Twenty-five years after the Sept. 11 terrorist attacks, physicians caring for World Trade Center (WTC) responders and survivors are confronting a changing health burden marked by aging, cognitive decline, and increasingly complex interactions between physical and mental illness.
Speakers described those challenges during a panel discussion at a Sept. 3 symposium hosted by Mount Sinai Health System. They also emphasized broader lessons for disaster preparedness, including the importance of tracking exposures early, monitoring affected populations for decades, and linking clinical care with research.
Steven Markowitz, MD, DrPH, an occupational medicine physician, internist, and epidemiologist at the City University of New York, moderated the discussion. He said about 150,000 people are enrolled in the World Trade Center Health Program, and 100,000 have WTC-related health conditions.
Speaking as a New Yorker, Dr. Markowitz said that, in addition to the four traditional seasons, New York has what feels like a fifth season: the period surrounding Sept. 11, when residents feel the anniversary approaching and remember what happened.
“For many people, that season actually is the whole year,” he said. These patients “never get a single season in which they forget about what they did and what they experience now.”
Dr. Markowitz recalled establishing a mobile health unit near ground zero in January 2002 to examine immigrant day laborers who had been highly exposed to WTC dust. He later opened a WTC clinic in Queens and conducted research on asthma and post-traumatic stress disorder (PTSD). He recognized the physicians, researchers, and advocates who have worked since the early 2000s to establish, maintain, and strengthen the health program.
Aging raises new concerns about cognitive decline
Michael A. Crane, MD, MPH, medical director of the WTC Health Program Clinical Center of Excellence at the Icahn School of Medicine at Mount Sinai, focused on the risks that responders may face as they grow older. The average age of the WTC Health Program population has surpassed 60, placing members at greater risk for cognitive impairment, he said. Depression and PTSD may add to that risk.
Dr. Crane identified frailty as one possible step along the pathway from mental illness to cognitive decline. Frailty may include slow walking, weight loss, reduced activity, weakness, and exhaustion. It also increases the risk of falls and heightens sensitivity to common medications.
Researchers are studying whether exercise, a healthy diet, adequate sleep, and fall prevention can interrupt that progression, Dr. Crane said.
“We’ve begun to question whether this pathway can be interrupted, whether we can cut this link,” he said. He encouraged responders to consider participating in studies examining those interventions, which could also produce lessons for older adults outside the WTC population.
Mental and physical health must be treated together
Sandra M. Lowe, MD, medical director of the WTC Mental Health Program at Mount Sinai’s Clinical Center of Excellence, said physicians must consider mental and physical health problems together. Patients treated for PTSD, depression, or anxiety may also have pulmonary disease, diabetes, sleep apnea, chronic pain, or cancer. Each condition can intensify the others and make care more difficult to manage.
Serious medical diagnoses may worsen depression and anxiety or reactivate trauma symptoms, she said. Psychiatric symptoms, in turn, may lead patients to miss monitoring appointments or cancer screenings. Retirement, social isolation, the death of a spouse, frailty, and cognitive changes may add to the burden.
“Mental and physical health are not separate stories,” Dr. Lowe said. “They are deeply interconnected, and they shape each other over the course of a lifetime.”
Improvement remains possible even when patients seek mental health treatment decades after 9/11, she added. Coordinated care involving mental health professionals, pulmonologists, oncologists, and case managers can help patients maintain function, relationships, and independence.
WTC Health Program offers blueprint for future disaster
Denise Harrison, MD, medical director of the World Trade Center Health Program at New York University Grossman School of Medicine, described the WTC Health Program as a model for responding to future disasters. One major lesson is that health effects may persist or emerge years after an event, requiring sustained monitoring and treatment. Later events, including wildfires and the COVID-19 pandemic, can worsen existing conditions and make it harder for researchers to understand disease progression, she said.
Exposure assessment should begin immediately, Dr. Harrison said. After 9/11, delays in determining who encountered specific substances — and at what levels and for how long — complicated research, medical care, and compensation. Future responses should rapidly gather environmental samples, weather information, occupational histories, and rosters of responders and community members.
Preparedness must also extend beyond traditional first responders to residents, students, local workers, and others affected by dust, trauma, or disruption, Dr. Harrison said.
She called for credible communication about uncertainty and changing risks, adequate protective equipment, and accessible services for vulnerable groups. She also called for systems that connect registries, clinical networks, public health surveillance, and research. Conflicting or overly reassuring messages about air quality and safety after 9/11 damaged public trust, she said.
“Preparedness must include recovery and not just response,” Dr. Harrison said. Recovery may require decades of continued care, medication access, housing and environmental support, monitoring, and research funding.
Responders call for continued research and advocacy
Sean Michael, a battalion chief with the Fire Department of the City of New York (FDNY) and a 9/11 responder, brought the perspective of patients receiving those services. He said the 25-year milestone should be viewed as a point for looking forward, rather than simply as an anniversary.
“We have to think 25 years in the future,” said Michael, a board member of 9/11 Health Watch. Continued advocacy and research funding are essential because new health problems may emerge and knowledge remains incomplete, he said. Cancer, for example, was not initially covered by the program.
Michael said the program has already changed outcomes for responders. “This program is extending their lives,” he said. “What can we do to keep improving the program?”
Earlier detection may help protect brain health
Benjamin J. Luft, MD, director and principal investigator of the Stony Brook World Trade Center Health and Wellness Program, provided one possible answer: identify cognitive changes earlier and determine which patients are most likely to experience serious decline.
About a decade ago, cognitive testing at the Stony Brook WTC Health and Wellness Program found mild cognitive impairment in 14.5% of patients, whose average age was 49. Recent assessments found mild cognitive impairment in 55% of patients, while 3% to 6% had impairment severe enough to be classified as mild to moderate dementia, Dr. Luft said. Similar findings have emerged from smaller groups of FDNY members and survivors.
Brain imaging showed thinning and atrophy in the frontal cortex and hippocampus among patients with cognitive impairment, Dr. Luft said. Blood and imaging studies also detected abnormalities involving tau, amyloid, and neurofilament light chain, but the pattern differed from that typically seen in Alzheimer’s disease.
The findings raise the possibility that neurotoxic exposures, psychological trauma, and subsequent biological changes altered the trajectory of brain aging, he said. However, further research is needed to understand the disease process and guide care.
“The consequences of 9/11 do not end when the smoke clears,” Dr. Luft said. “Our responsibility is to recognize cognitive change early and to identify those of greatest risk before the impairment becomes irreversible.”
