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In late 2003, Dr. Cynthia Lewis-Younger's Tampa, Fla.-based medical practice, Comprehensive Occupational Medicine for Business and Industry, began receiving patients who had worked in rescue and recovery more than 1,000 miles away at ground zero in New York City.

Patients came to her as part of a nationwide medical outreach program led by Mt. Sinai Medical Center in New York to check on the status of the World Trade Center workers and volunteers living across the country.

A specialist in occupational and environmental exposures to toxic substances far removed from the intense glare of politicians, unions, lawyers and the media in New York City, Lewis-Younger was well qualified to delve into her patients' conditions, and weigh the effect of ground zero exposures.

Her findings were not encouraging. Among dozens of workers and volunteers she treated, she found pervasive signs of physical and emotional distress. Through them, she caught a glimpse of what she called "a megadisaster," unlike anything she'd seen before.

"It can't really be compared to most building collapses or fires," she says. "Its victim count goes far beyond those who died on Sept. 11. There are thousands more who will be sick to a greater or lesser degree for the rest of their lives, and many whose lives will be shortened."

Lewis-Younger examined public safety, construction, janitorial, mental health and volunteer workers, all between 35 and 65 years old. She found that four out of five had chronic rhinitis, or disease of the nasal mucosa, which could arise from a range of underlying conditions.

Some patients suffered from airway or lung problems, including asthma and "RADS," or Reactive Airways Dysfunction Syndrome, a type of occupational asthma, whose symptoms include wheezing.

About half of the patients who came through her doors had posttraumatic stress disorder. One-quarter of the people she saw were, in her judgment, qualified for long-term disability due to their work at the World Trade Center cleanup.

Worse still, many of her patients, as many as 20 percent, were more vulnerable to the WTC's toxic gases than they otherwise would have been because of prior exposures to environmental health problems--smoking, for instance.

Because there were no prework screening, no record of individuals' use of protection equipment and very little medical monitoring of workers, Lewis-Younger says, it is difficult to know how the more vulnerable workers participating in the cleanup managed while on the job.

In hindsight, perhaps Lewis-Younger's findings on the medical state of the Trade Center volunteers were to be expected, for the conditions in which the workers gave their time, and maybe even their lives, were horrific.

Based on field investigations that began Sept. 22, 2001, eleven days after the attack, consultant John Moran observed workers in T-shirts on the debris pile in the smoke plumes without glasses, respirators or even hard hats. Nor were workers handling blowtorches using face shields.

"Contractors evidenced little if any attention to safety and health, let alone training, and communications and coordination among the various organizations with respect to safety and health particularly was isolated and difficult at best," wrote Moran in an Oct. 6, 2001, worker safety report to the National Institute of Environmental Health Sciences.

Moran and his colleague, Donald Elisburg, found "no evidence or even suggestions that any safety and health program was operative at the site, indeed the very opposite seemed to be the case."

When they wrapped up their work in early October, Moran and Elisburg were still stunned by the "complete lack of overall (safety and health) site coordination" including "a complete lack of participation by workers or their representatives" in safety management, according to Moran.

But a plan did exist. It had been issued in draft form 10 days prior, on Sept. 25, by Bechtel Corp., the San Francisco-based global construction firm, which was awarded a contract to develop a master safety and health plan.

Yet the plan never made it into the hands of the people who needed it most, according to unions and critics of former Mayor Rudolf Giuliani and the mayor's designated site manager, the Department of Design and Construction.

Both the Mayor's Office and the department refused to release copies of the draft plan, the unions and safety critics claim.

MULTIPLE THEORIES

Environmental safety agencies knew workers were at risk, yet didn't go to any lengths to enforce their own safety codes. They took thousands of air samples, with ambiguous results.

State and federal agencies had differing critical thresholds. The Occupational Safety and Health Administration standards differed from Environmental Protection Agency standards. No agency was prepared to assess the effects of the toxic combination of agents.

OSHA, the EPA and labor unions gave out respirators far in excess of the number of workers ever on the site. But many of them just weren't used, and workers weren't reprimanded for not wearing them.

Safety, it seemed, was relegated to an act of personal virtue rather than bolted into site command.

One theory is that assurances to the public about the absence of environmental hazards lulled workers and employers into indifference. Days after the attack, EPA and OSHA issued press releases saying Lower Manhattan was safe to enter.

New York City's Department of Design and Construction personnel "are not being exposed to unhealthy levels of chemicals and that air quality around the WTC is generally good," read an Oct. 17, 2001, OSHA communique.

Another theory is that the World Trade Center collapse decapitated the work safety leadership inside New York City's government.

"In the collapse of the towers, essentially the whole emergency response command structure of the FDNY was lost, as well as a majority of the department's (hazardous materials) instructors, technicians and specialists," wrote NIEHS consultants Moran and Elisburg.

The surviving FDNY leadership, which shared formal control over the site, provided a dubious role model for the other ground zero workers, according to the consultants. Except for the few specially trained firefighters, the bulk of them at the scene were dangerously inured to environmental hazards.

"They were used to walking through smoking buildings while chewing gum," Elisburg remarked.

Another theory has been that, in response to political pressure, work safety regulation was gutted. OSHA was quickly emasculated. Had the site been declared a hazardous waste site, OSHA's stature would have increased.

In effect, those with the technical knowledge of how to control for hazards stepped back, were pushed back or threw away the playbook.

Bruce Lippy, a hygienist for the International Union of Operating Engineers, the union covering heavy-equipment operators, recalls his early days at ground zero scanning the site with binoculars to see if his union members had their protective equipment on in their cabs.

Lippy, a safety consultant in Baltimore, draws a contrast between ground zero and Fresh Kills, the Staten Island site where debris was shipped by barge and under the control of the U.S. Army Corps of Engineers.

"It was ironic to me that they had 80 percent to 90 percent of compliance because the (Army) Corps was there." At ground zero "there were just too many cooks stirring the pot."

Neither Bechtel, nor the private contractors, nor the public agencies, checked for pre-existing health conditions among workers.

It is standard work-safety practice to make sure that, when personal protective equipment is distributed, someone helps precisely fit the equipment to the physiology of each worker, while a brief screening of individual risks is conducted.

This could have been done by either contractors or by a central command unit, intervening when workers were fitted for personal protective equipment or upon periodic intervals of employment.

Ground zero was ringed by seven temporary medical clinics, set up by the Federal Emergency Management Agency to care for workers, but FEMA tended to focus on traumatic injuries to the body, not to safety practices.

STAGGERING NUMBERS

The National Institute for Occupational Safety and Health estimates that 20,000 former rescue and recovery workers and volunteers need to be treated for physical or medical conditions they acquired during their work at the World Trade Center.

In a separate estimate, a task force set up by Mayor Michael Bloomberg in late 2006 found that about 10,000 former rescue and recovery workers need regular treatment, as well as about 30,000 residents, students and local workers.

Three categories of people are affected, according to the task force: New York City employees, other workers and volunteers who were at the site, and a third group not engaged in any way with rescue or recovery.

The hardest-hit are employees of the New York City Fire Department. About 3,500 active FDNY personnel need treatment. In addition, there are an estimated 800 to 900 members who elected to take disability retirement. They, too, will need some kind of treatment.

In percentage terms, it's estimated that 7 percent of FDNY firefighters need ongoing treatment for respiratory problems, 6.6 percent need mental-health medication, and 13.3 percent need counseling and medication, according to the task force.

Beyond the FDNY, which lost 343 firefighters on the day the towers collapsed, an additional, 2,600 New York Police Department personnel, 500 city workers, and 4,400 noncity workers and volunteers need ongoing treatment, according to the task force.

The task force also estimated that 250,000 local residents, workers and students were vulnerable to adverse health effects. About 6.8 percent of this group needs ongoing treatment.

Finally, it estimated that a fraction of 1 percent of all other New Yorkers needed respiratory treatment and about one-tenth of 1 percent required mental-health assistance.

So far, very few people have died as a direct consequence of the cleanup. One worker died from a fall at ground zero, and a handful of workers have died from conditions consistent with environmental exposure, such as interstitial lung disease.

So what, if any, is the physiological damage from the cleanup? It's on its way in the form of possible cancer, cardiovascular disease and other chronic diseases, according to Columbia University researcher Jeanne Stellman, who testified before Congress in March.

Stellman urged careful monitoring of cohort groups over many years to come.

PETER ROUSMANIERE is a Vermont-based columnist for Risk & Insurance®.

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September 1, 2007

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