Few events in American history have had the impact of the terrorist attacks of September 11, 2001. Ten years later the effects on a wide variety of areas ranging from our national psyche, military presence around the world, national security spending, and the check-in experience of air travelers are an astounding reminder of the unimaginable events of that Tuesday morning in September 2001. We will always remember where we were on that day and many of us, particularly those directly affected by the tragedy, must deal with the sequella on a daily basis.
For occupational and environmental medicine physicians September 11, 2001, will be remembered as a pivotal day. Indeed, for many of us our careers can be divided into the pre- and post-9/11 experience. Few dreamed that their training in the effects of toxic exposures, epidemiology, and worker protection would be so useful and needed during this unexpected national crisis and the health impacts that followed. Prepared by residency and experience to deal with issues of toxic exposures in factories and mines, occupational and environmental medicine physicians would utilize these skills in evaluating and treating firefighters, first responders and lower Manhattan residents/office workers who developed health effects due to the previously unknown combination of toxic exposures. In fact, within days of 9/11, groups of physicians and scientists were meeting informally to discuss how best to respond to the disaster.
Physicians of all specialties had rushed to Ground Zero and the surrounding hospitals but the injured survivors were unfortunately few; although, there were cases of severely injured burn victims whose lives were saved by the heroic efforts of the medical teams. The need for acute medical care lessened within several days, with the heart-breaking realization that there were few injured to care for, and the concern over the occupational and environmental health risks began to take precedence.
Thousands of workers and residents were unsure about the safety of the air in lower Manhattan and even more confused about the health effects of the residual dust. The Environmental Protection Agency had stated that the air was safe, but there was a growing mistrust among the population who after smelling the acrid air did not believe all was well. Local occupational physicians attended forums and met with community leaders explaining the implications of air/dust test results and advocated for proper cleanup and protection. Many of the banks and brokerage houses of lower Manhattan had extensive occupational medicine departments whose expertise was used to advise senior management about returning employees to their downtown offices. In-house occupational physicians also evaluated individual employees with air quality–related complaints or questions about the safety of returning to work with specific medical conditions. The occupational physicians performed this task admirably and their efforts were documented in The Wall Street Journal.
Occupational physicians at medical centers including Mt Sinai, NYU, Stony Brook, Bellevue/Gouverneur, UMDNJ, and Columbia University, as well as the medical department of the FDNY soon realized that a concerted effort would be required to diagnose and treat the firefighters, workers, and residents becoming ill from their exposures. Suddenly thrust into the national political limelight the physicians advocated for their patients. Though not necessarily well prepared for the task by their residency training, these physicians testified at Congressional hearings and were interviewed on network news and 60 Minutes. Funding for evaluation and treatment was provided first for recovery workers and later, through the efforts of community activists and local politicians, for lower Manhattan residents. Partly due to these continued efforts, the recently enacted Zadroga Bill will provide funds for medical care of these populations through 2016, although the needs are expected to continue indefinitely.
The funded institutions established centers of excellence and have provided medical services (including mental health care) to more than 50000 patients. They have cared for a wide range of conditions including asthma, gastroesophageal reflux disease, and posttraumatic stress disorder. With their unique experience in occupational medicine, they have attempted to determine whether diseases were related to exposure. This has included studies of sarcoid incidence and in a 2010 JOEM article, a study of myeloma incidence in responders. More than 200 scientific/medical articles have been published including many in the JOEM. A complete list of the JOEM publications is included in this edition.
How can we interpret the events of 9/11 and the impact on our specialty? Although responders who worked at Ground Zero came from all over the United States, the majority of occupational physicians may not feel that the disaster impacted their practice. While they may read the articles or attend lectures with interest, the actual impact is actually far more widespread. In the post-9/11 world, the skill set of the occupational physician has become more important and more visible in the academic, corporate, and private practice setting. Corporate medical directors have become even more integral to managers dealing with environmental health and pandemic issues with subsequent events including anthrax, bird flu, oil spills in the Gulf and radiation fears in Japan. No longer considered “the company GP” the specialized training and experience is viewed as necessary for corporate preparedness to deal with emergency situations. For academic medical centers, occupational physicians have become even more important in studies of populations exposed to toxins with ongoing studies of 9/11 populations proceeding and further studies of Gulf Oil workers being planned often based on the lessons learnt from 9/11. Private practitioners with training and knowledge can be called on for the expertise in responding to the environmental impacts of man-made and natural disasters.
What lessons for the future can be learned from the experiences of the occupational physician in the post-9/11 World. As noted above facets of the training have made the specialty invaluable in the assessment and treatment of environmentally related disease. These include toxicology, epidemiology, biostatistics, disease cluster investigation, and experience in the interpretation of pulmonary function and other laboratory testing. Risk communication is equally important but unfortunately has been more uneven in residency and other training programs. Occupational physicians, as trusted professionals, must be trained to explain complicated environmental health issues to varied populations ranging from community groups and advocates to corporate chief executive officers. Finally young occupational physicians must be trained to advocate for our patients and communities, testifying before local government organizations and Congress in the exemplary way that occupational physicians caring for 9/11 survivors and responders did. While occupational medicine residents receive training in conducting studies to determine causality of disease, few have experience in translating these into statements affecting public policy. This type of work will become important in the future debates as to which cancers should be added to the “WTC covered condition” list. Many of the studies published in the JOEM and listed following this editorial received national media attention when released. Evidence that a disease such as sarcoid or myeloma may be related to World Trade Center dust exposure has direct impact on policy and patient care. Finally, psychiatric conditions including posttraumatic stress disorder and depression should also receive more attention in the training curriculums as the occupational physician is often called upon to deal with the mental as well as the physical effects of disasters. Residency programs and training courses should be encouraged to include training in all these areas in their programs.
While we cannot reverse the tragic events of that morning in 2001, we can learn from the events and increase our skills to provide needed expertise to our nation and our patients. We can also continue to treat, monitor, and advocate for those affected. Scientific studies of the affected populations must continue and the results published. Doing so will be a lasting tribute to the many that died and continue to become ill.
Marc Wilkenfeld, MD
Chief Division of Occupational Medicine
Department of Medicine Winthrop University Hospital