Michael A. Crane, the medical director of the World Trade Center Health Program Clinical Center of Excellence at Mount Sinai, thought he would be seeing a lot of cases of lung cancer coming into his clinic.

“My greatest concern was that they were gonna get lung cancer,” Crane said.

He remembers treating 9/11 first responders during the immediate recovery. Workers would put on a mask and the filter would clog up within 30 minutes. The air was thick and impossible to breathe.

But 25 years later, an uptick in lung cancer hasn’t really panned out in the data—so far.

“Fingers crossed, fingers crossed, it might be off the table,” he said. “But of course, there’s no guarantees in life, as in anything else.”

In this episode of the Cancer History Project podcast, reporter Sara Willa Ernst sits down with Michael Crane to talk about the surprising twists and turns of treating 9/11 first responders over the past 25 years. He also offers his theory behind why the incidence of lung cancer didn’t spike as expected—an achievement, perhaps one of Crane’s proudest, that the program was able to accomplish.

The WTC Health Program was able to reduce smoking among first responders from 20% to just 3%, according to Mount Sinai data.

“When I die, and God asks me: ‘What did you do with your life?’ I’m gonna give them that statistic and demand to get into the doors. ‘Open the doors, buddy! Look what I did here,’” Crane said.

This interview is available on Spotify, Apple Podcasts, and YouTube.

An article about this interview appears in The Cancer Letter.

Coverage of 9/11 in The Cancer Letter

The Cancer Letter dedicated the Sept. 21, 2001 issue “to the stories, thoughts, and fears of individuals in the cancer research community as they experience this national crisis and suddenly confront an uncertain economy, with possible implications for federal research funding, and a difficult climate for travel and international communication.”

These articles have now been digitized:

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Episode transcript

Sara Willa Ernst: 25 years ago, when Michael Crane started treating 9/11 first responders, he thought he would be seeing a lot of cases of lung cancer coming into his clinic. He’s an internal medicine doctor and the medical director of the World Trade Center Health Program Clinical Center of Excellence at Mount Sinai. 

But so far, an uptick hasn’t really panned out in the data. 

His theory as to why, and perhaps his proudest achievement, is the success of the smoking cessation program. His team was able to take the smoking rate of 9/11 first responders from 16% to just 3. 

And perhaps that reduction was able to offset the cancer risk from breathing in toxic dust. 

On this episode of The Cancer History Project Podcast, I sit down with Michael Crane to talk about the shock of that day 25 years ago, the medical twists and turns since then… as well as the grief and the pride of caring for heroes that risked their lives.

The Cancer History Project Podcast is sponsored by City of Hope, the American Society of Clinical Oncology, the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, and the University of Texas MD Anderson Cancer Center. 

Sara Willa Ernst: Okay, great. Well,  Thank you so much, Dr. Crane, for coming onto the podcast. we’re really glad to have you. I mean, maybe we should just start from the very beginning. I mean, do you remember kind of where you were on 9/11? Do you remember that day? And I’ll just kind of give a disclaimer, I was in kindergarten at the time, but my brother was a student at Stuyvesant High School. So my own family has our own connection to 9/11. But do you remember where you were on that day?

Michael Crane: Well, I know you won’t believe this, but I was a little bit past kindergarten. I was a little, just a small amount. I acted that way, but I was past it. 

So I was medical director at Con Ed and it was a normal day. And I lived in Queens and I would basically drive into work either on the BQE or sometimes I’d go into the city. We had moved our office recently and we were at 4 Irving Place, right there in the lower part of Midtown. And so I was just, you know, drive to work, usual schedule of stuff to go to. I was a little bit late. It’s like mid-morning, and all of a sudden the traffic stops. It just stopped. I’m a New Yorker and this is the Long Island Expressway, so that’s not surprising. It all happens all the time. But this went on, and then I saw people… I didn’t have the radio on. These people were getting out of their cars and looking and pointing, and some of the folks were agitated, so I turned on the radio and I heard this plane had flown into the World Trade Center. 

I’m old enough to remember when a plane flew into the Empire State Building years and years and years ago, but it was a small plane. And they didn’t say on the news what type of plane had flown into World Trade Center. So we said, okay, that’s awful, but I’m sure everybody’ll be okay. And then the second plane hits, and now everybody’s standing outside their cars, kind of like walking in circles, kind of agitated. 

I basically realized I wasn’t gonna get into Manhattan no matter what. First the line of cars and then I knew something about the security precautions and that they would close the tunnels and all that stuff. So we had an office on the east side of the East River in Queens. That was one of their training centers, and I managed to get to that. And all the people in the lobby when I walked in were standing talking about this. And I said, What’s going on? And they said, Go up and have a look. And about six floors up you could get a good view. And the first tower had already collapsed. I can’t believe this is gonna happen.

Just as I got to the window, there was smoke coming out of the second tower and a big orange ball came out and the tower disappeared. It just disappeared.

And I’m a Catholic and I’m Irish and I prayed. Now that’s lesson number one from what I’m telling you. Don’t ever pray when you’re surprised by something, because God collects, okay? I said to God, I promise you that if you let me do anything about this, I’ll do it.

And here I am. So I put the shit out there, God collected, and here I am 25 years later. And I don’t regret it for a damn minute. Not one second. It is by far away the best work I’ve ever done for the best, bravest people, some of whom have passed on.

And I loved them with God knows, I loved them all. And it killed me when they died. But all of us together had the strength to keep going on. And I think we’ve created a really great program to take care of the folks.

Sara Willa Ernst: I’m wondering whether you started working with 9/11 first responders from the beginning and you know, when did God come knocking on your door trying to collect on the promise that you made?

Michael Crane: Well you picked that one up for sure because the knocking hasn’t stopped. Knock, knock, who’s there? Get to work, buddy. 

Sara Willa Ernst: You’re answering the calls though.

Michael Crane: Okay. Yes, I am. It’s been the joy of my life. I will tell you flat out, working with the responders is an absolute pleasure.

It has been exciting and interesting and scientifically challenging and watching them get better sometimes has been just like a touchdown. And watching them pass when they got sick has been extremely painful in being with them. But I wouldn’t trade it for anything. Not one minute would I trade. No, ma’am.

Sara Willa Ernst: Yeah. When did you first get involved in this work?

Michael Crane: So right after you know, I had that moment there, I couldn’t get to my office that day, so I went back home and I called everybody to try to get everybody in the next day. And the next day I got in, and I finally got through the tunnel, which was great. And I’m driving down I can’t remember the avenue there, to get to my office in the parking lot. 

This really stands out because it represents the whole rest of that month. Right on the corner, about two blocks north of my office, there was a flight attendant standing there with her bags, I guess waiting to be… a taxi or something. And that lady’s face told the whole story. This kind of blank and really not seeing what was in front of her, just standing there, the face of like shock or combat fatigue on this young flight attendant. And I realized when I passed her that that’s what I was going to encounter. 

And without belaboring it, as soon as I got into the building, I walked to my you know, the usual elevator with the way we get up to our clinic. I passed a bunch of people who I didn’t know, waiting to go out to work. And I figured, okay, those guys are on the way up. 

And then one of them said to me, ‘Hey doc.’ And I turned around and I said, ‘Well, hi.’ I don’t know these people. How do they know I’m a doctor? And then and then I looked more closely. This bunch of people were a bunch of folks that I had been working with for the last dozen years. I knew these people, I knew their names. I don’t know how to explain this. Their faces were different. Their faces had changed. Even from the ID tag to the picture, they were not… I would have walked right past them again. And I said, what happened to you guys? 

Apparently, they had been out right after the collapse, and they had been there when building number seven had come down. Which I guess, even to the people on the side at that point, was a surprise because those buildings weren’t supposed to fall or something, but this one came down. I said, ‘Well, what happened? What did you do?’ And they said to me, ‘Doc, we ran for our lives.’

Finally, meathead here finally got it. This is a shock disorder. This is like a stress disorder. And I am gonna see oodles and oodles of post-traumatic stress. These are wonderful, hardworking people. These were not some kind of crazies. These were salt of the earth, hardworking folks, and practically incapacitated, just standing there. 

That’s where we went first. I got some help from up at Cornell Medical Center, Dr. Joanne Difede came down to help organize counseling for post-traumatic stress. For the people who had lung disease, the medical department a couple blocks away by 14th Street there at the old Beth Israel, they just volunteered people and kept on sending them over. These pulmonary specialists. So we started treating it.

And then we had to do more. I mean, we had to make sure the people on site were being taken care of. So we went over, we picked some sites not too far from the towers and set up a van for respiratory testing, etc. I would see people coming in and out. 

The main thing, I mean they would diligently put the mask on and put the filter on and go off to work and they could breathe comfortably and it was good. The problem was with that dust cloud and what was in it, the filters would clog up within about 30 minutes. And then so we gave them, of course, we gave extra filters and stuff, but you can’t just hand everybody 8-10 filters and send them off because you’re with hundreds of people coming out, you run out pretty soon. So we really started to fall behind on that.

People were compensating by—they wear the mask on top of the helmet and sit over their faces, they’d wear a handkerchief. I said to them, ‘Look, come on out, let’s get you out.’ And basically they told me to go jump in the lake very politely. They weren’t gonna stop. They had lost friends. As one guy told me, ‘Doc, I got family in this pile.’ They were not gonna stop. 

And they were also when you got a little bit too close to it, they were so angry. They were so angry about this event, about what had happened, about the attack. It was really part of the energy that they were putting into, it was a kind of a rage. I mean, they just could not express it in any other way safely, I think, until they worked and worked and worked. 

So they pushed themselves really hard and a lot of them came back with cough and other World Trade Center syndromes. They would develop asthma-like conditions. And it was great to have the Beth Israel physicians there, who were just wonderful. That was it. We say to ourselves from fifty thousand feet. Well, these World Trade Center responders went in. They were exposed to this. They should have had better protection. They should have come out when the filters ran out, whatever. That wasn’t gonna happen. That wasn’t gonna happen. The emotional state of these people, they were gonna rescue anybody who was alive in that pile. And the hell with their health, they were gonna save these people. And it went on like that for as long as the possibility of rescue. And then it actually even intensified a little bit when it became an operation for recovery of the people who had died. That mission for them was just remarkable how they channeled all that passion and a lot of anger into bringing comfort to families who had lost people, finding a piece of paper, finding a picture, finding something, some memory of the people who had died in that collapse, really irregardless of their own health. The very definition of heroes. Heroes.

Sara Willa Ernst: Just so I understand, when you were working as a physician in the day and you know, the day of 9/11, the days after 9/11, was with the employees at Con Edison, people on the ground, or was it in a volunteer capacity?

Michael Crane: Yeah, I was the medical director of Con Ed and I had a clinic and I had a staff. So we just turned everything over and started seeing these people who were coming back with coughs and trying to get them treated. Some of them we could talk into going home. You gotta go home and get rid of that cough before you go back to work. 

Sara Willa Ernst: Yeah, So these are people out on the street fixing electrical poles. Like that’s my idea.

Michael Crane: No, they’re digging. They’re pretty much everybody’s digging now. Everybody’s trying, most of them. 

Sara Willa Ernst: Everybody.

Michael Crane: Yes, there are Con Ed people doing the recovery work, trying to repair the lines and you know, try to find the lines and try to make sure the gas pipes are not gonna implode and all around. Yes, the work was getting done, but many others were just coming from working three shifts a day, weekends. They just came to work and basically wouldn’t leave. And that was true of other companies and unions and just people. This was not just my group. This was generalizable. They worked like wild people, cleaning up that site and trying to get the remnants of individual people back to their families. And I was stunned at how they did it and their really heroic efforts. 

Sara Willa Ernst: Yeah. So you were saying at the time that people were kind of putting their masks on their heads, they would fill up their filter within thirty minutes. I mean, people didn’t really have a sense at the time as to what they were breathing in. Regardless, they were just filled with passion and filled with this, you know, public duty to go and help their fellow New Yorkers.Now that we have twenty five years in the rearview mirror and also, some more research as to what was actually in that dust, can you kind of give a sense as to what they were really signing up for in the first place?

Michael Crane: I think they really understood they were breathing toxic material. I really do. Because they watched other folks start coughing like immediately and not be able to come back. Many of them had been workers in the New York City underground systems for years, the sewers, the steampipes, the electrical equipment, the PCBs, all of that. Asbestos. 

So they were pretty cognizant of, I believe, of their risk. I just think for these days, they decided: risk be damned. We have to do this. And I don’t think they talked about it. I think each individual person went and did that and did it for days and days and days and days and kept going back. Because I think, it’s not that they didn’t care about their health, they certainly did. They were careful, excellent workers, but there was something that they felt was bigger than them that had to be addressed. 

It’s very much like what my dad talked about in combat in World War II. You get wounded, you don’t always stop. They would keep going. They would keep going because their buddy might need them or you know, needed them now. They had to keep some kind of firing thing going on. It was combat conditions. I mean, not exactly comparable, but to the extent that people are quote unquote getting wounded by breathing this stuff and pushing on, and helping each other. And then, if somebody fell or something, they’d drop everything and pull them up. It was, it was selfless. It was altruistic, it was, yes, it was dangerous. But they did it. They did it.

Sara Willa Ernst: Yeah. You’ve described them as true heroes who did it regardless of the cost. I wanna learn a little bit about the process of giving back to those people, specifically with the World Trade Center Health Program and the clinic that you run. Why don’t you tell me about the program? about what it’s like treating patients specifically with cancer, and also some of the research, the cancer research that has come out of the clinic as well.

Michael Crane: Sure. Let’s go in reverse order. So the cancer topics. Most of our research work is not really in cancer treatment. Most of the time we will be seeing a patient, we will do

regular kind of physical exams with blood tests and blood chemistry and we get an annual chest x-ray and then we’ll go from there any suspicious physical findings. Let’s say the guy’s suddenly wheezing or something, we’ll send them to the pulmonary doctor, just like I did when I was at Con Ed. If a person is having some kind heartburn or other symptoms or when it’s not being handled right, we’ll send them to that specialist. 

We operate like a medical practice, an adult medical practice in many ways. When we do suspect a cancer, let’s say we do and we do our regular exams and we do a chest x-ray is the part of that exam. If we see something suspicious, right, according to what our radiologists tell us about what a normal x-ray looks like, we will send that person to a cancer specialist, a pulmonary specialist, so they can look at what that thing is that we saw on the x-ray, and either, they’ll biopsy it, they’ll take another x-ray of it. They will help us identify what’s going on. And then obviously if it’s a cancer, onto the oncologists and get the treatment. If it’s something that’s benign or maybe it’s an area of inflammation, like a little bit of pneumonia that we weren’t sure about, they’ll get that treatment. 

So really what happens on the medical side is very much akin to a general medical practice for adults that provides pretty thorough care. And we also have most of the subspecialists that a general practitioner would have in the community. So you have a lung specialist, you have a heart specialist, kidney, we have all of that. 

The area that doesn’t get enough emphasis is the area I started talking about at the beginning because people don’t like to talk about it. For some reason, even heroes think that they’re supposed to be mentally calm and quiet and competent at all times. Even heroes. 

And even heroes when they are not that way, start to feel a little bit ashamed. ‘Gee, I’m weak. I’m bad.’ These are heroes. Capital H, right? Total heroes. And yet they are having post-traumatic stress disorder. They are having nightmares about working down there. They are having episodes during the day when the current reality fades away and they are re-experiencing what they experience on the plot, the so-called flashback. So many of these folks who are perfectly normal, wonderful, heroic individuals, are having post-traumatic stress disorder. And they say, ‘Am I doc, am I crazy? Am I crazy? Look at what’s happening to me. I don’t want to be crazy.’ And they’re not. They’re not. They are perfectly normal, wonderful, heroic people who were put in a hellish situation and did magnificent work. Magnificent work. And because they’re such good people, the power of their normal lives, the normal conscience gets really bothered by what they saw and what they had to do.

And sometimes they get this recurrence of events and nightmares and this syndrome. They get very ashamed because to them that’s a sign of being weak. It’s not weak. It’s a hero. That is a hero. And that’s a people we have to take care of, and we continue to take care of. 

The other folks can get severely depressed and not want to talk about it, severely depressed, and not want to show it. And sometimes they try to treat it with alcohol. Lots of heavy drinking after 9/11, which is not the great formula for it. But depression in the course of an event like that, we’re gonna see it. And thankfully, we have a good staff of mental health professionals who can treat that and the PTSD.

But the guys don’t want that. They don’t want to be sick. They don’t want to be depressed. ‘Doc. I’m not crazy.’ No, you’re not crazy. You’re a hero. And you’re living the experiences that a hero lives.

Sara Willa Ernst: And when exposed to what they’ve been exposed to and having to look it straight in the eye, I mean it would make a lot of sense that that wouldn’t just go in one ear and out the other immediately. That would stick with somebody over time, whether that’s one year or an entire decade, or twenty five years. 

Michael Crane: They exactly right. They don’t want it. They don’t want that. ‘Yes, I want to be a hero. Yes, I want to do that work. I don’t want this other thing. Doc, you doc, you don’t? No, you’re not gonna tell. I don’t have that, Doc.’ 

And I’ve had that argument many times, but they do. And I say, I can treat you. We can take care of you. And they still ‘I don’t want it,’ Doc. So we have the back and forth. I win. That’s right.

Sara Willa Ernst: Yeah. Because saying ‘I don’t want it’ doesn’t really work.

Michael Crane: That’s right. And usually we can talk them into treatment and by and large they do extremely well because they are so damn brave and such decent people. And because they have such courage that they can even confront an illness that brings them shame. Well while they have it, but they confront it anyway. Heroes.

Sara Willa Ernst: Mm-hmm. Yeah. I know you mentioned that this wasn’t really the bread and butter of the work that you do. So I’m gonna ask this question and if this is not your wheelhouse, just let me know. but I’m wondering when it’s come to 9/11 first responders and the cancer research that has been done. I’m just wondering what were some of the early research questions and what were kind of the unknowns at the very beginning. If you can give me like, ten years in we discovered this or fifteen years in, twenty five years, some kind of timeline of what we didn’t know and where we are now.

Michael Crane: Sure. so let me just get my okay, two thousand and one. Really So the research kind of grew organically out of what we were trying to do in the field. The example I used because he’s great and a great example, was Dr. Dave Prezant at the fire department. You know so many firefighters died. They were the front line of everything pretty much that I’ve been talking about. Huge exposure. Always running out of masks, heroically digging for people in that pile and on and on. 

And Dave, as a routine, for years had them take lung function tests. So he had that on all the firefighters. And shortly after 9/11, he repeated it on everybody and demonstrated in an article published, by some miraculous power that he has, one year to the day after 9/11, demonstrated that the firefighters had lost some lung function. And he continued that series of articles, which were then picked up by the New York Times. Clear demonstrations that these previously extremely healthy individuals had had loss of lung function. 

Among those reading those articles were congressmen and senators and regular people who said, ‘what are we gonna do to take care of these and the other guys?’ And these articles planted the seeds for the Zadroga Act, the act that provides the care and the treatment and the research dollars for the World Trade Center. So all of that, all of that comes directly from the research that went on. 

When it comes to cancer, I think the best thing that I can do is refer you to the NIOSH site because they list the most common cancers. The most common is the non-melanoma skin cancer, which is pretty common and also curable. And then you have prostate and thyroid. I’m blocking what comes third and fourth, but there are some of the lymphoma family of illnesses is on the list.

Most of those cancers well certainly the you know the basal cell skin cancer is easily treatable, so we can we can really we can really get that. They have a relatively high frequency, prostate and thyroid, and then they start to drop down a little bit. You know, there’s leukemia, but there’s not a lot of it.

So the cancer risk is definitely present. I would say that the risk is really at this point for all cancers. Thankfully that’s what the Zadroga covers. Zadroga will cover the cancers as soon as, you know, so we can get the treatment. 

A really remarkable thing for me has been really my greatest concern was that they were gonna get lung cancer.

I remember standing there. I walked around a corner, I couldn’t breathe. And I had to walk away. I didn’t have a mask on or anything. I was thinking to myself, ‘God, we don’t have enough respiratory stuff, we don’t have enough protection, the masks to give in. My god, what’s gonna happen?’ My number one concern was the respiratory health going forward. 

And when I got up to Mount Sinai, which I guess was 2006, people were already working on that, working on the research. But also specifically starting a very, very rigorous stop smoking program. 

Sara Willa Ernst: Among the first responders.

Michael Crane: Among the first responders. I’m sure you know about stopping smoking programs. It is really tough. You gotta keep going, you gotta keep encouraging, you need the add-ons, the gum, whatever, the nicotine replacement. But it really took hold through some wonderful magical intelligence of the responders. I mean and they dropped smoking like you know they were dropping yesterday’s news. And by now they’re down to below 3% of them smoke now as opposed to whatever it was 20%. And we do not have elevated rates of lung cancer at this point. And when I die, and God asks me ‘what did you do with your life.’ I’m gonna give them that statistic and demand to get into the doors. Open the doors, buddy. Open the doors. Look what I did here. But this was really concentrated work. People like their cigarettes. They use them to relax. But the responders understood, I think, very well, that this would be a risk too far and decided to go, ‘Okay, I’m gonna live with this discomfort and those things are going out of my mouth and into the garbage.’

Sara Willa Ernst: Yeah. I mean, look at the rate of smoking, like you mentioned, it’s a very clear risk factor that you’ve been able to diminish. But I’m wondering, in any ways, like when it comes to the exposure on 9/11 itself. I mean, you had mentioned, the New York Fire Department looking at lung function one year after the fact, studying this. You know, there’s evidence of asbestos in ground zero, people are breathing in stuff, it smells terrible, people are coughing. You would just naturally assume that pulmonary function, lung cancer would be a potential outcome of that exposure. Do we have any understanding of whether there is really that connection?

Michael Crane: Well, the numbers don’t show it. And when I say that, I want to get up and do my happy dance around the desk because I think at this point, at 25 years, with the pretty much, well not elimination, but the mass reduction in smoking, that particular cancer, fingers crossed, fingers crossed, might be off the table. Of course, there’s no guarantees in life as in anything else.

But we are also now looking at the other conditions. Heart disease is hotly debated. Some research, well lots of research indicates that you know exposure to particles will eventually cause an increase in atherosclerosis, arterial disease, etc., etc.

But that is not as what am I trying to say here? That is not as nicely I think understandable to folks who make laws and regulations and pass bills as lung cancer is. The American Lung Association has been saying for years, right? Standing at the top of the parapet, banging in drums saying, ‘lung cancer comes from those cigarettes, so stop doing it.’ It’s been out in the public. 

Also, the heart associations have made a big point about stopping smoking. But somehow, even though I want to say there’s increasing evidence that heart disease is a risk for our responders, and that it should be considered as a World Trade Center related condition, we haven’t broken through on that. I’m just trying to think of the last petition we made. I know we’ve been talking about it with our, you know, our NIOSH folks, but we haven’t gotten there yet. 

The other thing that is on the docket that is difficult for everyone are the cognitive issues that are developing. By some of the tests, like the MOCA, Montreal cognitive assessment, there is an increasing frequency of cognitive issues in our population. 

So someone who wants to challenge me on World Trade Center causation will say: ‘Mike, your population is now 62 years old on average, right? So you are in the age range where that starts to happen. Show me where World Trade put its foot on the accelerator to get numbers that would indicate that the exposure caused this.’ 

And that’s a back and forth right now. There’s very good papers out at Stonybrook that have those indications, but also, and this is a real complicator in this stew pot that’s cooking, depression and PTSD also seem to have a substantial role in later cognitive issues for populations like ours. So right now, two heart diseases and cognitive function are two of the biggest issues for researchers to be looking at for the World Trade Center population. It’s very current, it’s very active. 

Quite very good news is that the government is providing grant support to look at the issues. Stonybrook is one of the real hotbeds of that information and they’re working hard. Sinai is also working on it. So I think we have the people and the essentials to move this idea forward. But it’s rather difficult establishing a new population and a new illness under the Zadroga Act. And we’re on the road. That’s all we can say right now.

Sara Willa Ernst: Yeah. I wanna ask you one more question about lung cancer, if that’s okay. you were mentioning you know, the numbers haven’t really shown the connection between perhaps breathing in the air and that causing an increase of risk when it comes to lung cancer.

Michael Crane: No, I’m sorry. I didn’t mean to give that impression at all. I’m so sorry. 

Sara Willa Ernst: Yeah, correct me. Correct me.

Michael Crane: You’re right. I probably said it wrong. So that stuff is full of carcinogens, right? Full of carcinogens. And when a population walks in there, you’re gonna get a certain amount of risk for a certain number of people. Now, will that risk be elevated greater than the people who walk down the streets of New York City every day? Not known yet, right? Should be, given what we know, given the amount of toxic junk in there, right? So we just haven’t gotten to that place where the numbers say, ‘Hey, look, here’s Mount Sinai’s population, Crane, these people are above what would happen to the normal population. It’s because they had that exposure. You gotta demonstrate that statistically, write the paper, and then we can maybe get the government to do more for us.’

Cancer in general is covered under the World Trade Center Health Program explicitly in the Zadroga Act because everybody understood that just this argument would occur for years, and they wanted to get it out there and remove that concern from the responders. 

Plus, they felt if they highlighted it in the program that we on the ground would also do everything we possibly could to reduce the risk, as in our stop smoking program. So in a way it was saying, ‘Yep, we’re gonna cover it, but I wanna give you guys, you doctors a boot in the fanny to do all the protective stuff.’

Sara Willa Ernst: Yeah. So are you saying that not enough time has passed for us to really know whether or not there is that association between lung cancer and the exposure?

Michael Crane: I will posit right now that lung cancer is caused by that junk in the pile. For sure. In our population of responders who had this minimal protection—but they did have it—we seem to have a risk of exposure that needed that extra boost of the cigarette to cause the cancer. When you took that cigarette risk away, you slowed that down. In other words, we may have slowed it to the point it will not happen in a normal lifespan, right? So the people will maybe be at risk until they’re 92 and pass away. But if they had kept smoking, the risk would have raised its ugly head at 72, right? The way I put it together is we slowed the clock.

Sara Willa Ernst: So, you were talking about prostate cancer, thyroid cancer, maybe lymphoma or leukemia. The fact that those cancers are at a higher incidence compared to the regular population within the 9/11 first responders, 25 years later, is that surprising information to you? I’m just wondering your thoughts are now.

Michael Crane: I’m of the Zadroga school. That pile, any cancer risk. That pile is going to raise all cancer risk. And that’s I think what they were thinking when they said, we’re going to cover all cancers, right? We’re just going to get this off the table. Because when you have lung cancer or you have stomach cancer, the last thing you need is some guy debating whether you got it on the job. Okay. You were there. You’re covered. That was great.

Sara Willa Ernst: Yeah. I wanted to ask about this Washington Post article that I saw came out recently. I don’t know if you read it at all. 

Michael Crane: Was I in it? 

Sara Willa Ernst: No. 

Michael Crane: Good, okay. Then it was awful. It was terrible.

Sara Willa Ernst: But it did analyze reports from the World Trade Center Health Program. And it showed that the number of 9/11 survivors receiving aid for cancer had roughly tripled over the past five years. 

I’m just gonna cite some stats. In 2021, 8,800 survivors received aid for cancer treatment, and now there are around 27,000 survivors in 2026. 

I’m wondering, do you think the program is kind of entering a different phase now? A phase where, obviously, more first responders are battling cancer and that this is happening because cancer takes maybe a long time to develop in some cases, but also because it’s the aging population in some ways.

Michael Crane: All of the above. You just nailed it. I mean, you’re hired. First of all, the program itself has expanded, right? The responders came kind of piling in, and it had steady growth. This is something I do want you to write about, so please just hear me out here. The survivor population, the local population, people living there. That’s a different program than the responders. It’s a different combination with personal insurance on the survivor side. It’s not, as they say, not as great coverage, because you do have to bring your own personal insurance to play. So the survivor program didn’t encompass as high a percentage of the survivor population as the responder population. We think we had 90,000 responders down at the site, we have 90,000 people in the program now. The survivor population, the local population who lived and worked down there, was closer to 400,000. I think at the beginning of this year, it had some good growth, but I think at the beginning of this year it was like 55,000. So a much, much smaller population of the community people got into the program. Now, I don’t know all the reasons for that, but one of the things that’s starting now is the government is aware of that and they seem to be very attentive to try and get more of the community population in there. 

Remember, that was school kids, right? Grade school kids who are now maybe 30 or 35. They’re going to have kids of their own. If there’s an issue here for the young people because of that exposure, we want to know about that. We really want to know about it. Potentially there’s something that could pass between the generations that we don’t even know about. So my thing has been when we talk about the two populations, we have to increase the representation of the community population, the non-rescue and recovery people in this program to get the answers we need. I think it’s absolutely critical. And if you could make that a message of anything you say, I would be forever in your debt. I think really we should be ringing the bells from the rooftop for this next generation to make sure that they’re not gonna pass something on that we don’t know about.

Sara Willa Ernst: Mm. You see that as being part of maybe—hopefully—like the next phase of recovery and treating this population.

Michael Crane: I think yeah. The responders—how old are we?—62, 63. There are lots of issues, lots of problems, lots of illness, but we’re at least getting the care. 

These folks, I mean, those 400,000 people, every one of them should be monitored. Every one. 

The dust was there in the corner, when you open the drawer, the dust was there. You open the window, it’s on the windowsill. It didn’t get cleaned up. I mean look at the reports now, right? All the stuff that’s come out recently in the last few days. They really need to be encouraged to be in the survivor program. If the survivor program needs to be modified to get more people to come, we should modify it. Let’s take care of that population of people. They are deserving. They were there. They kept New York open. Come on, let’s take care of them.

Sara Willa Ernst: Yeah. I want to ask you one last question. I’ve kind of monopolized your time for the podcast. It relates to cancer and what we know and what we don’t know. We’ve talked a little bit about cancer incidence and certain cancers that have been more prevalent in the population compared to regular population. But I’m wondering what we know about cancer mortality at this point. Has that shown up in the academic literature so far? Or is it something, you know, one of the research questions that currently exists for the scientific community to try to answer?

Michael Crane: Yeah, no, I think it’s a great question. I’m just trying to think now, and I’m blocking on the article, but the overall mortality of the respondent population is lower than had been expected. Probably, that’s a combination of the healthy worker effect—you’re familiar with that? 

So, some combination of healthy worker and also the specifics of this program… 

Sara Willa Ernst: Why don’t you explain the healthy worker effect for our audience now?

Michael Crane: Okay. So if you go to work and you can go to your job every day and keep working, you are on average healthier than the person who may not be working. Why are they not working? Well, many, many reasons, but health is one of them. The general idea is that workers carry better health than the non-working population. And that’s been shown to be true. 

The interesting thing about World Trade and the World Trade Center program, and this is a disguised way for me to brag now. So you’re allowed to edit it out if you want to. But I’m going to be bragging right here. So to get at that problem, some of the researchers down from the New York City Health Department compared the New York City Police Department workforce to an external, another city work workforce police officer. So it’s police force to police force. They found that police officers in the World Trade Center program were healthier than the people at the other city who had not been exposed. 

It’s more complicated than that. But it’s two different things. One is, of course, the recognition that workers are healthier than you know non-workers. But the other thing, there’s the very special nature of a program that sort of really addresses the care and needs of working populations. The exposures they have, the risk they have—and again, I’m coming back to cigarettes—does have an impact on the course of lives.

And for me, this is the generalizable lesson from the World Trade Center Health Program. I think we give excellent care. I think that in general, American medicine also gives excellent care. However, the organization of it, the way the World Trade Center program has it organized to understand not only cardiac risk and this risk, but the absolute impact of work and work events on previously healthy working people and to address those specific risks like smoking that really exact exacerbate those risks and post-traumatic stress, which is frequently the result of incidents for public servants like policemen and firemen—addressing those really does make a difference in the life course and in the general and in the general contentment with a life. 

I think our program is a very good example for all of that. And that’s actually the reason why I come out and do these things, so young journalists will hear about it and repeat that.

So I’m doing propaganda to you right now.

Sara Willa Ernst: I think those are all the questions I have. I really wanted to thank you for taking time to talk to me. And obviously, thank you so much for your work taking care of 9/11 first responders.