By Jori Lewis

On the morning of September 11, 2001, a group of men hijacked a Boeing 767 bound for Los Angeles and flew it into the North Tower of the World Trade Center in New York City. Several minutes later another group of hijackers flew a similar plane into the World Trade Center’s South Tower. As a result, both towers collapsed in a cloud of steel, rubble, and dust in less than two hours. The attacks killed thousands of people: nearly 2,800 according to the official death toll, including the plane passengers, many occupants of the World Trade Center buildings, and first responders like firefighters and policemen who had been called to the scene after the initial crashes. Some died instantly, some died slowly, and some are dying still.

Besides the immediate annihilation caused by the fire and crumbling of the tower, the collapse of the World Trade Center towers would also prove dangerous to the living in the long term. That is because in the aftermath of the crashes thousands of people were exposed to extreme psychological trauma, harsh environmental conditions, and potentially harmful air pollutants. Between the columns of black smoke from the benzene-laced 90,000 liters of jet fuel (benzene is a known carcinogen); the dust cloud of asbestos, glass, pulverized cement, lead and polychlorinated biphenyls (PCBs) from the collapsed buildings; and the fact that fires on the site smoldered until the end of December 2001, the tragedy that took so many lives also heavily contaminated the surrounding air [1].  That dust spread far and wide all over lower Manhattan and across the East River into and across Brooklyn to points south for several miles [2,3].  But nowhere did the dust have more effect than on the people who stood right in it, the people who were involved in rescue, recovery, and clean-up efforts at the site [4,5].
 
Thousands of people worked on the rescue, recovery, and clean-up operations surrounding the World Trade Center disaster and were exposed to environmental hazards [6]. They rescued people from the wreckage and recovered bodies, they sorted through the ash and debris from the planes and the towers, and they carted away all that remained. In the years since the disaster, many of these workers have developed respiratory problems, inflammatory diseases like sarcoidosis, and posttraumatic stress disorder (PTSD).  Research suggests the workers’ involvement at the site is likely to blame.

Federal agencies have faced criticism over what some describe as inadequate actions to protect the health of Ground Zero workers, and many of those who have become ill after working at the site are still fighting for medical care and compensation.  This case study will address the occupational health implications of the World Trade Center disaster for these workers.

THE WORKERS
Construction workers, firefighters, police officers, emergency medical technicians, and many others worked to rescue survivors at the World Trade Center site and then stabilize and dismantle “the pile,” the mass of debris where the towers once stood [7].  By one estimate, 91,000 people participated in these efforts.

Definition of rescue, recovery, and clean-up worker:  New York State’s Workers’ Compensation Law and its Disability Law generally define rescue, recovery, and cleanup workers as those who worked at a World Trade Center site between September 11, 2001 and September 12, 2002. Eligible sites include not just Ground Zero, the area where the World Trade Center Complex once stood, but also: a large swathe of the surrounding area south of Canal Street or Pike Street, the Fresh Kills landfill on Staten Island, the New York City morgue, and the barge and truck operations between Lower Manhattan and Staten Island [8].

The City of New York estimates that some 91,000 people (including volunteers) worked on rescue, recovery, and cleanup efforts at Ground Zero and related locations [6]. The workers came from all walks of life; some were public employees, others were private workers, and still others were undocumented immigrants. They included, according to the Occupational Safety and Health Administration (OSHA): boilermakers, carpenters, cement masons, EMTs, ironworkers, electricians, plumbers, steelworkers, doctors and nurses, structural engineers, truckers, teamsters, most of New York City’s fleet of firefighters, many police officers, sanitation workers, and other volunteers from organizations like the Red Cross and the Salvation Army [6,9].

Efforts to study the health outcomes of this diverse group of responders provide a snapshot of these workers’ characteristics. The World Trade Center Health Registry is a voluntary registry to monitor the health of residents and workers alike after the World Trade Center attacks. The health registry enrollment was restricted to people who were present at the WTC sites between September 11, 2001 and June 30, 2002. More than 71,000 people have enrolled in the WTC Health Registry, and the single largest category of enrollees is rescue and recovery workers, with almost 31,000 people. That number includes more than 3,000 firefighters, close to 4,000 police officers, and 2,000 sanitation workers.

According to the registry, the rescue and recovery workers were mostly men; more than 70 percent of them were white; and some 93 percent of them were employed. The registry recruited rescue and recovery workers using: subway, bus, newspaper, radio, and ferry ads; e-mails; articles in trade newsletters and magazines; presentations at companies; visits to police stations and fire houses; web banners on organization web sites; and paycheck inserts. Registry employees used referrals from city agencies, state and federal agencies, trade unions, volunteer organizations, and outside contractors to identify eligible participants [10].

Rescue and recovery workers had one of the highest enrollment rates, as some 33 percent of the estimated eligible number of workers and volunteers enrolled in the World Trade Center Health Registry. The health registry had trouble reaching some eligible participants because they had incomplete or insufficient contact information for them [11].

The other 40,000 participants of the registry include residents of lower Manhattan, people present in the area during the attacks (survivors of damaged buildings, school children, workers at nearby offices, pedestrians, etc.). The WTC Health Registry had similar difficulties achieving an adequate response rate for this population as well [12].

THE WORK
City, state, and federal emergency management teams were deployed to the site immediately following the attacks to search for possible survivors. Those responders worked under difficult conditions, contending with continual fires, structural instability of nearby buildings, and widespread smoke. There were very few survivors in the pile of rubble, though. The rescuers pulled out the last person they would find alive on September 12 [13].

Soon, the operations switched from rescue to recovery of the dead and cleanup of the site. In order to do that, workers needed to clear the rubble, remnants of buildings that once stood 110 stories tall. Structural engineers estimated that the debris pile could weigh more than two billion pounds [14].

Employment Arrangements
The New York City Department of Design and Construction (DDC) coordinated the efforts of contractors, city agencies, and federal and state entities, including the Federal Emergency Management Agency (FEMA) and the US Army Corps of Engineers. DDC called in contractors to work on the recovery. It divided the site into four areas; each area was assigned a contractor, a structural engineering team, and a rescue team.

• Zone 1, the area near the North Tower, was assigned to the contractor AMEC Construction Management.
• Zone 2, the area including the South Tower, was assigned to Bovis Lend Lease LMB, Inc.
• Zone 3, which included the eastern half of the site, was assigned to contractor Tulley Construction Company.
• Zone 4, the area along the northern edge of the site and World Trade Center Building 7, was assigned to contractor Turner/Plaza Construction Joint Venture [14].

Teams worked day and night in shifts of 8 hours or 12 hours. According to one report, 5,000 workers labored at the site each day [7].

As the teams removed the debris, they loaded it on barges bound for Staten Island’s Fresh Kills Landfill. The landfill had been closed earlier in the year, but Mayor Rudolph Giuliani and Governor George Pataki worked with the City Department of Sanitation and decided to reopen it. Approximately 3,463 workers from the Department of Sanitation participated in the recovery and cleanup, with many of them stationed at the landfill or involved in bringing material to the landfill [15]. Once the debris arrived, detectives and forensic specialists sorted through it for human remains and other evidence. Some workers sorted through the debris by hand, while others workers used machines to find possible human remains and personal effects. The New York City Police Department and the Federal Bureau of Investigation oversaw this work [16].

DDC retained control of the WTC site until June 30, 2002, when the cleanup was declared complete.

HAZARDS OF RECOVERY WORK
Soon after the World Trade Center attacks, it became clear that workers would face unprecedented challenges during the rescue, recovery, and cleanup. Indeed, Assistant Secretary of Labor for OSHA John Henshaw said in a statement, ‘‘The World Trade Center site is potentially the most dangerous workplace in the United States’’ [17].

According to OSHA, the hazards of the World Trade Center Recovery process were many [18].  One report on worker injuries found that in the first month after the attacks, workers made 5,222 visits to nearby emergency departments and to temporary disaster medical assistance team facilities at the site. The most commonly reported problems included musculoskeletal complaints (like sprains, fractures, and dislocations), respiratory problems, and eye disorders [7].

More than 1,000 OSHA employees worked at WTC sites over the months to monitor safety conditions and train workers on personal protection and applicable safety rules [19, 20].  OSHA worked with teams from the Environmental Protection Agency to monitor and minimize potential exposures to hazardous substances [21].  In addition, the National Institute of Occupational Safety and Health (NIOSH) sent dozens of specialists to New York immediately after the attacks to collect air samples and monitor the situation for first responders [22,23].

Hazards
The size and complexity of the towers meant that their destruction posed a range of hazards for rescue, recovery, and cleanup workers. The hazards included:

Falls and Falling Objects: The World Trade Center site was a dynamic multi-level site where the risk of falling objects was always present. The site was unstable, and removal of piles of twisted metal could create sudden holes in different parts of the pile. OSHA reported one episode in which a crane fell 30 feet when a part of the pile suddenly gave way [24].  OSHA set up trainings to prevent falls and erected nets to catch falling debris [18].

Cranes: Contractors brought in enormous cranes, some of the largest in the world, to work the site. There were more than 30 cranes operating in the area, and detailed planning was necessary to ensure they could operate safely.

Heavy Equipment: Demolition workers and rescue workers worked the site in tandem for a time. Some pieces of demolition equipment – such as excavators, grapplers, and debris trucks – are not typically used in sites populated with rescue workers, but they were used at the World Trade Center. Rescue workers wore brightly-colored vests and maintained a perimeter around the heavy equipment.

Explosions: A number of materials at the World Trade Center site had explosive potential. A fuel tank with thousands of gallons of diesel fuel was buried underneath one of the buildings. Workers had to dig it out and empty the tank to avoid a possible explosion. There was also a parking garage below the World Trade Center full of cars (nearly 2,000) that posed a risk to workers. In addition, in order to cut the steel beams and rebar, workers used compressed gas cylinders full of oxygen and acetylene to fuel burners. On one occasion welders inadvertently ignited some ammunition that had been stored at the World Trade Center. That explosion injured several workers [25].

Dust and Air Pollution: The biggest hazard over time, though, has proved to be the World Trade Center dust. The attacks pulverized building materials -- including cement, wallboard, and glass -- and made them airborne. More than 60 percent of the total dust mass was pulverized cement.  With a pH of 10-11 (high alkalinity) this cement dust was very caustic, and it seared the upper and lower respiratory tract of workers when inhaled [26]. In addition, fires raged on the site for more than three months after the attacks, filling the air with smoke and fumes and continuing workers’ exposure to the dust, fumes, and combustion-derived pollutants. Investigators who have analyzed the content of the dust have identified: cement, glass, gypsum, calcium carbonate, cement dust, glass fibers, and asbestos. The same researchers also found metals like chromium, iron, magnesium, manganese, aluminum, barium, titanium, and lead as well as particles containing persistent organic pollutants like polycyclic aromatic hydrocarbons, polychlorinated biphenyls, and organochlorine pesticides—known carcinogens [2].

Uneven Protection from Airborne Hazards
Although dust was a major hazard, in the immediate wake of the disaster many workers were not adequately protected from it. One study of participants who worked on the pile during the first four days, when concentrations of toxic air contaminants was the highest, found that only 21 percent of responders said they used full- or half-face respirators [27]. Another study of NYC firefighters working at the site showed that although the number of responders using half-face respirators steadily increased (from 4 percent on day one to 57 percent during the second week), only 53 percent of them reported using the devices during most of their work time [28].  In the initial days, many used paper masks [25, 29], which offered little or no barrier to the dust. Appropriate respiratory protection for workers at the disaster site could have been uncomfortable to wear over long periods of time, required fit testing to work properly, and constrained communication between users, which made such equipment an unpopular choice.

Individual workers’ decisions about respirator use were made in the context of air-quality information that turned out to be misleading.  On September 13, 2001, the Environmental Protection Agency (EPA) issued a statement saying that the public should feel “reassured,” by the initial sampling [30].  The next day, a joint EPA-OSHA  news release said, “our tests show that it is safe for New Yorkers to go back to work in New York's financial district” [31,32].  And on September 18, 2001, EPA Administrator Christine Todd Whitman assured workers that the air quality in the area was fine. One week after the attacks Whitman said in a statement, “We are very encouraged that the results from our monitoring of air quality and drinking water conditions in both New York and near the Pentagon show that the public in these areas is not being exposed to excessive levels of asbestos or other harmful substances.” Whitman added, “I am glad to reassure the people of New York and Washington, D.C. that their air is safe to breathe and their water is safe to drink” [33].

A 2003 report from the Environmental Protection Agency’s Office of the Inspector General (OIG) found that the EPA had no basis at the time to call the air around Ground Zero “safe.” That report suggested that this misguided governmental boosting led contractors and workers to dismiss the need to wear respiratory protection.  The OIG report noted that on at least one occasion, a construction company’s laboratory director found it difficult to persuade the company’s management to mandate respirator use. The report notes, “On the basis of EPA’s statements about air quality, company officials questioned the Laboratory Director’s recommendations that workers wear respirators. Although he was able to convince his client that respirators were needed, he told us that it was difficult to convince workers to wear respirators” [30].  In general, although the rate of respirator use at Ground Zero increased over time, it still remained relatively low over the course of the cleanup [35, 28].

This contrasts with the conditions at the Fresh Kills site, where debris sorters wore impermeable and disposable Tyvek suits, respirators, and other protective gear. Approximately 90 percent of the workers at Fresh Kills wore respiratory protection devices [30].

Logistical challenges and a large cast of entities
Multiple government agencies from the local, state, and federal levels responded to the disaster at the World Trade Center. Many logistical support teams (FEMA’s Urban Search and Rescue (USAR) teams), and Incident Support Team (IST) members couldn’t reach the site for a few days because commercial flights were grounded until September 14, 2001. OSHA’s Manhattan offices were in Building 6 of the World Trade Center, so their response was hampered. Even for operational responders on the ground, communication was difficult because the phones (both landline and mobile) were not working. In addition, there were reports of malfunctioning equipment that made it difficult to gather information about the health and safety risks of the site [20].

Early on, labor unions were also involved in monitoring the situation on the ground with owners, contractors, and federal and state safety agencies [35].  The International Union of Operating Engineers and Transport Workers Union Local 100 worked to get more information about the air quality at Ground Zero and the possible effects of contaminants to their members. Other unions also fought for workplace environmental sampling; these included District Council 37, TWU Local 100, AFSCME, Public Employee Federation, Civil Service Employees Association, Communication Workers of America, Association of Legal Aid Attorneys, and Professional Staff Congress, among others [36].  The New York Committee for Occupational Safety and Health (NYCOSH) took an active role in coordinating efforts between unions, employers, tenant organizations, community-based groups, and other nonprofit organizations to get and disseminate more information about the environmental conditions on the ground. Some of these groups would later form the World Trade Center Community Labor Coalition [36].

Construction unions, contractors, and the City of New York began a partnership agreement with OSHA on November 20, 2001 to work together to monitor safety conditions at Ground Zero. Participating groups included: the New York City Department of Design and Construction and the Fire Department of New York (co-Incident Commanders); Building and Construction Trades Council of Greater New York; Building Trades Employers' Association; Contractors Association of Greater New York; General Contractors Association; and the four prime contractors at the WTC site: AMEC Construction Management, Inc.; Bovis Lend Lease LMB, Inc.; Tully Construction Co., Inc.; and Turner/Plaza Construction Joint Venture. The partnership provided for regular data collection, safety orientation trainings, bulletins, and discussions of important issues at the site [17].

Later, OSHA signed another agreement with the organizations involved in the Fresh Kills Landfill operation, including: U.S. Army Corps of Engineers, Environmental Protection Agency, New York Police Department, New York State Department of Environmental Conservation, New York City Department of Health, New York City Department of Sanitation; Hugo Neu Schnitzer East, Phillips and Jordan, Evans Environmental & Geosciences, Yanuzzi & Sons, Inc., Mazzochi Wrecking; Taylor Recycling Facility L.L.C.; International Union of Operating Engineers, Local 14-14B and Local 15; and Garner Environmental Services, Inc. [38].

OSHA’s focus on technical assistance rather than enforcement
In one report, OSHA describes its strategy at the WTC site this way:

OSHA’s strategy at the WTC was to pursue collaboration while suspending enforcement and providing consultation, guidance, and technical assistance with a sound safety and health plan. Our goal from the start was protection, not citation [18].

By September 2007, the agency continued to call its efforts to protect workers at the WTC site a success: 

Despite the highly dangerous rescue and recovery mission at the WTC, there was not one fatal accident during the 10-month clean-up operation. During this period, OSHA identified more than 9,000 hazards and saw that those hazards were corrected.  More than 3.7 million work hours were expended during this hazardous and lengthy rescue and recovery mission, yet only 57 injuries were recorded, none life-threatening.  This is a remarkable achievement given the nature and complexity of the work at this site including thousands of construction and emergency- response workers laboring each day in close proximity to heavy construction and demolition equipment.  OSHA played a critical role in protecting these workers [39].

Many critics of OSHA’s response say the agency should have issued citations for violations such as failure to wear respirators [40].  Indeed, many reports have noted that officials did not regularly enforce the use of respiratory protection [25,30,41].  There are lots of reasons for it; first, many of the organizations had different standards for the use of protective equipment on the site, which led to misunderstandings throughout the effort. At a conference of responders held in late 2001, many federal- and state-level participants said that site enforcement of personal protective equipment was relaxed so that the work could continue. Agencies like OSHA, which might normally act in an enforcement capacity and cite employers for failing to comply with safety regulations, were working as advisors [25,30].

OSHA’s regional administrator, Patricia Clark, the lead agency official responsible for the worksite, testified before a House of Representatives hearing about health and safety protections for 9/11 recovery workers. She reported that there was a requirement for workers in the pit and the pile to wear respiratory protection and that the requirement was enforced on the site by the City of New York and by the contractors themselves.  Ms. Clark indicated that she discussed with her staff on an ongoing basis whether they should issue citations under the authority granted to them by the federal Occupational Safety and Health Act (OSH Act).  She said:

We considered the issue of issuing citations, but we decided that that would not work under these circumstances.  …The Act allows gives us the discretion to do non-traditional enforcement, which is what we did here.  We provided technical assistance.  We worked with the other people at the site to establish a safety and health program with mandatory requirements that exceeded our standards.  We would not have been able to issue citations, except in a very, very few number of instances.  We did not have overexposures.  If we were to issue any citations, the employer has the right to contest those.  …I did not feel that we could issue citations that would provide immediate protection to workers.  I could not force immediate protections through citation process and issuance of penalties.  That would not have provided the immediate protection because the law allows employers to contest.  Contest periods can take from 2 to 7 years to go through the appeal process.  We needed to protect those workers immediately and that was why we did not choose to issue citations [39].

Critics say that this strategy meant that OSHA abdicated its role as a workplace safety regulator.  Dr. Jim Melius with the Laborers’ Health and Safety Fund noted: “I don’t believe that if there had been enforcement action that every entity on site is going to contest the enforcement actions. I think that most of them would have complied and I think in reality, most of them would have welcomed a single, strong voice that was in charge of safety at that site” [43].  Lee Clarke, the senior safety and health coordinator in District Council 37 of the American Federation of State, County and Municipal Employees (AFSCME) said in an interview with EHS Today, “Because this was such a horrendous situation, enforcement agencies adopted the attitude that all regulations went out the window, and that was totally irresponsible” [41].

COMMON HEALTH EFFECTS
It was not long after the collapse of the World Trade Center that first responders started complaining of sickness [44].  They had coughs and breathing troubles, nightmares and heartburn. Their illnesses varied, but some patterns emerged. Researchers have been studying the health ailments of people involved in the World Trade Center disaster for several years. The World Trade Center Medical Working Group puts out an annual report reviewing the latest medical research on the topic. The National Institute for Occupational Safety and Health (NIOSH) also maintains an exhaustive list of studies and reports about the health effects of the disaster [45].  This is a summary of some of their key findings.

Mental Health Disorders: Mental health complaints are some of the most common ailments to emerge from the disaster. Studies of the mental health effects of the attacks on people who participated in the disaster and recovery response have found that negative mental health impacts are widespread among responders. One analysis found that 20 percent of recovery workers and volunteers had symptoms of posttraumatic stress disorder (PTSD) and 44 percent were experiencing depression, anxiety, or sleep disorders [46].  That’s four times the rate found in the general population. Recent studies show that 9.8 percent of firefighters probably had elevated PTSD within the first year after the disaster, and the incidence only increased over the next four years.  Risk factors included: early arrival to the site, knowing someone who was killed on September 11, injury, or working the site for a long period of time. The impact was exacerbated if the worker previously had limited exposure to emergency situations [47].

Respiratory Ailments: Numerous studies have identified an association between exposure to the World Trade Center dust and respiratory symptoms [48-56]. Not long after the attacks, first responders showed signs of respiratory distress. Almost all of the exposed firefighters (99 percent) reported at least one new respiratory symptom within the first week after the attacks [57].  Within six months of the attack approximately three percent of firefighters had developed the “World Trade Center cough,” a persistent cough with “respiratory symptoms severe enough for firefighters to be placed on four consecutive weeks of medical leave” [44].

Responders and others exposed to World Trade Center dust were also more likely to develop asthma. A 2009 longitudinal study showed that 10.2 percent of people exposed to the dust and smoke developed asthma; among responders, 12.2 percent reported new asthma diagnoses. The study’s authors calculated an annualized rate of asthma diagnoses during the four months following the attack among adults exposed to the attack and its aftermath, and reported the rate of new diagnoses among exposed adults to be at least six times higher than the estimated rate for adults nationwide [58].

Exposure to the dust and smoke of the World Trade Center has also been linked to upper and lower respiratory illnesses like bronchitis, sinus problems, and lung disorders [51,59,60].

Sarcoidosis: Studies have suggested that firefighters had elevated levels of the inflammatory disease sarcoidosis in the years following the World Trade Center disaster [61-63]. It most commonly presents in the lungs but can also present in the skin and lymph nodes. Doctors think that sarcoidosis is a product of an abnormal immune response, typically from something inhaled [64].

Cancer: The James Zadroga 9/11 Health and Compensation Act, which took effect in 2011, requires NIOSH to periodically review current results of research into cancer among WTC responders, in order to determine whether any types of cancer should be added to the list of WTC-related health conditions eligible for coverage by the WTC Health Program (which is described below). In July of 2011, NIOSH issued a review that found mixed results among peer-reviewed studies and concluded, “insufficient evidence exists at this time to propose a rule to add cancer, or a certain type of cancer, to the List of WTC-Related Health Conditions” [65].

Shortly after NIOSH issued that review, researchers published a new study that found WTC firefighters had an overall cancer incidence ratio approximately 10% higher than that of a general population with similar demographics, and approximately 32% higher than that of non-WTC firefighters [66]. NIOSH will likely conduct another review in early- to mid-2012 [67] that will incorporate these findings.

HEALTH MONITORING, RESEARCH, AND CARE
Research into the health effects of the World Trade Center disaster on rescue and recovery workers will continue, using data collected by the World Trade Center Health Registry. Health monitoring and care for World Trade Center responders was provided for several years by the World Trade Center Medical Monitoring and Treatment Program; starting on July 1, 2011, that responsibility was transferred to the World Trade Center Health Program.

World Trade Center Health Registry: The registry is one the largest public health registries assembled in history [68]. Its purpose is to collect data on the health of some 71,437 participants to study the long-term public health implications of the disaster. The registry includes rescue, recovery, and cleanup workers who worked at the World Trade Center site and the recovery operations site on Staten Island, or the barges during the period September 11, 2001 to June 30, 2002 for at least one shift, as well as residents, building occupants, schoolchildren, and others who were in the area around the World Trade Center site on September 11, 2001. 

The Agency for Toxic Substances and Disease Registry (ATSDR) and the New York City Health Department launched The World Trade Center Health Registry in 2003 to monitor the long-term health effects of exposure to the World Trade Center disaster. At a press conference announcing the project Dr. Henry Falk, Associate Administrator for ATSDR and Director of CDC's National Center for Environmental Health, said:

The World Trade Center Health Registry will do what no other health survey is doing; it will record and measure the health impact of 9/11 in the broadest possible terms. The Registry is a tool for giving us health data that could guide how we respond to this kind of disaster for generations to come. The more people enroll - even if they feel perfectly healthy - the better our chances will be of understanding any health effects from this tragic event [69].

FEMA provided ATSDR with the initial $20 million of funding to establish and support the registry [70]. It has since then been transferred within CDC to NIOSH [71].

The registry works closely with NIOSH and the City of New York. The registry also partners with local groups, including labor unions, scientific teams, and members of the community. In fact, it maintains three advisory groups: the Community Advisory Board, the Labor Advisory Board, and the Scientific Advisory Board. These boards meet with World Trade Center Health Registry staff four times a year.

In order to enroll, in 2003 and 2004 interested participants completed a confidential baseline health survey. The registry finished a first follow-up survey in 2008 and will conduct another follow-up survey beginning in 2011, with periodic follow-ups over a total period of 20 years [72].  Registry data is a valuable resource for researchers and health professionals who want to know more about the health effects of the World Trade Center disaster over the long term, and many health studies using registry data have already been published. The registry also issues regular reports about its findings and maintains an online interactive tool of some of its initial findings online at http://nyc.gov/html/doh/wtc/html/registry/epiquery-methods.shtml [73].

World Trade Center Medical Monitoring and Treatment Program (MMTP): This program provided monitoring and treatment to workers and volunteers who were involved in the rescue, recovery, and cleanup activities at designated sites (south of Canal Street in Manhattan, in the Port Authority Trans-Hudson (PATH) transit tunnel, at the Staten Island landfill, on the barge loading piers, or at the Office of the Chief Medical Examiner) at some time during the period between September 11, 2001, and July 2002. Some residents of the affected areas, area workers, and schoolchildren also received care at clinics that received federal funding under the auspices of the program.

MMTP was coordinated by the Mt. Sinai Medical Center in New York City and worked with the National Responder Health Program and a network of clinics nationwide to provide treatment for people outside of the New York/New Jersey area. As of September 30, 2010, 52,978 responders and 4,936 community members had applied for the program and met eligibility criteria [74].

Participants received free and confidential yearly medical exams and treatments. The exams helped researchers evaluate the physical and mental health of responders and track illness patterns. Participants also received treatment for World Trade Center-related illnesses covered by the program.

The Medical Monitoring and Treatment Program established eligible conditions by considering: common conditions that responders reported at their annual exams; conditions that have been diagnosed in only some responders but have been suggested by scientific studies to have a relationship to World Trade Center rescue and recovery operations; and conditions that doctors and scientist believe will develop in the long term given the nature of the World Trade Center conditions and exposure. At the end of 2010, the list of eligible conditions included several aerodigestive disorders, mental health conditions, and musculoskeletal disorders.

MMTP relied on annual Congressional appropriations to the Department of Health and Human Services, the Centers for Disease Control and Prevention (CDC), and the National Institute for Occupational Safety and Heath (NIOSH), which administered the funds. The fiscal year 2010 appropriations totaled $70 million.

The World Trade Center Health Program (WTCHP) went into effect on July 1, 2011 and replaced the MMTP [75].  The program was established by the James Zadroga 9/11 Health and Compensation Act of 2010. It includes automatic enrollment for responders who were enrolled in the MMTP, and opens enrollment to up to 25,000 additional responders who meet eligibility criteria (as well as to 25,000 non-responder survivors). Like the MMTP, the WTCHP provides full medical screening and treatment benefits for covered medical conditions to eligible responders and community members. Unlike the MMTP, it is authorized in statute and financed by mandatory spending from the last quarter of fiscal year 2010 through the end of fiscal year 2015. Federal contributions will total $318 million in fiscal year 2012 [74].

Eligible responders and survivors will receive medical benefits through a network of Clinical Centers of Excellence. The list of covered conditions is as follows:

Aerodigestive Disorders
Interstitial lung diseases
Chronic Respiratory Disorder – Fumes/Vapors
Asthma
Reactive Airways Dysfunction Syndrome (RADS)
WTC-exacerbated chronic obstructive pulmonary disease (COPD)
Chronic Cough Syndrome
Upper airway hyperreactivity
Chronic rhinosinusitis
Chronic nasopharyngitis
Chronic laryngitis
Gastro-esophageal Reflux Disorder (GERD)
Sleep apnea exacerbated by or related to the above conditions

Mental Health Conditions
Post Traumatic Stress Disorder (PTSD)
Major Depressive Disorder
Panic Disorder
Generalized Anxiety Disorder
Anxiety Disorder (not otherwise specified)
Depression (not otherwise specified)
Acute Stress Disorder
Dysthymic Disorder
Adjustment Disorder
Substance Abuse

Musculoskeletal Disorders manifested on or before September 11, 2003
Low back pain
Carpal Tunnel Syndrome (CTS)
Other musculoskeletal disorders

COMPENSATION MECHANISMS
Workers’ Compensation
Some rescue, recovery, and cleanup workers are eligible to file New York State Workers’ Compensation claims. According to a September 2009 report from the New York State Workers’ Compensation Board, workers have filed some 11,627 claims. That number does not include claims from federal employees, uniformed police, firefighters, and sanitation workers, who are all covered under different workers’ compensation systems. Workers had until September 13, 2010 to file claims.

World Trade Center Disability Law
The World Trade Center Disability Law provides rescue, recovery, and clean up workers with the legal presumption that if they become permanently disabled due to an eligible illness, that condition was probably caused by World Trade Center related conditions. Such workers will be eligible for disability retirement benefits. Workers must have participated in the rescue, recovery, and cleanup for at least 40 hours any time between September 11, 2001 and September 12, 2002, or within the first 48 hours for any period of time. Workers must have registered with the New York State and Local Retirement System by September 11, 2010 in order to take these benefits now or in the future [76].

September 11th Victim Compensation Fund
The September 11th Victim Compensation Fund provided compensation to people injured by the attacks and relatives of the deceased. The fund allowed rescue and recovery workers who worked the site between September 11 and September 15 and who did not receive immediate medical treatment (within 24 hours) to file claims. All applicants to the fund, though, had to waive their right to sue the airlines involved or the government [77].

The fund was established by the Air Transportation Safety and System Stabilization Act (49 USC 40101), an act of Congress President George Bush signed into law on September 22, 2001 [78]. The fund processed 7,408 deceased victim claims with an average award of $1,677,633. The fund also paid out awards to 2,682 personal injury claimants. Those awards varied widely and ranged from a low of $500 to a high of $8.6 million [79].

The Zadroga Act reactivated the compensation fund and expanded the pool of eligible applicants to include “individuals who experienced injuries associated with the attacks or subsequent debris removal” [80]. The fund is expected to begin receiving claims in October 2011 and will receive claims for five years. Congress appropriated $2.755 billion for the fund's awards and administrative costs [81].

World Trade Center Captive Insurance Company
The World Trade Center Captive Insurance Company operates a $1 billion fund to insure New York City, its contractors, and subcontractors against claims emerging from rescue, recovery, and clean-up efforts at World Trade Center sites. The Federal Emergency Management Agency (FEMA) originally funded the company through a grant in July of 2004. The company was established as a not-for-profit insurance company and is run by a small staff and a five-member Board of Directors appointed annually by the New York City mayor. The board is made up of current and former city officials and representatives from lead contractors.

The $1 billion fund is not a compensation fund; it was set up to provide insurance coverage for the city. Since the disaster, thousands of workers filed individual claims against the city and the contractors for illnesses and injuries they sustained as a consequence of their work. Many claimed they didn’t receive the necessary protective equipment that would have kept them safe. But by 2008, of the more than 9,000 plaintiffs who had brought suits against the city only six had received a settlement for claims totaling $320,936. In contrast, WTC Captive had spent $103,700,734 in legal fees to defend the city and its contractors from suits filed by rescue, recovery, and clean-up workers [82].  Members of Congress criticized what they deemed excessive litigation on the part of WTC Captive.

In March 2010 WTC Captive reached a settlement agreement with over 10,000 plaintiffs. The settlement would establish a system to pay out between $575 million and $657 million in compensation to responders. The judge in the case, Alvin Hellerstein, rejected the deal, saying that the amount was both inadequate and was likely to be eaten up by lawyers’ fees. He ultimately accepted an amended version that increased compensation for plaintiffs to $712.5 million and reduced payouts to lawyers by $50 million [83]. The settlement had to be accepted by 95 percent of the plaintiffs in order to go into effect. In November 2010, 95.1 percent of the workers accepted the settlement. Lawyers stated that payments would total at least $625 million; the $712.5 million figure assumed all plaintiffs accepted the settlement. Individual payments will range from $3,250 to $1.8 million depending on the severity of injuries [84].

Conclusion
World Trade Center responders will continue to suffer adverse health effects from the 9/11 attacks and their aftermath for years to come. Researchers will continue to learn about the long-term impacts of the exposures workers faced during rescue, recovery, and cleanup efforts.

While everyone hopes to prevent similar attacks in the future, we will likely see more large-scale disasters -- whether hurricanes, wildfires, or oil spills -- that require large and sustained responses from rescue, recovery, and cleanup workers. Lessons from the World Trade Center response should leave us better prepared during future disasters to protect workers and to care for and compensate those who suffer as a result of their service to the public. 

View endnotes

Jori Lewis is an award-winning freelance writer and a radio journalist. She reports on the environment, global health and social justice.

The research and writing of this case study was supported by a grant from the Public Welfare Foundation.