On the evening of Tuesday, September 11, 2001—with fires burning at the site of where the twin towers had stood that morning and several thousand people still unaccounted for—a group of physicians from the Mount Sinai Selikoff Centers for Occupational Health met to discuss a plan of action for treating survivors and first responders who had rushed in to help.

Protégés of the late Irving Selikoff, MD—a pioneering researcher who was the first to definitively link asbestos exposure to lung cancer—these physicians knew how dangerous the air was at the site of the attack, which had been reduced to 1.8 million tons of burning rubble. The toxic stew of chemicals would later be found to include major hazards to human health, such as lead and other heavy metals, benzene, dioxin, and asbestos. The physicians also knew that serious illnesses could develop decades after an individual’s initial exposure, lessons they had learned from Dr. Selikoff and his groundbreaking research in the 1960s.

Over the course of their first meeting and several subsequent ones that included colleagues such as David Prezant, MD, Chief Medical Officer of the Fire Department of the City of New York (FDNY), the Mount Sinai physicians established a blueprint for what is now the World Trade Center (WTC) Health Program.

Today, 20 years later, the WTC program continues to receive new patients. It consists of six New York City-area medical centers, including Mount Sinai, and a separate treatment center exclusively for FDNY members. Together, the centers treat more than 80,000 emergency responders—firefighters, police, recovery and cleanup workers—as well as 30,000 people who worked, lived, or went to school near the disaster zone in lower Manhattan. Their medical care will be funded through 2090, under the federal James Zadrogra 9/11 Health and Compensation Act, which was signed into law in 2011.

“The Selikoff Centers had exceptional doctors and they worked their fingers to the bone getting this program off the ground,” says Michael Crane, MD, MPH, who joined Mount Sinai in 2006 as Director of the World Trade Center Health Program Clinical Center at Mount Sinai. “Their incredible dedication got this going. It was hardscrabble, making phone calls and asking people to speak out about the program. They were helped by community and civic leaders and members of Congress who got behind this. Their story is really an inspiration.”

Dr. Crane, whose program at Mount Sinai cares for roughly 23,000 responders, was medical director of Con Edison’s health program on 9/11. Immediately following the attacks, he was down at the site making sure Con Edison’s recovery workers had proper masks and breathing protection. But that was not the case for many other responders. The filters on their masks clogged up after an hour and workers were either too busy to replace them or could not find extra masks.

“You’d see the masks hanging off their faces,” says Dr. Crane. “They were running in to save people’s lives. They ran in without appropriate equipment and suffered the consequences.”

The dedication of the recovery workers was inspiring, says Dr. Crane. “So many of them had friends or relatives or people they knew or had trained with down there. Guys who ran down there had built the towers. So it was a tremendous emotional shock. They were energized by this passion to do something about it. So many of them said the same thing: ‘It’s family. I want to find them.’ It was deep and personal and real.”

Michael Crane, MD, MPH, left, and Julia Nicolaou Burns, Administrative Director, Selikoff Centers for Occupational Health

On 9/11, Craig L. Katz, MD, was the newly appointed Director of The Mount Sinai Hospital’s Psychiatry Emergency Room. But it was his leadership of the nonprofit organization, Disaster Psychiatry Outreach, which he had founded during his medical residency, which led to his direct involvement with the families of the victims, survivors, and responders. Almost immediately, Dr. Katz helped organize volunteer psychiatrists who met informally with these groups down at Ground Zero or at the Family Assistance Center that New York City had established downtown.

At the time, lung screenings for responders were being funded by the National Institute for Occupational Safety and Health (NIOSH), but no federal funding had been allocated for mental health. Yet the psychological effects of the troubling rescue and recovery mission were beginning to show.

A few months after the attacks, Dr. Katz says Mount Sinai’s Psychiatry Department received a phone call from the late Stephen Levin, MD, then Medical Director of the Mount Sinai Selikoff Centers for Occupational Health, who said, “ ‘I have all these rescue and recovery workers coming into my office and they’re crying. I don’t know what to do with them. I’m looking at lung exposures and they’re crying.’”

Craig L. Katz, MD

Looking to assist the workers, Dr. Katz, currently a Clinical Professor in the departments of Psychiatry, Medical Education, and System Design and Global Health, at the Icahn School of Medicine at Mount Sinai, wrote a three-page grant proposal to the private Robin Hood Foundation requesting funding for mental health. “That was the birth of the mental health program for recovery workers,” he says.

The Robin Hood Foundation would go on to provide the program with more than $6 million until 2011, when the Zadroga Bill was enacted, according to Dr. Katz. “Robin Hood typically funds underserved populations,” he says. “They agreed the rescue and recovery workers were an underserved population. They were largely men who don’t readily seek help for mental health issues. These blue collar guys were not our usual customers.”

Today, Mount Sinai’s World Trade Center (WTC) Mental Health Program actively treats close to 700 individuals under the leadership of Sandra M. Lowe, MD, Medical Director. “The people involved in the recovery and restoration operations were exposed to so much trauma,” says Dr. Lowe. “Some individuals developed post-traumatic stress disorder (PTSD), major depressive disorder, all kinds of anxiety disorders, and some developed substance misuse problems because that was one of the ways they tried to manage the symptoms they had.”

These mental health conditions, combined with the aero-digestive disorders, lymphoma, or lung cancer, which also stem from their work at Ground Zero, have created a complicated set of issues for this aging cohort of responders, many of whom are now in their 50s.

Sandra M. Lowe, MD

“Some members of the public may question the relevance of the WTC Health Center 20 years later,” says Dr. Lowe. “It is very relevant and needed. People are not aware of the ongoing physical or psychological struggles. We see an increased number of patients coming in for help. They have developed worsening physical conditions or now they’re retiring from the New York City Police Department. They may have been suffering PTSD for 20 years, but now they’re no longer afraid of the stigma associated with seeking help. They’ll say, ‘Doc, this is the first time I’ve told anyone about my nightmares.’ We hear the appreciation from the patients and their families.”

As time goes on, Mount Sinai’s clinical team also sees new health issues arising among responders, including the possibility of early cognitive decline. NIOSH is funding studies to determine whether exposure to toxins at Ground Zero is actually associated with this decline and whether there is a need for an early intervention program.

Kathryn Marrone, LCSW, Director of Social Work for the World Trade Center Mental Health Program, joined Mount Sinai in the summer of 2002 for what she was told at the time would be a one-year job monitoring and assessing the needs of responders. Almost two decades later, she is still working with these men and women. Only now, she says, they are aging and require a shift in services.

The responders “recovered bodies, saw people jumping from buildings, and watched the buildings collapse,” she says. “The level of trauma these individuals experienced was quite severe. They were completely confused about how to manage that emotionally.” But over the years, in their dealings with social workers, doctors, and other colleagues in the program, “Mount Sinai has become a lifeline for so many individuals. It is a place where they can turn because no one else quite gets what they’re experiencing.”