Testimony of

Stephen M. Levin, M.D.

Medical Director

Mount Sinai – Irving J. Selikoff Center for

Occupational and Environmental Medicine

Department of Community and Preventive Medicine

Mount Sinai School of Medicine

New York, NY 10029

Before the

Committee on Environment and Public Works

Subcommittee on Clean Air, Wetlands, and Climate Change

In a Field Hearing at

Alexander Hamilton U.S. Customs House

New York, NY

February 11, 2002

Chairman Lieberman, Senator Clinton, and Members of the Subcommittee.

I am pleased to appear before you today to discuss the health impacts of the attack on the World Trade Center on September 11, our understanding of the short-term and longer-range risks to health, and a perspective on what needs to be put in place to meet the needs of the thousands of workers and volunteers who played a role in the response to this disaster.

My name is Stephen M. Levin, M.D. I am Medical Director of the Mount Sinai – Irving J. Selikoff Center for Occupational and Environmental Medicine, in the Department of Community and Preventive Medicine at the Mount Sinai School of Medicine in New York. Our Center is funded by the New York State Department of Health and is part of a statewide network of occupational medicine clinics established by the state legislature to examine and treat workers who have developed illness or injury caused by their exposures at work. We have an explicit mission – to find ways to prevent occupational illness, placing us in the domain of public health. We provided over 6,000 patient services in the last year, and since September 11^th, we have examined more than 250 men and women who worked or volunteered at or near “Ground Zero.” Most of these individuals came to us because they had respiratory symptoms that developed after their exposures there.

Our Center has long experience with the health consequences of exposures in the construction environment, and we were able, therefore, to predict, unfortunately all too accurately, what health risks were posed by the exposures at and near Ground Zero – exposures to the wide range of airborne irritants present in the smoke and dust caused by the fires and the collapse of the towers, just reviewed by Dr. Thurston. As with most cases of illness caused by environmental agents, the likelihood of developing illness and the severity of that illness depend largely on dose – how much exposure has occurred.

I want to discuss today what we have observed among adults who were exposed at the World Trade Center site. My colleague and Department Chairman, Dr. Philip Landrigan, in the next panel will talk about risks to children. Among the people fleeing the buildings, the firefighters, police, and emergency medical technicians who responded, and the citizens who tried to help after the planes hit the towers – there were many who were caught in the huge, dense cloud of dust and combustion gases released by the collapse of the buildings. These groups had some of the worst exposures, inhaling high concentrations of smoke and dust. Those who came to the Ground Zero area after the collapse, in the first days and weeks after 9/11, to perform rescue and recovery work or to restore essential services there, also had heavy exposures, as they selflessly and often heroically did what they could in the effort to save lives. The thousands of construction and support workers who have been involved in the removal of debris from the site, often working 12 hour days, sometimes 6 or 7 days a week, also had all too frequent exposures to the dusts and gases which until recent weeks were a constant feature of the site.

We were concerned that these exposures would cause respiratory tract difficulties, and that is, in fact, what we have seen clinically. Problems range from persistent sinusitis, laryngitis, bronchitis, and among some, the first attacks of asthma they have ever experienced. The problems have been especially severe among those who had respiratory problems prior to September 11 – many have noticed a marked worsening of their pre-existing sinus problems or breathing difficulties. But what is perhaps most striking is the occurrence of respiratory problems – chest tightness, cough, shortness of breath, wheezing – among individuals who were in excellent physical condition before. The experience of our patients parallels that of the firefighters who have been evaluated by Dr. David Prezant, who I believe is here today and perhaps can comment later. High rates of respiratory illness have been found among the firefighters, a group well recognized to be physically fit prior to this exposure.

Some of our patients, once away from lower Manhattan, have noticed a general improvement in their symptoms, but find that exposure to cigarette smoke, vehicle exhaust, cleaning solutions, or other airborne irritants provokes reoccurrence of their symptoms, in ways that they never experienced before 9/11. Not all who were part of the effort at or near Ground Zero developed persistent respiratory problems; some are more susceptible to the effects of such exposures than others. The difficulty is, we have no way to predict who the susceptibles are. It is very important that, in addition to preventing further exposure to irritants as much as possible, treatment with appropriate medications be instituted as quickly as possible, to prevent these conditions from becoming lifelong, disabling illnesses.

In the past 2 months, we have seen similar respiratory problems emerging among some of the office workers who returned to buildings situated in the periphery of Ground Zero, especially those located downwind from the debris pile and the fires which were actively burning until December. For most, the symptoms of eye, nose, throat, and chest irritation are transient and not of serious concern. But we have patients with new onset asthma since their return to work in nearby buildings - people who were never previously asthmatic. Fortunately, most of my patients report that their symptoms are generally improving, now that the fires have for the most part been extinguished and the airborne irritant burdens have decreased.

A clinical feature, which surprised us in its frequency and intensity, is the degree of psychological distress among the early responders. Many of our patients who came to us for respiratory problems also reported persistent flashbacks of images and sounds of human trauma and horror they had witnessed, especially early on. Police officers, construction workers, and others have had sleep difficulties, depression or irritability, and many had difficulty controlling their tears whenever reminded of what they had seen, even months after the events themselves. The group debriefing sessions that many participated in at the site was simply insufficient to help such individuals resolve the effects of this experience on their emotional well-being.

To address the specific issue of exposure to asbestos at and near Ground Zero, it is important to note that asbestos has been found in the debris at the site itself and in settled dust on surfaces in nearby buildings. Fortunately, the concentration of asbestos fiber in outside air is low, and poses a correspondingly low risk of disease. For those who work at the Ground Zero site itself, respiratory protection to prevent inhalation of asbestos fiber is necessary, and the use of such respiratory protection is the current policy for workers at the site, although compliance can hardly be described as universal. A special group at increased risk for asbestos-related illness (twenty or more years from now) are the workers engaged in clean-up operations in offices and residential buildings near the site. For the household resident or office occupant whose exposure during the cleaning of settled dust is brief, there is a very low increase in risk of illness, even if the wrong methods are used. Such risk should be avoided, and Dr. Landrigan will likely address the special risk for children in such settings. The risk to unprotected building service workers, however, who perform dust-disturbing tasks day in and day out for perhaps months is of much greater magnitude. This group requires training and protection. Many are hired off the street, are not English speaking, and are among the most vulnerable of workers. That they should have been permitted to be exposed to asbestos dust in this fashion is a public health failure.

From the perspective of what needs to be done now, our clinical experience, taken together with what has been learned from the study of the NYC firefighters, points to the need for developing a medical surveillance program for those who placed themselves at risk in the course of their efforts – whether as employed workers or volunteers. A registry of those who were present at or near Ground Zero must be established as quickly and comprehensively as possible. Medical examinations, to identify persistent respiratory, musculoskeletal, and psychological conditions should be made available to all who were there, and treatment should be initiated where findings warrant it. The longer treatment is delayed, the more difficult treatment becomes, and the less successful the clinical outcome. If resources are made available, a consortium of medical institutions under the guidance of occupational/environmental medicine expertise can be established, working in coordination with the appropriate government agencies, to provide clinical evaluations and treatment programs. I am confident that we would receive full cooperation from relevant employers and labor organizations to facilitate the development of the registry and the clinical surveillance program itself. The many workers and volunteers who have given so much of themselves deserve no less.

Thank you, and I will be pleased to answer questions.