How U.S. Learned the Wrong Health Lessons From 9/11
By Brandon Keim
September 9, 2011
In the fall of 2001, the United States was confronted by
two major public health challenges: the anthrax mailings
and threat of a biological attack, and the subtler but
ultimately more harmful plume of toxic dust that that
rose from Ground Zero. The country was prepared for
In the months and years that followed, bioterror proved
to be the easier threat to confront, or at least to
spend money on. The plume's damage was harder to
address, not least because government officials
prematurely insisted on its safety. In both cases, one
theme is universal: The wrong decisions were made, and
lessons have been incompletely learned.
"I keep getting asked: Are we safer today than on 9/11?"
says Laurie Garrett, the Pulitzer Prize-winning author
of I Heard the Sirens Scream, a new book on 9/11 and its
public health aftermath. "My answer is that we've spent
an enormous amount of money, but I'm not at all
convinced that the expenses have made us safer."
Wired.com talked to Garrett about biodefense, the Ground
Zero plume and what can be learned.
The author of The Coming Plague: Newly Emerging Diseases
in a World Out of Balance and Betrayal of Trust: The
Collapse of Global Public Health, Laurie Garrett lives
in New York City. On the morning of Sept. 11, 2001, she
watched the horror from the Brooklyn banks of the East
River. I Heard the Sirens Scream is both a diary of that
fateful autumn and a journalistic investigation of what
Wired.com: What is the big, takeaway lesson?
Garrett: There used to be this big debate regarding our
national defense: Can the Pentagon fight a two-front
war? Back then, it was always couched in terms of
whether our military forces could be stretched so
thinly. I would ask the same of our public health
forces, our first responder forces, our medical forces -
and I would say that the answer is no.
What we see, when you look at the lessons of 9/11, is
that these people were burning candles at both ends.
They were thoroughly exhausted. We demanded of our
public health personnel a scale of performance that
lasted for weeks. And one of the things that was really
startling for me in the research to I Heard the Sirens
Scream was how extremely strapped our public health
people in New York City and Washington, DC were before
Afterwards, our health departments, our forensics
departments, were all on full alert. They didn't go off
alert until well after Thanksgiving. Many were
essentially running on fumes. I think they would say
that a lot of decision-making suffered out of
I also spent a lot of time looking at health departments
that weren't targeted, but still went on full alert and
stayed there for weeks. And they were so strapped by all
the hoaxes, all the phony anthrax letters, all the
honest, scared people who thought they were sick. Every
one of those reports had to go to a lab.
Wired.com: So in the immediate aftermath, we were
shorthanded. But the Bush administration soon
established a biodefense program. Did it take the right
Garrett: What we found out after 9/11, after the anthrax
mailings, and what resonated again with Katrina and
every major threat we've faced, is that it all comes
down to human beings.
Both private and public investors are often are often
taken with high-tech answers. They love to invest in
sensing devices and diagnostics and vaccines, in robotic
bomb searchers, in all these devices that can sense
explosives or anthrax in the air. A hell of a lot of
money went into both Department of Defense spending,
Health and Human Services spending. Everybody was
spending billions of dollars, basically on technology,
and technology is only as good as the personnel you
have. You need a well-trained, well-paid, substantial
infrastructure to use the technology and interpret what
the technology is saying to them. You can't take
somebody who is paid $15 and hour and has a job
description filed a couple notches above janitor and
think that this individual can be held responsible for
Wired.com: Is al-Qaida even the right threat to be
worried about? Don't we have more to fear from a natural
Garrett: Before 9/11, old-guard bioterror experts used
the phrase dual-use to refer to difficulties in
surveillance and verification: The same place that made
pharmaceuticals could make biological weapons. But now
the phrase gets used differently. People talk about bang
for their buck. They say, "This expenditure is good for
everyday health as well as this terrible thing that may
happen one day."
Dual-use now tends to justify stockpiling vaccines and
purchasing technology. But I would say the appropriate
use of the phrase is that the people you will rely on -
to protect Americans, to solve great biological
mysteries, to determine the appropriate responses - are
the same people you rely on every single day to make
sure the water coming from your tap is safe to drink,
that the air around your building is safe to breathe,
that the food you buy at your grocery store is safe from
I keep getting asked: Are we safer today than on 9/11?
My answer is that we've spent an enormous amount of
money, but I'm not at all convinced that the expenses
have made us safer. And on the public health side in
particular, I'm sure the majority of expenditures can be
characterized as a complete or borderline waste of
funds. `The majority of expenditures can be
characterized as a complete or borderline waste of
Wired.com: Give me an example.
Garrett: One of the major thrusts of the response to
anthrax was responding to smallpox. We spent a couple
billion dollars on vaccines, on bifurcated needles, on
testing, on every imaginable aspect of new product
development. This constituted a huge deployment at the
National Institutes of Health and Centers for Disease
Control and Prevention.
But the current generation of public health and medical
workers had never done a smallpox vaccination. People
had no idea how. It's not just a shot. You don't even
carry out the vaccine process the way you do polio.
There's a whole biological and epidemiological strategy
that has to be executed.
People often talk about how all the years spent
training, at huge cost, public health workers and
hospital workers all over America, to execute this
massive effort, constituted dual-use and somehow weren't
a waste of money. Really? Because it turns out the way
you'd carry out a vaccine campaign for smallpox isn't
the way you'd carry out of a flu immunization. We
learned that during the H1N1 swine flu outbreak.
Wired.com: So it would have been better to hire nurses
and doctors, to research pathogens and improve disease
Garrett: Absolutely. But here's the catch-22: Some
communities that were underserved historically, such as
the state of West Virginia, were able to hire workers
and boost their state health departments. And then the
states cut their budgets, because they were getting
federal money. Then, when the feds got wind of this,
they started penalizing local jurisdictions, demanding
that they spend their money on bioterrorism - "You can't
spend money on mammograms and syphilis monitoring and
infant health. How dare you!"
I remember being in a conference in Durango, Colorado.
All the people there were freaked out because they'd had
the first cases of West Nile viruses appear in the area.
But the governor had cut public health budgets across
the state. The threat of a real virus was overwhelming
them, and they had nobody to track it. And that's a
Every aspect of American infrastructure, especially
health, is genuinely capable of performing multiple
functions and has to be funded accordingly and
sustainably so. But we're seeing the opposite. Budgets
are getting hacked right and left. Health departments
are cutting right and left.
Wired.com: The problems you're talking about involve
large institutions and national-level bureaucracies.
They seem out-of-reach. Beyond complaining to a
politician, is there something people can do to make the
Garrett: When public health is at its best, it's a
local, community-based operation. The community knows
who its public health officers are. Most public health
departments are always looking for volunteers to go out
and do education and teach kids about cavities and
brushing their teeth. That's public health. It might not
sound sexy, it might not have bells and whistles, but at
a time when we're doing fiscal cutbacks on such a
dramatic level, if the public doesn't step up then those
functions don't get done.
Wired.com: On a different but related topic, what about
the plume over Ground Zero? Were we just as unprepared
Garrett: Without a doubt. The plume produced by the
World Trade Center disaster posed at least as many
scientific questions as the anthrax spores, and far more
It's only in retrospect that we can see what faced the
political leadership of New York City, the state, the
federal government and the White House. The issue on
their table was: How soon are we getting the economy
rolling again? That's all that was on anybody's mind. Is
al-Qaida done, or will there be more waves of attacks,
and can we get the economy back in gear?
Getting the economy back in gear meant convincing all
sorts of traders and investors who had been downtown,
trying to get to work on 9/11 - who had witnessed these
horrific events, who in many cases had lost colleagues
and friends and co-workers - and convince them that it
was safe to go back to work, that the horrors they were
going to walk past as they got back to their office at
Dow Jones or Goldman Sachs shouldn't affect their
It was a tall order. And on top of everything else they
had to be convinced that the air they were going to
breathe, that had a foul stench, a frightening hair-
stands-up-on-the-back-of-your-neck stench, was safe. The
pressure was on, and on so hard, that the Environmental
Protection Agency administrator Christie Whitman issued
a statement saying the air was safe, that there was
nothing to worry about, even though EPA scientists
hadn't yet crunched data. She had no science in front of
her, pro or con, that could advise that. It was not a
scientific announcement. It was political.
I show the before-and-afters in my book: What Whitman
was going to say, and how it was rewritten by the White
House Council on Environmental Quality, which was run by
James Connaughton, who'd been defending the asbestos
industry. We were told - including me, who was coughing
up blood on my pillow - that it was safe. But they had
no data! And when that data was made available, we
realized that what happened on 9/11 was a profound toxic
event that continues to have a profound impact. `They
had to be convinced that the air they were going to
breathe was safe. It was not a scientific announcement.
It was political.'
Wired.com: This tension between scientific and public
health reality on the one side, and political pressure
and misinformation on the other, has continued, hasn't
Garrett: Yes - but in some ways, we've asked the wrong
questions about the plume. There's a tendency to focus
on asbestos and cancer, but the most profound thing
about the plume is that almost all naturally-occurring
plumes are acidic. Their cloud cloaks particulates in a
chemistry that runs between a pH of 3 and 5. As a
result, the human body has evolved an acid escalator in
the respiratory tract.
When you're exposed to a microscopic piece of glass that
happens to have been produced by a volcanic eruption,
it's coated in a pH of 4. It gets into your lungs and
may make some tears in the alveoli, but the acid
escalator is triggered. Your body produces mucus that
surrounds the particle and produces an irritation effect
so you cough it up. The mucus allows it to slip and
slide until you cough it out of your lungs. You can look
at studies of firefighters who fought flames of
volcanoes, and most of them are completely healthy even
though they inhaled massive amounts of ash.
The problem with the World Trade Center is that it was a
chemistry of man-made garbage, a chemistry we have no
precedent for. The building was made of limestone
concrete, filled with computers and glass and steel. It
initially burned, at its interior core, at the heat of
inflamed jet fuel, above 3000 degrees Fahrenheit. This
underwent the phenomenal pressure of 110 stories
collapsing, then burned in a cauldron at the bottom for
almost four full months.
The result was that we had one molecule produced that
never existed on Earth before, and the plume chemistry
was highly alkali. It was as high as pH 13, and between
9 and 11 most of the time. The human body doesn't have
the ability to use this acid escalator for an alkali
What happens is that people inhale an microscopic shard
of concrete and it's wrapped in a chemistry with, say, a
pH of 10. It lodges neatly in your alveoli and causes an
irritation that makes you cough, but the cough is never
productive. That's the trademark of what's now called
World Trade Center cough. It's this constant sense of
irritation, but nothing ever comes up. The result is
that in some cases, the body produces an enscapulation
of the particle similar to what happens with
tuberculosis. This can lead to sarcoidosis, to creating
a concrete-hard microball or shard. The more you try to
cough to get rid of it, the deeper it goes in. And
wherever it goes, it's ripping things up.
When you look at victims of World Trade Center cough and
exposure, we're seeing a diverse array of symptoms.
Smoke from Ground Zero drifts east over Brooklyn. Image:
Wired.com: Is enough being done to care for them?
Garrett: No. First responders are getting the best of
what's available, and certain departments, such as
Philip Landrigan's lab, are doing a lot of work into
identifying these people and the domestic workers who
went into offices to clean up. The New York Fire
Department also has a huge commitment to this. But in
terms of thinking about general public exposure, a
decision was made to create the World Trade Center
health registry, and the problem was: Who qualifies to
be in it?
A decision was made to define it not in biological or
epidemiological terms, but in New York geography terms.
The registry is limited to people who can prove they
were downtown, in a certain proximity to Ground Zero,
during the first week after 9/11, or who reside below
Canal Street in the tiny triangle of Lower Manhattan, or
who returned to work before the all-clear was given.
That's a very small group of people.
I got hold of the NASA pictures, and you can see that
for most of the four months, the plume predominantly
blew from Ground Zero over Brooklyn. It left populated
areas by exiting over Coney Island and the Rockaways.
That's a swath populated by 2 or 3 million people.
Clearly if they'd defined the registry as including
everybody under the plume, it would have been this
massive registry of hundreds of thousands of people, if
not millions. But for all sorts of reasons, including
cost, it was defined so that there's only 77,000 people
in it. Nobody's funding studies that include Brooklyn at
In every study that I can find of Brooklyn, and most are
anecdotal, there's been a marked increase in adult-onset
asthma diagnoses. Asthma specialists in Brooklyn
hospitals have seen dramatic increases in influenza-
associated pneumonia, implying a decrease in lung
Wired.com: Is there anything that can be done about
Garrett: It may be too late, except to provide people
with a more dignified approach to assessing their
health. If an individual is having dry cough, if they're
gasping for air for two weeks every time the flu comes
around, and generally feel like there's sand in their
lungs, that person deserves the dignity of being
assessed for World Trade Center cough, of at least
knowing why they're like that.
The other issue, from the perspective of lessons
learned, is: When do you start distributing respiratory
masks? When do you say the air is safe to breathe? When
do you balance the lives of hundreds of thousands of
people against reopening the stock market? What signals
are given when every VIP who went to Ground Zero didn't
wear a mask?
A lot of firefighters and rescue workers have taken a
bad rap - "You were told to wear a respirator and you
didn't, so it's your fault." Well, yes and no. They're
down there lifting heavy steel beams, massive pieces of
concrete, and trying to wear protective gear when the
bulk of this work was done in the heat of September and
October. Those masks are horrible to wear. That would be
one technology that would be wisely spent money.
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