Are We Ready?: Public Health since 9/11

1. September 11 and the Shifting Priorities of Public and Population Health in New York City

O N E SEPTEMBER 11 AND THE SHIFTING PRIORITIES OF PUBLIC AND POPULATION HEALTH IN NEW YORK CITY 6 September 11, 2001, affected virtually all aspects of American life, from foreign policy and domestic security to philanthropy, social services, and health policy. Social welfare, public health, health care, and environmental issues, generally seen as separate spheres, are now increasingly understood as interrelated components essential to the mental and social wellbeing and emergency preparedness of a traumatized nation and city, and the opportunities to integrate these concerns are immense. The experience of 9/11 has highlighted the interrelationships between biological, sanitary, medical, social, and economic factors that together affect the well-being of populations. Perhaps more directly than any other recent event, analysts point out, September 11 has illustrated that a population’s health “encompasses a broader array of determinants of health than the field of public health has previously addressed,” making all the more critical the “emerging theory and practice of population health”—one that incorporates “the traditional concerns of public health” with “such issues as the effects on health status of . . . relative income and social status , racial and gender disparities, and educational achievement.”1 This chapter is organized both chronologically and thematically. We begin by reviewing the immediate response of New York City’s Department of Health to the attack on the World Trade Center and the subsequent anthrax episode. We then analyze the difficulty of establishing responsible policies to aid the city’s and nation’s return to normalcy in the face of enormous scientific uncertainty about the potential health haz- ards of dust, debris, and toxic materials in the neighborhoods and schools near the World Trade Center site. Finally, we address the special immediate threats that the disaster posed to the population’s health. Of particular importance were the social service and mental health sectors, largely organized through voluntary agencies: we discuss the immediate and longer-term responses of these agencies and the problems they encountered as they adjusted to long-term population health needs. Thus we begin with the narrowest conceptions of health as defined by the activities of the New York Department of Health and broaden our study to include the agencies and issues that affect population health policy. The immediate response to the attack on the World Trade Center showed the surprising strength of New York City’s existing public health and social welfare infrastructure, but the attack also revealed important weaknesses that will have to be addressed in the future. Though the decentralized system of social and public health services was in some respects an advantage in responding to unpredictable and varied disasters , the need for a greater degree of centralization of services and control was nevertheless apparent. At times the political and public health leadership effectively communicated what was known and not known about the dangers to residents’ health and welfare, while at other times political leaders with differing agendas propagated a confusing array of messages, leading to uncertainty and distrust among the broader public. The history we relate in the following pages must be understood as being deeply imbedded in ongoing political and social struggles around political power, race, neighborhood redevelopment, immigration, and the responsibilities of New York City’s largely voluntary social service system. Despite the ubiquity of the image of “a nation united” in the weeks after 9/11, in reality the depiction of the events, almost from the first minutes after the attack, was shaped by continuing social divisions between rich and poor, between black, Hispanic, and white, and even between Republicans and Democrats. For example, Joseph Bruno, the New York State Senate majority leader, was quick to compare the responses to 9/11 in the two communities most directly affected: New York and Washington. In New York, Bruno argued, an efficient and well-ordered emergency response system mobilized a vast array of resources that, under the leadership of Governor George Pataki and Mayor Rudolph Giuliani, both Republicans, calmed the public and answered the immediate needs of a traumatized community. As Bruno put it, “The leadership they provided moments after the disaster came after years of putting together an excellent response plan.” But in S E P T E M B E R 1 1 A N D S H I F T I N G P R I O R I T I E S / 7 Washington, D.C., Bruno maintained, the lack of effective...