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Sept. 11, one year later: A different kind of normal

Twelve months ago, the planes crashed. The world paused. Then, anthrax attacks amplified the panic. Some things have gone back to the way they were. Others changed forever.

By Victoria Stagg Elliott, amednews staff. Sept. 2, 2002.

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Howard Beaton, MD, chief of surgery and emergency services at New York University Downtown Hospital, the closest hospital to what was the World Trade Center, does some things differently now.

He never leaves home without his hospital identification, so he can prove he is a physician.

He also wears an American flag pin on his lapel, moving it from suit to suit as a constant memorial.

And he is aware that even the sunlight has been altered -- shadows from the twin towers no longer fall across his desk. "There are two huge buildings missing," he said. "I can't drive across town the way I used to get home. There's a lot more security around than there ever used to be. New York has changed."

The eerie quiet

Almost a year ago, the world went quiet. The skies emptied as air traffic was grounded.

Fears surfaced that cadaver organs headed for transplant and flu vaccine awaiting delivery (the shipping season had begun just a day before) might be lost, stranded on tarmacs. Medical conferences were cancelled or seriously disrupted.

A dark black cloud hovered over New York, raising concerns about air quality. New York physicians began reporting an upsurge in patients with asthma.

Meanwhile, blood banks were flooded with donations. Mental health professionals wrote more prescriptions for antidepressants and sleeping pills. Health-related charities saw dips in donations. Some doctors eventually reported a pregnancy boom.

Talk turned to bioterrorism. Physicians flocked to educational sessions about anthrax, tularemia and smallpox. Hospital disaster planning became important.

"In the past, people took it as a regulatory requirement, but it was done with the least bother possible. No one outside of the people responsible for it ever took it seriously before," said Dr. Beaton. "Now, we all understand that it's really serious."

Never the same

Some of the aftereffects have lessened. Many say that life has returned to normal; but it is a different kind of normal.

The black cloud over Manhattan dissipated, although concerns about air quality remain, despite reassuring statements from several government agencies. The pregnancy boom appears to be anecdotal. And charities have had to tighten their belts, although many feel this has more to do with the economy than the flood of money that went to charities related to Sept. 11 relief efforts. Interest in bioterrorism education has waned, and many feel the mental health concerns were oversold.

"I've seen a couple people who have posttraumatic stress disorder. They lost someone close to them or they directly experienced it," said Norman Sussman, MD, professor of psychiatry at the New York University School of Medicine. "But, in general, it hasn't been a pervasive thing."

Only two donor organs -- a liver and a pancreas -- were lost. About half of the organs harvested during the week after Sept. 11 made it to the originally intended recipients. Other organs were reallocated locally. Organs now move more slowly because of security restrictions, but they still make it.

Only two cases of flu vaccine spoiled, and there was enough for the season. Blood supplies have returned to crisis levels, although this is being blamed on new restrictions on who can donate.

"The supply is worse than it was a year ago," said Robert Jones, MD, president of the New York Blood Center. "People had an intense need to donate then, and we're trying to get them to come back."

Scientists who couldn't present their papers because of cancelled conferences published elsewhere. Physicians who had been counting on the conferences to fulfil their CME requirements found other sources.

Rural physicians feel J-1 crunch

Earlier this year, Andrew Eisenberg, MD, a family physician in Madisonville, Texas, had nearly recruited an internist/pulmonologist. The town of just more than 4,000 has long relied on a steady supply of international medical graduates with J-1 visa waivers. But the U.S. Dept. of Agriculture, which had been processing the application, abruptly pulled the plug, and the recruited physician went elsewhere.

All in all, 86 applications were in limbo.

"There are a lot of communities that were planning on these physicians practicing, and suddenly they were left out in the cold," said Fredric Moskol, executive director of the National Rural Recruitment and Retention Network. "It was a big loss."

After much pressure, the USDA finished processing those applications but has withdrawn from the program, leaving rural areas scrambling for new ways to address physician shortages. Many hope that another government agency may fill the hole left by the USDA's exit or that state programs will be expanded.

"If someone picks it up again without much more time going by, so people can get applications in, we'll be all right," said Keith Mueller, PhD, director of the Rural Health Policy Institute at the University of Nebraska.

But rural health experts stress that many areas of the country are dependent on international physicians. A way must be found to both fulfill the need and allay security fears.

"Initially, the reaction was: 'Oh my god, we have to do something about these foreign doctors,' " said Moskol. "But when you think it through, they've gone through a great deal of screening to get into this country, and the ones going out into the community to practice have completed at least a three-year residency here, if not more. It's not as if they're unknown."

Public health progress?

Ed Thompson Jr., MD, MPH, health officer for the Mississippi State Dept. of Health, says money is finally flowing to his department. The federal government has allocated more than $11 million for bioterrorism preparedness for his state, and he expects the infrastructure to help the state respond to other public health issues also, such as infectious disease outbreaks.

"The pipes have opened and money is coming," said Dr. Thompson. "It's a silver lining to this whole thing."

The infusion of cash to the long-neglected public health system is in part due to a change of image. It is now viewed as a first responder. Some officials have even had their cars equipped with red lights and sirens.

Public health officials are thankful for the long-awaited bounty, but there is concern about how the money will be spent and how long it will last. Will the money disappear as the events of 2001 fade into memory? Will other more common health problems -- like heart disease or diabetes -- be neglected in the meantime.

"Is this just what is going to happen for the next two or three years and then it goes away?" said Robert McLellan, MD, MPH, chair of the special committee on disaster planning and response for the American College of Occupational and Environmental Medicine. "We could hope that the threat goes away, but it should not diminish the recognition that we make ourselves vulnerable, not just to terrorism, but to a variety of other emerging diseases, if we allow our local health infrastructure to degrade."

Dr. Thompson's department, for example, received money from the federal government but did not receive money they requested from Mississippi. Some public health officials worry that more money from the federal government will just mean less money from cash-strapped states, negating any possibility of a budget boom.

"We've made dramatic progress in the year to upgrade, but we still have a long way to go," said Mohammad Akhter, MD, MPH, executive director of the American Public Health Assn.

"We still need to do a lot of work in terms of building the capacity. You look at the hospital emergency rooms. They're still as crowded as they were yesterday."

Era of cooperation

Paul Karis, MD, chair of emergency medicine at Saint Vincent Catholic Medical Centers in New York, has regular meetings with his counterparts at competing hospitals to discuss disaster planning, following new requirements from the Joint Commission on the Accreditation of Healthcare Organizations.

This is one of the more positive aspects of the post-Sept. 11 world. Facing a serious attack has altered the way stakeholders come to the table. Physicians, public health officials and those working in health-related government agencies say that communication lines are more open than ever before from department to department, agency to agency, across jurisdictional lines and between traditional competitors.

"We have had whole days talking about how we respond to smallpox as a city, including the hospitals, the fire department, police department, public health and FEMA," said Dr. Karis. "There's a lot of networking going on. Anytime you get people together who don't normally talk with each other, some good is going to come out of it above and beyond the mission that brought you there in the first place."

Anniversary anxiety

Most of the longer-lasting changes relate to increasing security or are by-products of disaster planning. Much of the world has returned to some sense of normalcy, although how normal it gets is directly related to proximity to ground zero.

"People are moving on and looking to the future." said Dr. Karis. "Hopefully, nothing else will come along that pushes us back."

Now thoughts are turning to the anniversary. Most believe there will be heightened levels of anxiety and depression. Fears of flying have already translated to reduced airline bookings and cancelled flights on the day. Most experts believe, though, that few will actually need treatment for emerging mental health issues. Medical conferences, often planned years in advance, are going ahead as scheduled.

"Some people feel that what happened has actually enhanced their appreciation for what they have," said Dr. Sussman. "People are spending more time with their family, and you could argue that this was a kind of corrective emotional experience. It reminded us not to live in some kind of materialistic fantasy world. We have a lot to be thankful for."

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 ADDITIONAL INFORMATION: 

Medicine, life interrupted

• Number of people now absent from Manhattan's downtown area after Sept. 11 because they died, their offices were moved or their companies went out of business: 100,000
• Number of donor cadaver organs that became unusable during the time airplanes were grounded after the attack: 2
• Amount of money awarded by Dept. of Health and Human Services for the production of 155 million doses of smallpox vaccine before the end of 2002: $428 million
• Number of J1-visa waiver applications interrupted by the U.S. Dept. of Agriculture's withdrawal from the program. The applications eventually were processed: 86

Sources: U.S. Dept. of Agriculture, General Accounting Office, United Network for Organ Sharing, Dept. of Health and Human Services

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As previously reported (AMNews, Nov. 26, 2001), Dr. Nemetz lost his main office, his records and hundreds of patients that day. Some patients died. Some just never returned to the downtown area, because their employers went out of business or moved across the river to New Jersey.

Dr. Nemetz has not returned to the area. He works from his midtown office, where business is gowing quickly.

"The downtown area is alive," he said. "But it's really hurting. To try to reopen a new office after we've just spent so much energy just surviving doesn't seem like the smartest thing to do."

But within a couple of years, Dr. Nemetz does hope to return to the Trade Center area. He remembers the 10 years he spent at that location fondly.

"It was a lovely place to come to work every day," Dr. Nemetz said.

"We had the best patient population in the world. They were very educated, medically sophisticated, responsible, employed adults."

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Weblink

Report, "The Immediate and Future Role of the J-1 Visa Waiver Program for Physicians: The Consequences of Change for Rural Health Care Service Delivery," Rural Policy Research Institute (http://www.rupri.org/pubs/archive/reports/P2002-3/)

National Rural Recruitment and Retention Network (http://www.3rnet.org/)

HHS response to Sept. 11 and anthrax attacks (http://www.hhs.gov/hottopics/healing/)

GAO reports on terrorism (http://www.gao.gov/terrorism.html)

American Public Health Assn.'s response to Sept. 11 (http://www.apha.org/united/)

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