Health legacy of 9/11: Respiratory, emotional complaints persist among those exposed

Protocols created to help responders now ill; many scattered across U.S.

The question, "Were you exposed to the World Trade Center disaster?" is probably not what you typically ask when conducting a risk assessment or patient history. But if the person you are interviewing complains of respiratory symptoms or reflux disease, or if mental health problems or substance abuse disorders are present, and the person might have been living or working in New York on Sept. 11, 2001, it is a question you should add to the list.

Five years after the terrorist attacks, New Yorkers and others throughout the country still experience World Trade Center-associated physical and mental illness, according to the New York City Department of Public Health and Mental Hygiene (NYCDPH). NYCDPH has developed guidelines for health care providers to suspect, diagnose, treat, and refer patients who are suffering ongoing physical and emotional consequences of exposures to the terrorist attack.1

The New York guidelines were released in September 2006, and placed on the department's website because health officials know that hundreds of people who were exposed to the World Trade site are scattered across the country. (See Key Occupational and Residential Exposure History Questions, in the box below.)

Key occupational and residential exposure history questions

Ask: "Were you exposed to the World Trade Center disaster?"

If patient answers yes, ask further questions regarding the nature and duration of exposure, such as:

1. Were you showered by the cloud of debris and dust when the towers collapsed?

2. Were you in Manhattan on the streets near the World Trade Center at the time of the impact of the planes, the collapse of the towers, or shortly afterwards?

3. Did you work or volunteer at the World Trade Center site providing rescue and recovery, cleanup, construction, or support services, or at the World Trade Center Recovery Operation on Staten Island or on a barge? What tasks did you perform? Did you consistently use a respirator? If so, describe what kind.

4. If you lived, worked, volunteered, or attended school in lower Manhattan in the months after September 11th, what was the condition of your home, work, or school?

5. Are there other WTC-related exposures that concern you?

Source: New York City Department of Public Health and Mental Hygiene, Clinical Guidelines for Adults Exposed to the World Trade Center Disaster, 2006.

Lingering health price of 9/11

Hundreds of thousands of people in Lower Manhattan on 9/11 were exposed to the dust, smoke, gases, and airborne debris created by the crash of the airliners into the towers, the fires, and the subsequent collapse of hundreds of tons of building material when the towers fell. Added to that, an estimated 40,000 rescue and recovery workers were exposed to caustic dust and toxic pollutants following the attacks, and thousands of workers and volunteers have since had respiratory and other health problems, according to experts.

Most were from the New York area, but many came from all over the country to help. Military reservists, nurses, physicians, firefighters and paramedics, construction and utility workers, police, and members of countless volunteer organizations were in and around the disaster sight in the months following. Documenting the exact number of people who were at the World Trade site on 9/11 and in the days and weeks following the attack is nearly impossible, officials say, because of the number of people and agencies who responded.

The rates of responders' symptoms and pulmonary function abnormalities correlate to how early they arrived at the site. Those who were there at the time of the attacks and tower collapses, or who arrived shortly thereafter, suffered the heaviest exposure.

More than 70% of responders who have sought screenings at Mount Sinai arrived at the site between Sept. 11 and Sept. 13. Within weeks, many were complaining of upper respiratory irritation.

Later, between July 2002 and April 2004, nearly 70% of the nearly 10,000 World Trade Center responders examined at Mount Sinai School of Medicine reported new or worsened respiratory symptoms, according to a study released in September 2006 by Mount Sinai researchers.2

Mount Sinai has conducted medical and mental health programs serving 9/11 responders since 2002. The study details findings from the World Trade Center Worker and Volunteer Medical Screening Program coordinated by Mount Sinai since 2002. The program is the largest multicenter effort to examine people who worked and volunteered at the World Trade Center and other 9/11 sites.

The illnesses have persisted, the report found, and, in some cases, at rates far exceeding normal rates. Emergency responders who have been administered pulmonary function tests have shown abnormalities at twice the rate found in the general population. Researchers point out that before the attacks, the workers who went to the World Trade recovery site were mostly strong and healthy and were not already suffering from the conditions they began experiencing afterward.

"World Trade Center cough" is now a recognized complaint seen at Mount Sinai and clinics that treat responders; some responders still report coughing up black particles inhaled at the site. Those treated, and whose cases are monitored by Mount Sinai and the National Institute for Occupational Safety and Health, have reported respiratory symptoms (e.g., laryngitis and sinusitis); lower respiratory disorders such as asthma; depression and post-traumatic stress disorder; and musculoskeletal complaints. (See Potential World Trade Center-Associated Conditions, in the box below.)

Potential World Trade Center-Associated Conditions

Inhalation or ingestion of dust and fumes at the World Trade Center affected the mucous membranes of the nose, sinuses, pharynx, gastrointestinal tract, and respiratory tract. The symptoms and signs of these conditions include:

  • Sinus, nasal, and postnasal congestion
  • Heartburn, hoarseness, and throat irritation
  • Shortness of breath and wheezing
  • Chronic cough

Some clinicians have described a syndrome consisting of a triad typified by:

  • Upper airway cough syndrome (postnasal drip syndrome)
  • Asthma/reactive airways dysfunction syndrome (RADS)
  • Gastroesophageal reflux disease (GERD)/ laryngopharyngeal reflux disease (LPRD)

Source: New York City Department of Public Health and Mental Hygiene, Clinical Guidelines for Adults Exposed to the World Trade Center Disaster, 2006.

In releasing the Mount Sinai report, one of the researchers urged anyone who worked at the World Trade site on or after 9/11 to be screened.

"It is important that those who gave so heroically in the aftermath of the disaster be assured that they will be able to get all the medical care they need," says Philip J. Landrigan, MD, chair of Mount Sinai's Department of Community and Preventive Medicine.

According to the NYCDPH, construction debris, cement dust, glass particles, tar, cotton and asbestos fibers, and soot filled the air. Respirators were in short supply, and the paper masks that were available provided inadequate protection.

The Mount Sinai report describes the amount of particles that were inhaled by people in Lower Manhattan as lifetime doses.

And the effects might not be fully known, health experts say. They have not ruled out the possibility of World Trade Center-related cancers, and the effects on children who were in schools in the area of the attacks are still being determined.

Screening those who were there

Health officials, many alarmed at the growing number of health complaints arising or worsened in people who were at the attack sites, have long demanded the government develop protocols for health care workers, pointing out that standardized guidelines can lead to suspicion of conditions that otherwise might escape detection.

For example, those at the Ground Zero site are not the only group the NYCDPH says should be considered vulnerable to post-9/11 health effects. Other groups include:

  • Being caught in the dust cloud on 9/11;
  • Dismantling damaged building structures in the surrounding rubble, or handling World Trade Center debris without adequate protection;
  • Cleaning affected commercial and residential buildings in lower Manhattan;
  • Cleaning or reoccupying homes covered in dust;
  • Being exposed to high levels of dust or smoke while restoring services in lower Manhattan.

Thus, just because someone is an electrician in Los Angeles today does not preclude exposure to 9/11 illness.

Emotional effects of the terrorist attacks on New York and Washington also continue to surface and be identified, the NYCDPH guidelines point out.

More than one in ten (11%) of those seeking treatment at Mount Sinai screened positive for serious psychological distress, the medical center's report indicates.

People who were injured in the collapse of the buildings, who witnessed the injury or death of others during the attack, or who were involved in the rescue and recovery efforts, experienced considerable psychological stress and direct trauma, New York health officials say. Indirect trauma may also have resulted from the loss of a loved one or from constant exposure to graphic media coverage of the attacks.

World Trade Center-related physical illness or economic hardship may also have caused psychological stress. For most individuals, acute stress symptoms abated quickly, within a month, but some developed disorders such as post-traumatic stress disorder (PTSD), depression, generalized anxiety disorder, or substance use disorders.

Health care providers can serve an important role in the identification, evaluation, treatment, and referral of trauma-related mental health disorders, Landrigan says. Medical and mental health providers should:

  • Be alert to risk factors and signs that may indicate one of the identified World Trade Center-related disorders;
  • Establish a trauma history and screen for mental health disorder risk factors;
  • Assess for symptoms of PTSD, depression, anxiety disorder, and substance abuse disorders;
  • Educate patients about normal stress reactions;
  • Diagnose/manage/refer conditions consistent with treatment guidelines.

For those outside the New York area, the nationwide network of the Association of Occupational and Environmental Clinics ( offers medical screenings for 9/11 workers.

For more information:

1. Friedman S, et al. Clinical guidelines for adults exposed to the World Trade Center disaster. City Health Information. 2006;25:47-58. Available online at

2. Herbert R, et al. The World Trade Center disaster and the healthcare of workers: Five-year assessment of a unique medical screening program. Environ Health Perspect (online). Available at

Mount Sinai Medical Center, World Trade Center Medical Screening Program. Information online at