U.S. officials say the nation's health system is ill-prepared to cope with a catastrophic release of radiation, despite years of focus on the possibility of a terrorist "dirty bomb" or an improvised nuclear device attack.

A blunt assessment circulating among American officials says "Current capabilities can only handle a few radiation injuries at any one time." That assessment, prepared by the Department of Homeland Security in 2010 and stamped "for official use only," says "there is no strategy for notifying the public in real time of recommendations on shelter or evacuation priorities."

The Homeland Security report, plus several other reports and interviews with almost two dozen experts inside and outside the government, reveal other gaps that may increase the risks posed by a nuclear accident or terrorist attack.

One example: The U.S. Strategic National Stockpile stopped purchasing the best-known agent to counter radioactive iodine-induced thyroid cancer in young people, potassium iodide, about two years ago and designated the limited remaining quantities "excess," according to information provided by the U.S. Centers for Disease Control and Prevention to ProPublica. Despite this, the CDC website still lists potassium iodide as one of only four drugs in the stockpile specifically for use in radiation emergencies.

The drug is most effective when administered before or within hours of exposure. The decision to stop stockpiling it was made, in part, because distribution could take too long in a fast-moving emergency, one official involved in the discussions said. The interagency group that governs the stockpile decided that "other preparedness measures were more suitable to mitigate potential exposures to radioactive iodine that would result from a release at a nuclear reactor," a CDC spokesperson said in an email to ProPublica.

Japan's ongoing nuclear crisis may prompt officials to revisit that conclusion. With radiation levels higher than expected outside the evacuation zones in some areas, the Japanese government recently asked the United States for potassium iodide. The federal government agreed to send some of its dwindling stockpile of the liquid version used in children or adults, which is due to reach its expiration date within about a year. The government is currently "finalizing the paperwork," according to an official with the U.S. Department of Health and Human Services.

Another example: While hospitals near nuclear power plants often drill for radiological emergencies, few hospitals outside of that area practice such drills. Most medical personnel are untrained and unfamiliar with the level of risk posed by radiation, whether it is released from a nuclear power plant, a "dirty" bomb laced with radioactive material, or the explosion of an improvised nuclear weapon. A dirty bomb would cause major damage at the scene but spread little radiation. The explosion of a nuclear weapon would devastate the surrounding area and create radioactive fallout.

Many states don't have a basic radiation emergency plan for communicating with the public or responding to the health risks. Even something as fundamental as the importance of sheltering inside sturdy buildings to avoid exposure to radioactive fallout from a nuclear explosion -- which experts say could determine whether huge numbers of people live or die -- hasn't been communicated to the public.

Recently the White House and other federal officials concerned about deficiencies in public readiness met with experts to explore what might be done to make nuclear events more survivable. "The bottom line is that the citizenry are not prepared at all," said Michael McDonald, president of Global Health Initiatives, who participated in White House and congressional briefings.

The Department of Homeland Security report acknowledges that officials are poorly prepared to communicate with the public and that the current organization of medical care "does not support the anticipated magnitude of the requirements" following an attack with an improvised nuclear device. It says the United States has "limited" treatment options for radiation exposure and notes that staff and materials aren't in place to carry out mass evacuations after a large-scale release of radiation. "The requirements to monitor, track, and decontaminate large numbers of people have not been identified," the report said. The Department of Homeland Security has convened groups to work on filling the gaps.

Underlying the preparedness problems is the need for additional research. It isn't known, for example, how a nuclear blast and electromagnetic pulse would affect modern communications infrastructure, or to what extent modern buildings can protect people from nuclear blast, heat and radiation effects.

A report prepared last year by the Council on State and Territorial Epidemiologists was equally pessimistic about U.S. readiness. Based on surveys of public health officials in 38 states, it concluded that "In almost every measure of public health capacity and capability, the public health system remains poorly prepared to adequately respond to a major radiation emergency incident." Forty-five percent of the states surveyed had no radiation plan at all for areas outside federally mandated nuclear power plant emergency zones. Almost 85 percent of the officials said their states couldn't properly respond to a radiation incident because of inadequate planning, resources, staffing and partnerships.

More troubling was the fact that the situation hasn't improved since a similar survey was taken in 2003. "Most of those comparisons appear to indicate either the same poor level of preparedness and planning or a decline in capacity," the report said.

The nation's investment in emergency preparedness seems likely to decrease rather than increase, experts say, because of massive federal and state deficits.

President Obama's proposed budget would cut funding for a federal hospital preparedness program by about 10 percent. The release of proposed federal regulations that would require hospitals to meet emergency management standards has been delayed.

"If the public isn't demanding that we be better prepared, the politicians won't put the money in for us to be better prepared and the regulators" won't require it, said Dr. Arthur Cooper, a professor of surgery at Columbia University and director of trauma and pediatric surgical services at Harlem Hospital Center. "It all begins with the public knowing this is a problem that's got to be solved and it's worth spending some money and effort to try to be prepared in a real way."

Hospital Preparedness

In the days after nuclear fuel at Japan's Fukushima power plant began to overheat, the greatest threat to one hospital within 50 miles of the plant wasn't radiation, but fear. Many staff members had fled, and government emergency workers hadn't delivered food and medicine needed for the 120 patients. Dr. Masaru Nakayama, director of Kashima Hospital in Iwaki, Japan, said it took time to convince people that the area around the hospital was in fact safe.

Yet in national surveys, U.S. hospital workers have expressed fears similar to those of Dr. Nakayama's staff, saying they would be less willing to report to work for a radiological or nuclear incident than for other types of emergencies. They also said they feel unprepared for the work they would be required to do, even though the risk of radiation exposure from treating contaminated patients outside the danger zone is considered negligible when workers are properly trained and wear protective equipment.

"The level of education for disasters across the board in American hospitals is really pretty terrible," said Dr. Cooper. "People don't have a good sense of how to focus on any disaster, let alone a radiation disaster. Radiation adds a level of complexity that most folks aren't prepared to face."

Cooper said hospital drills have improved in recent years, "but they occur far too seldom and they end far too quickly and they're far too superficial to really prepare a hospital for a major disaster."

"Shutting down part of the hospital's work for a period of time to conduct a full-scale exercise, that's daunting for a hospital," he said. "Trying to ‘do the right thing' and provide employees with in-depth disaster education across the board is not something they're going to do unless it becomes a major regulatory mandate."

Dr. William Fales, an associate professor of emergency medicine at Michigan State University and a regional medical director in southwest Michigan, said he has yet to see a hospital outside of a nuclear reactor's emergency planning zone conduct a drill for a nuclear or radiological emergency.

In the courses Fales teaches for medical professionals, he has seen firsthand what little baseline knowledge many of them have. In one exercise they are treating mock bombing victims when they are suddenly told that the explosive was a dirty bomb packed with radioactive material. Typically they drop everything, run the patients outside and remove their contaminated clothing. But that reflects a lack of knowledge of a basic principle—that medical workers should treat a patient's life-threatening traumatic injuries from a bomb blast before worrying about radiological decontamination.

"It's amazing," Fales said. "It's a kneejerk reaction because they hear the word ‘radiation.' … Imagine what would happen if, God forbid, we had a real terrorist bombing and a rumor started on TV that it was a dirty bomb. How many potentially salvageable trauma patients would be compromised by that reaction?"

Health workers made a different mistake at a recent radiation emergency conference sponsored by the CDC. When a workshop leader in a white decontamination suit asked nurses to practice cutting the garments off a mock contamination patient, one volunteer slid the scissors quickly from ankle to torso. That could send radioactive debris flying, the leader warned. The more careful approach took about two minutes—a long time if hundreds are awaiting assistance.

Knowing when a patient has been contaminated versus exposed to radiation is an important distinction that is acquired with simple training. "If you put a chicken in a microwave and cook it, it comes out a rubbery chicken, but it doesn't come out contaminated," Fales said. "It's been irradiated, but it's not radioactive."

Fales said few participants in his training courses think about doing a quick survey with a radiation detector to verify the existence of contamination. At many hospitals, most workers don't even know where the Geiger-Müller counter is kept.

Facing a Worst Case Emergency

The American Medical Association devoted the March issue of its journal, Disaster Medicine and Public Health Preparedness, to the No. 1 scenario on the federal government's list of 15 planning scenarios for emergency preparedness—a nuclear explosion equivalent to the force of a 10-kiloton trinitrotoluene (TNT) blast on a major population center.

Using Washington, D.C. as an example, one study estimated that 180,000 hospital beds could be needed after such a detonation and that 61,000 of those patients could require intensive care. But Washington typically has only about 1,000 vacant beds—and there are only about 9,400 vacant intensive care unit beds in the entire United States.

After a nuclear blast, hospitals would likely fill with trauma patients. Later, others would arrive with acute radiation syndrome, which can take days to manifest and affects multiple organ systems. Without supportive care, about 50 percent of people exposed to 3.5 Gray, a measure of radiation dose, would die. Proper care would almost double the exposure level at which 50 percent would survive, but only a small fraction of American medical professionals have training and expertise in treating radiation injury.

Given that not enough beds would be available, hospitals and first responders would have to choose which patients to save. Authors of the journal articles recommend basing those decisions in part on how much radiation exposure patients have received and treating only those with a reasonable chance of surviving. "It's very hard to turn someone away who needs medical care who comes to your hospital," Cooper said. "I don't think any American hospital is prepared to do this kind of triage."

The staff would be hampered by a shortage of the laboratory equipment needed to help evaluate so many patients, a lack of approved devices to rapidly quantify the level of radiation exposure, and a lack of approved medicines to counter the cellular effects of radiation. About $200 million in federal funding has been invested since 2008 to develop diagnostics and treatments, but HHS officials say most are still years away from approval.

Even getting the protective measures that do exist, including potassium iodide, where they are needed is a challenge. Michigan has developed a round-the-clock dispatch system with ready-to-go medical packs designed for a range of emergencies and stored at 16 sites around the state. Four of those sites stock radiological countermeasures.

"We think we're one of the few states that's really designed a statewide system that can deliver these countermeasures," Fales said. In the case of one particularly expensive drug provided by the federal government, "my sense is in a lot of states it's sitting in a warehouse in the state capital, hopefully secure and warm. On a Saturday night if something goes boom in a location on another side of the state, how long will it take to get it to where it's needed?"

Improving Future Response

One of the top priorities in preparing for a major nuclear disaster is readying ordinary citizens for the role they will have to play. "The common misperception is any nuclear blast means everybody's vaporized," McDonald said. "That's just wrong."

But experts say the government has done little to educate the public about its responsibilities.

When police and fire departments have run nuclear exercises in conjunction with federal authorities, "they haven't included the public," McDonald said. "They've basically treated it like a classified event."

The motivation may be to safeguard the public from fear and panic, McDonald said, but "it does almost no good for the federal government to be talking about this with the top officers and not have the public understand what to do." Although government websites including ready.gov and cdc.gov contain useful preparedness information, there is no single website the public can turn to for up-to-the-minute public health information in disasters.

One of the crucial things the public must know is when to evacuate and when to shelter underground or in a heavily constructed building. Yet making decisions on sheltering and evacuation and communicating those decisions to the public is precisely what the Homeland Security report found government agencies aren't inadequately prepared to do.

Sheltering in place could make a major difference in how many people live or die, because the danger of fallout decreases rapidly as radioactive elements decay and debris is dispersed. The dose rate drops 90 percent every seven hours.

"You can't wait until the event to put out this information," said Dr. James James, director of the American Medical Association's Center for Public Health Preparedness and Disaster Response.

Many experts predict that without more education, people would likely flee as many are doing in Tokyo and as many Americans did after the Three Mile Island nuclear accident in 1979. An estimated 144,000 people—many times more than the number advised to do so—needlessly left the area due to fear and inadequate information.

"Such an exodus would extend panic and devastation far beyond the locus of the event, draining food, water, medicines, gasoline, and other resources from surrounding communities and potentially causing gridlock that would severely compromise many elements of the official disaster response," according to a modeling study published by University of Chicago researcher Michael Meit and colleagues in the same issue of the journal.

Not knowing what to do would be especially harmful to those who are least likely to be able get out of harm's way: children and the elderly, people with disabilities, and patients with chronic illnesses requiring regular treatment. The federal government enacted a number of reforms after elderly and disabled people died after Hurricane Katrina. But those reforms aren't necessarily reflected in critical front-line emergency plans. A federal court in California recently found the city of Los Angeles violated the Americans with Disabilities Act and other laws for failing to consider the needs of the disabled in its emergency response plans.

Dr. Eric Toner, a senior associate at the University of Pittsburgh Medical Center's Center for Biosecurity in Baltimore, said the key to protecting as many people as possible during an emergency is offering them frank communication about what is known and unknown.

"Nature abhors a vacuum. If credible officials aren't out there constantly, that void will get filled with people who don't know what they're talking about or have different agendas."

Still, there is no guarantee the public will act on information once they get it. Several years ago Michigan, like many other states, sent vouchers for potassium iodide to people living within a 10-mile radius of a nuclear power plant. The goal was to give them the medication free of charge from local pharmacies, so they wouldn't risk their lives searching for the drug in an emergency, when they should be sheltering in place or evacuating.

But only about 6 percent of the residents picked up their allotted supply, said Fales, the Michigan regional medical director, a rate that's similar to some other states. "So much for pre-event planning," he concluded.

ProPublica's Sasha Chavkin contributed to this report.

Clarification: We have added that the Department of Homeland Security has convened groups to work on the gaps identified in its preparedness report.