Gray powder sprang through Mariama James's downtown apartment's terrace doors and windows, and settled in her rugs and children’s bedrooms.
Barbara Burnette was a detective in the police force. She licked the soot out of her throat and mouth for several weeks while she worked on the rubble pile, without wearing a mask.
All three of them are now part of more than 111,000 people who have enrolled in World Trade Center Health Program. This program provides free care for people with potential dust-related health issues.
People are still reporting illnesses related to the attacks two decades after the collapse of the twin towers.
The U.S. spent $11.7 billion to date on compensation and care for people who were exposed to dust. This is $4.6 billion more than the amount it gave to families of those killed or injured on September 11, 2001. A government fund that pays people who may have been affected by the attacks has provided payments to more than 40,000 people.
Scientists are still unsure how many people suffered from health problems after being exposed to the tons of concrete, asbestos, glass, gypsum, and other materials that fell on Lower Manhattan during the towers' collapse.
Many of the conditions that are common to the public among those enrolled in this health program include skin cancer, acid reflux, and sleep apnea. There is no way to tell if someone's condition is caused by Trade Center dust or other factors like smoking or obesity.
This has caused friction over the years between doctors and patients who doubt their diagnosis.
Mariama James explains, "Most people thought that I was crazy back then."
Initialy, it was difficult for her to convince doctors that her children's chronic sinus problems, asthma, and chronic ear infections were caused by the dust in her apartment.
Many years of research have yielded partial answers to 9/11 health issues like hers. Chronic inflammation of the sinuses or nasal cavities, or reflux disease, is the most common condition among federally enrolled people. This can lead to symptoms such as heartburn, sore throat, and chronic cough.
It is not clear why this happens. Doctors believe it could be due to chronic inflammation in the bodies that was initially caused by irritation from dust.
One of the most prevalent and persistent health conditions is post-traumatic stress disorder, which affects approximately 12,500 participants in the health program. Nearly 19,000 people enrolled in the health program have a mental disorder that is believed to be related to the attacks. Over 4,000 people have a type of chronic obstructive lung disease (or a group of potentially debilitating respiratory problems).
Some physical ailments can be healed with time, while others cannot. Many people who had a chronic cough as first responders have seen it disappear or fade over time, while others have not shown much improvement.
According to Fire Department research, about 9% of firefighters who have been exposed to dust still experience persistent coughs. Around 22% of firefighters report feeling shortness or difficulty breathing. Around 40% of people still suffer from acid reflux or chronic sinus problems.
Fire Department personnel who worked at ground zero were tested for their lung function. The results were 10-12 times higher than what is normal due to the aging process in the first year following 9/11.
Doctors are optimistic that their worst fears regarding a tsunami of deadly 9/11 cancers have not come true.
At least not yet.
Over the past 20 years, nearly 24,000 people who were exposed to dust from trade centers have developed cancer. It has occurred at rates that are comparable to what researchers expect to see in the general population. Most people have skin cancer. This is often caused by the sun.
Researchers have found that the rates of certain types of cancer, including thyroid cancer, malignant melanoma and prostate cancer, are slightly higher than previously thought. However, this could be because more patients are being monitored by medical surveillance programs.
"We don't have the enormous elevations of cancer that I was afraid of," Dr. Michael Crane, director at Mount Sinai's World Trade Center health clinic, says. "I was afraid that we would have epidemic lung cancer."
One study found that the cancer mortality rate for paramedics and firefighters in cities exposed to Trade Center dust was actually lower than it is for most Americans. This could be due to frequent medical screenings that catch cancers early.
Burnette is one of the beneficiaries of the screening. She was treated at Mount Sinai for hypersensitivity pneumonitis and fibrosis, a condition she contracted after three weeks spent in ground zero's swirling dust.
One of these 2017 visits resulted in the detection of lung cancer.
Burnette states, "Had it not been for the program or Dr. Crane, I don’t know if they would have found it." She has been through two rounds of chemotherapy since then. Although it hasn't completely cured her, it has helped to keep the cancer at bay.
In its early years, the majority of federal health program enrollees were firefighters, police officers and others who worked on the debris heap. In recent years, however, the majority of applicants have come from Lower Manhattan residents. This includes Carl Sadler, who was at Morgan Stanley's 76th Floor office in the Trade Center's South Tower when the aircraft was hijacked and struck it.
"There were millions upon millions of pieces of paper that flew out. Credenzas. Computers," Salder says. Salder says, "We saw chairs fly by that looked like they had human beings in them."
He made his way down the escalators and stairs to the street, then he moved on with the crowd. He explains that a big explosion occurred as they reached Water Street, a block from the Fulton Fish Market. "Everything just turned black and gray, and it was like a tsunami. We were all covered in soot."
Sadler was initially in good health. After the attacks, Sadler's health was good. But after a while, he began to feel tired and prone to recurring bronchitis. He had to stop playing soccer and skiing in his 60s.
He said, "I had just breathing problems." But he didn't know what they were.
He is now 80 and has been diagnosed with acid reflux disease, asthma and thyroid cancer. He was also successfully treated for skin melanoma and thyroid cancer. He thought it was just part of growing older, until a friend suggested that he sign up for the World Trade Center's health program.
He said, "You have many health problems. You have had many health problems. Sadler recommends that you register.
The health program was expanded to 6,800 members last year. Its members may not all be ill at the moment. Many people have signed up to protect themselves against cancer. Many have seen their condition improve. According to program statistics, around 1,000 people were treated in-patiently last year and approximately 30,400 received outpatient care.
Although the victim compensation fund receives payments for victims of the attacks and has an unlimited budget from Congress it is possible that the medical program will run out of funds. To cover a funding gap expected to start in 2025, members of Congress introduced a bill that would add $2.6 billion over ten years.
Anyone who lives or worked in Lower Manhattan or a small part of Brooklyn can be eligible for free medical care if they have certain illnesses. This includes more than a dozen airway and digestive disorders, 10 psychological disorders, and at least 20 types of cancer.
Researchers are also looking into adding conditions to the existing list. Dr. John Howard is the program's administrator. He says that autoimmune diseases like rheumatoidarthritis are being investigated now.
An early estimate suggested that up to 490,000. This is partly because you don't need to prove your illness was related to the September 11 attacks in order to be eligible. A person is presumed eligible if they have a condition on this list.
Howard states that lung cancer is covered regardless of the attribution issue. "If you have lung carcinoma, we won't analyze how many pack years you smoked."
What will the next 20 years look like for those who were there that morning and the weeks that followed?
The federal health program enrollees are now on average 60 years old. Dr. Jacqueline Moline is the director of the World Trade Center medical clinic at Northwell Health. She is concerned that people will experience more health problems as they get older. She noted that asbestos-related cancer can develop in as little as 40 years after being exposed.
Moline states, "We are just getting there where we might begin to see stuff." Moline is also concerned about the long-term effects of post-traumatic stress.
There are also fears that the constant jolts adrenaline and other stress hormones associated with PTSD could lead to heart disease or weakening of the immune system. The emotional and physiological effects of September 20, 20 years ago could be reverberated in debilitating new ways.
Crane, who has been treating ground zero respondents since the beginning, said one thing based on the continued stream of new patients: This issue isn’t going away.
He said, "They keep coming." "They keep coming in the door."