Forced to seek a substitute for dosage, Prezant used the only firm data he had: time of arrival at ground zero, based on the assumption that conditions were worst immediately following the collapses.2 He divided the responders into four groups. The first consisted of the 1,858 individuals who were already on the scene on September 11 when the towers plummeted to the ground and, consequently, were engulfed by the dust clouds. The next group, made up of 9,435 individuals, had arrived on the afternoon of Day 1 and throughout Day 2, September 12. Those two groups represented the bulk of the department. Prezant created a third group for the 2,031 who had arrived for the first time on Day 3 or later. Finally, 187 members of the fire department who had not spent any time at ground zero became the fourth group.
Kelly and Prezant gave every member of the department a standardized questionnaire and then grouped the findings by time of arrival. The results were devastatingly clear for both physical health and mental well-being. The Day 1 group had the highest rates and greatest severity of every symptom: daily cough, shortness of breath, wheezing, chest pain, sinus congestion, lower-respiratory problems, acid reflux, and stress. The other groups had progressively less severe reactions the later they arrived at the scene. The bottom line: The race to get to ground zero first turned out to be a race to disaster and disease.
As he pursued this line of reasoning, Prezant oversaw the department’s administration of standardized breathing tests to measure how being at ground zero had damaged the firefighters’ lungs. These tests were particularly valuable because Prezant had already established baselines with similar tests that the fire department had administered every 12 to 15 months since 1997. This made it possible to compare with a degree of scientific certainty a firefighter’s health before and after working at ground zero. Firefighting is dangerous under any circumstances, but it’s especially hazardous in a city such as New York, where firefighters work in close quarters and are exposed to a vast range of pollutants. Under normal conditions, lung capacity decreases every year, from a combination of aging and the cumulative harmful effects of exposure to hazardous materials while fighting fires. On average, Prezant had calculated the loss to be about 31 milliliters a year from 1997 to 2001. But in the first year after the terrorist attacks, firefighters lost an average of 372 milliliters—that is, about the amount of air in a regular can of soda, and equal to about 6 percent of a firefighter’s 6-liter lung capacity. Importantly, this is the equivalent of 12 years of normal lung function loss. As in Prezant’s other studies, those who arrived first were hurt worst. The study also looked at steps the firefighters had taken to protect themselves, and it reported what was already clear to anyone who had watched the tumultuous activity at ground zero. Most of the people there had not worn respirator masks that could have shielded them from the worst hazards. Nearly 80 percent of the rescuers who were first to arrive on 9/11 said they rarely or never used a respirator. Many who had tried to protect themselves used flimsy dust masks that did little to keep out the smoke or loose asbestos fibers. And most of those who got hold of adequate masks were quick to whip them off when they became too uncomfortable. By the time respirators had become readily available, work habits had formed and intense exposures had already occurred.
By the end of September, most firefighters were being treated for what Prezant came to call World Trade Center cough, which he defined as a syndrome of persistent, almost continuous dry, nonproductive cough, accompanied by a range of upper- and lower-airway symptoms severe enough for the firefighters to be able to go on medical leave for at least a month. During the first three weeks, the men paid no attention to the symptoms as they raced to find survivors trapped in the debris. The fear of finding one of their brothers too late drove them into a frenzy, and they ignored their own health, ignored admonitions to wear protective gear, and ignored their own professional sense that the air at ground zero was too dangerous to breathe for even a short while. By the time some came to the fire department’s clinic for evaluation, treatment, and answers, they had become the walking wounded, many fearing that their lives would be cut short and forever changed by this event.
Prezant’s own medical condition improved after a few months. Over time, many firefighters who initially came in with trade center cough had stabilized or gotten better, and some were already back on the job. Yet others remained ill, with a few sliding deeper into their illness. Nearly 1,000 never regained the physical abilities to return to the life they loved; after they presented objective evidence of their impairment, they qualified for disability pensions from the fire department. Prezant developed an extensive body of knowledge about the dust that had covered his city. Working with Paul Lioy, he learned what it was made of and how it could hurt the firefighters. But what he didn’t know yet, and this bothered him, was why the dust had had such a grievous impact on some firefighters while not at all affecting others. It really didn’t matter to him what Christie Whitman or the Daily News said about the hazards of the dust. Clearly, something in the dust made it more harmful than ordinary demolition rubble. What he had learned about the physical characteristics of the dust, and the sheer volume of it in the air after the collapse, also made it clear that this health problem would continue far into the future. He was certain that some of the men would get better. He also figured that some would wind up not getting either better or worse, but would simply remain the same. And with the certainty he was forced to muster because of his scientific training, he knew that it was inevitable that some of them would, through no fault of their own, get worse, despite the assurances of the EPA and Giuliani that there was nothing to worry about.
But Kelly and Prezant worked for the city and would have to carefully measure their words, balancing their need to safeguard the welfare of the firefighters for whose health they were responsible against the requirements of the city that employed them as it tried to regain its footing. They worried that there probably would be pressure to keep some of the more distressing findings quiet, while broadcasting widely other findings that downplayed the dangers. They knew that advocacy medicine had its role but that it needed to be based on a strong foundation of credible evidence. They believed that the monitoring and treatment program needed long-term funding, not a short burst of emotional support. Prezant finally realized that God had saved him on September 11 for a reason. He had not rushed heroically into a burning building to rescue people trapped inside. But he was left in a position to help many who were desperate for answers. His goal now was to avoid the political blame game and remain true to the mission, which was to provide the best monitoring and treatment program, pursue the best science, and follow the results wherever they led.
Science would speak for itself.
Endnotes
1 Prezant, David, “Inhaled Steroids Used as Preventative Treatment Post 9/11.” Presented at the 73rd annual assembly of the American College of Chest Physicians, 24 October 2007, Chicago.
2 Fire Department, City of New York, Bureau of Health Services, World Trade Center Health Impacts on FDNY Rescue Workers: A Six-Year Assessment: September 2001–September 2007. Available at http://home.nyc.gov/html/fdny/html/publications/wtc_assessments/2007/wtc_2007.shtml.
6. Building a science
The gasping firefighters who reluctantly dragged themselves away from the pile to see Drs. Kerry Kelly and David Prezant had responded immediately, and bravely, to the largest disaster they had ever experienced. On the enormous mound of twisted steel, shrouded in the choking smoke and ash of super-hot fires below ground—standing like sentries at the gates of hell—they became symbols of the city’s resolve. But in truth, with their buckets and pickaxes, they were no match for the devastation left by the terrorists. If there was anybody left to rescue, the firefighters needed big help reaching them.
The help had started to arrive almost at once. Within days of the attack, an army of construction workers in hardhats and overalls was crawling over the debris pile alongside the firefighters who worked in their heavy bunk
er gear. And like the firefighters, many soon found that after working a 12-hour shift, their throats felt like they had been Roto-Rootered. They simply could not stop coughing. Unlike the firefighters, however, they did not have access to a central medical office. They had to see their own doctors, who, for the most part, were general practitioners who rarely, if ever, treated exposures to hazardous dust. They tended to misdiagnose the symptoms, fooled by the flulike runny nose and itchy throat, and prescribed antibiotics, which did no good at all. But most of the construction workers, driven by an overwhelming sense of patriotic duty at an extraordinary time, simply ignored the discomfort they were feeling, forgoing a visit to the doctor so they could keep on working.
By the beginning of October, a handful of non-uniformed ground zero workers had made their way to a busy uptown clinic just off Fifth Avenue where they knew the doctors and the doctors knew them. The clinic was the Irving J. Selikoff Center for Occupational and Environmental Medicine at the Mount Sinai Medical Center. The Selikoff Center had a long-established relationship with some of New York’s most powerful unions and, for decades, had been the first place to go for workplace medical issues. That was never more so than when asbestos exposure was involved. Most recently before 9/11, the clinic’s work had shifted somewhat. Federally funded programs to remove asbestos in schools and other public buildings, along with the end to the use of asbestos insulation in new buildings in New York, had sharply reduced the number of asbestos-related cases at the clinic. Its doctors now most commonly saw repetitive strain injuries, torn muscles, and broken bones.
Then came 9/11. For a time, the 100-foot-high pile of steel and concrete at ground zero represented the most dangerous workplace in America. The construction workers suffered their share of broken bones and eye injuries (but not a single fatality). They also thought they heard Christie Whitman say the air was safe. But what they were experiencing while they worked on the pile seemed to be anything but safe. Adding to the confusion was what they saw there every day. They knew that firefighters were, by nature, keenly aware of safety issues because their lives depended on always knowing the dangers they were rushing into. But there they were, digging through the pile without wearing protective gear. The only logical conclusion the construction workers could reach was that wearing the uncomfortable respirators and suffocating dust masks was unnecessary. They also saw that visiting dignitaries did not even wear paper dust masks. Nobody seemed to be taking seriously the advisories to wear protective gear. But one thing these guys did know: Working with the cranes and grapplers that had been brought in to move the steel beams was extremely dangerous. Those gigantic machines needed to be given a wide berth, and when they were slinging a big load, nobody was supposed to be anywhere nearby. It made common sense to be in constant communication with the people around you, including the operators of those behemoths. And to do that, you couldn’t be wearing protective breathing gear that muffled your voice, or safety goggles that cut off your peripheral vision.
That’s the gist of what workers told the doctors at the Selikoff clinic about the pile. For these doctors, the danger had been evident from the moment they watched the towers fall. Being located miles from ground zero, neither the clinic nor Mount Sinai had been directly involved in the immediate response to the disaster. Other hospitals, located closer to the trade center, had been put on standby to receive the wounded. On September 11, many of Mount Sinai’s doctors who lived outside the city had been stuck on the George Washington Bridge and other crossings and had to turn around and go home. With much of New York City cordoned off and telephone service knocked out, several from the Selikoff clinic had decided to meet outside the city. They’d gathered at the Westchester County home of Dr. Jaime Szeinuk, an occupational medicine specialist at Mount Sinai. It was September 13, and reality had already sunk in. The doctors, like everyone else, had seen the twin towers turn to dust, and their stomachs had tightened as they’d repeatedly watched the towering plumes of debris steamroll through the city streets. But the dust meant more to them than to other New Yorkers because they had spent most of their professional lives trying to understand the devious ways that tiny dust particles and other microscopic bits and pieces can create havoc in the human body.
Few understood this more intensively than Dr. Stephen M. Levin, a driving force at the Selikoff Center for two decades. Levin was a nationally recognized leader in the field of occupational medicine. He had developed an abiding affection for working-class people and a penchant for making trouble for the corporations that exploited them. Levin had once been a protégé of Dr. Irving Selikoff himself. Selikoff had been a pioneer in the field, researching the links between asbestos and a range of diseases, including mesothelioma, which is almost exclusively connected to exposure to the fireproof mineral. Selikoff, too, had a long history of working with labor unions in the New York area, starting with a clinic he’d opened in the early 1950s in the blue-collar New Jersey city of Paterson.
After working in Paterson for several years, Selikoff had been approached by the local asbestos workers’ union, which wanted him to take care of its members, mostly workers from the United Asbestos and Rubber Company plant that had produced asbestos insulation for boilers and turbines from the start of World War II until it shut its doors in 1954. As Selikoff screened the workers and treated them for various illnesses, he noticed an unusual pattern. The lungs of most of the men were badly scarred, which Selikoff suspected was the result of constant exposure to the asbestos fibers they had worked with. He also saw cases of mesothelioma every year when, statistically, the disease was so rare he should hardly have seen any among that comparatively small group of men.
His curiosity piqued, Selikoff collected the workers’ medical records. Based on the evidence he found there, he eventually established a strong link between long-term exposure to asbestos in the workplace and such crippling diseases as asbestosis. He continued to study asbestos-related illnesses, sometimes running into resistance from the asbestos industry, which denied him access to employee work histories. But Selikoff worked around the companies by going directly to the unions, which understood the significance of his work. In a later study, he screened 17,800 asbestos insulation workers and firmly established the link between the mineral and the disease. Selikoff came to believe that even brief exposure to a small amount of asbestos could scar lungs and lead to cancer. He also explored the synergistic, or multiplying, effect of asbestos exposure and smoking tobacco. His studies showed that an asbestos worker who also smoked had a significantly greater chance of developing lung cancer than a worker who did not use tobacco.
As Selikoff continued his research, unions used his findings to seek compensation for workers at the United Asbestos and Rubber Company, Johns Manville, and other asbestos manufacturers. Besides the breakthrough research he was conducting, Selikoff’s effectiveness came from being a master at taking his findings into the realm of public opinion. He often testified at public hearings, and he aggressively lobbied public officials, including President Lyndon Johnson, to restrict the use of asbestos. By the early 1970s, when Selikoff was a well-established occupational health researcher and an esteemed member of the Mount Sinai staff, legislative efforts to severely restrict the use of asbestos in new construction were enacted. Because of its ability to resist fire, asbestos had come to be widely used to fireproof the steel superstructures of new buildings. Before its use was officially limited (it has never been completely banned, even to this day), many builders decided to stop applying asbestos insulation altogether.
That included the Port Authority of New York and New Jersey, which, in the late 1960s, had embarked on one of the biggest construction projects ever, erecting the two tallest buildings in the world along with several smaller structures in a single complex in Lower Manhattan. The project moved from the drawing board to reality as the shipping industry left Brooklyn and Manhattan and moved to the new berths for containerized cargo ships that had been built on New Jersey’s waterfront
in the 1960s. As the old maritime port of New York faded, the tattered buildings of the Washington Market, an area near the waterfront in Lower Manhattan that housed produce stands and stalls selling radio equipment and other merchandise, were razed. On the cleared site, the Port Authority began construction of what it described as a new vertical port, grandly named the World Trade Center—twin 110-story cracker boxes that would realign the New York skyline. The steel of the North Tower was sheathed in fire-retardant material containing a relatively high concentration of asbestos from the ground level up to at least the 34th floor. But the spraying stopped there.1 The Port Authority decided, under pressure from Selikoff and others, to switch to a different material, called slag wool, that did not contain any asbestos and that engineers showed was at least as effective as asbestos at holding back flames, without being toxic. That move represented a substantive victory for Selikoff that would have a profound impact on his legacy three decades later, when the towers disintegrated and the asbestos fireproofing was unleashed.
Levin felt a special kinship with Selikoff and saw in him an archetype for a rabble-rousing doctor who, through his clinic, stood up for working-class people. Similar to Selikoff, Levin had started out as a blue-collar doc in a blue-collar town—not his native Philadelphia, but Pottstown, Penn., where he had practiced for several years in the 1970s. He moved to Mount Sinai in 1979 to join Selikoff’s occupational medicine team. He’d taken the position because it combined so many of his interests—public health, clinical medicine, research, teaching, and troublemaking. “It seemed like a satisfying thing to do, and Selikoff was a good model for that because he made lots of trouble for companies that did bad things,” Levin said. They worked together until Selikoff’s death in 1993.
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