In January, 2006, shortly after James Zadroga died at his parents’ house, in Little Egg Harbor, New Jersey, Dr. Gerard Breton received a call from the Ocean County Medical Examiner’s Office. A retired hospital pathologist, Breton now conducts autopsies for the county on contract. Compared with its more violent neighbors—Newark, to the north, and Atlantic City, to the south—the central New Jersey shore tends to generate uncomplicated deaths: heart disease, liver failure, sunstroke. Zadroga’s death, at the age of thirty-four, was different. Medical records showed that his health had been failing for almost five years, apparently owing to degenerative lung problems, which had forced him to go on sick leave from his job as a New York City homicide detective in 2002. He had spent the last year of his life dependent on a portable oxygen tank. After Zadroga died, on January 5, 2006, his father, Joe, requested an autopsy.

James Zadroga died several years after working at Ground Zero. Illustration by Alex Williamson

At the morgue, Breton surveyed the body. He noted two small bruises on the chin and a pair of faint scars on the abdomen—from stab wounds, he speculated—along with several tattoos. Cutting inward from the armpits to the pubic bone, he folded back the muscle and removed the rib cage with a saw. Six feet tall and weighing two hundred and sixteen pounds, Zadroga was solidly built, despite losing weight rapidly in the final months of his life. Even so, Breton recalls being struck by the size of Zadroga’s lungs, which had a reddish, meaty appearance, and were unusually firm to the touch. “Normally, the lungs feel soft and spongy,” he said. Lifting the lungs onto a scale, he also found that they were exceptionally heavy—almost three times the usual weight.

A dissection revealed the cause. Zadroga’s lungs contained a vast number of foreign-body granulomas: knots of scar tissue that build up around inorganic particles, like the pearling around sand grains in an oyster. The scarring was so extensive and severe that the right ventricle of Zadroga’s heart had thickened from the strain of trying to force blood through the ravaged vessels and capillaries. “It’s not unusual to find a few granulomas in a lung,” Breton noted later. “But usually this is something you see here and there.” The granulomas in Zadroga’s lungs were all over.

Breton couldn’t identify the gritty particles lodged in the tissue with his microscope, though he remembers thinking that some of them looked “dustlike.” He sent a sample to the Armed Forces Institute of Pathology, which identified the foreign material as a combination of talc, cellulose, calcium phosphate, and methacrylate plastic. Breton also spoke to Joe Zadroga, who said that his son’s health had begun to deteriorate in the weeks following the World Trade Center attacks. Shortly after joining the recovery effort at Ground Zero, Joe said, James had developed a persistent cough.

After talking with Joe, Breton had little doubt about the underlying source of Zadroga’s lung trouble. In his final report, he concluded that James Zadroga had died from respiratory failure due to severe panlobar granulomatous pneumonitis. He added that he felt “with a reasonable degree of medical certainty that the cause of death in this case was directly related to the 9/11 incident.”

News of the diagnosis spread quickly. The hazy air in which rescue teams worked was already suspected of contributing to everything from chronic coughs to cancer, and Zadroga’s death was widely seen as the harbinger of an epidemic. A few weeks later, the senators for New York and New Jersey—Charles Schumer, Hillary Clinton, Robert Menendez, and Frank Lautenberg—wrote to George Pataki, who was then the governor of New York, urging him to extend the list of 9/11 victims, and to compensate the families of first responders who became chronically ill after working at Ground Zero. The letter called attention to the predicament of Zadroga’s four-year-old daughter, Tyler Ann, now orphaned—Zadroga’s wife, Ronda, had died the previous year—and in the care of her father’s parents. “Detective Zadroga served with great courage in the line of duty and paid the ultimate sacrifice for his heroism,” the senators wrote, adding that his death “will not be the last to be suffered by the brave Americans who rushed to Ground Zero in the hours and days after September 11.”

The so-called Zadroga Act, which Pataki signed in August, 2006, provided generous benefits to the families of city workers who died of 9/11-related illnesses. Tyler Ann became one of the first recipients. But there were other complications to come. In order for Zadroga’s name to be added to the official victims’ list—and, ultimately, engraved on the National September 11 Memorial—his status as a casualty of 9/11 had to be verified. In the summer of 2007, copies of Zadroga’s autopsy report and medical history (and, later, slides of tissue taken from his lungs) were sent to the Chief Medical Examiner of New York City, Dr. Charles Hirsch. In October, he returned his verdict. Calling his assessment “markedly different” from Breton’s, Hirsch disputed the claim that the talc and the cellulose found in Zadroga’s lungs came from Ground Zero. Instead, he said, the embedded material was pharmaceutical debris produced by injecting a solution of crushed prescription pills.

The news provoked an uproar. The Daily News ran an editorial accusing Hirsch of “smearing” Zadroga’s reputation. The president of New York’s Detectives’ Endowment Association suggested that the city was trying to arm itself against pending class-action suits from Ground Zero workers. A congressional delegation demanded that an independent panel be established to investigate all deaths connected to dust exposure at the 9/11 sites. “The history of 9/11 should not be decided behind closed doors by one person,” Carolyn Maloney, a New York congresswoman, announced. Michael Moore took up the cause on his Web site.

At a conference a few days later, Joe Zadroga appeared with Michael Baden, a celebrity forensic pathologist who had used one of Zadroga’s lung-tissue slides for a segment on 9/11-related illness in his HBO series, “Autopsy: Postmortem with Dr. Baden.” Baden, a former Chief Medical Examiner of New York City who is now the forensic pathologist for the New York State Police, announced that he had reviewed the evidence and had no doubt that James Zadroga had died as a result of exposure to toxic dust at Ground Zero. There was no sign of any drug addiction, Baden said. “You could see glass fibres in there. You don’t get that from injecting drugs.”

In the months since the announcement, Baden has not changed his view. Discussing the case with me in his apartment, eighteen floors above the Museum of Modern Art, he acknowledged that granulomas can result from injecting ground-up medication—as happens when heroin users inject a solution of crushed methadone tablets—but disputed the idea that the wreckage in Zadroga’s lungs could have been caused by shooting up. “People who have chronic lung disease from drug abuse have long histories of drug abuse, rehabilitation, doctors going in and out,” he said. “You can’t hide that sort of drug abuse.” He had noted earlier that Breton had observed no needle scars on Zadroga’s arms. “If I saw needle-track scars, that would make me think right away: intravenous abuse.”

Baden would not speculate on what lay behind Hirsch’s finding, though he wondered whether the case had involved something political. Either way, he said, he found the assessment baffling. “I think that Dr. Hirsch seems to have been misled by the fact of finding talc and cellulose, which can be found in people who grind down drugs that are meant for oral consumption. But they can occur in other ways.” He said that he considered the assessment not only medically wrong but also “nasty”—a mean-spirited swipe at a guy “who was at Ground Zero, who really worked hard on the pile.”

The Office of the Chief Medical Examiner has the unrenovated pallor of a forgotten city agency. Dimmed by a concrete overbite, the street entrance manages to look at once ominous and shabby—a homely approach to an agency that houses one of the largest and busiest forensic labs in the country. Even by the standards of other big cities, New York has a prolific capacity to produce dead bodies, and, as Chief Medical Examiner, Charles Hirsch is responsible for the processing of some twenty-five thousand fatalities a year—nearly half the city’s annual total. Roughly fifty-five hundred of those cases require autopsy, including all deaths that are violent, sudden, mysterious, or in some way related to public or consumer safety—an infant asphyxiated by a car seat, say, or a runner who died from applying too much topical muscle cream.

Hirsch’s role is covertly powerful. Medical examiners are frequently required to testify in criminal cases, and in the past few years he has overseen the investigation of several high-profile fatalities, including the sudden death of Heath Ledger and the fatal child abuse of Nixzmary Brown. Being the final medical authority in such cases—particularly those involving police brutality or city negligence—can be politically fraught, and, in New York, administrative infighting and sheer population density combine to create a singular institutional challenge.

For someone occupying such a controversial position, Hirsch has managed to remain unusually invisible—in part because, unlike many medical examiners, he rarely speaks with the press. In the course of his nineteen-year tenure, he has never been interviewed on television, and has hardly ever been quoted in print. Jonathan Hayes, a senior medical examiner who has worked in the office since 1990, told me that one of Hirsch’s maxims is “Medical examiners get into trouble by saying too much, too soon, or to the wrong person.”

Privacy, however, can also create problems. By refusing to detail the evidence supporting his interpretation of Zadroga’s death, Hirsch appeared secretive, fostering suspicions about his motives and the validity of his verdict. Policemen in particular felt betrayed. Barbara Butcher, who coördinates crime-scene investigations between Hirsch’s agency and the Police Department, said, “There are cops I’ve known for years who wouldn’t talk to me about it.”

When I visited Hirsch recently, he had, as usual, been in his office since seven in the morning. (His departures are less consistent. He lives with his wife just a few blocks north of the office, and Hayes told me, “I’ve looked up from bodies and seen Dr. Hirsch standing there at three in the morning.”) Hirsch is seventy-one years old. Courteous and mannerly, he walks with a slight forward cant—the lingering effect of an operation to repair a herniated disk. Although his face is lean, the cheeks are rosy, with large ears and dark eyebrows framing a nose that is slightly off center. Before coming to New York, Hirsch went to school in Chicago and worked in Cleveland, and his habits still reflect Midwestern tastes: sober suits worn with narrow suspenders, and, for pleasure, a pipe of Captain Black tobacco. When making a point, he occasionally taps one finger lightly on the desktop. His speech is so soft that one has to strain to hear it.

At an afternoon meeting, conducted with ten of the agency’s thirty forensic pathologists, Hirsch received brisk updates on a dozen ongoing investigations, including the apparent suicide of an eighty-year-old man, and the autopsy of a woman who was found mummified in her apartment wearing nothing but a sweater. Hirsch listened to these recitations quietly, removing and folding his glasses with care. Dissatisfied with the evidence presented in the suicide, he asked about the meaning of a note found on the man’s kitchen table, which was addressed to relatives in Eastern Europe and ended, simply, “Farewell.”

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“Was the letter dated?” he asked. “Do you know how long it was sitting there?”

He also lingered on the mostly full bottles of prescription medication that were found in the room. “People who want to kill themselves tend to empty every bottle,” he noted. A discussion ensued. A medical examiner pointed out that the only empty bottle recovered from the scene contained Ambien, a sleep aid—but that the toxicology panel had found no traces of Ambien in the body. The bathroom cabinet contained an unfamiliar antibiotic, possibly bought in Eastern Europe, and not listed in any of the standard pharmaceutical resources. Hirsch listened politely until the conversation ended. Then he turned to address the medical examiner in charge of the case. “The note isn’t compelling, and the toxicology is borderline at best,” he said quietly. “If you’re going to conclude that this is an intentional self-destruction by medication, you’re going to have to prove it.”

Hirsch is known for his willingness to challenge seemingly obvious conclusions, a tendency that, in politically charged cases, has often made him unpopular. In 1989, a twenty-five-year-old black man named Richard Luke died in police custody after being physically restrained by the arresting officers. Although the medical examiner’s office confirmed extensive bruising, Hirsch ruled that Luke died not as a result of police brutality but from acute cocaine intoxication—a verdict that prompted street protests. Hirsch insists that he has been unaffected by the excoriation following his findings on the Zadroga case but noted that he had received requests from several senators urging him to change his assessment. “It’s the only instance in which political pressure has been exerted on me,” he remarked tartly.

Since the controversy, Hirsch has revealed little about the evidence in the case, but when we spoke he stressed the fact that the granulomas in Zadroga’s lungs were concentrated in the arteries and not in the alveoli. Drug users who inject crushed pills routinely develop granulomas, because insoluble fillers used to bind a pill’s active ingredient don’t get digested—as they would if a pill was swallowed—and, instead, circulate through the bloodstream, eventually lodging in the narrow pulmonary arteries. The condition is well known and is sometimes referred to as “mainliner’s lung.” When I spoke to Michael Baden, he argued that Zadroga’s lungs were in such bad shape that it was impossible to tell where the damage had originated. Hirsch disagreed. Crystals lodged in the pulmonary arteries can sometimes get pushed into the alveoli, he observed, because of the constant pressure of surging blood, but the same force does not exist in reverse. Therefore, the matter in Zadroga’s pulmonary arteries must have entered his lungs through the bloodstream, not through inhalation.

The type of material found in Zadroga’s lungs was also significant. Talc and cellulose are widely used pharmaceutical ingredients, Hirsch noted, but neither was considered a major respiratory hazard at Ground Zero: talc because it wasn’t found in the air in abundance; cellulose because it is not considered particularly hazardous. (The molecules are too large to pass through the elaborate filtering apparatus of the upper airway.) The absence of needle marks Hirsch deemed insignificant, because clean needles cause less scarring.

Talking about the case later, Jonathan Hayes remarked that one of the dangers of forensic pathology, particularly in dramatic cases, is that people see what they expect to see. “I think there’s a possibility that that’s what happened here,” he said. “This guy’s been down in the World Trade Center, spent hours after hours on the pile. You look at his lungs: oh, they’re full of scar tissue and inflammation!” He went on, “As Dr. Hirsch would say, ‘Sometimes it’s necessary to slay a beautiful theory with an ugly fact.’ ”

Interestingly, Hirsch was himself exposed to the miasma of debris created during the 9/11 attacks. Early that morning, he rounded up a small crew of examiners and drove to the base of the burning towers to scout sites for a temporary morgue. With an investigator named Diane Crisci, he walked south along the West Side Highway and had just reached the pedestrian walkway connecting the World Trade Center to the Winter Garden when the south tower collapsed.

The blast threw Hirsch underneath the walkway, where he was battered by flying rubble but sheltered from the worst of the falling debris. When he opened his eyes, Hirsch recalled, the air was so black that he couldn’t tell whether he was on the surface or buried. He spat out the dust and located Crisci. Together, the pair hobbled away from the devastation—Hirsch with a sprained ankle and a gashed wrist, Crisci disabled by a broken leg. Hirsch arranged medical care for Crisci, then hitched a ride back to the office, his arm still bloody and his clothes covered in dust.

When I asked Hirsch whether he had experienced any symptoms from this exposure, he was emphatic that he had not. When I persisted—did he, at least, worry about the long-term effects?—he grew terse. “There’s no point in worrying about things that you can’t control,” he said.

For professional reasons, Hirsch said, he continues to follow the epidemiological research, particularly a recent study that showed a statistical increase in sarcoidosis—an inflammatory disorder that attacks the lungs and other organs—among firefighters who worked at Ground Zero when the smoke was thickest. Last May, the weight of this study persuaded him to revise his opinion of five years earlier on the death of Felicia Dunn-Jones, a forty-two-year-old lawyer who died five months after being trapped in the initial explosive plume. In his review, Hirsch noted that, while the sarcoidosis that killed Dunn-Jones may have been present before 9/11, the illness had almost certainly been exacerbated by the particulate-laden air she inhaled on the morning the towers fell. The ruling made Dunn-Jones the first dust casualty to be entered on the official list of 9/11 victims. It also prompted a number of other families to resubmit cases that had been closed.

Each of these claims will be examined, Hirsch told me, and as more information becomes available some deaths may eventually be reclassified. But the results may be slow in coming. Hirsch said that he’d had letters from survivors who had developed cancers of one form or another, and that he could only reply that the scientific evidence isn’t there yet. “It’s going to take a lot of epidemiologic investigation,” he said.

This attitude of scientific caution is not always welcomed by those who have lost a loved one to degenerative illness. “I would never misrepresent the reality that there are people who are terribly unhappy with us,” Hirsch acknowledged. “I sometimes have to tell the family, ‘You know what’s in your heart. I have to go with the evidence.’ ” As difficult as such conversations are, he believes that truth ultimately allows the living to come to terms with the dead. In a lecture that he gave in 1997, Hirsch discussed the medical examiner’s “sacred responsibility” to talk to the bereaved. “None of us lives comfortably with uncertainty,” he observed. “Once they know and understand the facts, even if unpleasant, most people have the ability to make their peace with reality.”

One Sunday in early March, I drove down to Little Egg Harbor, two hours south of New York City, to see Joe and Linda Zadroga. It was a cold day, with a brisk wind that whipped sand up from the roadsides and drove it against the sides of saltbox houses and trailered boats. Anchoring the tip of a small cul-de-sac, the Zadroga house, with an observatory window and wide, steeply raked front steps, is so much larger than its neighbors that at first I mistook it for a church. In the driveway, a pair of vintage cars sat covered next to a silver Ford pickup whose rear window had been transformed into a memorial: the World Trade Center towers framed by an American flag, and the legend “James Zadroga, Detective NYPD. Gone but not Forgotten. Fidelis ad Mortem.”

Joe greeted me at the door. A former cop, like his son—he was the chief of police in North Arlington—he is stocky, with a bullish neck and shoulders and expressive hooded eyes. His wife, Linda, a petite woman with a deep tan, seemed tiny next to him. She wore a bright-pink sweatsuit and a silver heart-shaped pendant with a photograph of her son, inscribed “Jimmy.” Sitting in the breakfast room, which overlooks a stretch of silvery shoreline, Joe talked about nearby Atlantic City (“She goes sometimes. I don’t”), and bowed his head when Linda groused about his attachment to old T-shirts (“He holds on to everything”). Tyler Ann wandered in—a wary six-year-old in pink camouflage pajamas—and fussed with Joe’s chair before wandering out again. When the conversation turned to James, Linda excused herself. “She don’t like to talk about it,” Joe said with a shrug.

Joe was just back from Washington, D.C., where he had attended a rally in support of the James Zadroga 9/11 Health and Compensation Act, introduced by Representative Maloney. Since his son’s death, Joe has become a regular presence at such events; last year he attended about one a month. The attention that followed Breton’s autopsy has added a disorienting public overlay to an otherwise private sorrow, and Joe seemed distinctly conscious of the symbolic pressure. But he was less concerned with arguing the merits of 9/11-related compensation claims than with affectionately recalling his son’s good-old-boy ways. He cheerfully described James as “a partyer,” who, during his days as a beat cop, would cadge meals from the Fire Department—“He always knew which firehouses had the best cooks”—and who, assigned to work on street crime, had an intuitive ability to sense who in a crowd was concealing a gun. There was a good-natured quality to this banter: a cop’s-cop fondness, couched in jokey bravado. “That’s his tough guy,” Joe said, sifting through photographs of James that included one of him posing solemnly with a foot-long striper. He lingered over a later shot, taken at the ceremony when James made detective. In the picture, James stands with one arm around his wife, a pretty brunette with a shy smile. Dark-haired and baby-faced, he is powerfully built—a younger version of his father. He regards the camera with a lightly mocking pride.