‘First In, Last Out’ — The Enduring Impact Of 9/11 On First Responders

September 7, 2021

By Aara Ramesh

In and among the 2,996 people who died at the World Trade Center (WTC) on September 11, 2001, were 343 firefighters and paramedics, 23 New York City police officers, and 37 Port Authority police officers. They were just a fraction of the thousands of first responders and volunteers who were on site to help evacuate those trapped on the higher floors of the buildings, and those who worked, lived, and went to school in the surrounding areas.

In the early days after 9/11, the Environmental Protection Agency, still grappling with the scale of the attack, told search and rescue crews that the air around the crash site was safe and would not cause long-term harm. It wasn’t until years later that the truth emerged — the collapse of the buildings had released toxic fumes and particles that would come to haunt those present.

The most common refrain around 9/11 — “Never Forget” — rings particularly true for first responders, who even now, twenty years later, don’t have the luxury of beginning to forget the horrors they witnessed firsthand in the immediate aftermath of the Twin Towers’ collapse. Even as the country moves forward, facing new disasters and crises, many of those survivors and first responders continue to live with considerable physical and emotional trauma.

Today, in the first of our series on the post-9/11 landscape, we fittingly take a look at the lives of those first responders who breached the World Trade Center even as it was crumbling and who were the last to leave Ground Zero after the clean-up, eight months and 19 days later.

Legislative Response

In response to the attacks, the George W. Bush government swiftly established the September 11 Victim Compensation Fund (VCF) to assist those injured within 96 hours of the attacks (around Sept. 15). The Fund was active from 2001 to 2004.

After much lobbying from survivors, their families, and others, in January 2011, then-president Barack Obama signed into law the James Zadroga 9/11 Health and Compensation Act of 2010 (Zadroga Act). This law revived the VCF for a five-year period that would end in October 2016.

The Act was named after an NYPD officer, James Zadroga, who responded to the disaster at Ground Zero. Previously a healthy non-smoker, Zadroga died of a respiratory illness in 2006, and was the “first person whom health officials declared died due to toxic chemical exposure” at the crash sites, as well as the first to receive a settlement from the VCF (in 2004).

History of the VCF
Infographic source: The September 11th Victim Compensation Fund

Before that deadline, however, in December 2015, President Obama reauthorized the Act and the VCF for an additional five years, set to run out in December 2020. In February 2019, it was determined that the money the VCF still had was insufficient to cover all pending and projected claims, necessitating changes to the Fund’s policies.

A handful of months later, President Donald J. Trump signed the Never Forget the Heroes: James Zadroga, Ray Pfeifer, and Luis Alvarez Permanent Authorization of the September 11th Victim Compensation Fund Act (VCF Permanent Authorization Act), which seemingly put the matter to rest for good by extending the claim-filing deadline to October 1, 2090, roughly nine decades after the attack.

The VCF And The WTC Health Program

The VCF covers first responders, debris clean-up and construction crews, and all survivors from the exposure zone of the WTC, Pentagon, and Shanksville, Pennsylvania crash sites. Per official estimates, around 55,000 people have submitted claims to the VCF. In the first three years of its existence, between 2001 and 2004, the VCF paid out over $7 billion to the victims’ families and to those injured in the attacks.

The Zadroga Act and its subsequent iterations also established the WTC Health Program, a federal initiative that serves over 100,000 responders to and survivors of the various 9/11 attacks. Administered by the National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention (CDC), and Department of Health and Human Services, the Program “provides no-cost medical monitoring and treatment for certified WTC-related health conditions,” and also “funds medical research into physical and mental health conditions related to 9/11 exposures.”

There is no official federal definition of who constitutes a first responder. Generally, however, this group is considered to include all manner of professions that involve responding to public safety emergencies, such as emergency medical technicians (EMTs), hospital ER staff, law enforcement agents and police officers, and firefighters. 

Per the Department of Homeland Security, the term generally covers those who “in the early stages of an incident are responsible for the protection and preservation of life, property, evidence, and the environment.” This includes “Federal, State, and local governmental and nongovernmental emergency public safety, fire, law enforcement, public safety telecommunicators/dispatcher, emergency response, emergency medical services providers (including hospital emergency facilities), and related personnel, agencies, and authorities.”

In the context of 9/11, this would include Fire Department of New York (FDNY) personnel, New York Police Department (NYPD) officers, and Port Authority staff, as well as around 4,000 Federal Bureau of Investigations (FBI) employees and those responding to the crash sites at the Pentagon and Shanksville.

The latest quarterly report from the CDC said that, as of June 2021, 81,460 responders and 30,582 survivors were enrolled in the WTC Health Program, across the country. Almost two in three of the former category (57%) is made up of general responders, while FDNY responders comprise 15% and Pentagon/Shanksville Responders 1%. Over 4,600 of the total have passed away.

Infographic source: The Centers for Disease Control and Prevention

Physical Health Problems

The long-term debilitating effects of nuclear weapons are well documented, but most people may not be aware of the hazards associated with a building collapse, which extend far beyond burn injuries.

At the WTC site, around 400,000 people were exposed, for a prolonged period, to the soot and dust from the burning buildings, which contained “more than 2,500 contaminants including glass, lead and mercury.” Experts estimate that 24,000 gallons of jet fuel exploded, with the resulting fire covering 100,000 tons of organic debris and 230,000 gallons of various oils present in the buildings. 

In addition, the fires continued to burn for days after (some until December), further releasing chemicals like asbestos, carbon monoxide, hydrogen sulfide, and crystalline silica, which formed the backdrop for ongoing search, rescue, and recovery missions.

As a result of this toxic cocktail, many present at the site were diagnosed with health problems ranging from persistent coughs and respiratory illnesses to at least 68 types of cancer. Per experts, the dust was found to increase propensity of lung problems, respiratory symptoms, sinus problems, chronic bronchitis, emphysema, Chronic Obstructive Pulmonary Disease (COPD), and/or asthma. It was also found to cause digestive and musculoskeletal disorders.

An estimated 10,000 people were discovered to have developed 9/11-related cancer by 2018. This ranges from prostate and thyroid cancer to multiple myeloma and leukemia. As of 2015, some studies found, over 7,000 FDNY Firefighters and EMTs had been treated for a condition related to being involved in WTC clean-up operations.

Per official estimates, around 3,496 people have died in the 20 years since the attacks, as a result of the events of 9/11. These numbers could well be much higher though, and probably are, since disclosing such illnesses to federal authorities, even for employees, is voluntary. 

Since 2011, the NYPD says, more than 200 former and current officers have died from 9/11-related complications, while around 500 more have developed cancer from their exposure to the toxic fumes. The FBI says at least 1,000 of its current and former employees are seeking treatment for conditions developed as a result of working at or near the 9/11 crash sites. The Bureau adds that at least 17 of its employees have died from these illnesses. 

Unfortunately, this problem was only exacerbated by the Covid-19 pandemic. Many 9/11 first responders were in their 30s in 2001, putting them in their 50s today. In fact, the average age for a 9/11 first responder today is about 59–60, making them borderline high-risk targets for the virus.

In addition, many of are even more susceptible due to their 9/11-related comorbidities, of which cancer and respiratory disorders like asthma and COPD are the most dangerous. Per some estimates, nearly half of FDNY medical responders ended up with Covid-19. Around 32 of the 158 people with a 9/11 illness who died between Sept. 2020 and April 2021 also suffered from Covid-19.

Emotional And Cognitive Problems

In addition to the myriad physiological problems described above, the most enduring and debilitating challenge faced by 9/11 first responders and survivors is long-lasting post-traumatic stress disorder (PTSD), depression, and survivor’s guilt. Some say this is “the most common health effect of 9/11,” and that around one in five adults directly exposed to the attacks developed PTSD — a rate four times greater than that typically found in the general population. Per some estimates, over 3,700 WTC first responders have been diagnosed with mental health stress-related conditions.

Lately, as reported by the Washington Post, researchers have also been exploring a link between “mild cognitive impairment” and the 9/11 fumes. In some extreme cases, this has even manifested as dementia. Per experts, some of the cognitive deficiencies they are noticing in people in their 50s is more typical of individuals in their 70s, if they are present at all. These usually manifest as memory loss or loss of comprehension.

Though the exact cause isn’t known, researchers suspect this could be due to the toxic air and/or PTSD these responders were exposed to. Per the Post, “The air at Ground Zero contained chemicals and microscopic particles that are toxic to brain cells and have been linked to higher risk of Alzheimer’s and other dementias.” Unfortunately, while some mental health disorders are covered by the VCF, cognitive ailments are not.

Much like with physical health issues, Covid-19 too has taken a toll on the mental health of 9/11 first responders. At the very least, the familiar feeling of a nationwide emergency and lack of clarity around the future have re-traumatized those who were on the job 20 years ago and still working on the front lines of the pandemic.

In addition, some are reporting that the PTSD they live with has been exacerbated by the fear of contracting the virus and isolation associated with the lockdowns. Left vulnerable, they are unable to connect with peers. Last year, many were unable or unwilling to risk exposure by attending annual 9/11 memorial ceremonies, which can be crucial to their healing and general wellbeing.

With two decades having passed — and now with the apparent end of the War on Terror with the U.S. withdrawal from Afghanistan — it is relatively easy for the rest of us to relegate the events of 9/11 to history books. According to FDNY Battalion Chief Timothy Rice, ”The further we get away from 9/11, the harder it is to encourage people to remember.” He added, “If we start to forget 9/11 or incidents like Pearl Harbor, the focus goes away. This remembrance, I believe, goes hand-in-hand with ensuring that we’re doing everything we can as a country to prevent the next one.”

But for the survivors and first responders, the nightmare is as real as it was in 2001. In the words of Richard Roeill, a retired Nassau County firefighter and rescue swimmer, on the day, he and his peers “had family members and friends of [missing people] giving us pictures, saying, ‘Please, if you see my husband, my brother.’ […] I went down there thinking I was going to save the world. That I was going to bring someone home.”

In the end, no matter how much time has passed, scenes like that can never really be forgotten by those who were there.