- Email: [email protected]
11: the view ahead
Comment
ratio 1·22, 95% CI 1·01–1·48). Increased heart-diseaserelated mortality in these participants was also reported, with hazard ratios that suggested a dose-response relation (adjusted hazard ratio 1·21, 95% CI 0·80–1·83, for intermediate WTC-related exposure and 2·06, 1·10–3·86, for high exposure). Although the overall lower than expected death rates seem to be reassuring, they are consistent with the healthy worker and healthy volunteer effects seen early in other cohort studies,8 and these findings suggest that mortality effects of the disaster are measurable 10 years later in a subset of the exposed population. Of course, some questions still remain unanswered by this study. Did those non-rescue and non-recovery workers with the highest exposure who stayed near ground zero stay because of pre-existing illness? Were they too sick to leave? Perhaps that single comparison represents a sampling bias. Although the exposure and the death rates are temporally related, are they in fact causally related? These are questions that are simply not answerable by a database study, no matter how large the sample. Outside of psychiatric research, few data on the long-term sequelae of any terrorist event exist, but researchers caring for the WTC victims and responders are systematically rectifying that lack of reliable information.9–13 The study by Jordan and colleagues replaces supposition and assertion founded on anecdote with cold, hard, incontrovertible, well presented data. Most of the focus on disaster management is on preparation, critical mortality, and response, and that is why this article is so important. As a society, the more data we have about the events, plans, opportunities,
responses, motivations, modus operandi, and especially the aftermath, the more devices we have to take the terror out of terrorism. *James M Feeney, Marc K Wallack Saint Francis Hospital and Medical Center, Hartford, CT 06103, USA (JMF); and Metropolitan Hospital Center, New York, NY, USA (MKW) [email protected] We declare that we have no conflicts of interest. 1
2 3
4
5 6
7 8
9
10 11
12
13
Warga C. Man’s death from World Trade Center dust brings Ground Zero toll to 2753. New York Daily News June 18, 2011. http://articles.nydailynews. com/2011-06-18/local/29691833_1_world-trade-center-year-of-lungdisease-inflamed-cells (accessed July 15, 2011). Feeney JM, Goldberg R, Blumenthal JA, Wallack MK. September 11th 2001 revisited, a review of the data. Arch Surg 2005; 140: 1068–73. Cushman JG, Pachter HL, Beaton HL. Two New York City hospitals’ surgical response to the September 11, 2001, terrorist attack in New York City. J Trauma 2003; 54: 147–55. Goldman H. New York, US commemorate Sept 11 anniversary with ceremonies, protests. Bloomberg News Sept 12, 2010. http://www. bloomberg.com/news/2010-09-11/new-york-u-s-commemorate-sept-11anniversary-with-ceremonies-protests.html (accessed July 15, 2011). Duffy KT. Sentencing statement, United States of America v Mohammad A. SaZameh et al. S593CR.180 (KTD). May 24, 1994, p 36. US Congress Senate. Permanent Subcommittee on Investigations, hearings on global proliferation of weapons of mass destruction. Washington DC: Committee on Governmental Affairs, 1996: 21. Frykberg ER. Medical management of disasters and mass casualties from terrorist bombings: how can we cope? J Trauma 2002; 53: 201–12. Jordan HT, Brackbill RM, Cone JE, et al. Mortality among survivors of the Sept 11, 2001, World Trade Center disaster: results from the World Trade Center Health Registry cohort. Lancet 2011; 378: 879–87. Brackbill RM, Hadler JL, DiGrande L, et al. Asthma and posttraumatic stress symptoms 5 to 6 years following exposure to the World Trade Center terrorist attack. JAMA 2009; 302: 502–16. Aldrich TK, Gustave J, Hall CB, et al. Lung function in rescue workers at the World Trade Center after 7 years. N Engl J Med 2010; 362: 1263–72. Weiden MD, Ferrier N, Nolan A, et al. Obstructive airways disease with air trapping among firefighters exposed to World Trade Center dust. Chest 2009; 137: 566–74. Reibman J, Lin S, Hwang SA, et al. The World Trade Center residents’ respiratory health study: new-onset respiratory symptoms and pulmonary function. Environ Health Perspect 2005; 113: 406–11. Berninger A, Webber MP, Cohen HW, et al. Trends of elevated PTSD risk in firefighters exposed to the World Trade Center disaster: 2001–2005. Public Health Rep 2010; 125: 556–66.
9/11: the view ahead See Articles page 888
852
In The Lancet, Juan Wisnivesky and colleagues1 report on persistent health effects in 27 499 World Trade Center (WTC) rescue and recovery workers, 9 years after Sept 11, 2001 (9/11). The WTC disaster is among the most highly studied disasters in history. Many publications have reported on health effects in WTC rescue and recovery workers in the weeks, months, and years after the disaster.2–13 We have learned much about the health implications of exposure to the complex mixture of contaminants in dust and smoke generated
from the collapse and incineration of the WTC. However, in reality, the research done thus far has provided almost as many questions as it has answers. One of the main questions relates to the long-term trajectory of health effects in individuals exposed to the dust and smoke. Wisnivesky and colleagues found that the 9-year cumulative incidence of asthma was 27·6% (number at risk: 7027), sinusitis 42·3% (5870), gastro-oesophageal reflux disease 39·3% (5650), and spirometric abnormalities 41·8% (5769). In New York City police officers, www.thelancet.com Vol 378 September 3, 2011
cumulative incidence of depression was 7·0% (number at risk: 3648), post-traumatic stress disorder 9·3% (3761), and panic disorder 8·4% (3780). In other rescue and recovery workers, cumulative incidence of depression was 27·5% (number at risk: 4200), post-traumatic stress disorder 31·9% (4342), and panic disorder 21·2% (4953). More than a fifth of these rescue and recovery workers had multiple physical and mental health problems. For most disorders, Wisnivesky and colleagues reported a dose-response relation with exposure (ie, number of days worked at the WTC site, exposure to the dust cloud, and work on the debris pile), with the greatest incidence in the highest exposure category. Thus, as the authors state: “[there is] a substantial burden of persistent physical and mental disorders in rescue and recovery workers who rushed to the site of the WTC and laboured there for weeks and months 10 years ago.” Studies have shown persistent health effects in WTC rescue and recovery workers who first attended the WTC site, and in those with high exposure to the environment at the site5,7–9,13 as well as those with more moderate exposure.11,12 We now know that, in one of the largest WTC rescue and recovery cohorts, health effects have persisted for almost a decade. These latest findings leave no doubt about the necessity of continuing health monitoring, treatment, and research for WTC rescue and recovery workers. The persistent physical and mental health effects in some WTC rescue and recovery workers have resulted in an unprecedented societal burden in caring for those who gave so much of themselves in a time of unspeakable tragedy. A long-term battle to continue necessary funding for monitoring, treatment, and research has resulted in the implementation of the James Zadroga 9/11 Health and Compensation Act of 2010,14 which establishes a federally funded WTC health programme. This programme provides funding for clinical centres of excellence that provide monitoring and treatment services, and data centres that receive, analyse, and report on data associated with health effects of exposure to the WTC. The research component is vital, as it will allow informed decisions to be made in the future, both medically and politically. Through such research we might eventually understand fully the nature and extent of the health effects of the WTC disaster. Considering a broader perspective, the results reported by Wisnivesky and colleagues emphasise the critical www.thelancet.com Vol 378 September 3, 2011
Steve Wood/Rex Features
Comment
importance of including the study of long-term health effects in any future disaster-response plan. Historically, little information has been available about the longterm health outcomes of most disasters. Ideally, national and local health services should be equipped to provide health surveillance systems and resources in the weeks, months, and years after a disaster.15 As the response to the WTC disaster has proven, long-term monitoring and surveillance can be successful in tracking persistent health effects that could burden affected populations. In view of the health effects on individuals and the potential societal burdens, such as health-care costs, the inclusion of long-term health monitoring and research for future disaster planning would be prudent. Furthermore, the allocation of resources to undertake such efforts would be a wise investment. As we mark the 10th anniversary of 9/11, reports of persistent health effects are a sobering reminder that the disaster has had far-reaching effects. Fortunately, our knowledge of these effects is rapidly improving, and studies such as that reported by Wisnivesky and colleagues represent important steps forward. One cannot help but wonder what will be reported when we mark the 20th anniversary of this tragedy. For now, the view ahead is still murky, much like the plumes of acrid smoke that rose in New York City a decade ago. Matthew P Mauer New York State Department of Health, Center for Environmental Health, Troy, NY 12180, USA [email protected]
853
Comment
I declare that I have no conflicts of interest. 1
2
3
4
5
6
7
Wisnivesky JP, Teitelbaum SL, Todd AC, et al. Persistence of multiple illnesses in World Trade Center rescue and recovery workers. Lancet 2011; 378: 888–97. Prezant DJ, Weiden M, Banauch GI, et al. Cough and bronchial responsiveness in firefighters at the World Trade Center site. N Engl J Med 2002; 347: 806–15. Landrigan PJ, Lioy PJ, Thurston G, et al. Health and environmental consequences of the World Trade Center disaster. Environ Health Perspect 2004; 112: 731–39. Tapp L, Baron S, Bernard B, Driscoll R, Mueller C, Wallingford K. Physical and mental health symptoms among NYC transit workers seven and one-half months after the WTC attacks. Am J Ind Med 2005; 47: 475–83. Herbert R, Moline J, Skloot G, et al. The World Trade Center disaster and the health of workers: five-year assessment of a unique medical screening program. Environ Health Perspect 2006; 114: 1853–58. Mauer MP, Cummings KR, Carlson GA. Health effects in New York State personnel who responded to the World Trade Center disaster. J Occup Environ Med 2007; 49: 1197–205. Stellman JM, Smith RP, Katz CL, et al. Enduring mental health morbidity and social function impairment in World Trade Center rescue, recovery, and cleanup workers: the psychological dimension of an environmental health disaster. Environ Health Perspect 2008; 116: 1248–53.
8
9 10
11 12 13
14
15
Brackbill RM, Hadler JL, DiGrande L, et al. Asthma and posttraumatic stress symptoms 5 to 6 years following exposure to the World Trade Center terrorist attack. JAMA 2009; 302: 502–16. Aldrich TK, Gustave J, Hall CB, et al. Lung function in rescue workers at the World Trade Center after 7 years. N Engl J Med 2010; 362: 1263–72. Mauer MP, Herdt-Losavio ML, Carlson GA. Asthma and lower respiratory symptoms in New York State employees who responded to the World Trade Center disaster. Int Arch Occup Environ Health 2010; 83: 21–27. Mauer MP, Cummings KR, Hoen R. Long-term respiratory symptoms in World Trade Center responders. Occup Med 2010; 60: 145–51. Mauer MP, Cummings KR. Impulse oscillometry and respiratory symptoms in World Trade Center responders, 6 years post-9/11. Lung 2010; 188: 107–13. Kleinman EJ, Cucco RA, Martinez C, et al. Pulmonary function in a cohort of New York City police department emergency responders since the 2001 World Trade Center disaster. J Occup Environ Med 2011; 53: 618–26. Department of Health and Human Services. World Trade Center Health Program requirements for enrollment, appeals, certification of health conditions, and reimbursement; interim final rule. Fed Regist 2011; 76: 38914–36. Cook A, Watson J, van Buynder P, Robertson A, Weinstein P. 10th anniversary review: natural disasters and their long-term impacts on the health of communities. J Environ Monit 2008; 10: 167–75.
Medical care for workers exposed to the WTC disaster
Corbis
See Articles page 898
854
In The Lancet, the report by Rachael Zeig-Owens and colleagues1 marks important progress in the assessment of health outcomes for rescue and recovery workers who were exposed to the aftermath of the Sept 11, 2001 (9/11) attacks. Over 50 000 workers were exposed while responding to the World Trade Center (WTC) incident, attempting to rescue survivors and recover the dead, clearing the site, or cleaning the surrounding buildings.2 These workers were exposed to an incompletely characterised mix of asbestos, alkaline cement dust, pulverised building materials, and fire
smoke for many days and weeks, often without proper protection.3 Hundreds of these people are disabled and can no longer work, and thousands have become ill and continue to receive medical treatment nearly 10 years after 9/11.4 Until now, documentation of illnesses in WTC rescue and recovery workers has been based on data collected during medical examinations or follow-up health interviews.4–6 The only study on cancer outcomes in these workers was a small case series of multiple myeloma (n=8).7 Case studies, although useful for alerting the health-care community about the potential for new or late emerging illnesses, are of little value for determining WTC-exposure-related health outcomes due to self-selection and case-ascertainment biases. The study by Zeig-Owens and colleagues is the first to assess chronic or latent diseases in a defined study population. Zeig-Owens and colleagues report an early assessment of cancer outcomes in 9853 men who were employed as New York City firefighters, and describe a modest excess of cancer in WTC-exposed firefighters compared with rates in non-exposed firefighters. The WTC-exposed firefighters had a 10% higher (95% CI −2 to 25) overall cancer incidence ratio than was expected in a similar demographic mix from the general male population in the USA, and a 32% higher (7 to 62) incidence than in non-exposed firefighters. www.thelancet.com Vol 378 September 3, 2011
ratio 1·22, 95% CI 1·01–1·48). Increased heart-diseaserelated mortality in these participants was also reported, with hazard ratios that suggested a dose-response relation (adjusted hazard ratio 1·21, 95% CI 0·80–1·83, for intermediate WTC-related exposure and 2·06, 1·10–3·86, for high exposure). Although the overall lower than expected death rates seem to be reassuring, they are consistent with the healthy worker and healthy volunteer effects seen early in other cohort studies,8 and these findings suggest that mortality effects of the disaster are measurable 10 years later in a subset of the exposed population. Of course, some questions still remain unanswered by this study. Did those non-rescue and non-recovery workers with the highest exposure who stayed near ground zero stay because of pre-existing illness? Were they too sick to leave? Perhaps that single comparison represents a sampling bias. Although the exposure and the death rates are temporally related, are they in fact causally related? These are questions that are simply not answerable by a database study, no matter how large the sample. Outside of psychiatric research, few data on the long-term sequelae of any terrorist event exist, but researchers caring for the WTC victims and responders are systematically rectifying that lack of reliable information.9–13 The study by Jordan and colleagues replaces supposition and assertion founded on anecdote with cold, hard, incontrovertible, well presented data. Most of the focus on disaster management is on preparation, critical mortality, and response, and that is why this article is so important. As a society, the more data we have about the events, plans, opportunities,
responses, motivations, modus operandi, and especially the aftermath, the more devices we have to take the terror out of terrorism. *James M Feeney, Marc K Wallack Saint Francis Hospital and Medical Center, Hartford, CT 06103, USA (JMF); and Metropolitan Hospital Center, New York, NY, USA (MKW) [email protected] We declare that we have no conflicts of interest. 1
2 3
4
5 6
7 8
9
10 11
12
13
Warga C. Man’s death from World Trade Center dust brings Ground Zero toll to 2753. New York Daily News June 18, 2011. http://articles.nydailynews. com/2011-06-18/local/29691833_1_world-trade-center-year-of-lungdisease-inflamed-cells (accessed July 15, 2011). Feeney JM, Goldberg R, Blumenthal JA, Wallack MK. September 11th 2001 revisited, a review of the data. Arch Surg 2005; 140: 1068–73. Cushman JG, Pachter HL, Beaton HL. Two New York City hospitals’ surgical response to the September 11, 2001, terrorist attack in New York City. J Trauma 2003; 54: 147–55. Goldman H. New York, US commemorate Sept 11 anniversary with ceremonies, protests. Bloomberg News Sept 12, 2010. http://www. bloomberg.com/news/2010-09-11/new-york-u-s-commemorate-sept-11anniversary-with-ceremonies-protests.html (accessed July 15, 2011). Duffy KT. Sentencing statement, United States of America v Mohammad A. SaZameh et al. S593CR.180 (KTD). May 24, 1994, p 36. US Congress Senate. Permanent Subcommittee on Investigations, hearings on global proliferation of weapons of mass destruction. Washington DC: Committee on Governmental Affairs, 1996: 21. Frykberg ER. Medical management of disasters and mass casualties from terrorist bombings: how can we cope? J Trauma 2002; 53: 201–12. Jordan HT, Brackbill RM, Cone JE, et al. Mortality among survivors of the Sept 11, 2001, World Trade Center disaster: results from the World Trade Center Health Registry cohort. Lancet 2011; 378: 879–87. Brackbill RM, Hadler JL, DiGrande L, et al. Asthma and posttraumatic stress symptoms 5 to 6 years following exposure to the World Trade Center terrorist attack. JAMA 2009; 302: 502–16. Aldrich TK, Gustave J, Hall CB, et al. Lung function in rescue workers at the World Trade Center after 7 years. N Engl J Med 2010; 362: 1263–72. Weiden MD, Ferrier N, Nolan A, et al. Obstructive airways disease with air trapping among firefighters exposed to World Trade Center dust. Chest 2009; 137: 566–74. Reibman J, Lin S, Hwang SA, et al. The World Trade Center residents’ respiratory health study: new-onset respiratory symptoms and pulmonary function. Environ Health Perspect 2005; 113: 406–11. Berninger A, Webber MP, Cohen HW, et al. Trends of elevated PTSD risk in firefighters exposed to the World Trade Center disaster: 2001–2005. Public Health Rep 2010; 125: 556–66.
9/11: the view ahead See Articles page 888
852
In The Lancet, Juan Wisnivesky and colleagues1 report on persistent health effects in 27 499 World Trade Center (WTC) rescue and recovery workers, 9 years after Sept 11, 2001 (9/11). The WTC disaster is among the most highly studied disasters in history. Many publications have reported on health effects in WTC rescue and recovery workers in the weeks, months, and years after the disaster.2–13 We have learned much about the health implications of exposure to the complex mixture of contaminants in dust and smoke generated
from the collapse and incineration of the WTC. However, in reality, the research done thus far has provided almost as many questions as it has answers. One of the main questions relates to the long-term trajectory of health effects in individuals exposed to the dust and smoke. Wisnivesky and colleagues found that the 9-year cumulative incidence of asthma was 27·6% (number at risk: 7027), sinusitis 42·3% (5870), gastro-oesophageal reflux disease 39·3% (5650), and spirometric abnormalities 41·8% (5769). In New York City police officers, www.thelancet.com Vol 378 September 3, 2011
cumulative incidence of depression was 7·0% (number at risk: 3648), post-traumatic stress disorder 9·3% (3761), and panic disorder 8·4% (3780). In other rescue and recovery workers, cumulative incidence of depression was 27·5% (number at risk: 4200), post-traumatic stress disorder 31·9% (4342), and panic disorder 21·2% (4953). More than a fifth of these rescue and recovery workers had multiple physical and mental health problems. For most disorders, Wisnivesky and colleagues reported a dose-response relation with exposure (ie, number of days worked at the WTC site, exposure to the dust cloud, and work on the debris pile), with the greatest incidence in the highest exposure category. Thus, as the authors state: “[there is] a substantial burden of persistent physical and mental disorders in rescue and recovery workers who rushed to the site of the WTC and laboured there for weeks and months 10 years ago.” Studies have shown persistent health effects in WTC rescue and recovery workers who first attended the WTC site, and in those with high exposure to the environment at the site5,7–9,13 as well as those with more moderate exposure.11,12 We now know that, in one of the largest WTC rescue and recovery cohorts, health effects have persisted for almost a decade. These latest findings leave no doubt about the necessity of continuing health monitoring, treatment, and research for WTC rescue and recovery workers. The persistent physical and mental health effects in some WTC rescue and recovery workers have resulted in an unprecedented societal burden in caring for those who gave so much of themselves in a time of unspeakable tragedy. A long-term battle to continue necessary funding for monitoring, treatment, and research has resulted in the implementation of the James Zadroga 9/11 Health and Compensation Act of 2010,14 which establishes a federally funded WTC health programme. This programme provides funding for clinical centres of excellence that provide monitoring and treatment services, and data centres that receive, analyse, and report on data associated with health effects of exposure to the WTC. The research component is vital, as it will allow informed decisions to be made in the future, both medically and politically. Through such research we might eventually understand fully the nature and extent of the health effects of the WTC disaster. Considering a broader perspective, the results reported by Wisnivesky and colleagues emphasise the critical www.thelancet.com Vol 378 September 3, 2011
Steve Wood/Rex Features
Comment
importance of including the study of long-term health effects in any future disaster-response plan. Historically, little information has been available about the longterm health outcomes of most disasters. Ideally, national and local health services should be equipped to provide health surveillance systems and resources in the weeks, months, and years after a disaster.15 As the response to the WTC disaster has proven, long-term monitoring and surveillance can be successful in tracking persistent health effects that could burden affected populations. In view of the health effects on individuals and the potential societal burdens, such as health-care costs, the inclusion of long-term health monitoring and research for future disaster planning would be prudent. Furthermore, the allocation of resources to undertake such efforts would be a wise investment. As we mark the 10th anniversary of 9/11, reports of persistent health effects are a sobering reminder that the disaster has had far-reaching effects. Fortunately, our knowledge of these effects is rapidly improving, and studies such as that reported by Wisnivesky and colleagues represent important steps forward. One cannot help but wonder what will be reported when we mark the 20th anniversary of this tragedy. For now, the view ahead is still murky, much like the plumes of acrid smoke that rose in New York City a decade ago. Matthew P Mauer New York State Department of Health, Center for Environmental Health, Troy, NY 12180, USA [email protected]
853
Comment
I declare that I have no conflicts of interest. 1
2
3
4
5
6
7
Wisnivesky JP, Teitelbaum SL, Todd AC, et al. Persistence of multiple illnesses in World Trade Center rescue and recovery workers. Lancet 2011; 378: 888–97. Prezant DJ, Weiden M, Banauch GI, et al. Cough and bronchial responsiveness in firefighters at the World Trade Center site. N Engl J Med 2002; 347: 806–15. Landrigan PJ, Lioy PJ, Thurston G, et al. Health and environmental consequences of the World Trade Center disaster. Environ Health Perspect 2004; 112: 731–39. Tapp L, Baron S, Bernard B, Driscoll R, Mueller C, Wallingford K. Physical and mental health symptoms among NYC transit workers seven and one-half months after the WTC attacks. Am J Ind Med 2005; 47: 475–83. Herbert R, Moline J, Skloot G, et al. The World Trade Center disaster and the health of workers: five-year assessment of a unique medical screening program. Environ Health Perspect 2006; 114: 1853–58. Mauer MP, Cummings KR, Carlson GA. Health effects in New York State personnel who responded to the World Trade Center disaster. J Occup Environ Med 2007; 49: 1197–205. Stellman JM, Smith RP, Katz CL, et al. Enduring mental health morbidity and social function impairment in World Trade Center rescue, recovery, and cleanup workers: the psychological dimension of an environmental health disaster. Environ Health Perspect 2008; 116: 1248–53.
8
9 10
11 12 13
14
15
Brackbill RM, Hadler JL, DiGrande L, et al. Asthma and posttraumatic stress symptoms 5 to 6 years following exposure to the World Trade Center terrorist attack. JAMA 2009; 302: 502–16. Aldrich TK, Gustave J, Hall CB, et al. Lung function in rescue workers at the World Trade Center after 7 years. N Engl J Med 2010; 362: 1263–72. Mauer MP, Herdt-Losavio ML, Carlson GA. Asthma and lower respiratory symptoms in New York State employees who responded to the World Trade Center disaster. Int Arch Occup Environ Health 2010; 83: 21–27. Mauer MP, Cummings KR, Hoen R. Long-term respiratory symptoms in World Trade Center responders. Occup Med 2010; 60: 145–51. Mauer MP, Cummings KR. Impulse oscillometry and respiratory symptoms in World Trade Center responders, 6 years post-9/11. Lung 2010; 188: 107–13. Kleinman EJ, Cucco RA, Martinez C, et al. Pulmonary function in a cohort of New York City police department emergency responders since the 2001 World Trade Center disaster. J Occup Environ Med 2011; 53: 618–26. Department of Health and Human Services. World Trade Center Health Program requirements for enrollment, appeals, certification of health conditions, and reimbursement; interim final rule. Fed Regist 2011; 76: 38914–36. Cook A, Watson J, van Buynder P, Robertson A, Weinstein P. 10th anniversary review: natural disasters and their long-term impacts on the health of communities. J Environ Monit 2008; 10: 167–75.
Medical care for workers exposed to the WTC disaster
Corbis
See Articles page 898
854
In The Lancet, the report by Rachael Zeig-Owens and colleagues1 marks important progress in the assessment of health outcomes for rescue and recovery workers who were exposed to the aftermath of the Sept 11, 2001 (9/11) attacks. Over 50 000 workers were exposed while responding to the World Trade Center (WTC) incident, attempting to rescue survivors and recover the dead, clearing the site, or cleaning the surrounding buildings.2 These workers were exposed to an incompletely characterised mix of asbestos, alkaline cement dust, pulverised building materials, and fire
smoke for many days and weeks, often without proper protection.3 Hundreds of these people are disabled and can no longer work, and thousands have become ill and continue to receive medical treatment nearly 10 years after 9/11.4 Until now, documentation of illnesses in WTC rescue and recovery workers has been based on data collected during medical examinations or follow-up health interviews.4–6 The only study on cancer outcomes in these workers was a small case series of multiple myeloma (n=8).7 Case studies, although useful for alerting the health-care community about the potential for new or late emerging illnesses, are of little value for determining WTC-exposure-related health outcomes due to self-selection and case-ascertainment biases. The study by Zeig-Owens and colleagues is the first to assess chronic or latent diseases in a defined study population. Zeig-Owens and colleagues report an early assessment of cancer outcomes in 9853 men who were employed as New York City firefighters, and describe a modest excess of cancer in WTC-exposed firefighters compared with rates in non-exposed firefighters. The WTC-exposed firefighters had a 10% higher (95% CI −2 to 25) overall cancer incidence ratio than was expected in a similar demographic mix from the general male population in the USA, and a 32% higher (7 to 62) incidence than in non-exposed firefighters. www.thelancet.com Vol 378 September 3, 2011