The coronavirus struck nearly 20 years after the terror attacks in the United States on 9/11 and in a drastically different manner: slowly at first and essentially invisible, a far cry from the explosions after airliners slammed into Manhattan’s Twin Towers with the scene immediately beamed worldwide.

But the two crises — which will likely shape generations of New Jerseyans — share certain commonalities when it comes to public health. Both disasters prompted unprecedented levels of anxiety and depression, especially for those intimately involved in the response, experts note, and are likely to have long-lasting impacts on individuals, families and communities.

Both 9/11 and the COVID-19 pandemic have led people to view the responders — firefighters and emergency medical personnel then, and nurses, doctors and other caregivers today — as heroes, a term experts acknowledge can be good and bad. Sometimes the “hero” label can prevent these responders from seeking help for their own mental health or substance abuse issues, clinicians said, and those who endured 9/11 may find it even harder to handle with the pandemic stress of today.

“If you are dealing already with mental health issues, anything pre-existing, you don’t bode well if there is some kind of major trauma,” explained Jodi Streich, mental health director for the World Trade Center Clinical Center of Excellence at Rutgers University, one of a network of federal programs set up in the wake of the terrorist attacks to assist responders and others who experienced health issues as a result of their time at ground zero.

“The health care workers are now our first responders,” Streich said, and they face a similar strain as those who rushed in to save lives when the World Trade Center towers collapsed.

First responders reluctant to seek help

First responders of all kinds are sometimes less willing to seek help when they need it, experts note, which creates an additional challenge. “This is a very hard population to take care of because they are people who take care of other people and are not used to taking care of themselves,” added Dr. Iris Udasin, the center’s medical director.

Streich said that while the COVID-19 pandemic has triggered significant stress for health care providers and the public, individuals who have a history of post-traumatic stress disorder — like the center’s 9/11 patients — are particularly at risk for a relapse. “All of us are noticing as clinicians, and just as human beings, the heightened irritability and anger” among people, she said. And for those with PTSD, “It’s a whole new, re-awaking of the previous trauma.”

Udasin, a professor at Rutgers’ School of Public Health, said the center contacted its more than 2,000 patients to check on their well-being during the pandemic, which proved fatal for some. Many 9/11 survivors struggle with lung damage, she said, symptoms of which can mask the appearance of COVID-19 and make them more vulnerable to infection and serious illness.

“Many of our patients were short of breath already,” Udasin said. “I lost a few patients to COVID who thought it was asthma or COPD.” Another died of suicide, caused in part by the isolation resulting from the pandemic lockdown, she said.

COVID-19 has killed more than 650,000 people nationwide, including some 27,000 in New Jersey, where more than 1.1 million residents have been diagnosed with the disease since it first emerged in March 2020, state statistics show. Since then, COVID-19 has caused nearly 90,000 New Jerseyans to be hospitalized, and case counts and hospital admissions continue to tick upward with the growing presence of highly transmissible variants of the coronavirus.

Spreading tragedy

Nearly 3,000 people died in the Sept. 11, 2001 terrorist attacks — including 750 New Jerseyans — and some 6,000 more were injured. But the death toll from that crisis continues to mount, as thousands more have since succumbed to cancer, lung damage or other illnesses linked to toxins emitted from the smoldering pile of debris at ground zero, which was the site of a rescue and recovery mission that lasted nine months.

The disparities in total fatalities hint at how the pandemic’s impact may eventually overshadow that of 9/11. The coronavirus “was a tragedy for everyone. Nine-eleven was an assault on all of the United States, but if you lived in Nebraska you felt sad about 9/11 but you weren’t exposed to the toxins if you lived in Nebraska,” Udasin said.

But there are clearly commonalities too. “People are still dying from both. I think that’s one parallel,” said Steve Cicala, a founding member of the New Jersey Emergency Management Task Force, which was created in the wake of 9/11 to help coordinate the state’s response to mass-casualty events. Cicala lost his wife, a nurse, to COVID-19 in April 2020.

Despite the different nature of these two catastrophic events, the response to 9/11 has informed how New Jersey reacted to the pandemic, according to those involved. The EMS task force — a nonprofit that is available to help coordinate large, multijurisdictional emergency responses — itself is an example of that process, members said. And its work evolves more with each crisis or incident, with members learning from every hurricane, train crash or other big event, Cicala explained.

“Before 9/11, EMS was a loosely knit group of agencies. There really was no connective tissue,” recalled Mickey McCabe, another founding task force member who also runs a private ambulance company in Bayonne he started in 1973. McCabe recalled his struggle to effectively deploy assistance to ground zero from among the 200 ambulance units that had showed up on their own at Liberty State Park that day, all determined to help despite the lack of a coordinated plan.

Being prepared

Members said that since then the task force has used grants and other funding to acquire resources that were beyond the reach of local responders. The list includes ambulances with extensive medical equipment that can transport 20 prone patients at once, mini-ambulances for off-road use, and a unit that can refill multiple oxygen tanks at once. “It’s grown from a loose-fitting group with a vision, and we started to knit together a patchwork and make it work,” McCabe said.

Part of the task force’s evolution has involved working with local responders to create action plans that can help guide decisions in a crisis. As a result, the task force now has plans for some 15 different scenarios — from dealing with tropical weather to performing water rescues to evacuating hospitals — that give them a head start when disaster hits.

But all plans, including pandemic plans created by the task force, should be considered a starting point and need adjustment in real time, responders said. A COVID-19 response framework drafted by state officials was essentially abandoned when the pandemic’s requirements quickly outpaced the response outlined on paper.

“These plans are really guidelines,” said Lou Sasso, another task force leader who also serves as Middlesex County’s emergency response coordinator. “These situations are always a little bit different and require flexibility,” he said. “But with bright people, the right resources and the right plans, that’s how you make things work.”

The state Department of Health also worked to beef up various preparedness programs after 9/11. Department spokesperson Dawn Thomas said federal funding was used to augment the capabilities of 22 local health departments that now serve as a coordinated public health network.

Lasting impacts

“One of the lasting impacts was foundation building — building and sustaining relationships with healthcare systems and local health departments, particularly in regard to preparedness,” Thomas said. The alliances have continued, she noted, allowing the state to funnel additional federal funds to local hospitals for emergency preparedness needs.

The work of the EMS task force has also benefited from the relationships members have built over the decades with local responders and community groups. The group’s connection to state officials has also strengthened significantly in recent years, providing new opportunities to support larger public health efforts, which became critical during the pandemic.

In March 2020 task force members helped state officials set up the massive, drive-through COVID-19 testing sites. Weeks later, the team was called in to evacuate dozens of frail elderly residents from the St. Joseph’s Senior Home in Woodbridge, which had been overrun by COVID-19 infections. The group worked with state officials and local providers to create pop-up vaccination sites at the Jersey Shore this past Memorial Day. By June, the organization had taken on the near-daily responsibility of distributing vaccine doses from a storage facility in Mercer County to vaccination sites throughout the state.

“We’ve become sort of the tip of the spear in some respects for the state Department of Health,” Sasso said, enabling the state to quickly expand testing or vaccination capacity in communities hard-hit by COVID-19. “We’ve become their boots on the ground when it comes to public health.”

Task force members are pleased with the group’s progress and McCabe said he is proud of how EMS response has evolved to become more coordinated in New Jersey, which is known for its fierce commitment to local, or home rule. “I think we are far ahead of where we were on Sept. 10, 2001,” Cicala said. “We have come a long way and we are more prepared now than we ever were.”

However, there is always a need for additional funding, members said. New communication equipment is high on the list of needs, Sasso said, and it isn’t cheap. “Updating and maintaining what we have [is the priority]; if we could enhance it, even better,” he said.

What lessons can be learned?

Udasin, from the Rutgers World Trade Center clinical program, said there is also a need for greater investment in mental health care. Access to treatment has improved over the years, she said, but insurance coverage for behavioral health care remains sub-par. And for some there is still a stigma around asking for help with psychological issues, she explained.

“That’s one lesson we should take out of this crisis,” Udasin said. “It took a long time to make the treatment of mental health as accessible as physical health [treatment] in our world. And as a world, we need to collectively treat mental health better, to treat people’s fears better.”

Streich, the mental health director at the same Rutgers program, said people also need to understand that it can take time before survivors are ready to discuss a trauma with others. It took a while for some of the World Trade Center first responders to accept mental health help, she said, and it may be the same for those now on the pandemic’s front lines.

“That’s the thing with PTSD, you’re not going to see it right at the moment,” Streich said. “But I do think it’s coming. Especially for all those who are burnt out and haven’t allowed themselves to deal with the current situation.”

In that way, both 9/11 and the pandemic are likely to share a sad and lasting legacy. “That’s the thing with mental health: It’s permanent,” Streich said. Treatment can save and improve lives greatly, she said, but “you don’t ‘get over’ the problem. It’s really always there.”

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