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Journal of Occupational & Environmental Medicine:
doi: 10.1097/JOM.0b013e318229a536
Book Reviews

Dust: The Inside Story of Its Role in the September 11th Aftermath

Wilkenfield, Marc MD, MPH

Section Editor(s): Borak, Jonathan MD; Department Editor

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Author Information

Chief, Division of Occupational Medicine, Winthrop University Hospital, Mineola, NY

Books for review should be sent to Jonathan Borak, MD, Clinical Professor of Medicine and Epidemiology, Yale School of Medicine, 234 Church Street (#1100), New Haven, CT 06510; E-mail:

Dust: The Inside Story of Its Role in the September 11th Aftermath

Paul Lioy. Lanham, MD, 2010., Rowman & Littlefield. ISBN: 978-1-442201-48-4

Much has been written about the destruction of the World Trade Center (WTC) on 9/11. Soon after the WTC Towers fell occupational physicians and environmental scientists began to worry about the health implications of those who survived and those who were to work on the recovery effort. The initial concerns about the dust were overshadowed by the immediate efforts to find and rescue survivors. As it became evident that there were few survivors more attention began to be paid to the environmental health effects. The events of 9/11 caused what has become the largest man-made environmental health disaster in the history of the world. Thousands of firefighters, recovery workers, and Lower Manhattan residents/students/office workers became ill. Many become became totally disabled and the New York City Medical Examiner has determined that inhalation of the dust produced by the collapse was the cause of death in a growing number of cases. The health implications continue though today with tens of thousands of workers/survivors in medical monitoring/treatment programs. The political intrigue and mistrust of the government's handling of the exposures and cleanup have been played out in both the media and Federal Courts where the then head of the Environmental Protection Agency (EPA) Christine Whitman (who on September 14, 2001, stated that the air of New York was safe to breathe) has been named in a lawsuit. The enormity of the health problems from the dust is illustrated by the recent passage of the Zadroga Bill, which President Obama signed in January 2011. The bill will provide more than 4 billion dollars for monitoring, treatment, and compensation of illness related to 9/11, much of which was due to dust inhalation.

What was the dust that has caused so much illness, economic loss, political backlash, and government mistrust? Dr Paul Lioy, Professor and Vice Chair of the Department of Environmental and Occupational Medicine at Robert Wood Johnson Medical School, attempts to answer these questions in the aptly named “Dust: The Inside story of its role in the September 11th Aftermath.”

In this well-written and flowing work, Dr Lioy describes the environmental/health story of the dust from the beginning when he, like hundreds of millions of others watched the horrible story unfold on television. Dr Lioy was well prepared to help. With a long history of expertise in exposure science, he became part of a team, which included occupational physicians. The team was brought by National Institute of Environmental Health Sciences to Lower Manhattan within a week of 9/11 to determine what was in the dust that so many were being exposed to. Unlike the many medical studies that have looked at health effects of 9/11, Lioy's book is unique in that it concentrates on the content and nature of the dust while including the fascinating story of the politics and risk communication occurring following this unprecedented type of exposure.

The technical aspects of the dust and their effects on the body are written in an easy to understand manner which can be appreciated by the lay-public as well and also is useful for the occupational physician. Occupational physicians dealing with dust and chemical exposures will find it extremely interesting and useful as they process clinical care of individuals exposed to any type of dust or chemical. Dr Lioy is able to convey the emotion surrounding what might be thought of as an extremely technical analysis of the dust. This can best be summarized by his response to question by a local resident: “How can you describe the dust?” Dr Lioy, despite his years as a scientist and myriads of technical data from studies of the dust, responded that the dust contained “everything that we hold near and dear to us.”

The collection and characterization of the dust is well reviewed and explained by Dr Lioy. Occupational physicians and other medical professionals with experience in exposure science will find this detail of interest. To many readers the story of the politics of the dust will be more intriguing. The technical details are intertwined with the political story of the dust, which again is retold in a cogent and interesting manner by Lioy. The dust contained a variety of potentially toxic substances and the particulate matter itself was damaging to the lungs. Five thousand tons of chrysotile asbestos were used in the construction of one of the World Trade Center, until Mayor Lindsay halted the spraying on the advice of Dr Irving Selikoff, a pioneer and iconic figure in the field of Occupational Medicine. As Lioy recounts, the overwhelming concern when the Towers collapsed was over asbestos, a known carcinogen and cause of lung scarring. The initial tests conducted on the dust revealed a low asbestos content, which gave a false sense of security to those responsible for making recommendations about the air quality. The low asbestos levels also detracted attention from what in hindsight appears to have been exposures hazardous to the health of workers and residents. Partially on the basis of these results, residents returned to their homes, workers returned to their offices, and the New York Stock Exchange reopened. Recovery workers did not use respiratory protection for a large variety of reasons ranging from low availability early on to feeling that they could not as effectively conduct the search for survivors and remains with the hindrance of additional equipment in what was already one of the most difficult and dangerous worksites imaginable. Lioy points out that one of his best photos of the workers illustrates this point. In the photo three workers are present, one wearing a mask, one with a mask draped around his neck, and one with no mask. In this case Lioy aptly describes the unfortunate nonuse of respiratory protection but the photo brings the point home.

Lioy describes another important controversy surrounding the dust, the question of cleanup. The EPA and numerous private contractors provided cleanup and pre- and post-cleaning testing. The issue of what dust came from the Trade Center and what levels of remaining dust was safe for returning residents and office workers was the cause of much disagreement and public bewilderment. The public concern and outcry about the dangers of the dust and the intervention of Senator Joseph Lieberman and Hillary Clinton led to the formation of the EPA WTC Technical Advisory Panel whose mission are well described in this book. Lioy cochaired the panel and 14 other members (including this writer), representing a broad spectrum of expertise and opinion, tackled the difficult task of the determination of a signature for WTC dust and what would constitute and effective cleanup. Lioy's telling of the story reflects the emotions involved in the panel's work. After 2 years of review and public meetings the Panel was dissolved by the EPA before answering the questions it was charged with. The political and scientific community was unprepared to deal with the new and unique questions raised by the unprecedented disaster. The confusion and unpreparedness was magnified by the affected community's anger and frustration. The EPA completed its original cleanup and to this day the public health implications are unclear.

In summary, Dust is a well-written work about an important subject. It should be of interest to occupational physicians, safety and health professionals, and policy makers. Perhaps by studying the lessons of 9/11 we can prepare for what may be similar events in the future.

Marc Wilkenfield, MD

Chief, Division of Occupational Medicine

Winthrop University Hospital

Mineola, NY

©2011The American College of Occupational and Environmental Medicine


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