New ventilation units blast curtains of purified air between patients and nurses in Washington Hospital Center's emergency room. Outside, yellow tarpaulins and water taps can decontaminate people on the sidewalk.
Nearby, a 2,400-square-foot "ready room" has 110 portable beds and cots, three "decon" showers and 1,000 prepackaged "undress/redress" kits for victims, complete with rubber sandals.
The new equipment at Washington's busiest emergency room, trauma and burn center was made possible with $10 million in federal funds -- a fraction of what has poured into localities and first responders after the Sept. 11, 2001, terror attacks.
Since the attacks, the United States has allocated more than $250 million to improve emergency preparedness at public health agencies, hospitals and laboratories in Virginia, Maryland and the District. About one-third has gone to the capital region, including more than $60 million into the District and $20 million to the immediate suburbs.
But three years into a multibillion-dollar national buildup, a review of where the local money has been spent and interviews with two dozen local and national experts reveal gains in technology and personnel but little reassurance that a biological outbreak of the kind officials fear would be contained around the nation's capital.
Emergency rooms remain overloaded, public health offices are understaffed and Washington area doctors, health directors, lab technicians and hospital officials say despite all the activity, there is no coherent plan.
"What we really haven't connected is a system," said Susan Allan, health director of Arlington County and a member of the bioterrorism committee of the National Association of County and City Health Officials. "We're putting together a lot of individual pieces, some of which may be strong . . . and some may be very weak. But if you've got a chain, and one link is fragile, you might as well just not have bothered."
As funding has increased, its impact has been blunted and diluted by changing federal priorities, lack of consensus on goals, overlapping bureaucracies in the region and the sheer difficulty of hiring hundreds of medical specialists in such a short period, officials said.
As Daniel Ein, head of the Medical Society of the District of Columbia's emergency preparedness committee, put it: "What do we need? How do we best achieve it? How do we coordinate it? If you find out, would you let me know?"
William Pierce, a spokesman for the federal Department of Health and Human Services, declined to comment for this article.
To be sure, the money has brought successes. Virginia has spent the lion's share of its federal public health aid, about 60 percent of $68 million, on staff -- rebuilding an almost nonexistent public health corps, according to a breakdown of funds received since 2001 from the Centers for Disease Control and Prevention.
"The whole idea of emergency planning in public health didn't really exist before 9/11," said Lisa G. Kaplowitz, Virginia's deputy commissioner of health. The grants have paid for 100 field workers, including about 20 epidemiologists, planners, trainers, medical consultants and nurses in Northern Virginia.
Maryland also channeled two-thirds of its CDC grants -- $12.4 million -- to counties in 2003, the only year for which it could provide a breakdown, said Dianne L. Matuszak, director of Maryland's Community Health Administration. Much of the remainder has gone to hardware: information networks, laboratory equipment and pagers, laptops, wireless networks, e-mail and backup communication systems.
State health labs also have made big gains. Virginia's $40 million facility is a national showcase. Maryland has tripled its secure lab capacity and quadrupled the number of its technicians to 27. Even the District Department of Health, which almost shut its facility five years ago, will seek this year to meet federal standards for handling such substances as ricin, smallpox and plague.
Overall, state officials say, emergency response has improved. It now takes hours instead of days to mobilize for such crises as a tuberculosis scare in Chesapeake, Va., in June that affected 2,500 people; a food-poisoning outbreak that sickened 100 high school students in a program at the University of Maryland at College Park in August; and a false anthrax alarm in Anacostia that shut down 11 postal facilities serving 250,000 customers in November of last year.
"We could tell you how many computers we have bought, but that's not saying we have a system. The College Park response is an example of how we have a system," said Julie Casani, director of the Maryland's Office of Public Health Preparedness. "Are we there at the point where I can put my feet up and sigh? No, but we're pretty darn close."
Casani's view, however, is rare among area officials.
Since 2001, Arlington's Allan said her office has been dispatched on one new federal initiative after another -- to administer smallpox vaccinations to thousands of first-responders; prepare for an influenza pandemic; prepare for a SARS-like respiratory outbreak; complete a state and two separate regional plans to distribute drugs from the federal Strategic National Stockpile; design response plans for new federal early-warning sensors; and build capacity for mass casualties.
Several initiatives were unsuccessful or duplicative, officials say, feeding mission fatigue. For instance, Arlington diverted 24 health workers for six months to educate and inoculate thousands for smallpox in 2002, but in the end only 43 people signed up.
About 25 people were inoculated in Alexandria. "It was a tremendous effort, and no one ever satisfactorily explained, at least to me, that there was enough of a threat assessment to justify why we did it," said Alexandria Health Director Charles Konigsberg.
Hospital officials said economic and practical concerns are slowing an HHS goal to set aside 500 hospital beds per million residents for emergency surge capacity.
Hospitals can free up to 20 percent of their beds in short order, perhaps 1,600 in the region, and are spending $3 million to buy 450 more. But that does not meet the HHS mandate.
Medical historians say that no population-based health emergency in the past century produced more than 150 treatable casualties in a U.S. hospital. Still, Virginia hosted a major exercise this summer that hypothesized 40,000 casualties from a plague release at a NASCAR auto race in Richmond.
"At some point we've got to be practical about it," Konigsberg said. "You really can't plan for 40,000-casualty catastrophes with existing resources."
Meanwhile, the Bush administration cut 20 percent of its aid to state health agencies this year and used it to speed up medicine distribution plans for 21 large cities.
"At a time when states are being asked to expand their role in disease surveillance and emergency preparedness, such a cut will jeopardize our ability to protect the public," Virginia Health Commissioner Robert B. Stroube testified to Congress.
Administration officials say that states were slow to spend the money and even cut their own spending as grants rolled in. Maryland's health department, for instance, has cut 685 full-time and contractual workers since 2001.
Second-guessing about priorities exists. Scott J. Becker, executive director of the Association of Public Health Laboratories, cited the rollout "under cover of darkness" of the BioWatch airborne detection system two years ago.
Homeland security, environmental and health agency officials said the 30-city system can provide early warning of a biological attack. Public health officials do not question the potential value of such systems, but they say a false alarm in Houston last year showed that the government failed to determine how agencies should respond before unveiling it on a day's notice.
"If you don't have a fire department to respond and see if it's a real fire or not, what's the point of the smoke detector?" Allan asked.
Health officials say more should be done to recruit health workers. Struggling to compete with private practices and biotech firms, the District, Maryland and Virginia each reports that one in six, or 40 of 241, new federally funded jobs are unfilled. "We've never been able to spend all our money. We're always trying to recruit researchers and dealing with a lot of turnover," Maryland Laboratories Administration Director John M. DeBoy said.
Local officials acknowledge shortcomings. The District's troubled health department is on its fourth acting or permanent director in 24 months. The District committed only 59 percent of $30.1 million in CDC grants since 2001 and spent just 42 percent, $11.7 million, as of Sept. 30.
"It's been very distressing to us to see the revolving door at DOH," Ein said.
Turnover and leadership also are challenges. "Just to keep track of 23 local jurisdictions, as well as federal agencies and the military . . . is overwhelming, almost," said Jeffrey A. Elting, medical director for bioterrorism response coordination for the D.C. Hospital Association. With two years on the job, he said, "I'm beginning to think I'm the old man in this arena."
For now, officials say they will do as much as they can. They just aren't sure whether it's enough.
"When something does happen, people will come screaming like crazy, asking, 'Why weren't more things done?' " Elting said. "With the funds we were given, we did everything we could."