Managing Chronic Illness in Patients

townsendletter The Examiner of

Alternative Medicine

April 2006 #273

www.townsendletter.com

Health Status of Rescue Workers Improved by Sauna Detoxifi cation

58 TOWNSEND LETTER for DOCTORS & PATIENTS – APRIL 2006

ChemicalExposures at theWorld Trade Center

by Marie A. Cecchini, MS; David E. Root MD, MPH;

Jeremie R. Rachunow, MD; and Phyllis M. Gelb, MD

Use of the Hubbard SaunaDetoxification Regimen toImprove the Health Status ofNew York City Rescue WorkersExposed to Toxicants

TOWNSEND LETTER for DOCTORS & PATIENTS – APRIL 2006 59

BackgroundOn September 11, 2001, the

attack and collapse of thegigantic World Trade Centertowers caused an enormousrelease of toxic substances intoa densely populated urbanenvironment. These includedasbestos, radionuclides,benzene, dioxins, poly-chlorinated biphenyls (PCBs),fiberglass, mercury, lead, silicon,sulfuric acid29 – agentsassociated with cancer as well assevere lung pathology, neuro-logical and cardiovasculardisease, and a myriad of immunedysfunctions.

Emergency workers wereexposed to unprecedented levelsof these chemicals andbreakdown products during theensuing eight and one-halfmonth rescue and cleanup effort.Daily exposures continued asfirefighters, paramedics, police,clean-up crews, and otherpersonnel continued theirefforts, working long hours forover eight months after theattack. Personal ProtectiveEquipment (PPE) was notalways available or wasgenerally ineffective inpreventing the rescue workersfrom absorbing contaminants byinhalation, ingestion, or dermalexposure.8

There is no doubt that thetens of thousands of men andwomen who participated in therescue and recovery operationswere exposed to a wide range oftoxins, many of which are knownto accumulate in body tissues,with half-lives measured inyears or decades.12.28 Exposuresymptoms have not abated withtime; instead, a substantialnumber of those exposed areexperiencing worsening healthstatus involving multiple organ

systems. Studies demonstrate adefinite link between exposuresto WTC-derived airbornepollutants and respiratorydisease.2

The acute complaints ofemergency responders wereoften pulmonary.14,19,38 However,other debilitating healthconsequences exist. Thedepression, anger, and lowmotivation commonly reportedamong this population andassigned to Post-TraumaticStress Disorder are more likely

indicative of toxic encephalo-pathy.16 Other major concernsinclude persistent pulmonaryand digestive tract inflammatorysyndromes, such as reactiveairways dysfunction syndrome(RADS), reactive upper airwaysdysfunction syndrome (RUDS),gastroesophageal reflux disease(GERD), and inflammatorypulmonary parenchymalsyndromes, as well asrespiratory tract and non-respiratory malignancies.5,10,47

Sauna DetoxificationThe method of detoxification

developed by Mr. Hubbard is a preciseprotocol documented for mobilizing fat-stored toxins and enhancing theirelimination while restoring metabolicbalance. The protocol has long beenestablished as safe.45 Previous casereports,39,51 as well as a number of non-randomized, controlled studies ofexposed workers (includingfirefighters),21 demonstrate thatdetoxification reduces body burdens ofPCBs, PBBs, dioxins, various drugs,and pesticides44,46 with concurrentsymptomatic improvement.44,20,22

Publications over the past twodecades also show that this regimen canimprove memory, cognitive functions,immune parameters, and generalphysical condition in different studypopulations.44,46

The detoxification protocol isstandardized17 and includes thefollowing:

• A daily regimen of physicalexercise, immediately followed byforced sweating in a sauna at 140-180°Ffor two-and-a-half to five hours withshort breaks for hydration to offset theloss of body fluids and cooling.

• Nutritional supplementationcentered on gradually increasing dosesof crystalline niacin (nicotinic acid) topromote lipid mobilization of storedtoxicants and stimulate circulation.

• Administration of additionalvitamins, minerals, electrolytes, andoils includes vitamins A, D, C, E, Bcomplex, B1; multi-minerals includingcalcium, magnesium, iron, zinc,manganese, copper, and iodine; sodiumand potassium; and a blend ofpolyunsaturated oils including soy,walnut, peanut, and safflower.

Each of these program componentshave biologic roles that support healing.The integrity of physiological systems– including those associated withdetoxification, cellular repair, immuneprocesses, and neural and endocrinefunction – depends upon nutritionaland vitamin status. Of note are niacinand the use of oils as a source ofessential fatty acids. The inclusion of abalanced complement of additionalnutrients is aimed at maintainingsupplies adequate for increaseddemand.

Niacin can shift the adipose-bloodequilibrium of toxin concentrations bystimulating release of fatty acids from

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1. Reference thyroxine (T4) levels are 4.0-12.0 ug/dL; reference T3 is 24-39%;reference free thyroxine is 1.1-4.5 ug/dL; and reference TSH is 0.27-4.2 uIU/mL

2. Statistically significant (p < 0.05).

Figure 1: Improvement in Health-RelatedQuality of Life

Figure 2: Change in Symptom Severitywith Detoxification

Figure 3: Change in Use of Medications withDetoxification: N = 324

Figure 4: Change in Balance Test: N-53

Figure 5: Change in Reaction Time withDetoxification: N=58

Figure 6: Average Thyroid Hormone Levels

Number of Medications atCompletion

TOWNSEND LETTER for DOCTORS & PATIENTS – APRIL 2006 61

PCBs.7 Niacin raises high densitycholesterol (HDL-C) more effectivelythan either of the commonpharmacologic interventions, statin orfibrate therapy, and has been proven toreduce cardiovascular events inmonotherapy studies.4

Niacin coenzymes are necessary formore than 500 enzymatic reactions,particularly in the form of nicotinamideadenine dinucleotide (NAD).36 Niacincoenzymes are required forbiotransformation of foreign compoundsas a step in eliminating thosecompounds from the body.24 They alsoregulate liver detoxification pathwaysso that the activated radicals of phaseI detoxification are rapidly conjugatedwith glutathione or other compoundsduring phase II.48 Further, marginaldeficiencies in folate, vitamin B12,niacin, and zinc increase the rate ofspontaneous chromosome damage.9

Niacin coenzymes regulate DNA strandbreak repair.30,54

Inclusion of polyunsaturated oilsenhances detoxification and alsoreplaces the essential fatty acidsmobilized from stores. The walnut andsoy oils used in this regimen containhigh levels of omega-3 fatty acids; thesafflower, soy, and peanut oils are richin omega-6 fatty acids. Polyunsaturatedoils can line the intestine and preventre-uptake of toxins that have beeneliminated through large intestinepathways.40 Oils may also have a directeffect on toxin elimination.33,41,42

This rehabilitative therapy isprovided on a daily basis, seven days aweek, and averages 33 days forcompletion. (The range was 23-106days.) Body weight, pulse, and bloodpressure are monitored before and aftereach daily session with body weightkept constant throughout. Physiciansmonitor individual client programs.

Rehabilitating Rescue WorkersRecognizing that they had had an

unprecedented exposure, a group offirefighters and union officials felt thata program should be available to rescueworkers that specifically addressedbody accumulations of toxins. Theycontacted the Foundation forAdvancements in Science andEducation (FASE) for assistance inmaking the detoxification regimenavailable to exposed personnel.

An independent facility funded byprivate donations was set up inSeptember 2002 in lower Manhattan,providing this therapy without charge.

To date, more than 500 have completedthe program in Manhattan and at asecond facility established on LongIsland. The great majority have beenuniformed rescue workers, includingfirefighters, paramedics, sanitationworkers, and police. A small number ofindividuals who lived or worked in theWTC or near the site have alsocompleted the program.

The primary goal of this project isto restore quality of life and job fitnessto those exposed to toxic materials atthe WTC site. The focus to date hasbeen to identify individuals who are notresponding, or not recovering fully, afterreceiving medical treatments beingoffered to WTC exposure victims.

Outcome MeasuresIndividuals are referred to the

project because of persistent symptomsfollowing exposure to WTC toxins. Theproject’s rehabilitative goal emphasizesrestored quality of life (“wellness”).Additionally, the project includesongoing tests to identify the full rangeof health effects associated with theWTC exposures and evaluating theefficacy of detoxification in resolvingspecific effects. A complete set of testsare given before and afterdetoxification.

To evaluate the effectiveness of thisrehabilitative therapy, participants aregiven a structured medicalexamination. Participants alsocomplete a comprehensive HealthHistory and Symptom Surveydeveloped specifically for this project.This survey gathers basic demographicinformation; employment history andrelevant work exposure questions;recent symptomatology focusing on thecluster of symptoms common toenvironmental exposures; and thenumber of lost workdays. Clients alsoundergo intelligence quotient (IQ)testing, as well as a panel of standardlaboratory tests including CBC,comprehensive metabolic panel, thyroidpanel, lipid panel, ECG, and urinalysis.

The First Three Years:Review of 484 Cases

As previously noted, more than 500men and women who were exposed toWorld Trade Center contaminants havecompleted the detoxification program.This report summarizes a recent reviewof medical folders from the 484 men andwomen who enrolled in the programbetween September 2002 andSeptember 2005: 273 firefighters, 52

sanitation workers, 19 paramedics, 23police officers, and 117 others. Of these,63 individuals left the program prior tocompletion. These results indicate arange of benefits that sum up toimproved quality of life and job fitness.

The number in each test samplevaries to some extent. Certain testswere added or changed as the projectevolved, and therefore not all tests wereperformed on all clients. Results aredescribed only for those individuals whohad multiple data points on that test.Emphasis has been placed on thefindings of greatest interest.

A. Healthy Days and Job FitnessThree core questions from the CDC

Health-Related Quality of Lifeinstrument are included in thestructured health history and symptomsurvey. These quantify the number ofdays physical and mental health wasnot good, as well as how many days poorphysical or mental health keptindividuals from doing their usualactivities, such as self-care, work, orrecreation. These were completed by allclients who underwent detoxificationafter June 2005.

• Prior to enrollment individualsaveraged 4.4 days of limited activityand 2.1 days missed work per month.

• After detoxification, theseindividuals reported 0.2 days of missedwork or limited activities (this includesthe month they underwent therapy).(See Figure 1.)

A majority of rescue workers seekingdetoxification treatment are concernedthat their health problems might forcethem to leave their jobs. The majorityof these individuals are between 35 and45 years of age (ranging from 20 to 77years); many have young children.While forced retirement of these menwould be costly to the city, the disabilitybenefits that each individual manmight expect are not sufficient tosupport a family. Thus, anxieties abouthealth are compounded by financialconcerns and further complicated by adetermination to continue on the jobwithout mentioning symptoms.

B. Symptom SeverityThe Health History and Symptom

Survey consists of 50 items on ten scalesfor systems commonly impacted bychemical exposure and is used to assess

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62 TOWNSEND LETTER for DOCTORS & PATIENTS – APRIL 2006

changes in symptoms over the courseof sauna detoxification. Responses arenormalized to take into account the factthat there are different numbers ofquestions per category of symptoms.Improvements on all symptom scales(manifestations consistent withexposures to the range of toxicantsknown to be released at the WTC site)were especially strong. (See Figure 2.)

C. Need for MedicationThe case review revealed that

almost half the individuals were takingas many as 16 medications to relievetheir exposure symptoms. At programcompletion, 84% of those clients nolonger required medication becausetheir exposure symptoms abated. Of theseven percent still taking medicine, usewas reduced to only a single medicationin most cases. As these symptomsabate, clients are able to reduce andultimately eliminate the medicationsthey are taking. (See Figure 3.)

These clients work in professionsthat require a high level of fitness.Those who had been on medications foran extended period experienced the sideeffects as unwelcome (if not dangerous)impediments to both their accustomedstate of well-being and their job fitness.

D. Vestibular FunctionImpairment of vestibular function is

associated in the literature with toxicexposures.34,35 The postural sway test isa sensitive and reliable method ofmeasuring balance developed for fielduse measuring the mean speed alongthe path moved with eyes open andwhen eyes are closed.23 Pre/postdetoxification balance testing wascompleted on a random cohort offirefighters exposed to WTC toxins.There is a statistically significantdifference (p = 0.12) between sway testresults before and after detoxification,with the pre-detoxificationmeasurements significantly impaired,as demonstrated by increased swayspeed, compared with predicted resultsof reference populations (see the “zero”line in Figure 3).

Balance is crucial to firefighters. Ifbalance is impaired, a firefighter maynot be able to remain upright in a darkarea. Following detoxification, theexposed firefighters have sway test

values that approach those of anunexposed reference population. (SeeFigure 4.)

E. Reaction TimeImpairment of Choice Reaction Time

(CRT) has been previously shown infirefighters exposed to PCBs.21,32 CRTtesting measures cognitive function:vigilance, discrimination, and speed ofreaction (abilities that are obviouslycrucial to firefighters, police, orparamedics). Pre/post detoxificationCRT testing was completed on arandom cohort of firefighters exposedto WTC toxins.

Firefighters have faster thanpredicted measures of both SingleReaction Time (SRT) and CRT, as seenin the negative variance from predictedresults. The improvement in CRTfollowing detoxification is statisticallysignificant (p<0.1) and suggestsimprovement in cognitive function. (SeeFigure 5.)

The findings of neurologicimprovement are consistent withimprovements noted in earlierdetoxification studies involvingfirefighters.21 Following a transformerfire in Shreveport, Louisiana, 17firefighters with a history of acuteexposure to polychlorinated biphenyls,dibenzofurans, and dibenzodioxinsunderwent neurophysiological andneuropsychological tests. Prior todetoxification, five of the 17 hadabnormal current perception thresholdmeasurements. Following therapy, allshowed improvement with two clientsreturning to normal range. In this samestudy, firefighters had improved scoreson memory tests, block design, trails B,and embedded figures. These findingsraised the possibility that damageheretofore thought to be permanentmay in many instances be partiallyreversible. It is interesting that in thesesmaller studies, vestibular and reactiontime results were not observed.

F. Intelligence QuotientReduced IQ can be a result of toxic

exposure and has significant economicimpact.13,15 All clients completed NovisIntelligence Quotient tests before andafter participating in the detoxificationprogram. Clients complete a differentversion of this test on each testingoccasion, therefore improved test scoresare not a reflection of learning.

While there is no data on the IQlevels of exposed workers prior to

exposure, the measured averageincrease of almost four points of IQfollowing detoxification is statisticallysignificant over that measured prior totherapy (p<0.005) and may suggestrestored cognitive function.

G. Blood CholesterolLipoprotein profiles are a predictive

factor for atherosclerosis and coronaryheart disease.53 Low density lipoprotein(LDL-C) carries cholesterol from theliver to the cells where it is used. Ifsupply exceeds demand, excess LDL-Ccan cause harmful build-up ofcholesterol along arterial walls. Highdensity lipoprotein (HDL-C) helpsreverse cholesterol transport, preventsendothelial dysfunction, and containsanti-inflammatory, anti-oxidant, andantithrombotic properties. Lipoproteinprofiles can be adversely affected bychemical exposure.3

• Before therapy, 14% of clients hadtotal cholesterol above 240 mg/dL with50% above 200 mg/dL. LDL-C wasabove 130 mg/dL in 30% of clients, andHDL-C was below 40 mg/dL in 19.5%.

• Following therapy, over 70% hadtotal cholesterol and LDL-C levels inthe desirable range. LDL-C remainedabove 130 mg/dL in 11.6% of clients, andHDL-C was below 40 mg/dL in 12%.

H. Thyroid FunctionOver the last decade, a growing body

of research has associated a range ofadverse endocrine effects with toxicexposure, including thyroid effects.49

Exposure to toxic metals, chemicalpoisons, and a number of drugs can alsoinfluence the peripheral fate of thyroidhormones.18

• Thirty percent of all clients in thisgroup have abnormal levels of thyroid-related hormones at the start oftherapy.

• Following therapy, 66% of thosewho had elevated levels now havenormal thyroid function with theremaining third improved.

As a group, average thyroxin levelsare within the normal range, though atthe high end at enrollment. Astatistically significant trend exists forthe lowering of thyroxin levels duringthe detoxification process.

Pituitary production of thyroidstimulating hormone (TSH) is an earlyindicator of compromised thyroidactivity. When the thyroid glandbecomes inefficient, as in earlyhypothyroidism, the TSH becomes

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elevated even though the T4 and T3may still be within the “normal” range.Average TSH levels in clients areelevated prior to enrollment and returnto normal range during the regimen.(See Figure 6.)

Case Study: Captain in the USArmy National Guard

A 34-year-old Captain and AUH-60Black Hawk Pilot in the US ArmyNational Guard was deployed to theWTC rescue effort between September11, 2001 and March 2002. Prior todeployment, he had an excellent healthhistory with no tobacco, alcohol, or drughistory. He was hospitalized onSeptember 16th for breathingdifficulties, and his medical recordsindicate several subsequenthospitalizations for asthma andpneumonia requiring intubation. Hismental condition deteriorated includingflashbacks of the WTC incident.Additional symptoms characteristic ofchemical exposures developed over timeincluding severe stomach and chestpain, memory problems, and disturbedsleep. By December 2003, the Army hadrevoked his flight orders, afterinvesting approximately $3 million inhis flight training.

He was referred to the New YorkRescue Workers’ Project by physiciansafter discussing the alternatepossibility of a long-term steroidregimen. At enrollment into theprogram, he was taking ten medicationsdaily including Albuterol, Advair, andNexium. Laboratory tests resultsincluding CBC, comprehensivemetabolic panel, thyroid panel, lipidpanel, ECG, and urinalysis were allwithin normal ranges. Diagnosed withWTC exposure, he elected to undergodetoxification treatment.

During treatment and coincidentwith improved symptoms, he graduallydiscontinued use of all medications. Oncompletion of sauna detoxification, hewas medically evaluated by internalmedicine specialists at the DeploymentHealth Clinical Center, a unit at WalterReed Army Medical Hospital. Hisirritable bowel syndrome, cough, andbreathing difficulties were completelyresolved, medical records state, “He isnow able to run five miles in 50minutes.” Other symptoms improved,including sleep apnea and congestion;he has mild pollen allergies. Withinmonths of treatment completion, he hadpassed all physical tests necessary andwas deployed to Iraq in a non-flight

capacity. Eighteen months followingtreatment, he passed all medical andmental tests to receive full flightclearance. He then directed the airspacefor rescue efforts in New Orleansfollowing the destruction of hurricaneKatrina and has subsequently beenpromoted to the rank of Major.

Summary of ResultsReview of initial test results and

medical history questionnaires revealsthe following:

• All clients reported improvementin subjective symptoms.

• All clients reported improvedperception of health.

• Health History and SymptomSurvey (selected questions) foundconsiderable reductions in days of workmissed on the start of the detoxificationprogram, leading to reduced concernsabout forced retirement.

• Due to symptom improvement,84% of those clients requiringmedications to manage symptomsrelated to WTC exposure were able todiscontinue their use.

• Over half the clients requiredmultiple pulmonary medications onentry to achieve near-normalpulmonary functions (measured as FVC& FEV1). On completion ofdetoxification, 72% of these individualswere free of pulmonary medication yethad improved pulmonary function tests(data not shown).

• There was a statisticallysignificant improvement in thyroidfunction tests.

• There was a statisticallysignificant improvement in ChoiceReaction Time (CRT) and IntelligenceQuotient (IQ), suggestive ofimprovement in cognitive function.

• Statistically significantimprovement in Postural Sway Testindicated improvement in vestibularfunction.

DiscussionWhile the data presented in this

paper was collected in the context ofroutine outcome monitoring ratherthan in a controlled study, the resultsare encouraging. The number of WTC-exposed individuals (more than 500)who have achieved the rehabilitativegoals of sauna detoxification therapy –restoring quality of life and job fitness– is significant. The improvements inself-reported symptoms, an indicationof a marked return to wellness, are

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supported by reduced need formedication. These findings are furtherconfirmed by objective measures.

This regimen has greatly reducedthe number of work days that rescueworkers miss due to illness, and hasresolved anxieties that careers will beend prematurely in disabilityretirement. Anecdotal reports fromspouses, family members, andemployers describe dramatic changes inthe quality of family life as a result ofsuch improvements.

Initially, public health officialsexpected that the majority of themanifesting symptoms would reducewith the passage of time. This hope hasnot been realized. Not only aresymptoms persisting after more thanfour years of customary treatment,rescue workers who previously had notreported significant health problemsare now falling ill. Workers andresidents alike have persistent, new-onset respiratory symptoms27,37 andincreased risk of asthma,25 particularlyamong children.50 A recent FDNY studyindicates that all the WTC-exposedFDNY rescue workers experiencedaccelerated declines in lung function inthe year following the attacks.1

In addition to rescue workers, theWTC Health Registry enrolled 14,725residents who reported living below

64 TOWNSEND LETTER for DOCTORS & PATIENTS – APRIL 2006

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Canal Street on September 11, 2001,representing 25% of the totalresidential population south of CanalStreet at the time, according to the 2000US Census. Enrollment interviewsbetween September 5, 2003 andNovember 20, 2004 indicate persistentrespiratory and mental healthsymptoms in this population.26

Although EPA officials initiallydownplayed the potential hazards ofWTC air and dust, subsequentgovernment response reflectssignificant concern regarding thepotential public impact of thisunprecedented exposure event. Publicfunds now support six health screeningprograms to monitor ground zeroworkers.

While this work is important, it ismade complicated by the nearly infinitevariations in individual exposure insuch incidents – including the numberand type of toxic agents involved, thelevel of each toxin present at a specificlocation, the form of the toxic particle,and the route of exposure. Further,little is being done to determine whatforms of treatment and rehabilitationmight be appropriate in the aftermathof a toxic event of this magnitude.

This omission has precedents.Veterans returning from Vietnam andthe first Gulf War, convinced that theirhealth had been impaired by chemicalexposures, have been offered little inthe way of relief. Public health effortsand government funding have focusedon characterizing exposures andidentifying relationships betweenobserved health effects and specifictoxins.

Advising health care providers andpublic health agencies regardingresponse to terrorist incidents thatmight involve chemical weapons, theCenters for Disease Control (CDC)recently observed that, “Treatingexposed persons by chemical syndromerather than by specific agent probablyis the most pragmatic approach to thetreatment of illnesses caused bychemical exposure.”6

There are good reasons to apply thisperspective to occupational andenvironmental exposures, increasingthe emphasis on providing reliefwhenever possible. Given theprobability of future terrorist events or

chemical accidents, proactive remediesfor known effects of chemical exposure,including chronic effects that, thoughnot life-threatening, are sufficient todestroy quality of life, must beidentified and implemented.

The Hubbard method is the onlysuch treatment being offered to NewYork rescue workers. Theimprovements attained in almost 500cases argue for broader implementationof the program, supported by additionalevaluation and research efforts. That alarge percentage of those affected by9/11 exposures are not responding toexisting treatments after more thanfour years; that the opportunity toimprove the job fitness of firstresponders in one of the nation’s mostimportant cities exists; and that thepossibility that syndromes beingtreated as “post traumatic stress” arein fact the result of toxin-induceddamage – all this argues strongly forand adds urgency to this initiative.

Marie Cecchini, MS, is the ResearchDirector of the Foundation forAdvancements in Science andEducation (FASE); David Root, MD,MPH is the Medical Director of theSacramento Occupational MedicalGroup; and Jonnie Rachunow, MD andPhyllis M. Gelb, MD are both associatedwith the New York Rescue WorkersDetoxification Project, New York, NewYork.

CorrespondenceMarie CecchiniFASE – Foundation for Advancementsin Science and Education4801 Wilshire Blvd, Suite 215Los Angeles, California 90010 USA323-937-9911www.fasenet.org

References1. Banauch G, Weiden M, Hall C, Cohen H, Aldrich

T, Arcentales N, Kelly K, and Prezant D,Accelerated pulmonary function decline afterWorld Trade Center particulate exposure in theNew York City Fire Department workforce.Chest. 2005; 128:213S (abstr).

2. Banauch GI, Dhala A, Alleyne D, Alva R,Santhyadka G, Krasko A, Weiden M, Kelly KJ,Prezant DJ, Bronchial hyperreactivity and otherinhalation lung injuries in rescue/recoveryworkers after the World Trade Center collapse.Crit Care Med. 2005; 33:S102-6.

3. Bell FP, Iverson F, Arnold D, Vidmar TJ, Long-term effects of Aroclor 1254 (PCBs) on plasmalipid and carnitine concentrations in rhesusmonkey. Toxicology. 1994; 89:139-53.

4. Berge KG, Canner PL, Coronary drug project:experience with niacin. Coronary Drug ProjectResearch Group. Eur J Clin Pharmacol. 1991;40 Suppl 1:S49-51.

5. Butterworth RF, Complications of cirrhosis III.Hepatic encephalopathy. J Hepatol. 2000;32:171-80.

6. Center for Disease Control (CDC), Recognitionof chemical illness associated with exposures tochemical agents United States, 2003. JAMA.2003;290: 2247-2248.

7. de Freitas AS, Norstrom RJ, Turnover andmetabolism of polychlorinated biphenyls inrelation to their chemical structure and themovement of lipids in the pigeon. Can J PhysiolPharmacol. 1974 52:1080-94.

8. Feldman DM, Baron SL, Bernard BP, LushniakBD, Banauch G, Arcentales N, Kelly KJ, PrezantDJ, Symptoms, respirator use, and pulmonaryfunction changes among New York Cityfirefighters responding to the World TradeCenter disaster. Chest. 2004; 125:1256-64.

9. Fenech M, Micronutrients and genomicstability: a new paradigm for recommendeddietary allowances (RDAs). Food Chem Toxicol.2002; 40:1113-7.

10. Ferenci P, Treatment of hepatic encephalopathy.Indian J Gastroenterol. 2001; 20 Suppl 1:C90-4.

11. Findlay GM, DeFreitas AS, DDT movement fromadipocyte to muscle cell during lipid utilization.Nature. 1971; 229:63-5.

12. Fireman EM, Lerman Y, Ganor E, Greif J,Fireman-Shoresh S, Lioy PJ, Banauch GI,Weiden M, Kelly KJ, Prezant DJ, Inducedsputum assessment in New York Cityfirefighters exposed to World Trade Center dust.Environ Health Perspect. 2004; 112:1564-9.

13. Gregersen P, Klausen H, Elsnab CU, Chronictoxic encephalopathy in solvent-exposedpainters in Denmark 1976-1980: clinical casesand social consequences after a 5-year follow-up. Am J Ind Med. 1987; 11:399-417.

14. Herbert RLS, World Trade Center worker andvolunteer medical screening program. Report ofinitial findings to the National Institute forOccupational Health and Safety of the Centerfor Disease Control and Prevention. 2003

15. Hosovski E, Mastelica Z, Sunderic D, RadulovicD, Mental abilities of workers exposed toaluminum. Med Lav. 1990; 81:119-23.

16. Houck P, Nebel D, Milham S Jr, Organic solventencephalopathy: an old hazard revisited. Am JInd Med 1992; 22:109-15.

17. Hubbard, L Ron, Clear Body Clear Mind, BridgePublications, 2002.

18. Kelly GS, Peripheral metabolism of thyroidhormones: a review. Altern Med Rev. 2000;5:306-33.

19. Kelly KJ, Connelly E, Reinhold GA, Byrne M,Prezant DJ, Assessment of health effects in NewYork City firefighters after exposure topolychlorinated biphenyls (PCBs) andpolychlorinated dibenzofurans (PCDFs): theStaten Island Transformer Fire HealthSurveillance Project. Arch Environ Health. 2002;57:282-93.

20. Kilburn KH, Is the human nervous system mostsensitive to environmental toxins? Arch EnvironHealth. 1989; 44:343-4.

21. Kilburn KH, Warsaw RH, Shields MG,Neurobehavioral dysfunction in firemen exposedto polychlorinated biphenyls (PCBs): possibleimprovement after detoxification. Arch EnvironHealth. 1989; 44:345-50.

22. Kilburn KH, Warshaw RH, Boylen CT, ThorntonJC, Respiratory symptoms and functionalimpairment from acute (cross-shift) exposure towelding gases and fumes. Am J Med Sci. 1989;298:314-9.

23. Kilburn KH, Warshaw RH, Hanscom B, Balancemeasured by head (and trunk) tracking and aforce platform in chemically (PCB and TCE)exposed and referent subjects. Occup EnvironMed. 1994; 51:381-5.

24. Klaidman LK, Mukherjee SK, Adams JD Jr,Oxidative changes in brain pyridine nucleotidesand neuroprotection using nicotinamide.Biochim Biophys Acta. 2001; 1525:136-48.

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The stunning photographs appearing with this article were taken by MarkRoddenberry, who generously donated their use. Roddenberry, a professionalphotographer, moved to New York in November 2000 to pursue his career. OnSeptember 11th, he was in his studio, eight blocks north of the World TradeCenter. On that day and on the days that followed, Roddenberry’s access to thearea, his close ties to the community, and his brilliant eye allowed him to capturethe devastation of the site and the American people’s initial efforts to cope.Roddenberry, too, was grasping for understanding as he set out to record theoverwhelming tragedy.

“Once I got to the front door, there was one split second when I almost wentback,” he said. “…where there was normally a steady flow of traffic, there werenow 10,000 people walking, like there was a parade going north…I turned back.I couldn’t do it. It just broke my heart…I remember grabbing the doorknob…it wasas though a voice said. ‘Hold on one second. If you do not take these pictures, youwill forever regret it.’”

Thanks to Mark Roddenberry, these remarkable and tragic images will remainforever in the world’s view.

An exhibit of Roddenberry’s 9/11 photographs, entitled “Avenue of theStrongest,” will be on display at the San Antonio (Texas) Public Library throughoutthe month of March. A portion of this exhibit can be viewed online atwww.avenueofthestrongest.us.

25. Landrigan PJ, Lioy PJ, Thurston G, BerkowitzG, Chen LC, Chillrud SN, Gavett SH,Georgopoulos PG, Geyh AS, Levin S, Perera F,Rappaport SM, Small C, Health andenvironmental consequences of the world tradecenter disaster. Environ Health Perspect. 2004;112:731-9.

26. Levin SM, Herbert R, Moline JM, Todd AC,Stevenson L, Landsbergis P, Jiang S, Skloot S,Physical Health Status of World Trade CenterRescue and Recovery Workers and Volunteers –New York City, July 2002 - August 2004. MMWRMorb Mortal Wkly Rep. 2004; 53:807-812.

27. Lin S, Reibman J, Bowers JA, Hwang SA,Hoerning A, Gomez MI, Fitzgerald EF, Upperrespiratory symptoms and other health effectsamong residents living near the World TradeCenter site after September 11, 2001. Am JEpidemiol. 2005; 162:499-507.

28. Lioy PJ, Gochfeld M, Lessons learned onenvironmental, occupational, and residentialexposures from the attack on the World TradeCenter. Am J Ind Med. 2002; 42:560-5.

29. Lioy PJ, Weisel CP, Millette JR, Eisenreich S,Vallero D, Offenberg J, Buckley B, Turpin B,Zhong M, Cohen MD, Prophete C, Yang I, StilesR, Chee G, Johnson W, Porcja R, Alimokhtari S,Hale RC, Weschler C, Chen LC,Characterization of the dust/smoke aerosol thatsettled east of the World Trade Center (WTC)in lower Manhattan after the collapse of theWTC 11 September 2001. Environ HealthPerspect. 2002; 110:703-14.

30. Magni G, Amici A, Emanuelli M, Orsomando G,Raffaelli N, Ruggieri S, Enzymology of NAD+homeostasis in man. Cell Mol Life Sci. 2004;61:19-34.

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