As Levin and several other Mount Sinai doctors met in Szeinuk’s home that September 13 morning, they had no doubt that tons of asbestos had been blown into the air above and around the pulverized trade center. They figured that the asbestos also had forced its way into offices and apartments in the area, spreading the hazards far and wide. Some of the doctors understood the enormity of the disaster because they had responded to an earlier crisis at the trade center. In 1993, terrorists had filled a rented truck with explosives and detonated it in the basement garage beneath the towers. The explosion blew a hole five stories deep, killing 6 people and injuring 1,000. A team from Mount Sinai, led by Levin, had been among the first medical personnel at the scene. He had rushed to the complex with respirator masks for responders, who were engulfed in the choking smoke from the explosion and fire. Levin had helped distribute the equipment, personally fitting the masks to the responders and making sure they understood how important it was to keep the protective gear on while they were working.
With that experience in mind, Levin was ready to help again after the twin towers fell. He’d called the New York City health department and offered to distribute respirators as he had in 1993. He had no idea how many would be needed, but he was willing to transport all that he had on hand, to help fit the workers with appropriately sized masks, and to show them how the masks were to be used. But the city was slow to respond. Levin thought it odd, but he persisted because he feared that the rescuers were being exposed to great danger every minute they worked without protective gear. Several hours later, he realized that the wait had been for nothing. When the city finally came back with its answer, it was, “No, thanks.” It became clear that this incident was not going to be a repeat of 1993, although he didn’t know why: “That was a disturbing indication to me that things were different now.”2
At their first meeting in Westchester County, Levin and the other doctors hadn’t worried only about asbestos. Watching television, they’d realized that underground infernos continued to release acrid smoke laced with toxic chemicals from the plastics and furnishings in the destroyed offices. They’d seen workers wiping dust from their eyes as they struggled to remain on the pile. Levin knew there was no way people could work in that environment without coming down with acute, and maybe chronic, respiratory problems. To him it seemed tragic that victims of the horrendous attack would be followed by more victims, this time victims of exposure to the dust. Victims upon victims. Casualties after casualties. And if Selikoff’s experience with asbestos in Paterson was any guide, the problems would linger for three, four, or five decades.
The doctors vowed not to leave their meeting until they had come up with a plan. “We saw ourselves as part of the public health infrastructure,” Levin recalled. “We were a repository of expertise. We thought that we ought to sit down and talk about what we were seeing, what we thought the exposure was going to be, what the potential health consequences were going to be, and put together an advisory for the medical community on treating patients.”
They knew there were irritants in the air, not just from the smoke, but from other components of the dust, and that they were likely to trigger serious health problems. Levin, for one, had seen it before, in the 1975 telephone company fire that Prezant and Kelly also considered a watershed in the city. Years after the fire, he had examined retired firefighters who were exposed to the burning plastics in the phone company building. Some still had reactive airways dysfunction syndrome, often called irritant-induced asthma, 25 years later.
From experience, Levin and the other doctors knew that the dust released by the implosion of the huge towers was unique. Other violent events—volcanoes, earthquakes, and hurricanes—unleashed huge amounts of dust. But in an earthquake, buildings tend to topple over and the debris remains in large chunks. The towers had pancaked, each floor smashing into the one below, descending so quickly and with such compressive force that the concrete in the structures had been ground into particles so fine they could be drawn into the deepest airways of the lungs, causing lasting damage.
The doctors spent more than seven hours at the Westchester house that day, putting together a set of clinical guidelines that could walk a general practitioner through diagnosis and treatment of injured ground zero workers. They identified the likely skin rashes and outlined the high probability of post-traumatic stress, even among the uniformed responders who had been through disasters before, but never anything like this.
Levin then called the city health department again to say that the Mount Sinai physicians had prepared a clinical advisory, but that it would carry more weight and reach more doctors if the city put its name on the document and used its networks to distribute it widely. Once again, the department turned down Levin’s offer. The city was more accustomed to putting out warnings of flu outbreaks or vaccination advisories. The health department suggested that Mount Sinai post the advisory on its own website. Levin argued that doing so would have limited impact because most doctors would not be looking for it there. Reluctantly, Mount Sinai did post the guidelines on its website by December, but it had little effect and the clinic saw widespread evidence that workers were continuing to be misdiagnosed. (The health department eventually did publish its own clinical guidelines, but not until 2006. Officials said they waited until they had sufficient evidence that the dust was linked to serious and persistent illnesses.)
Snubbed a second time by the city, Levin wondered what the department’s actions really meant. “I had many friends at the department, and I could tell there was a policy being established above them that we are not going to acknowledge the health consequences and the risks of what was going on down there because we’ve got other compelling interests.” To Levin, public health did not seem to be the Giuliani administration’s overriding concern; getting the city back to business was.
Before their Westchester County meeting broke up, Levin and the other doctors decided to make the Selikoff clinic freely available to ground zero workers. The doctors agreed to take extra shifts to handle the anticipated onslaught of ill and injured. But when they returned to the city, they were in for a surprise. Levin was intent on spreading the word about the dangers. He went down to ground zero himself and attended safety meetings, urging contractors to have their workers wear respirators. The clinic’s industrial hygienists met directly with union shop stewards at ground zero, pleading with them to get tough with workers who ignored warnings about personal protection. They told the union leaders that the uptown clinic was available for workers who needed medical care and urged everyone to come in. But for the first two weeks, no one did. The office space the clinic occupied on the ground floor of an apartment building at 5th Avenue and 101st Street on Manhattan’s Upper East Side remained unnaturally quiet. Levin was baffled and began to think that perhaps he had misdiagnosed the problem and that the dust wasn’t harmful. He asked the health department if patients were being seen elsewhere. He was stung again when the official reminded Levin that the department had said things were not so bad and that the irritations he thought he had noticed on TV were simply seasonal allergies. After all, it was autumn.
Just as Levin started to wonder where he had gone wrong, the first worker showed up at the clinic asking for help. Levin had worked with the man, a health and safety expert for one of the big unions, and knew he had been healthy and free of symptoms prior to 9/11. The man had spent two days at ground zero, and now he had a range of ailments, from sinusitis to new-onset asthma. Whatever doubts Levin had about sounding the alarm were dispelled by this first patient. After him, the floodgates opened. Workers and volunteers who had put off getting help for themselves so they could concentrate on the recovery at ground zero were by now too sick to continue working or no longer felt that it was unpatriotic to worry about their own health.
As more workers filed in, the clinic cobbled together a larger staff and additional equipment. But they were soon overwhelmed. There seemed no end to the people needing help. Un
ion leaders realized that a big problem was developing. The Central Labor Council, representing the city’s biggest unions, was already concerned about the loss of jobs and all the people who would need special assistance, and fast. The council reached out to the New York State AFL-CIO for help, and the state group got in touch with Sen. Hillary Clinton. She met with the union leaders and asked them what it would take to help their members. She encouraged them to think big and ask for everything they needed now, because in six months it would be a lot harder to get the government’s attention. Ed Ott, a former health and safety officer for the Oil, Chemical, and Atomic Workers Union, knew that the trade center was about the last job in Manhattan that blew asbestos on the girders during construction. “That meant the guys were working on a toxic waste pile,” he said.3 He received a phone call from Joel Shufro, executive director of the New York Committee for Occupational Safety and Health, who was worried because so many of the workers he’d seen on television were not wearing masks. Ott knew that there was no way to get those guys off the pile while there was a chance of rescuing anyone still alive in the rubble. “They were in crisis mode,” he said. Afterward, though, when it would become a recovery and cleanup operation, he expected there to be a need for clinical services and a way for workers to undergo baseline examinations to track any spike in ailments. It wasn’t going to be enough for them to simply go to their own doctors if they felt ill. They’d need to come to a centralized location, whether or not they felt sick, so doctors trained in workplace hazards could check them out.
A long and mutually beneficial relationship had developed between the Selikoff Clinic and New York’s unions. It initially arose because of Selikoff’s asbestos research, and it expanded and matured under the guiding hand of Dr. Philip Landrigan, another Selikoff protégé and a pioneer in environmental and occupational medicine. Landrigan, a long-distance runner whose Jesuit education at Boston College left him with a quietly philosophical bent, became a prodigious researcher himself. After graduating from Harvard Medical School, he trained in pediatrics but also showed an interest in occupational medicine. He joined the Centers for Disease Control’s Epidemic Intelligence Service and later went to Cincinnati to work with the National Institute for Occupational Safety and Health (NIOSH), a new arm of the CDC whose focus was the workplace.
Selikoff had helped clear the way for this new field and drew some of its earliest criticism. After his work with asbestos, he and others concerned about workplace safety did not want to be in the position of having to study linkages between toxins and diseases after they had already caused widespread suffering. Waiting until the diseases can be linked with medical certainty to exposure left the medical research community sitting on the sidelines while people died. The complex links between environmental contamination and disease are extremely difficult to prove with any degree of certainty, a situation not unique to occupational medicine, but one that brings the field a greater degree of scrutiny than other areas of medicine. The economic consequences for industries involved can be great. That sets up a high-stakes struggle that often gives the advantage to employers. Occupational disease specialists realize that, to get out in front of a problem, they need to urge limits on exposure before links can be proved definitively.
To put protective measures in place to avoid future health problems for employees, researchers have to gather enough scientific evidence to support a logical hypothesis about the connection between hazardous substances and certain illnesses. Making such links is not always an exact science, but it can prove invaluable if workers can be protected from disease.
Occupational medicine often pushed back the frontiers of medical knowledge, understanding that waiting for fail-safe proofs can be a death sentence for workers. Certainty is sometimes a luxury they cannot afford. Doctors in the field are constantly forced to walk the line between conclusive proof and informed guesses, between guarded warnings and alarmism, between science and advocacy. Epidemiological research can show the relevance of increased disease in a group of workers exposed to a certain contaminant. But it cannot so easily explain why an individual worker got sick. With his Jesuit training, Landrigan knew it was a fundamental epistemological problem, and one that big corporations—led by the tobacco companies—would always cite in their defense. In their work, the Selikoff clinic doctors staked their reputations on well-accepted criteria such as the consistency of their findings to substitute for absolute scientific certainty. The clinic’s doctors also were willing to testify on behalf of injured workers who qualified for workers’ compensation. These aggressive efforts to help workers forged bonds of trust with labor unions and made corporations—and sometimes government agencies—suspicious.
When Selikoff grew older and gave up administrative duties at the hospital, Landrigan was lured back from NIOSH to take over Mount Sinai’s Division of Occupational and Community Medicine. He got to meet Selikoff there because the division oversaw the one-afternoon-a-week occupational health clinic where he saw patients. Dr. Ruth Lilis, a pulmonologist, had started the clinic in 1973 and spent the next three decades at Mount Sinai. After six years as head of the Occupational Epidemiology Program in Cincinnati, Landrigan arrived at Mount Sinai in 1985 with a firm commitment to occupational and environmental medicine, and a goal of expanding the work of Selikoff’s clinic. But he needed to devise a way to pay for this greater role. Landrigan approached the state legislature, buttonholing Frank Barbaro, the powerful head of the assembly labor committee. Barbaro convened a public hearing about occupational health, and Landrigan testified that there was a great unmet need in New York. Barbaro proved to be sympathetic but unconvinced. He told Landrigan that he was uneasy about moving forward without proof of how big a problem the state had. They settled on a compromise, a $100,000 one-time grant that allowed Landrigan to document the extent of occupational disease in New York. Landrigan’s final report produced startling conclusions. He estimated that there were 35,000 new cases of occupational disease a year in the state, some so serious that they led to as many as 7,000 deaths annually. Landrigan’s task force calculated that the cost to the state of the top five occupational diseases was $600 million a year.
The approach worked, and when Landrigan returned to the assembly in spring 1987, he had already pulled together a large and powerful coalition of elected officials and labor leaders with the political weight to get the state to act. The legislature voted to create a statewide chain of occupational health centers, funded through yearly appropriations and coordinated through the New York State Department of Health. The head of the program who oversaw the new clinics was Dr. James Melius, an epidemiologist who had replaced Landrigan at NIOSH. (The two would work together again in the aftermath of 9/11.)
After so many years with government, Landrigan knew how dangerous it would be to rely solely on annual legislative appropriations. He rejoiced in having convinced the legislature to create the clinics, but he worried that legislative fiat could choke off any chance of success. Without long-term funding, it would be difficult for the new clinics to hire doctors, buy expensive medical equipment, or find reasonable space to rent. The legislature came up with a unique solution. It decided to tap the worker compensation premiums paid by employers and divert a small percentage of the money to the clinics. The one at Mount Sinai, named in honor of Selikoff, was, and remains, by far the biggest. The main clinic, and a series of satellite offices, receives about $2.5 million a year from the state, which is supplemented by funds received for providing clinical services.
The Mount Sinai clinic was able to jump in the way it did after the September 11 attack because of the bond that it had established with labor and because of the work it had done with the unions over the previous two decades. No other medical setting in the country may have been so well suited to respond to the unprecedented conditions at ground zero, and certainly none enjoyed greater confidence from the workers themselves. The Selikoff clinic was the biggest occupational health center between Boston and Wash
ington. It was a leading research center in the field, and it had trained an entire generation of residents and fellows. Many of the ground zero workers who came to the clinic after 9/11 had been there before. They trusted Levin and the other doctors and agreed to be screened and tested by them. Many shared the same set of interlaced conditions—sinusitis, trade center cough, acid reflux, reactive airways problems—and worried about what was happening to them. This cascade of problems made them miserable and portended worse in the future.
By November, Landrigan’s concerns about the potential health threat of working at ground zero had grown more urgent. In an article published in Environmental Health Perspectives, a scientific journal, he wrote that asbestos is “a major threat to the health of workers at the World Trade Center site,” despite pronouncements from the EPA that the majority of dust samples the agency had collected did not contain dangerous levels of asbestos. In his article, Landrigan raised the specter of long-term health risks that included lung cancer and malignant mesothelioma. “Protection against these risks requires the provision of proper respirators to workers and the undertaking of health and safety training programs that emphasize the need for constant wearing of respirators, for proper fit testing, and for frequent changing and cleaning of filters.” Landrigan also was one of the first to publicly call for a formal registry of workers at the site to keep track of who was there, when they arrived, and how long they stayed—all factors that would undergird later studies. He pointed out that baseline chest x-rays, establishing a worker’s state of health at the time, would make it possible to accurately measure the effects of exposure to the dust, and he urged that blood samples be tested for PCBs, dioxins, and other toxins. Landrigan’s long history in the field of occupational medicine guided him; he was both looking back on the way other exposure issues had been handled in the past, and flipping forward to anticipate what hard data he and others would need to make their case if the dust turned out to be as harmful as they feared.
City of Dust Page 13