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Twenty-five years after the Sept. 11 terrorist attacks, the health toll among firefighters who responded to the World Trade Center continues to grow.
The New York City Fire Department added 36 names to its World Trade Center Memorial Wall on Sept. 2, honoring members who died from illnesses related to their work in the rescue and recovery effort.
They join more than 400 FDNY members who have died from World Trade Center-related illnesses since 9/11, when 343 members of the department were killed at the World Trade Center.
For healthcare professionals, the continuing toll underscores a key occupational health lesson that extends well beyond 9/11: The health consequences of catastrophic exposure may not become apparent until years or even decades later.
“Some health effects appeared relatively quickly. Others, including cancers and other chronic diseases, have taken years or decades to become apparent. That long latency is one reason continued follow-up remains so important,” said Jooyeon Hwang, PhD, associate professor at UTHealth Houston School of Public Health.
What Firefighters Were Exposed to After 9/11
When the World Trade Center towers collapsed, concrete, glass, insulation, silica, asbestos, metals, and other building materials were pulverized into a dense dust cloud. Fires continued for months in the debris, generating additional combustion by-products.
“Thus, firefighters were not simply exposed to fire smoke, but to a complex, volatile environmental disaster,” Hwang said.
One reason researchers have been able to study the long-term effects is that the FDNY had an established occupational health service before 9/11. After the attacks, that infrastructure supported nearly 25 years of continued occupational health examinations and research.
“That combination of health information before 9/11 and long-term follow-up afterward gave researchers a rare chance to study health over the long term: Specifically, they were already examining the firefighters’ health before the appearance of disease rather than only after,” Hwang said.
That history matters especially when studying chronic occupational diseases that may take years to develop.
“If we begin to explore a firefighter’s work history only after a cancer diagnosis, much of the exposure history is already behind us,” Hwang said. “That is why understanding a firefighter’s full work history is critically important for their long-term health.”
Firefighter Cancer Risks Extend Beyond 9/11
The World Trade Center disaster created an extraordinary exposure environment, but concerns about occupational exposure are not limited to firefighters who responded to 9/11.
Routine firefighting involves repeated and highly variable exposures that can be difficult to reconstruct over an entire career. The toxins encountered, the amount of exposure, its duration, and the route of exposure can differ from one response to another.
In 2022, the International Agency for Research on Cancer classified occupational exposure as a firefighter as carcinogenic to humans.
“For me, the important point is that the classification does not address just one chemical, one fire, or fire smoke alone. It reflects the complex occupational exposure environment of firefighting,” Hwang said.
The classification does not mean every firefighter will develop cancer or face the same risk.
“The important question is no longer simply whether the occupation is hazardous. We need to identify where exposures can be prevented or reduced,” Hwang said.
Researchers can measure what happens at a fireground, detect biological changes that may occur before disease develops, document occupational histories and follow later health outcomes through surveillance and cancer records.
The challenge is connecting those pieces across a firefighter’s career.
“Connecting them across a firefighter’s career can help identify which exposure patterns matter most, where biological changes may provide an early signal, and what prevention or appropriate cancer screening practices may have the greatest impact,” Hwang said.
What Nurses Should Know About Firefighter Health
For nurses, the 25 years of firefighter health research following 9/11 reinforce a key takeaway: A patient’s occupation and exposure history can be an important part of the broader health picture.
Firefighters in different parts of the country may work under different conditions, encounter different mixtures of hazards and accumulate those exposures differently throughout their careers. That variability makes it important to look beyond “firefighter” as a single, uniform exposure.
Hwang said healthcare should not wait until disease develops to begin piecing together decades of occupational exposure, and nurses can help by documenting work histories earlier and more consistently.
“We should not have to wait for a cancer diagnosis to reconstruct what happened during the previous 20 or 30 years of a firefighter’s career. We can reduce preventable exposures, record more detailed occupational histories, follow health through occupational health surveillance, and make appropriate cancer screening part of firefighter health maintenance.”
Those efforts also have to reflect the realities of firefighting.
“Effective prevention has to fit the realities of the job. Firefighting will always involve hazards, but that does not mean every exposure is unavoidable. The better we understand when, where, and how exposures occur—and how they relate to health over time—the better we can target prevention and act earlier.”
For Hwang, those lessons give the 25th anniversary significance beyond remembrance.
“Twenty-five years after 9/11, the responsibility is not simply to remember what happened. It is to make sure that what has been learned helps protect the firefighters serving today and in the future.”
