Johnson, Sara B. MPH; Langlieb, Alan M. MD, MPH, MBA; Teret, Stephen P. JD, MPH; Gross, Raz MD, MPH; Schwab, Margo PhD; Massa, Jennifer; Ashwell, Leslie BsC; Geyh, Alison S. PhD
The 2001 terrorist attacks on the World Trade Center (WTC) in New York necessitated enormous rescue, recovery, and cleanup operations. In the aftermath of the attacks, the heroism and sacrifice of first responders such as firefighters, police, and medics has been widely recognized. However, the contributions of other workers at Ground Zero and the Freshkills Landfill on Staten Island (where the debris from the site was taken to be sorted) have been less publicized. The number of workers involved in the WTC cleanup and recovery effort as truck drivers, heavy equipment operators, mechanics, laborers, and carpenters has been estimated to be in the thousands.1,2 They worked to move the rubble from the debris pile, drove trucks to haul debris from Ground Zero to the Freshkills Landfill, and performed recovery tasks, such as locating body parts. This article addresses the effect of the cleanup and recovery work on these workers.
The conditions for personnel at the disaster sites were treacherous. Workers encountered hazards, including fire, smoke, falling and unstable debris, toxic fumes from combustion products, and dust clouds made up of pulverized building materials.3 The short-term physical health effects of WTC rescue and recovery work have been shown to include musculoskeletal injury, respiratory problems, and eye injuries.4–6 In addition, evidence of mental health effects is beginning to emerge. Fifty-one percent of rescue and recovery workers who self-referred to a voluntary screening program were found to meet the threshold for a clinical mental health evaluation, and the rate of posttraumatic stress disorder was found to be approximately four times that of the general male population.7
The focus of disaster planning is often on training and providing resources to traditional first responders such as law enforcement, firefighters, hazardous materials teams, and health professionals.8–12 Similarly, disaster site injury and illness surveillance systems generally are designed to monitor the health of traditional responders during rescue and recovery operations. Security, construction, sanitation, and utilities workers do not receive training in dealing with disaster events. In addition, after the WTC attacks, workers who came to the site primarily to participate in the cleanup effort were excluded from some work site health surveillance programs because they were “not directly assigned to rescue and recovery operations.”4 Although several programs were put in place beginning in 2002 to provide health screening and limited treatment for all responders and volunteers, these programs are voluntary and may not capture the experiences of individuals who do not feel their exposure or symptoms are serious enough to warrant help.7 Thus, cleanup and recovery workers risk being overlooked in disaster planning and response activities.
The World Trade Center Clean-Up and Recovery Worker Health Survey was implemented by the Johns Hopkins Bloomberg School of Public Health approximately 18 months after the attacks. The survey assessed cleanup and recovery workers’ exposures at the site, as well as somatic and mental health symptoms after exposure. This investigation has yielded a wealth of information on these topics; however, one question in the survey shed unexpected light on workers’ experiences. At the end of the survey, workers were given the opportunity to deviate from the structured survey format and share any aspect of their experiences they wished. Their responses provide important insight into how their work at the WTC site and Freshkills Landfill has changed their lives, how they coped, and how workers like them might be better protected in the future.
This study relies on qualitative methods and helps to document how workers processed their experiences, a key predictor of traumatic stress.13 The goal of the study is not to quantify the proportion of respondents who gave a particular response but rather to use these responses as an opportunity to explore common themes and experiences. A qualitative approach provides first-person insight into the health effects of disaster cleanup on a population of workers who have been largely overlooked in favor of traditional first responders. These data provide contextual detail that can help researchers interpret and focus quantitative research with this population of workers.
Materials and Methods
Survey Instrument and Subject Identification and Recruitment
The World Trade Center Clean-Up and Recovery Worker Health Survey included questions on exposure assessment, a health history, and physical and mental health modules. The 62 question survey took approximately 20 minutes to complete. An open-ended question near the end of the survey asked: “Is there anything else you’d like us to know about your experience?” Respondents were provided with one third of a page in which to respond.
Subjects were recruited from local unions organized by the International Brotherhood of Teamsters, the International Union of Operating Engineers, the Laborers International Union of North America, and from the New York City Department of Sanitation. These organizations had a significant number of members or employees working at Ground Zero and/or at the Freshkills Landfill site.
Surveys were mailed between March and June 2003 to all individuals identified by these organizations as having worked on either site. Surveys were mailed either from Johns Hopkins School of Public Health or from the participating organization, if that organization did not agree to release contact information. Each survey was accompanied by a letter of disclosure, brochures about available health services for WTC workers, and at the discretion of the member’s organization, a small incentive. A reminder postcard was mailed approximately 2 weeks after the initial mailing. Completed surveys were returned between March 2003 and June 2004. Responses were tracked using a relational database. Participants provided written permission for the use of excerpts from their survey responses. The research protocol was approved by the Johns Hopkins Bloomberg School of Public Health’s Institutional Review Board.
Data and Analysis
Data for this study are drawn from responses to the open-ended survey question, which gave workers an opportunity to share their views in an unstructured format. These data were coded and content analyzed using qualitative methods.14 Common themes of the responses are presented below.
A total of 1114 surveys were returned. A description of the respondents by labor organization, and organization-specific survey response rates are included in Table 1. Of the 1114 respondents, 332 (30%) volunteered a response to the open-ended question about their experiences. Some respondents used the space to provide detail about the kind of work they did, or to clarify an earlier response. Most respondents wrote about their physical and mental health problems, the lack of preparation and support they felt to do the job, and the pride they felt for having been involved.
Somatic and Injury Complaints.
The results from this investigation are based on the 332 individuals who answered the open-ended survey question. Twenty four percent of respondents reported a current somatic complaint, or an injury related to their cleanup work. These accounts were in addition to responses provided to structured health questions earlier in the survey, and often reflected high levels of concern. Injury accounts included burns, herniations, and strains. Most somatic complaints involved respiratory problems including: shortness of breath, wheezing, sinusitis, nosebleeds, congestion, and “WTC cough.” For many workers, these health effects continued to have an impact on their usual activities. One man, who completed the survey 18 months after the disaster wrote: “[I] used to play the trumpet, now [I] can’t inflate a balloon without coughing and losing breath.” Workers who were diagnosed with cancer and other health problems after the disaster worried they were occupationally related.
Concerns about Future Health Effects.
In addition to current health issues, many respondents wrote about their fear of future health effects. These fears stemmed from not knowing what they had been exposed to. “What was that smell at ground zero? What is going to happen many years from now to my health? Are we all going to be sick?” Concerns about exposure also prompted one woman to fear for her fetus when she became pregnant, fears that resulted in her decision to terminate the pregnancy.
Mental Health Symptoms.
Approximately 10% of respondents volunteered in their open-ended answers that they had experienced or were currently experiencing mental health symptoms including trouble sleeping, depression, anxiety, posttraumatic stress disorder, and suicidal thoughts. Several reported they had been prescribed anti-depressants for these symptoms. Many workers reported using alcohol and drugs to cope. “The aftermath of 9/11 continued to get me depressed. I began to drink alcohol and use cocaine… Before 9/11 I had never had any history of drug and alcohol abuse.” Other respondents noticed more subtle, less specific changes after the disaster: “I did my duty and used my skills at the WTC, but someplace in the rubble and carnage, I lost myself.”
Many workers reported reliving their experiences in nightmares or during daily activities: “If I see shoes or pants discarded on the street or highway, it brings me back to those days of cleanup at [Freshkills].” Visions of body parts and the smell at the sites, which many workers equated with “the smell of death,” often were referred to as part of these flashbacks. “On occasion, when I see pictures or TV scenes of the disaster site, the smell of the site comes back to me. I can smell it right now.”
Lack of Preparation and Training
Lack of Respiratory Protection.
More than 40 respondents described their concerns that they were not given respiratory protection while working. “I didn’t have the proper respirator, nor was I given any instructions. I took it upon myself to bring a simple white 3M respirator.” One worker reported his exchange with a safety representative: “[He] told me over the phone to hold a towel in front of my face while I work. We both knew this was not possible or effective.” Some workers were provided with respirators after complaining to management. “A few days after working at the debris pile I requested respirators and I was issued paper disposable masks. Five weeks later, the … workers were sent to… be fitted for proper respirators after the union and workers protested.”
Lack of Training and Policy Resources.
Respondents commonly felt they were less protected than police, fire, and emergency medical personnel, whom they felt received appropriate personal protective equipment more promptly. One respondent felt that workers were at increased peril because they had no training in disaster response or personal protection; in addition, they felt they were not protected by some public policies designed to make it easier for first responders to receive compensation for occupationally related health problems. Several respondents equated their lack of preparation with a lack of concern on behalf of their superiors. “I wasn’t being treated and protected like everyone else. It became insulting…. ”
Many respondents felt inadequately warned about the potential hazards of their jobs and the measures they needed to take to protect themselves, although others appeared to have this information: “We were not told to clean our uniforms and boots, but in many places we went for food, we were told we could not go in if we came from Ground Zero.” Similarly, they were concerned about the debris they brought home on their clothes and skin. “I worry that I brought illness into my home and worry that my wife or children were exposed to whatever was at the site.” As one worker pointed out: “[We] should have come home the same way we came in… To take a little time to protect the workers in the beginning would have been a blessing for all in the end.”
In addition to feeling ill-prepared to address the physical hazards of the job, they also felt poorly prepared to handle many of the emotional demands. They felt particularly unprepared to work with human remains, both logistically and emotionally: “Seeing all the material from the [site] and the rotten smell of death was a traumatizing experience.” Workers reported feeling the weight of their families’ emotional burden as well. One worker described his distress when his preschool-aged son’s comments reflected fear and sadness he had hoped to shield him from. He tearfully told his father: “I’m sad about the people that died in those buildings.”
Coping and Pride
Workers devised strategies for coping, such as writing poetry and drawing. Despite their personal sacrifices, many workers reported being proud to have been able to help. Some found work on-site therapeutic: “Working on the cleanup… was probably the best possible therapy. I feel for those who wanted to contribute, but couldn’t.” Even those who reported work-related health problems often felt compelled to stay: “I stayed working after the doctor gave me medication. I didn’t want to leave. I wanted to help, so I stayed.”
Descriptions of workers’ personal horrors were often closely followed by statements of pride at having been able to perform a valuable service to those who had died in the WTC attacks, and to the nation as a whole. “I will never forget what I saw. I will always be proud that I was there to help.” Many offered that they would do it again if needed.
Desire for Recognition
Workers reported they felt undervalued given their commitment to the cleanup effort. Some workers wanted to be recognized by their employer. “[We] moved hundreds of tons of dust, debris, body parts, and who knows what else. It would have been deeply appreciated to at least have been recognized by our Department as other Departments recognized their employees.” Other workers voiced their desire that their efforts receive more widespread acknowledgment. “The uniform services received all the attention and outreach from their unions, while there were hundreds of other workers exposed to the same conditions that were ignored.”
This report is the first to “give voice” to cleanup and recovery workers, who experienced a similar exposure to the disaster site as the traditional first responders, and who, by their own accounts, have been largely invisible in the public and political consciousness.15,16 In addition, workers’ personal testimony reveals that many have suffered mental and physical health effects similar to those found with the more recognized first responders. For example, rescue and recovery workers and volunteers have been found to have elevated rates of PTSD, anxiety and depression, as well as respiratory and musculoskeletal problems.4,6,17,18 These qualitative data are a particularly valuable complement to quantitative survey results, as they help to elucidate the cognitive and psychological impact of workers’ experiences in their own words.
Workers in this study alluded to feeling marginalized in comparison to the uniformed services, whom they saw as better protected, better prepared, and better recognized for their efforts. These nontraditional responders generally receive little or no training in the use of personal protective equipment, disaster response strategies, and coping skills. Thus, they may be particularly vulnerable to illness, injury, and mental health problems.
In addition to lacking the training and equipment that might prevent or decrease negative health outcomes, cleanup, and recovery workers are not protected by some public policies that create a safety net for traditional first responders in the event of work-related health problems. In particular, state “heart lung presumption” laws assume that a variety of causes of death and disability are job-related for firefighters, police, medics, and hazardous materials professionals.19 Without these protections, the burden of proving an occupationally related illness remains with the worker. A bill moving through the New York legislature would extend such protection to sanitation workers.20
Respondents saw their lack of training and public policy protection as part of a larger pattern of being overlooked in the disaster response process. Many respondents felt frustrated that they were not acknowledged for their work and personal sacrifice. This prolonged their distress, making it more difficult to reach closure.
The experiences of these responders can be used to help inform planning and response efforts for future disasters. Planners should anticipate a broader disaster response group beyond firefighters, law enforcement, and health professionals. Planning activities that account for the “downstream” effects of disasters, beyond initial search and rescue operations, will help in this effort. Many of the workers identified may not work directly at the disaster site. For example, Peterson and colleagues report that mortuary workers charged with handling the remains of mass casualty victims are at risk for post traumatic stress disorder and other mental health sequelae.21
Several lessons emerge from the workers’ cleanup experiences. In particular, employers and labor organizations can help workers by clearly articulating a disaster response plan, providing strong leadership, and offering thorough worker training. Some experts have suggested that work practice changes, such as limiting shifts and using stress-management skills, can promote adaptive functioning among responders (Anthony Ng, Personal Communication). More research is needed to determine whether these practices would be a useful addition to worker-training programs. In addition, given the potential burden of mental health problems in cleanup and recovery workers, employers and government agencies should facilitate disaster mental health services. Workers should receive training before an event or should have a training plan ready to be implemented immediately in the event of a disaster. Most employers currently provide health and safety training that could be augmented to include preparation for responders. Training might include use of personal protective equipment, coping strategies, normal emotional and physical reactions to extreme traumatic stress, and available resources for physical and mental health services. Systematic investigation into the educational needs of various groups such as literacy level, language skills, and work culture should be considered when crafting materials and training for these workers.
Finally, we should take care to explicitly recognize the efforts and sacrifices of all workers who assist in disasters. Acknowledging the contributions of cleanup and recovery workers may not only help to ensure their inclusion in future planning efforts but also improve their sense of satisfaction with a difficult job. Beyond equity, such recognition may have important mental health benefits for workers already struggling to balance the satisfaction they feel for being of service, with the horrors of their personal experiences.
Workers in this study chose the experiences they wanted to share with us; therefore, the pattern of responses we report should not be interpreted as a quantitative indication of the prevalence of physical or mental health symptoms in this population. For example, it is impossible to know, for many respondents, whether or not their mental health symptoms were caused by their work on this job. Further, it is possible that more severely affected workers self-selected into this optional portion of our survey. Nonetheless, the mental health burden on this population appears to be substantial. As a qualitative, exploratory endeavor, this study was not designed to be generalizable to the larger population of workers. This approach, however, did uncover information that might have been overlooked using purely quantitative methods.
The September 11, 2001, terrorist attacks on the WTC were an unprecedented challenge for disaster planning and provide important lessons for future disasters. By their own report, many cleanup and recovery workers have suffered persistent, sometimes debilitating consequences of their work. Their experiences are qualitatively similar to other more recognized responders. Thus, to better protect a greater number of responders in the future, the historical focus on preparing and supporting “first” responders should be reconsidered more broadly. Planners will need to anticipate nontraditional workers who might be involved in disaster response, assess their needs with respect to training and support, and craft plans to provide these resources. Understanding and anticipating the needs of these workers can help mitigate the public health toll of future disasters.
This work was supported by the National Institutes of Environmental Health Sciences through supplemental funding to the Johns Hopkins Center for Urban Environmental Health, grant number P30 ESO 3819-16S1.
The authors gratefully acknowledge George Everly for his thoughtful comments on the manuscript.
1. Elisburg D, Moran, J National Institute for Environmental Health Sciences (NIEHS) Worker Education and Training Program (WETP) Response to the World Trade Center (WTC) Disaster: Initial WETP Grantee Response and Preliminary Assessment of Training Needs. 10–6-2001.
2. Kipen HM, Gochfeld M. OEM and the World Trade Center. Occup Environ Med. 2002;59:145–146.
3. Centers for Disease Control and Prevention. Use of respiratory protection among responders at the World Trade Center site–New York City, September 2001. MMWR 2002;51:6–8.
4. Berrios-Torres SI, Greenko JA, Phillips M, Miller JR, Treadwell T, Ikeda RM. World Trade Center rescue worker injury and illness surveillance, New York, 2001. Am J Prev Med. 2003;25:79–87.
5. Bradt DA. Site management of health issues in the 2001 World Trade Center disaster. Acad Emerg Med. 2003;10:650–660.
6. Prezant DJ, Weiden M, Banauch GI, et al. Cough and bronchial responsiveness in firefighters at the World Trade Center Site. N Engl J Med. 2002;347:806–815.
7. Mental health status of World Trade Center rescue and recovery workers and volunteers—New York City, July 2002-August 2004. MMWR. 2004;53:812–815.
8. Hammond J, Brooks J. The World Trade Center attack. Helping the helpers: the role of critical incident stress management. Crit Care. 2001;5:315–317.
9. Beaton RD, Johnson LC. Instrument development and evaluation of domestic preparedness training for first responders. Prehospital Disaster Med. 2002;17:119–125.
10. Acosta JK, Levenson RL Jr. Observations from Ground Zero at the World Trade Center in New York City, part II. Theoretical and clinical considerations. Int J Emerg Ment Health. 2002;4:119–126.
11. Sharp TW, Brennan RJ, Keim M, Williams RJ, Eitzen E, Lillibridge S. Medical preparedness for a terrorist incident involving chemical or biological agents during the 1996 Atlanta Olympic Games. Ann Emerg Med. 1998;32:214–223.
12. North CS, Tivis L, McMillen JC, et al. Coping, functioning, and adjustment of rescue workers after the Oklahoma City bombing. J Trauma Stress. 2002;15:171–175.
13. Everly GS, Jr. A Clinical Guide to the Treatment of the Human Stress Response. New York: Plenum Press; 1989:26.
14. Creswell JW. Qualitative procedures. Research Design: Qualitative, Quantitative, and Mixed-Methods Approaches. Thousand Oaks, CA: Sage Publications; 2003:179–207.
15. Feldman DM, Baron SL, Bernard BP, et al. Symptoms, respirator use, and pulmonary function changes among New York City firefighters responding to the World Trade Center disaster. Chest. 2004;125:1256–1264.
16. Skloot G, Goldman M, Fischler D, et al. Respiratory symptoms and physiologic assessment of ironworkers at the World Trade Center Disaster Site. Chest. 2004;125:1248–1255.
17. Injuries and illnesses among New York City Fire Department rescue workers after responding to the World Trade Center MMWR. 2002;51:1–5.
18. Physical health status of World Trade Center rescue and recovery workers and volunteers—New York City, July 2002-August 2004. MMWR. 2004;53:807–812.
19. New York General Municipal Law, 207-r. 2003.
20. Marchi L. Establishes a presumption with respect to heart disease which results in disability for members of the uniformed force of a paid sanitation department. State of New York Senate Bill 3299-B. 2003.
21. Peterson AL, Nicolas MG, McGraw K, Englert D, Blackman LR. Psychological intervention with mortuary workers after the September 11 attack: the Dover Behavioral Health Consultant model. Mil Med. 2002;167:83–86.