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 neither.
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 followed.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 the attack.
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 exhaustion.
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 form?
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 stopping al-Qaida.
Wired.com: Is al-Qaida even the right threat to be worried about? Don't we have more to fear from a natural pandemic?
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 salmonella.
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 funds.'
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 surveillance networks.
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 typical example.
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 situation better?
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 for that?
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 political issues.
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 financial dealings.
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 it?
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 trigger.
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.
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 all.
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 function.
Wired.com: Is there anything that can be done about this?
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.
Images: 1) Memorial lights in lower Manhattan. (Eric Mueller/Flickr) 2) Ground Zero, seen from the Brooklyn Bridge on Sept. 11, 2001. (Laurie Garrett)
See Also:
