Public health and medical disaster responses: The untold story of 9/11
As the former National Coordinator of Disaster Volunteers for the American Red Cross, Dr. Kelly B. Close was on the front lines of the emergency medical response following the 9/11 attacks in New York City
By Kelly B. Close, MD
You never know when your life is going to change.
My red business suit was almost buttoned, and I was rehearsing my presentation for the Milford, Connecticut Red Cross board of directors, even though my mind kept wandering to my wedding just nine days earlier in Walt Disney World. An urgent call from my new husband to come to the television interrupted my wedding day dreams. As soon as I saw the images of the first plane hitting the World Trade Center, I knew that my plans for the day – maybe even my life – had changed.
As the National Coordinator of Disaster Volunteers for the American Red Cross and an emergency physician, I had a mission. For the prior six months, I had been working with the President of the Red Cross on plans to create disaster medical response teams within each local Red Cross chapter. These local teams would coordinate the medical response during the first few days of a disaster until, if needed, federal medical teams could be organized and dispatched.
At the time, the Red Cross was a support agency to the Department of Health and Human Services for public health and medical disaster response (Emergency Support Function 8: ESF-8). The intention was to fill a need and get closer to the Red Cross' roots because was it was founded by Clara Barton in 1881 after her experiences on the battlefields of the Civil War. The next major disaster was to be my opportunity to vet this potential new Red Cross function, and this was it.
I was an hour from New York City. I gathered supplies and drove in. As I crossed into the city, there was an eerie silence. I was the only car on the southbound side. Everyone else was driving, walking or running in the opposite direction. I had imagined rioting and looting occurring while the police were preoccupied with the disaster response, but that was the last thing on anyone's mind. The city streets were barren once I got into the city, except for the cloud of debris in the distance which was spreading uptown from the collapse of the towers.
An unprecedented disaster
Ground zero looked like Pompeii, and the smell was unmistakable. It was dark, even during the day. Street signs were covered and landmarks were destroyed, making navigation between the pile, St. Vincent's Hospital, and the triage areas difficult. Complex masks, such as the N-95, were useless because they clogged in a few minutes. Demand out-paced the number of surgical masks available from the incident command center and my small stash. I spent the first two days assessing the medical response, which was not organized, as we had anticipated.
Make-shift triage areas were run by whoever took charge and had no connection to the appropriate supplies that we had located at Chelsea Piers, a good distance away. For instance, the largest triage area, which was located at Stuyvesant High School next to ground zero and the incident command center, was run the first day by a second year medical resident with no significant disaster or emergency medical experience. Since there were only lacerations, eye injuries and asthma attacks of rescue workers, I just ensured that the supplies got there and addressed two even bigger issues that I discovered inadvertently.
The FBI closed over 14 city blocks to any traffic, except to those rescue workers with a federal response plan ID. We called this the "affected area," and it was a much larger area than just ground zero. An unintended consequence was that the volunteer rescue workers who had come from all over the country and even Canada feared that they would not be let back into the relief operation if they left to go to a hotel at night. They were right.
As a result, rescue volunteers were sleeping on the streets with no pillows, no blankets, no masks and no shelter. The Red Cross eventually put up two respite facilities in the affected area for them, but in the meantime we tried to get pillows, blankets and supplies to each "homeless" rescue worker on the street.
Another unintended consequence was that any residents still in the affected area had no transportation, home healthcare, pharmacies, grocery stores, restaurants, communication systems, emergency services, and often no power or water. This area contained a large number of residential high-rises. Literally thousands of people were stranded in their homes and traumatized.
There was no system or plan to address the special needs of these people, many of whom were elderly, mentally ill, non-English-speaking immigrants and/or disabled. The healthy and young just walked or ran out; the others heard the thunder of the planes crash into the WTC and molten steel collapse near them but languished in uncertainty with no way to determine what had happened.
Due to economies of scale, the Red Cross usually waits for disaster victims to come to their established centers for assistance, but this disaster required a different approach. I created multi-disciplinary outreach teams that included nurses, social workers, family service providers (assistance with new housing), mass care specialists (food and water), and for the first-time, physicians.
These outreach teams used donated RIM Blackberry devices to communicate through email. I had never seen a Blackberry before, probably because it was not officially released until 2002. I quickly became addicted. It may have been a Red Crosser who first coined the term "Crackberry."
The outreach teams went door to door to ensure no one was missed. The building managers unlocked the doors of those with no initial response. The name of the resident and his/her status was documented because, relatives were often concerned that he/she had died in the collapse of the towers or alone in his/her apartment. The members of these teams were all local volunteers since the airports were closed- neighbors helping neighbors. The Red Cross had an established system for incorporating new, local volunteers into a disaster response in order to give local residents a way to contribute and help their communities heal. In fact, the Red Cross used over 18,000 new, local volunteers in the first three weeks after September 11th.
Managing the aftermath of 9/11
The issues that the outreach teams found were diverse. One building had 33 stories and a pitch-black stairwell due to no windows or electricity. I recruited the National Guard from the incident command center to form a human chain with flashlights to carry over one hundred residents out. One resident was clearly delusional and a review of his empty pill bottles revealed that he was a schizophrenic. Two Red Cross volunteers with Masters in Social Work spent hours talking him down and then getting him to an emergency department.
We also found heart patients having chest pain, diabetics with high sugars and emphysema patients with difficulty breathing – all sitting helplessly in their apartments. They could not call 911. One man proudly refused to go to the Red Cross shelter because he thought it would be like a New York City homeless shelter. This was something that I had not thought of before because in places like Florida where disasters are common, residents are aware that the Red Cross shelters are temporary sources of food, shelter and support, usually in schools and churches, with all new and clean accommodations.
In the Chinatown area of New York City, several thousand Asian immigrants refused to leave their homes because they had nowhere to go and did not speak English – the Red Cross arranged for supplies, food and water to be brought to them.
Four days into the disaster, we discovered a thirty year old woman with advanced multiple sclerosis. She normally received 10-12 hours of home care daily because she was virtually paralyzed from the neck down, but the security measures prevented her nurse from reaching her. This young woman had been sitting in her own excrement without food or water for days without knowing what had happened. Volunteer nurses immediately cleaned her and her new, bleeding skin ulcers while we made arrangements to address her multitude of issues. There were great unanticipated needs for the most vulnerable among us.
The FBI restricted access for over three weeks, and it was months before transportation and commerce would resume. This event was unprecedented. A religious book store owner who lived above his store in the affected area brought-up several issues that plagued people who lived in the affected area. He had no mail service. Getting bills and mail-order prescriptions was impossible, and a visit to the main NYC post-office demonstrated that it would not be worked-out for months. His Internet was down. His business was non-existent. All aspects of his life were impacted.
The government, first responders, non-governmental organizations and many, many others did an incredible job, given the circumstances, during the September 11th relief operation but the past 10 years have seen great strides in improving disaster response. The Red Cross president made poor decisions about how and when to request additional donations to the Red Cross during the September 11th disaster operation.
As a result, the Red Cross received considerable criticism, and Congress' discussions about providing Red Cross medical personnel with malpractice and tort protection ended. On my recommendation, the Red Cross decided to not invest in coordinating the medical response. Malpractice lawsuits are a poor use of donated dollars.
Instead the government created the Medical Reserve Corps within the Office of the Surgeon General which was meant to fill this role. My concerns were:
- The Office of the Surgeon General had no significant experience coordinating volunteers.
- Once the focus on disaster response waned, the government funding would dry up for medical reserve corp.
- Medical volunteers would have limited opportunities to practice disaster response on real disasters because they would be solely local teams, whereas with the Red Cross had planned to deploy them in other roles to disasters around the country in order to gain experience in general disaster response.
After attending a disaster training course in Israel this year, my observations were confirmed that the United States has a long way to go in the arena of disaster medical and mental health response, especially for those with the greatest needs.
September 11th changed my life as it did most peoples. Now, a mission of mine is addressing the public health and medical gaps in disaster response, domestically and internationally.
About the author:
Kelly B. Close, MD, MPH, is the Director of Emed Health a the Center for Emergency Medicine of Western Pennsylvania, Inc. She is also an adjunct professor in the School of Health and Rehabilitation Sciences. She can be reached by email at firstname.lastname@example.org.