As these grim thoughts ran through his mind, he suddenly came to the kind of conclusion that only a doctor could reach in such a situation. For someone who was buried and suffocating, he thought, he was taking an awfully long time to die. He was no firefighter, but he’d been to many fires. Rescuers had often told him that the secret to staying alive in a collapse was to find a pocket of air. Anticipating that he would be completely buried by debris, he struggled to his hands and knees to create what he imagined to be a reservoir of air. The pulverized contents of the building kept falling as he struggled to protect his life-saving air pocket. The air around him had turned thick with dust. It coated his eyes and nearly blinded him. He breathed in jagged particles that burned his throat. He coughed so hard he thought he would suffocate. His mouth was filled with the remains of the pulverized building that just seconds before had towered over him.
Then it was quiet. He tried to move, and when he did, he felt something strangely solid over him. Two pieces of paneling from the destroyed offices had fallen near him, creating a lean-to that deflected debris. He pushed off the boards and took stock of his condition. His head hurt. So did his right leg. His back felt like he had been worked over with a tire iron. But what bothered him most was not the pain. It was pitch black, and he couldn’t see a thing.
Prezant feared that he had injured his eyes. He knew it was morning, but he couldn’t see the sky at all. The air was thick with material, like a charcoal paste, he later remembered it. He thought he might be buried inside a crevasse beneath a much larger mound of debris. Or perhaps the falling material had created a tunnel around him, blocking out the light but somehow miraculously keeping him alive. He tried to orient himself, retracing where he had been when he’d been knocked down. Remembering that he had been heading toward the river, he tried to move in that direction, out of the tunnel and into the light.
Later Prezant would watch videotapes of the dust cloud roiling through the streets of lower Manhattan. As a lung specialist, he knew that the unusual nature of the dust that he—and all the firefighters—had been exposed to carried risks. What they inhaled and, because of the extraordinary density of material in the air, what they had swallowed, how it tasted, how it made breathing nearly impossible and triggered a choking cough—all were factors he would take into account as he tried to figure out what effect the dust would have on firefighters. And he knew firsthand what it had been like, because he had been there with them.
Kelly also had avoided death. She had been caught in the dust cloud just as a firefighter had pushed her into the protective cover of a building entrance. Her eyes had burned horribly, but her cough was minimal. Unlike Prezant, who had no personal connection to the department and had grown up with no passion for firefighting except childhood curiosity (his mother told him the two places he’d always ask to be brought to as a child were the Bronx Zoo and the neighborhood firehouse), Kelly descended from a long line of firefighters. Her grandfather had been a chief, her father was a retired lieutenant, her brother was a dispatcher, and other relatives were still on the job working as firefighters. Because of her sensitive nature and her obvious care for their well-being, firefighters fondly referred to her as Mother Theresa. She, too, had noticed the extreme density of debris in the air and had worried about its impact on firefighters. To her, it seemed like a blizzard, when the air is so thick with snow that all the light and sound is absorbed and all that’s left is an opaque, muffled undertone. Near-silent and near-dark, the air suffocated her. The dust blinded her. The silence confounded her.
In the smoky aftermath of the collapses, the two physicians managed to meet up near the Staten Island Ferry Station just south of the trade center. They joined a handful of fire officials and worked their way back uptown. As they trudged north, they ran into a straggling army of dust people, office workers in ties or smart skirts, completely dusted with chalky powder from head to toe. Dazed, some were in shock; most were silent. The doctors could do nothing for them, so they kept moving north. They passed a Korean grocery store that had not closed. The shopkeeper was tending his shelves as though nothing extraordinary had happened. Kelly took the hose he used to water flowers and washed out her eyes. They then headed north again, quickly coming to an open hardware store where Kelly found a working telephone. She reached her mother and asked her to phone her husband and Laura Prezant to tell them that, despite what they were watching on television, both of them had somehow survived. They continued up Broadway to an office building opposite City Hall Park, where they set up a makeshift triage and urgent care center in the lobby and supplied it with medicine and bandages from an adjoining drug store. Several hours later, a fire department official urged them to move somewhere safer. The chiefs were increasingly concerned about 7 World Trade Center collapsing. Prezant resisted. He’d already relocated once. But the medical team was eventually convinced that it wouldn’t be safe to stay there. They moved the medical equipment across the park to the main building at Pace University, near the Brooklyn Bridge (the location of the original swamp that was home to the leather industry in New York, including Joel Kupferman’s Worth Leather). When 7 World Trade Center came down, the dust plume quickly spread through lower Manhattan, crossed the gently curving paths of historic City Hall park, and reached the steps of Pace.
Prezant had set up his triage center inside, anticipating a long line of severely wounded who never came. The medical team worked for long hours, treating many survivors with irritated eyes, persistent cough, and some with mild wheezing. By early evening, the doctors and nurses had completed countless eye washes but had not treated more serious injuries. At 9:30 p.m., Prezant and Kelly ordered the lights out and the doors shut.
That was just the start of their long medical mission. When the cough Prezant developed that first day did not go away, he suspected something was not right. The human body has built-in defenses that protect it from airborne contaminants. Under most circumstances, those systems function well. But on September 11, the staggering amount of dust in the air overwhelmed those natural filters just as they had clogged air monitors around the site. People were forced to breathe through their mouths, but as they gulped for precious air, they swallowed the swill floating around them. Large particles normally are trapped in the upper airways, where they can do short-term harm before being expelled. But this was different. The tremendous concentration of foreign material in the air and the all-out effort by the rescuers meant that, as they breathed hard, they pulled the larger particles deeper into their lungs and, for some, into their stomachs.
At the end of that first chaotic day, Prezant was disappointed. Unlike the unnamed hero doctor of 1993, he had not rescued anyone. But his time would come. Being buried by debris and engulfed by dust gave him invaluable insights. “I thought I had done nothing, but by being there, I had experienced the fear and the stress, but also the inhalation, [that the firefighters themselves had lived through].” He had a glimpse of what it was like for them, and now, like them, he had a deep, stubborn cough that was lasting far longer than expected.
Knowing that exposure to such an intense burst of contamination could lead to trouble, Prezant treated himself with inhaled steroids. After the pharmaceutical company AstraZeneca supplied Budesonide inhalers, he offered the same treatment to every firefighter willing to take it. More than 2,700 signed up, but most dropped out right away. Some started but stopped after a day or two when they saw that results were not immediate. Others may have been scared off because they confused the medications with anabolic steroids. Only 158 stuck with the program for the full four weeks of treatment. A subsequent analysis, funded by the drug company and conducted by Prezant, showed that although corticosteroids should not be used in place of adequate respirators, those who tried the medication had better lung function and quality of life 18 months after 9/11 than those who hadn’t used it.1
Prezant’s own health issues were not dictating the course of treatment he prescribed for the department, but his health d
id make him much more aware of what the responders were going through. And that, combined with the medical evidence he was collecting as the burly firefighters, most of whom had been in peak physical condition before 9/11 (documented in the regular physicals they underwent), came to him weakened by a nagging, dry cough, led him to the early conclusion that this should be treated as an exposure incident instead of as a fire.
In the first weeks after the attacks, as Prezant continued to see firefighters with disturbingly similar symptoms, something bothered him. If EPA tests were showing only trace levels of hazardous material, why was the cough persisting for so long? He suspected that he was missing something, but what?
Something else weighed heavily on his mind. Both he and Kelly had for years dealt with the unfortunate legacy of an earlier tragedy that was deeply troubling to the city’s firefighters—and to firefighters around the world. In 1975, a fire had broken out at a telephone company switching station at 13th Street and Second Avenue in downtown Manhattan. In the 11-story building, miles of cable wrapped in polyvinyl chloride had carried the immense volume of calls into and out of the financial district. The fire had been started by a short circuit or arc at an open splice in the PVC cable deep in a basement vault. It then had spread up to the main distribution frame on the first floor, spewing acrid smoke and dangerous gases. Firefighters had been exposed to the smoke throughout the 16 hours it had taken to bring the fire under control.
“Every firefighter is 100 percent certain that everyone who fought the telephone company fire died, and nothing anyone can say can convince them otherwise,” Prezant commented. Self-contained air tanks had not been widely used in the 1970s, and the fire department’s medical staff was not as attuned to the dangers of chemical exposures as it would become in later years. No coordinated screening and monitoring program had been established following the telephone company fire. Prezant and Kelly had tried to reach out to survivors in the mid-1990s, without much success. “Because there was no testing, and no monitoring, there are no answers,” Prezant remarked. Without data, the belief that everyone exposed to the smoke had been poisoned by it and eventually died of cancer had become widespread. But the rumors were undoubtedly worse than the facts. Prezant concedes that some firefighters did die from cancer and emphysema—but how many, no one could tell. Proving that it was the chemicals unleashed by the telephone company fire instead of by other fires in an area of the country that already has elevated cancer rates turned out to be nearly impossible, given the absence of careful study.
That 1975 disaster and its aftermath had stoked mistrust between the rank-and-file and the department that Kelly and Prezant worked hard to overcome. In 2001, facing a new disaster, they had many questions and faced many uncertainties. But they knew they could not afford to repeat the mistakes of 1975. They had to have data. They had to give reliable answers. “Dr. Kelly and I heard about this a million times, and we did not want that to happen again,” Prezant recalled. Within a week of the 2001 attacks, they began to consider options for dealing with the persistent cough and whatever else might come at them. Kelly was also extremely concerned that because of the horrors they had witnessed at ground zero, firefighters would be especially vulnerable to post-traumatic stress disorders (PTSD).
The doctors decided to see firefighters at department headquarters in Brooklyn and geared up to receive significant numbers of them. They stockpiled medicine and began to develop treatment protocols. With the help of the International Association of Firefighters, Kelly and the director of her department’s counseling unit, Malachy Corrigan, recruited mental health counselors to supplement their small staff, anticipating an influx of firefighters needing help. But hardly anyone showed up. Firefighters still believed there were people to be rescued, and that left little time for taking care of themselves. Still, a few did straggle in, and their conditions showed that something definitely was wrong. Those initial impressions convinced the doctors that they needed a comprehensive medical monitoring and treatment program for everyone. But first they needed to get the fire department brass on board, including the nonuniformed fire commissioner, who deals directly with City Hall.
“Dr. Kelly and I went to see Tom Von Essen, who we had previously worked closely with on a variety of health and safety efforts,” said Prezant. “We told him that we have to have this monitoring program.” Von Essen, Mayor Giuliani’s civilian Fire Commissioner, thought it was the right thing to do, but he anticipated what City Hall and others might ask: Why was monitoring necessary, and wouldn’t it imply that the dust was dangerous, contradicting what the EPA and the mayor were saying? Those who were less interested in firefighter health and safety than those at headquarters might ask why the department should go out of its way to look for problems. Kelly and Prezant reminded the commissioner of the telephone company fire in 1975. “The fire department didn’t look then, and the message that came out was that 100 percent of the people there got cancer,” Prezant told him. He argued that even if, by actively looking for symptoms, they found that 10 or even 50 percent of the firefighters had come down with some illness (a highly unlikely possibility), it would still be far less than the perception created by the phone company fire, which was that the smoke had killed everyone. He firmly believed that the facts would turn out to be far less frightening than the rumors.
Von Essen found this argument persuasive and convinced Giuliani to back this ambitious effort. Kelly and Prezant then had free rein to advocate for a monitoring and treatment program, and they convinced everyone that they were acting directly on behalf of the mayor, which was a slight exaggeration. Kelly spoke before Congress, and Prezant before the International Association of Firefighters. Both met with the Federal Emergency Management Agency (FEMA) and the National Institute for Occupational Safety and Health (NIOSH). They convincingly argued that they had the credibility and experience to make such a program work. A strong point in their favor was that only the fire department had medical data, including pulmonary function tests, that predated the September 11 attacks. Comparing those records with current data would be the key to objectively determining the impact of the dust and using that information to create a medical program that could actually help firefighters. Before long, they applied for and received help from the Centers for Disease Control (CDC) that amounted to $4.8 million over two years. Although the funding didn’t actually arrive until December, Von Essen had the monitoring begin in October 2001, giving the fire department a monitoring and treatment program with full management and union backing long before anyone else.
Two important decisions were made at this initial stage that would significantly improve the data coming out of the department down the road. Kelly and Prezant convinced the CDC that, in addition to covering active-duty firefighters, the monitoring needed to include retirees. This later became a crucial aspect of the program, as thousands retired or went out on disability after the ground zero cleanup ended. The only way to come to any conclusions about causality was to follow the firefighters for a long time, including the years after they retired and left the job. The second critical step came when the CDC agreed to provide advanced biomonitoring, something the FDNY wasn’t equipped to do. Prezant was concerned that, in the first hours after the buildings were struck, there had been no active air monitoring. Conditions for firefighters on the pile at that time were believed to be the worst experienced by any recovery workers, and the physicians were worried they may have been exposed to a brew of deadly chemicals that no air sampling had captured. The federal government agreed to do the tests. Blood and urine samples were taken from 321 firefighters who came in for help during the first four weeks. The samples were shipped to the CDC daily and were analyzed for heavy metals, dioxins, and PCBs. When the results came back, none exceeded what are considered safe thresholds. That provided important insights into the hazards present at the site, which came into play later when the federal government assembled a larger screening and monitoring program at a consortium of hospitals,
including the Mount Sinai Medical Center. Because those early samples did not detect any heavy metals, it was decided that the consortium didn’t need to test for them, a step that helped keep costs in check and freed up dollars to screen a broader range of people.
The testing also underscored another aspect of the scientific response—the importance of administering the right test and of understanding how to interpret the results. Early in 2002, the New York Daily News reported that the Port Authority had found elevated mercury levels in the blood of four out of ten Port Authority police officers. The results led the city’s Department of Environmental Protection to threaten to shut down the site completely until the source of mercury could be isolated. There was conjecture that it came from the thousands of fluorescent light bulbs in the buildings. The site never was shut down, and the mercury scare soon faded as calmer heads pointed out that the proper test for environmental mercury exposure was urinalysis. Blood tests pick up mercury that occurs within a few days of exposure, and the mercury usually comes from eating fish. The fire department had done the more reliable test, urinalysis, and did not find mercury to be an issue of concern.
When the blood and urine samples from the 321 firefighters were compared with samples from others who had not been at ground zero, analysts found troubling results. Although so little time had passed, the firefighters showed trace amounts of nine different chemicals of concern—mostly, the scientists believed, components of the raging fires called polycyclic aromatic hydrocarbons. In and of themselves, the chemicals would not have been a concern in such low concentrations. But doctors were worried that these were signs of far worse things to come. They also had stumbled on what would eventually become a central tenet of the investigation, the string they would use to hold it all together. In most studies of environmental exposure, a key factor is dosage, the amount of time each individual is exposed to harmful material. Simply put, the more exposure, the greater the risk. Prezant believed that work records would show the amount of time firefighters had spent at ground zero, which would then permit him to calculate exposure. But he was disappointed to find that, in the utter chaos of the days right after the attack, uniform work records were far from error-free and were not suitable for use in the studies he needed to do.
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