In severity of illnesses after 9/11, training made a difference, researchers say
A growing body of research shows that most 9/11 workers developed a combination of adverse physical and mental conditions, but those trained for disaster work fared better. Thousands of rescue, recovery, and clean-up workers were exposed to risks and pressures that went uncontrolled and unevaluated. Jeanne Mager Stellman, Ph.D., a Columbia University Mailman School of Public Health professor emerita, has worked to assess the results of their exposure.
Stellman has been part of a team from the Mount Sinai Medical Center that coordinated one of three World Trade Center Medical Monitoring and Treatment Programs. Although people vary in their response to trauma, Stellman’s research shows that the degree to which workers developed adverse mental and physical conditions—and their severity—depended in part on how prepared they were in body, mind, and experience.
Those who were better prepared tended to fare better with the long hours, strenuous and chaotic working conditions, unpredictable physical risks, and stress of handling body parts and personal effects of victims. For example, construction workers were more affected by the trauma than police officers and firemen, even though the latter two groups suffered more fatalities. While it is not possible to preselect most characteristics that lead to resilience, Stellman found that adequate training can make a difference in workers’ experiences at a disaster site.
Roughly 92,000 people with different skills and backgrounds worked together on rescue, recovery, and cleanup operations during the six months after 9/11. They included traditional first responders like firefighters, police, and paramedics, as well as construction, utility, and public-sector workers. In addition to smoke from fires that burned until December 14, according to the National Institute for Occupational Safety and Health, the workers were immersed in thousands of tons of dust-like debris from the sudden disintegration of 6 million cubic feet of masonry, 5 million square feet of painted surfaces, 7 million square feet of flooring, 600,000 cubic feet of window glass, and countless roomfuls of interior furnishings, business documents, and personal belongings.
Stellman and the Mount Sinai team found that most workers were emotionally affected by what they experienced. In one of their analyses, workers’ answers revealed some of their memorable experiences. Seeing and working with body parts was significant for many. “[I] put bodies into body bags,” one first responder said. “Worked with [my] hands. Seen expression on faces of people buried alive.” Another phrased it differently, “Saw entire jet engine, arm, leg—No way of escaping it—felt like Armageddon—Pools of blood, arms, legs.”
The smell was salient for many. They generally identified it with dead bodies, even though bodies made up a small portion of what they were inhaling. As one first responder said, “Worked on the pile. Bucket brigade. Smell overwhelming. Picked up body parts.” Another noted that he “Saw body parts, the smell of death everywhere.” Yet another remarked, “I hope I never have to smell that smell again.”
Even people experienced with trauma noted the scale. One police worker said, “Worked on homicides for many years, but never saw anything like this. Beyond anybody’s imagination.” He added, “Also had to work at plane cash site in Queens—easier than WTC ‘cause actually found intact bodies.” As one military veteran said, “Picking up body parts and taking them to temporary morgues. Worse thing I’ve seen and I’ve been in combat.” Another military veteran said that being at the site caused flashbacks; “Looked like a battleground. Was in Vietnam. Marine corp. Flashbacks of Vietnam.”
The result of experiences like these is that of the 10,123 workers who completed one of the Monitoring and Treatment program’s questionnaires, more than 6,200, or 62 percent, met the criteria for substantial stress reaction.
Those with substantial stress reaction have a moderate or higher level of at least one of 17 symptoms on a standard PTSD checklist. Typical symptoms are intrusive and unwanted memories, nightmares, difficulty sleeping, irritability, outbursts of anger, trouble concentrating, being upset by reminders of the trauma, and being alert, watchful, or on guard.
For more than 4,500, or 45 percent, the symptoms lasted for as long as five years. For Stellman, these types of results show that “Working in 9/11 recovery operations is associated with chronic impairment of mental health and social functioning.”
The second most common stress reaction was PTSD. At 11.1 percent, Stellman says that PTSD prevalence in the workers is comparable to that in U.S. war veterans. This number is higher than the three to four percent found in the U.S. adult population. Of those with PTSD, Stellman reports that 50 percent also had panic disorder, depression, or both, as well as more than double the risk for an alcohol problem and more than 17 times the risk for social disability.
Stellman points out that most research and clinical studies focus on conditions like PTSD, depression, and panic disorder because they qualify as psychopathologies or psychiatric disorders. Substantial stress reaction is not considered to be severe enough to count as a psychopathology or psychiatric disorder, so tends to be overlooked, leaving large numbers of symptomatic people out of many programs.
Stellman says that those with substantial stress reaction would benefit from more attention and treatment. She cautions that by ignoring so many workers with substantial stress reaction, researchers and clinicians are missing a major mental-health problem; “focusing attention only on probable psychiatric disorders markedly underestimates the full psychological burden and its social ramifications.”
Stellman and the Mount Sinai team found that psychological problems usually accompanied physical ones. “It will be essential in future environmental disasters,” Stellman says, “to understand that mental health problems will certainly accompany effects of toxic exposures on physical health.”
She points out that when both mental and physical problems are present, they tend to play off each other. For example, an asthma attack can bring on an episode of PTSD, and the reverse.
According to their findings, the types and severity of workers’ illnesses varied depending upon the combination of training, experience, and history they brought to the site. How prepared they were to handle the stress of their work affected how they fared both mentally and physically. Stellman says, “life is a set of complex exposures and complex relationships, and any exposure is going to be exacerbated by the stress a person is under.”
Although it is not well understood, the interactions between stress, trauma, and the environment workers are exposed to can, according to Stellman, “contribute to the development of a wide range of medical conditions, including cardiovascular, pulmonary, gastrointestinal, and autoimmune disorders.”
For 9/11 workers, experience and training made a difference to stress levels that can affect health outcomes. “Construction workers probably suffered the most,” Stellman says, “because they lacked the training, experience, coping skills and support.” They chose a line of work dealing with rivets and dry wall, not body parts. Police, firefighters and EMTs were self-selected in the sense that they had already chosen and survived in a stressful line of work. They also received more training and had support groups in place.
For Stellman, “events like 9/11, Fukishima, and war call upon ordinary people to do extraordinary things, and eventually some are going to pay a high price for doing the job in front of them,” but the proper training can help to reduce that price.
