On September 11, 2001, almost 700 New Jerseyeans lost their lives in the World Trade Center. Yet, as New Jersey is often seen as a crossroads between New York and Philadelphia, many do not recognize the huge impact 9/11, and the subsequent Anthrax letters, had on our state and how involved NJ’s public health personnel were in the response.

I had been named acting commissioner of the NJ Department of Health and Senior Services (NJDHSS) less than a month before the attacks. We held our first staff meeting the morning of the 9/11 attacks. While the attacks were on New York soil, the interdependence between NYC and NJ made it clear that our response would need to be as supportive to the region-wide public health needs as possible.

On 9/11 itself, we spent most of our time attempting to gain situational awareness of any injured survivors, and to mobilize health resources— vaccinations, blood products, and burn unit beds — that might be needed. With the Department of Human Services in the lead, NJ immediately set up a support area at Liberty State Park, which is little over a mile from Ground Zero, across the Hudson River. This location was chosen based on the presumption that there would be many injured people and we’d need a triage area to take care of those injured before transport. We needed contingencies if hospitals became overwhelmed and thousands of people needed blood, wound treatment, or even tetanus shots. Sadly, all these needs became moot as it became clear that the nature of the disaster had led to many deaths, but few others severely injured.

The Liberty State Park site, not needed for the injured, was rapidly ‘repurposed’ as a support site for the social and immediate psychological needs of survivors and family members of those who had died. Less dramatically, and yet just as supportive, was the development of a ‘paperwork’ support network, to process documents for survivors and families of the dead in a situation where documentation of death was missing.

On the day of 9/11, and in the weeks that followed, the simple public health functions — registrations, surveillance, documentation —assumed new importance for the public, and required many hours of ‘routine’ but critical work.

The transition between this supportive role, during9/11, and a leadership role during the October anthrax exposures, was oddly imperceptible. As one of our public health reactions to 9/11 was the set up and maintenance of phone banks for citizens to call in with any types of questions, a direct connection between NJDHSS and NJ public health staff and the public was almost constant. Still, as call volume tapered off near the end of September, we decided to decrease those assigned to the phone banks.

At that same time, the first Florida anthrax case was found, and we, of course, were placed on alert, but at a distance. Even when we received notification from the NYC Department of Health that cases were appearing in media outlets in Manhattan, the threat in NJ seemed remote. Still, as many New Jerseyeans worked at the media centers in NYC — such as the famed30 Rockefeller Plaza Building — we reactivated the phone center, anticipating calls from citizens regarding their risk. On Saturday, October 13, we reopened the phone bank.

On that same day, my team participated in a conference call with all the health officers in the United States. At the end of the call, it was mentioned that the anthrax likely was delivered by mail and probably came from somewhere in New Jersey. Then the call ended. My team looked at each other, perplexed at the casual way the origin of the letters was handled, almost as an afterthought. Although the first (at that time only) known batch of letters were apparently processed in NJ, a few miles from our office, we were assured that ‘mere’ processing was not a public health concern. Basically, the consensus interpretation of the available data at the time was that, if a letter is sealed and it goes through postal processing, it was not a threat until formally opened.

Stunningly, while we were being reassured on that call, data was coming though our phone bank that would shortly forever overturn that consensus. Two perceptive local NJ physicians, having read new reports of the NYC cases, and the NJ postal center origin, called our phone banks to report unusual, persistent skin illnesses in two postal workers from that center. The physicians calling were ‘sure’ these cases were most likely to be a spider bite, but they wanted to be safe rather than sorry. Similarly, the highly competent but still junior staff who took the calls was almost apologetic in passing the reports on, but wanted to make sure all information was available to the Department’s leadership.

I immediately informed the Federal Bureau of Investigation (FBI) and began the process of obtaining permission to test the samples the private physicians had. As I did this, the FBI seized the samples and sent them to Atlanta for anthrax testing.

The following Monday, just two days later, there were confirmed anthrax letters in Washington, D.C. We were still waiting on our samples to be processed, however we knew that they came from the Hamilton postal facility. By Wednesday, when one of the two NJ suspect cases was confirmed as a case of cutaneous anthrax, the FBI shut the processing center down to do a thorough but rapid crime scene investigation. After a few hours of processing evidence, the FBI let us know that the building was ours.

We met with the post office staff well into that evening and eventually I decided that, since the building was closed and occupationally related anthrax had already occurred there, I couldn’t deem the building safe unless I was offered some rapid testing method to show it ‘clean.’ I was assured that this could happen within 72 hours; my response was, then we’ll reopen in 72 hours.

It turned out it was over three years before that building was deemed safe to reopen.

After another worker developed cutaneous anthrax that following Friday, we began operating on the premise that any worker at that site was potentially exposed, and we decided to immediately propose post exposure antibiotic prophylaxis. Unfortunately, the Centers for Disease Control and Prevention (CDC) didn’t agree that the cases here demonstrated exposure at a distance, and did not support our decision to treat, and discouraged my request for materials from the Strategic National Stockpile. I still regret not pushing my Governor to demand SNS deployment anyway, as a way to force CDC’s hand.

Without CDC support, NJDHSS scrambled to find Cipro and a place to deliver the medication. At that time NJ didn’t have an Emergency Health Powers Act, so there wasn’t a specific law that gave the public health commissioner direction or powers to organize such a mobilization of private resources on short notice. Today, a NJ Health Commissioner, with gubernatorial support, could do things like work directly with pharmacies and pharmaceutical distributors to get the necessary antibiotics, and with local facilities like hospitals to immediately use their facilities to dispense medicine.

While our unilateral decision to keep the facility closed and to treat early led to much debate in our state press, it clearly prevented further exposure in a grossly contaminated building. It also probably saved exposed workers from developing disease — if not from dying of anthrax. And, even while this debate raged around, the NJ public health and health care community worked to ‘make it happen’, collecting Cipro, setting up treatment clinics, doing thousands of ‘white powder’ laboratory tests, and continuing to man the phones.

We made the particularly fortunate decision to inform the postal service and unions of the information at exactly the same time each day. This gave all interested parties time to hear new information, to vent about the stress and uncertainty in private, and then to present the public a consistent story. There were no arguments in the media — at least between the postal works, management, and public health — and this solidarity undoubtedly led to NJ workers showing the best adherence to their treatment compared to other, more contentious sites. Miraculously —or perhaps due to early preventive treatment and diligent diagnosis in the community, NJ had no fatalities due to anthrax. We had a lot of cases and a lot of people exposed, but we did early preventive therapy and had health care workers on the front lines who bought into our response.

Basically, by applying general public health principles, making sure communication systems were set up, listening to what the public and providers were telling us, working closely with the workers involved and reacting quickly to get samples tested, our response saved lives.

It has been 10 years since September 11, 2001and the anthrax attacks, yet the lessons for public health from the series of months will not go away.

To me, the biggest change the public health world has seen over the last decade has been our incorporation into the law and public safety community. Surveillance, preparedness, prevention and population based thinking come to play repeatedly during both the planning and response phases of most of our emergency responses. However, I’d have to be willfully blind not to see that there are fewer people in public health departments in NJ now than there were in 9/11.Today, we might respond with a better trained and equipped workforce, but there would be many fewer at the front lines. To me, the most tired and dangerous cliché is ‘doing more with less.’ Any individual public health worker will almost certainly do more individually then he or she might have during those months in the fall of2001, but, as a group, we’re at clear risk of ‘doing less with less’. Which action of that fall would be shortchanged today due to lack of staff — one less worker on a phone line to take a report, one less physician to consider making that call? What impact would that have on the outcome? At the time, if we had a second postal site that had been grossly contaminated we would have been overwhelmed. We simply didn’t have the ability to fully respond across multiple locations. Now, would we be able to handle even one?

Given the times we live in, I’m sure we’ll find out just what we can accomplish with our current resources.

Dr. George DiFerdinando, Jr., M.D., M.P.H., FACP, Director, New Jersey Center for Public Health Preparednessat UMDNJ-SPH Co-PI, New York-New Jersey Preparedness and Emergency Response Learning Center AdjunctProfessor of Epidemiology, UMDNJ-SPH

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