It's important to control exposure at the site because these individuals don't have their own safety on their mind when going in."
It is paramount, Howard says, to protect the workers who are doing the rescuing and recovering. Otherwise, these workers will have to deal with health issues for the rest of their lives.
Says Howard: "To me, the real take-home lesson is prevention."
Sidebar: Evacuation Plan is Critical
While more than 3,000 people lost their lives as a result of the Sept. 11 attacks on the World Trade Center, thousands more survived. David Gold, an occupational safety and health expert with the International Labor Organization, believes those lives were saved because of an effective evacuation plan.
"Where a large number of workers are concerned, it is not possible to evacuate the working areas in a timely manner without an evacuation plan," Gold said.
To create an effective evacuation plan, you need to "know before you go," according to the Evacuation handbook from Coastal Training Technologies Corp. Specifically, Coastal advises employers to know five basic concepts:
1. Know the risks Know of every scenario that might require an evacuation of your workplace, from a fire to a tornado to a toxic chemical leak. Different causes lead to different types of evacuation.
2. Know the path A good evacuation plan makes sure the entire means of egress for example, not just a door, but also the hallways and stairwells is safely available, and, when possible, it suggests multiple or alternate means of egress. An exit needs to be large enough to accommodate all the workers who might have to use it, including workers with disabilities.
3. Know the people Evacuation plans need to take into consideration those who may require some assistance in evacuating (for example, those who are physically disabled, hearing-impaired or new to this country/job and are unfamiliar with evacuation procedures). Your evacuation plan should be designed to make sure everyone makes it to safety.
4. Know the destination Just as the nearest door isn't the entire exit path, being outside your building doesn't mean you've completed your evacuation. Different situations may call for different evacuation destinations, and some plans may have multiple destinations depending on the circumstances one for a fire, one for a flood, etc. Other plans may refer to a "refuge area" where workers should seek shelter after successfully exiting a building.
5. Know the drill A proper evacuation drill tests everyone's knowledge of the evacuation plan. A well-designed drill may simulate the blockage of certain exits, and certain workers might be asked ahead of time to simulate injury or disability. The goal of proper evacuation drilling is to make those procedures just as automatic as routine ones.