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Jim Bruncati worked for the New Jersey State Police at the time of the 9/11 attacks. He'd been assigned to monitor the mental fitness of a New Jersey search and rescue team at the Javits Center in New York, making sure they could continue their work after 12-hour shifts on the pile each day.

"Nobody wore masks," Bruncati recalled. "We're wearing them for COVID, we didn't wear them walking through the dust of downtown Manhattan. You didn't think of it, you just went in and that was it."

Now, two decades out from Sept. 11, 2001, those who were downtown that day or immediately afterward are still dealing with the fallout. Bruncati and his partner, who was diagnosed with non-Hodgkin lymphoma, faced serious health consequences related to their exposure downtown.

Extensive research on this group of responders, rescuers, and civilians has revealed a series of trademark health effects that only continue to emerge with time, including respiratory problems, post-traumatic stress disorder, and cancers. The findings from these studies, however, have strengthened the case for expanding the World Trade Center Health Program, which provides healthcare for 9/11 responders and survivors. They've also shaped the way medical and safety experts approach workplace health in ways that can minimize future health crises following a major event.

Of the more than estimated to be directly affected by the environmental hazards, trauma, and contaminants of the attacks, 81,460 first responders and 30,582 "survivors" (people living or working downtown) enrolled in the WTC Health Program. More than 71,000 have signed up for the WTC Health Registry, which sends out health surveys annually.

Enrollees in the registry have taken part in dozens of studies published in peer-reviewed journals. Many of those papers use data from cohorts of thousands, further strengthening their takeaway health lessons for the future.

"We have a greater awareness of the immense impact that the responder and surrounding survivor populations of disasters will incur," said Liam Lynch, a safety and health specialist for the New York Committee for Occupational Safety and Health (NYCOSH) and program coordinator for the WTC Health Program. "That it's not just the acute trauma, but that it's chronic conditions that this population is going to have to live with, and that we as a society have to take care of them."

Effects on Physical Health

'The cough'

A plume of smoke, ash, and debris following the collapse of the towers engulfed lower Manhattan and stretched into Brooklyn, exposing civilians and recovery workers alike to particles of building materials and byproducts of combustion. Later, the cloud settled, leaving a thick layer of toxic dust on every surface. More than 70 known carcinogens were identified at the WTC site, and those with the most exposure to it developed a range of acute conditions.

Perhaps the most distinct of these conditions is what became known as the "WTC cough." It was a condition first described by in New York, and colleagues in a in 2002.

Almost every expert 乌鸦传媒 spoke with said this was the study that sparked awareness about post-9/11 exposure-related health.

More than 10,000 New York firefighters who participated in rescue and recovery efforts following the collapse of the towers had a medical evaluation shortly thereafter. A total of 332 of them were diagnosed with WTC cough, characterized by an ongoing cough that started after a firefighter was exposed to the site, with respiratory symptoms serious enough to warrant medical leave for at least 4 weeks in a row. Another 102 had bronchial hyperreactivity.

Because firefighters were subject to regular spirometry tests even before 9/11, and then again afterward, the research showed a clear change from before and after the event.

"Because they had data from before 9/11 on the New York City Fire Department, their data stood up to all kinds of scrutiny," said Iris Udasin, MD, of Rutgers University School of Public Health and a medical director of their Environmental and Occupational Health Sciences Institute Clinical Center. "The original cough papers were groundbreaking."

Udasin was also a principal investigator for the WTC Medical Monitoring and Treatment Program longitudinal study, and serves on the steering committee for the same program. She treats patients within the WTC Health Program.

Respiratory conditions

Respiratory problems were another common condition physicians saw among their 9/11 populations in the immediate following years. from 2006 found that among 12,079 responders from the Fire Department of the City of New York (FDNY), their 1-second forced expiratory volume had decreased, on average, by the equivalent of a 12-year decline due to aging.

"These responders, they had lost several years' worth of lung function in terms of just exposure to the site," said Michael Crane, the medical director of the WTC Health Program Clinical Center of Excellence at Mount Sinai, which serves the largest group of WTC Health Program patients. He's also the medical director of the Selikoff Centers for Occupational Health and a professor in the Department of Environmental Medicine and Public Health at Mount Sinai. "These were young, healthy firemen who had really damaged their lungs, and here was the proof. So the literature on lung disease took off after that."

Studies have also shown that 9/11 survivors, , and higher than the general population.

Denise Harrison, MD, is the clinical director for the WTC Health Program at the NYU Grossman School for Medicine and also treats program patients at Bellevue/NYU's Occupational and Environmental Medicine Clinic. She said unlike asthma, for coverage under the program. Research on the FDNY spurred its addition.

"[COPD], unlike asthma, is not time-sensitive," Harrison said. "This is one way ... that has influenced how we make decisions about responses with exposures like this."

Cancers

Experts also said that a number of papers linking cancers appearing in patients years later to their 9/11 exposures were seminal. "In terms of seriousness of what's wrong with people, elevated levels of cancer ... and pulmonary fibrosis, they build a case for the Congressional bill that pays for the care of our patients," said Udasin.

Udasin is referring to the , named for an officer who died of 9/11-related heath issues. The bill provides funding for the care of who qualify if their health problems can be directly linked to the events of 9/11. Cancers weren't included in the qualifying conditions until research on the responders and survivors helped the program's WTC Scientific Advisory Committee .

It appeared that three types of cancers were more frequent in firefighters with exposure from the attacks than in those without exposure: thyroid cancers, non-Hodgkin lymphoma, and melanoma.

More recently, -- the FDNY, the WTC Health Registry, and the General Responder Cohort -- and confirmed the same pattern of elevated cancers in all three, adding prostate cancer definitively to the cancers of concern.

Now, Lynch said, 68 types of cancers meet the criteria for coverage, provided the patient can show they were present at the WTC area in the days and weeks immediately following 9/11.

And Crane said that, surprisingly, showed that the rate of cancer survival for the WTC Health Program was better than that of New York State overall. He suspects it's because of early detection, and ease of access to care within the program.

"This is free to them, they have no copays, you know, they have quite a bit of say about where they get their appointments," he said. "It may be that by catering to this population in that way, you reduce the barriers that they would have normally."

Effects on Mental Health

Post-traumatic stress disorder

Bruncati recalled talking to another police officer in the months following the attacks. The officer admitted that he couldn't bring himself to drive anymore since 9/11.

Bruncati asked him, "Don't you think you should see anyone about this?" "'No,'" he remembers the officer replying. "'I just don't drive.'"

"Cops are very reluctant to go for help because they don't want to have their guns taken away, they don't want this type of thing to affect a promotion," Bruncati said.

Witnessing or participating in recovery and rescue following the 9/11 attacks led to profound mental health effects -- most commonly, post-traumatic stress disorder (PTSD). A study that evaluated patients from the second-largest of the clinics tasked with administering care through the WTC Health Program found that of the 3,231 responders being monitored, after their exposure. Of those, half still had it 11 to 13 years later.

"There is also a very stubborn and disturbing subset of individuals who appear to not only not be getting better, but may be getting worse," said Travis Kubale, PhD, associate director for research planning and care integration for the WTC Health Program at the National Institute for Occupational Safety and Health (NIOSH). "This is one of the first publications to document that trend," he said, and it has helped inform research on effective interventions.

Responders with more severe "exposure" also had higher rates of PTSD. Severity was rated based on how early they arrived on the scene, if they were caught in the dust cloud related to the collapse of the towers, if they knew someone who was injured, saw human remains, and how long they worked.

Crane mentioned other studies on PTSD, including one that revealed in WTC responders. Some, especially "non-traditional" responders like construction workers, engineers, or volunteers, had PTSD that was chronic or delayed-onset.

"These papers really laid the foundation about the severity of the conditions. They also helped Congress decide, 'Well, we better fund this because these people are seriously sick,'" Crane said. He said it also prompted subsequent research using the trajectories as a model for what happens after other disasters, such as the trauma seen in soldiers who had been to Afghanistan.

First responders and survivors also experienced than the general population.

In addition, experts highlighted the significance of research on comorbidity, especially the interaction of physical health with mental health. Crane noted that many conditions that can occur together -- like asthma and PTSD, or even asthma and gastroesophageal reflux disease -- can sometimes present with similar symptoms, which can confuse patients and doctors in their treatment.

Not only this, but together, he said the costs for treatment can rise exponentially.

"I think the medical progression in general has some real questioning to do about how these combinations interact to impact the overall course of someone's life," Crane said.

Lessons learned from 9/11 continue to emerge, even decades later. When it comes down to it, experts say, it's partially because of our most human impulses during a crisis.

"Disaster sites are extremely emotional, and we want to rush in and rescue everybody at all costs," Lynch said, "and that's kind of how we approach things, instead of taking time to also care for our responders who are rushing down there."

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