20 years after the Twin Towers fell, we’re still not prepared for disasters.
“THEY COULDN’T ALL BE DEAD.”
Dan Avstreih ’98 MD’02 will always remember standing on the observation deck of the World Trade Center in the middle of a lightning storm, when he was a teenager.
“It’s like standing up in fireworks. It was just the most incredibly beautiful thing, and that will remain one of the top memories of my whole life,” says Avstreih, who grew up in New York. “And literally the next time I was standing there, it was in the rubble of it.”
On September 11, 2001, Avstreih was a fourth-year medical student on an emergency medicine rotation at the University of Pittsburgh. He was in a medevac helicopter hangar when he saw breaking news footage of a gaping, fiery hole near the top of the North Tower.
The longtime medic and member of the Rhode Island Disaster Medical Assistance Team watched helplessly as a passenger plane plowed into its twin, a few dozen floors below where he’d stood during that storm.
“And then came the report of the United 93 crash, 90 minutes south of the hangar,” Avstreih says. Finally he could do something. “I was like, well, I’ll go down to Shanksville.” His car already packed with emergency gear, the 24-year-old sped off.
As soon as family physician Kerry Kelly MD’77 learned about the first plane, she hightailed it from a Staten Island hospital to the Battery. As the chief medical officer of the New York City Fire Department, she knew her firehouse brothers and sisters, working to rescue hundreds of people from the infernos, would get hurt and need her help.
In Rhode Island, the RIDMAT leader’s quiet morning at home quickly went sideways. “My son was 6 months old and I was actually feeding him when I saw on the news the plane hit,” emergency physician Selim Suner ’86 MS’87 MD’92 RES’96 F’04 recalls. “I ran to the hospital, and at 10 a.m. I got the phone call saying, ‘You guys are on alert.’” He began pulling together his team and their gear.
Kelly was already treating firefighters on the scene when the first tower began to fall. A captain grabbed her and pulled her to safety; they immediately returned to triaging fallen comrades. Then the second tower came down. Again, a firefighter saved her life. “It was all black and dark,” Kelly says. “We went back up there and we just kept working.” As she searched for survivors among chunks of concrete and twisted steel and shards of glass and flames and body parts, Kelly couldn’t quite wrap her head around the scale of the apocalypse. “We had real hopes that people were going to be caught underneath,” she says, “that we could go rescue them and that they couldn’t all be dead.”
“IT’S BIZARRE HOW MUCH DUST THERE IS.”
In Shanksville, Avstreih helped “build a city in a field”: creating infrastructure for the teams of responders like first-aid stations, bathrooms, phones. “I spent the entire day and night doing medical logistics in support of what was pretty quickly deemed to be a recovery operation,” he says. All the while, he was keeping tabs on the RIDMAT. As soon as they mobilized, Avstreih was back in his car, en route to New York.
He rendezvoused with the team north of the city. Meanwhile Suner and the Massachusetts team leader headed to ground zero to scout sites for their medical tents and equipment. “It was dark. It was disastrous,” says Suner, who has family in the city. “9/11 was just a big ball of emotion.”
“Once you got on the ground and saw the magnitude of the collapsed structure … you realized that the ability to save individuals as a result of that collapse is minimal,” David Marcozzi RES’02, MD, says. He was Brown’s chief emergency medicine resident that year, and the CMO of the RIDMAT. “It doesn’t mean you don’t hold out hope. It also doesn’t mean, importantly, you’re not there to assist those that survived or the other responders.”
The RIDMAT set up its coordinating center in a community college and four satellite medical stations—including one in a deli—and began treating rescuers and bystanders. Locals trapped inside the cordoned-off tip of Manhattan were “wandering the streets,” Suner says, “totally in shock with severe psychological trauma.” His team treated burns and lacerations, bruises and broken bones. They even helped a few rescue dogs, thanks to Brown’s chief veterinarian, the late James Harper, VMD, another member of the team.
And then there were the airborne hazards. Fires burned for months; ash and particulate lodged in people’s eyes and throats and lungs. They inhaled jet fuel fumes and asbestos. Dust from pulverized concrete coated everything, and hung in the air. In her nearby FDNY triage clinic, Kelly was treating asthma, GERD, sinus problems, racking coughs. Avstreih remembers how surreal it was. “Everything is covered in dust,” he says. “I mean, it’s bizarre how much dust there is.”
Up to 10,000 people each day were digging through the smoking pile, searching for survivors. At the peak, Suner says, the DMATs were treating 500 rescuers a day. “They were taking risks” trying to save people, he says; once their cuts were bandaged and their ankles wrapped, they headed back to the scene. On October 9, efforts switched from rescue to recovery. “Once that psychological pressure was off, and someone of authority said, ‘Guys, the rescue is over, no one else is going to survive this,’ then people are more careful,” Suner says. Fewer than 20 survivors were pulled from the wreckage—none after September 12.
“I WILL CARRY IT WITH ME UNTIL MY LAST BREATH.”
The psychological toll was enormous. Suner says that of the thousands of patients seen by DMATs in the first six weeks, more than half presented with mental health concerns. Every team had mental health workers, who treated the rescuers even as they tried to look out for each other.
“It’s really a family more than a team of people who take care of each other,” Suner says. “You get to know people and know their behaviors. And during a disaster if someone’s acting out of sorts, you figure out that something’s going on and get them help.” But, Marcozzi warns, there’s a flip side to that familiarity: if someone’s decline is gradual, “you might not see it because you’re with them every day.”
Firefighters, medics, doctors—this wasn’t a group that was used to confronting their feelings. 9/11 left even the helpers feeling helpless.
“There was nowhere to hold this degree of tragedy,” Avstreih says. “Sometimes you don’t want to even scratch the surface because people are barely holding it together. And if you touch the glass and it breaks, you don’t know what to do with this.” “All of us who were exposed to the mental health effects of that day carry it with them,” Marcozzi adds. “I will carry it with me until my last breath.”
The FDNY lost 343 members on 9/11. Some of them Kelly had just patched up after the devastating Father’s Day fire that killed three firefighters in Astoria that June. “So many of the people who I just put back to work after injuries had died, so each of these events takes a lot out of you,” she says. “It’s traumatic.”
Two weeks after the attacks, Kelly gave searing testimony before the Senate Health Committee about the horrors she and her colleagues had witnessed and how much they had lost, and pressed the legislators to fund psychological care for firefighters and their families. That support enabled the department to hire more mental health workers.
But Kelly still found herself in that role. As she treated firefighters’ asthma and cuts and burns in the months after 9/11, she listened to their stories. “The emotional support in family medicine—I think this is probably one of the most important parts of being a doctor,” she says. “And because I had been there … they didn’t feel that separation. … They would say to me, ‘I don’t want to talk to a counselor who doesn’t know anything about what happened. I’ll talk to you.’” “It just was probably cathartic that they could talk about it,” Kelly adds. “But also it was a way of understanding what was going on, and we just kept seeing different medical problems arise.”
“WE KNEW THEY WERE HEALTHY.”
Just as it was immediately clear that New York’s recovery would be long and hard—it took nearly 100 days to put out all the fires at ground zero—and that most people’s trauma would linger for a lifetime, rescuers and medical workers knew the physical toll would be a lasting one.
Kelly likes to say they established the World Trade Center Health Program on September 12, 2001—though it would take nearly 10 years to get it funded. That was the day she started seeing some of the tens of thousands of first responders, steelworkers, residents, cleanup workers, and volunteers sickened by the toxic dust and fumes enveloping the disaster zone.
“The air that day was just filled with black soot and smoke,” she says. “There were so many different chemicals that we were being exposed to.”
Few wore masks at all times. As Avstreih says, even though masks were standard-issue PPE, “Standard and how standardly used are two separate things.” It was difficult to communicate while wearing masks, Suner says, and amongst the heat and the flames, they impeded hydration.
“I mean, everyone knew that in theory, dust was bad,” Avstreih says. He notes the irony—18 months into the COVID pandemic— when he adds, “Wearing a respirator for that period of time is really difficult.”
Today everyone who worked and volunteered at ground zero is regularly monitored for chronic conditions from lung diseases to cancers to mental health disorders. But the WTC Health Program wasn’t a given.
“It really was quite an undertaking to get the program up and running,” Kelly says with characteristic understatement. For years, her office operated on a patchwork of public and private grants to treat survivors while amassing the data they needed to fight for long-term funding. Fortunately, they were starting from a solid foundation.
“Pre-9/11, because we had done regular medicals on our members, we really knew that they were a healthy population,” Kelly says. “We knew their breathing tests, we knew their bloodwork, we really knew a lot about their general health.” Because carcinogen exposures were already a concern for firefighters, they had pre-existing cancer data too.
The medical office got federal funding to do 10,000 physicals on FDNY members from October 2001 to the following February. Right away, Kelly and her colleagues detected a pattern of illness. They noted when a firefighter arrived at ground zero—before or after the collapse, or a few days later—and how much time they spent there.
“There was definitely, definitely a correlation,” she says. “That really was very helpful in helping the scientific community and the political community see the consequences of that exposure.” Yet it took years to secure the billions of federal dollars needed to monitor and treat the thousands of WTC survivors.
It ultimately took the relentless dedication of a beloved comedian—as well as Kelly’s own patients—to get Congress to pay attention. “Jon Stewart was amazing at his support, and just the faces and the stories of our affected patients really played a large role too,” she says. “It’s very hard to look into the eyes of some of the people who were fighting cancer for so many years, many rounds of chemo, and just the loss of their physical well-being due to their exposure.”
In 2011, President Obama signed into law the act establishing the WTC Health Program, which covers all first responders and survivors. More than 17,000 firefighters are enrolled in it today. Since September 11, 2001, 254 have died from related illnesses.
“IT GIVES ME FUEL TO KEEP PUSHING.”
A year before the terrorist attacks, Marcozzi was sworn in as a captain in the US Army Reserve. “Raising my hand, electing to serve and put on the uniform was a step that I felt obligated to do to give back to my country,” he says.
He was mobilized as a medical officer during Hurricane Katrina, twice to Iraq, and once to Afghanistan. “It was palpable to me, 9/11, being on the ground there,” Marcozzi says. “Obviously a direct attack against the United States, both in New York City and Washington, DC, had relevance to me standing on the ground in Afghanistan and Iraq.”
After Katrina, Marcozzi brought his expertise in emergency preparedness and health delivery to the Senate’s Bioterrorism and Public Health Preparedness Subcommittee, where he helped draft the 2006 Pandemic and All-Hazards Preparedness Act. From there he took senior positions at the US Department of Health and Human Services and then the White House, serving under Presidents Bush and Obama.
Now Marcozzi is a professor of emergency medicine at the University of Maryland and chief clinical officer of its medical center. Since the start of the pandemic, he’s served as senior medical adviser to Governor Larry Hogan. He’s diplomatic in his critique of the federal response to COVID, but doesn’t hide his dismay that some key measures called for in that 2006 bill— like the appointment of a central figure to coordinate disaster response and funding for hospitals’ emergency preparedness, the CDC, and the public health infrastructure—didn’t materialize.
“Preparedness … is mainly funded through grants and then, when we realize we aren’t prepared, funding after the fact is provided in supplementals—the Ebola supplemental, Sandy supplemental,” Marcozzi says. “At its core, disaster preparedness is a quality measure. Just like hospital-acquired infections or medication errors, preparedness should have greater attention so that we measure, appropriately resource, and improve our hospitals’ readiness.” For Marcozzi, 9/11 is an annual reminder that we can improve health care preparedness for any disaster.
“Reflecting on the lives lost that day gives me fuel to keep pushing,” he says, “to make sure that we are better today than we were yesterday.”
“YOU SHOULDN’T TRY TO FIX THE EMOTIONS.”
After residency at the University of Michigan, Avstreih, who’s dual boarded in emergency medicine and EMS, moved to Virginia. He’s an attending at Inova Fairfax Hospital and an EMS physician for the Fairfax County Fire and Rescue Department—“one of the primary responders to the Pentagon site,” he notes. 9/11 prepared him in unexpected ways for the pandemic. “The tail of disasters is always longer than people perceive,” Avstreih says.
“In December of 2001, they were still going through rubble at this pile. It wasn’t in the news. There are daily COVID fatalities now. But it’s been probably a solid year since ordinary people were dropping off boxes of coffee or their couple extra N95s because they wanted to make a difference. And that’s one of the emotional challenges of these events. You can do anything on adrenaline for a day or two or even three. You can’t do it for months. You certainly can’t do it for years.”
Now that he’s a leader, Avstreih says he tries to “model being OK with the idea that things aren’t OK.” “Humans like to fix things. … Most of us in emergency services particularly like to fix things,” he says.
“One of the things that [9/11] has taught us in a positive way is, you shouldn’t try to fix the emotions associated with this. You just remember them and pay respect to them.”
Even as he cherishes more positive memories from the 9/11 response—of the nation coming together, of celebrated chefs serving gourmet meals to rescuers alongside regular folks making peanut butter sandwiches, of everybody stepping up to help each other—Avstreih laments how much has changed. “If humanity was taking care of each other as much as they were on September 12th we would be in some really amazing places,” he says.
“YOU’RE GRATEFUL TO BE ALIVE.”
Kelly retired from her post as CMO three years ago, but she’s still working for the WTC Health Program at the FDNY, overseeing members’ cancer care. “It gives you a sense of purpose that you survived a horrible day, you’re grateful to be alive, and you have a reason to keep moving forward,” she says.
Kelly helped establish a longitudinal program to keep retirees coming back. “They’re very committed to the program,” she says. Every year on 9/11, she attends a ceremony at the Firemen’s Memorial on the Upper West Side, and another for all those who’ve died of illnesses since that day.
Their names are inscribed on a wall at headquarters—many of them people she knew personally. The list grows every year. “It’s always been a privilege to work with them,” Kelly says.
“Even now, when we have people who have cancers, almost to the person they will say, ‘I had 15 more years than the people who died that day,’ ‘I had 20 more years than the people who died that year.’ They are very grateful for the fact that they did survive, and that they did have those years to either see their children grow or see grandchildren or just have a life.”
“YOU DON’T GET MONEY TO PREPARE.”
After 9/11, Suner says, “it was clear that disaster medicine was my chosen field.” Now a professor of emergency medicine, of surgery, and of engineering at his alma mater, he coauthored a widely used textbook and has written countless papers on the subject. He established a disaster medicine fellowship program at Brown to educate emergency physicians from around the world. Plus he chairs the Rhode Island Hospital Emergency Preparedness Committee.
The growing demands of that role eventually forced him to leave the RIDMAT a few years ago. “Every time there’s a disaster, there’s an increased awareness,” he says. They get an infusion of funds. But memories fade. “And then the money runs out. Five years without a disaster, you don’t get money to prepare.”
Money is critical, of course, but it’s not everything; Suner’s lessons in teamwork from the DMAT were critical during the pandemic. As soon as members of the hospital’s emergency preparedness team started hearing about a novel coronavirus in China last winter, they broke out their pandemic protocols and started stockpiling PPE. When it came time to stand up a field hospital, “the culture of getting things done, no excuses,” made it possible.
Suner goes to New York all the time to see his family, but he’s never returned to ground zero. “I don’t know why. I’m probably repressing some feelings,” he says. He only remembers it’s 9/11 each year when Marcozzi texts him a photo of the two of them amid the ruins; he knew this was the 20th anniversary only because his son is 20 years old. But at home, in his office, Suner keeps the hard hat he wore, and his mask and his boots still covered in gray dust. “I never cleaned them,” he says.