The sight of FBI agents in moon suits swarming over an anthrax-contaminated building barely a month after the September 2001 terrorist attacks struck fear into the heart of nearly every Floridian.
The contamination at the American Media building in Boca Raton killed a picture editor, infected two other workers, and brought home to the public that bioterrorism was a significant threat to homeland security.
Yet the swift response by authorities showed that Florida, which had been focusing on public-health issues for more than two decades, was doing something right - and it sharpened resolve to continue preparing for potential crises.
Now Florida - a state all too familiar with emergency after four hurricanes battered it last year - may be emerging as a model for bioterror preparedness. But even its boosters caution that much still needs to be done to address areas of vulnerability.
"I'm pleased this recognizes the work we've done, but it isn't something that allows us to sit back because we are still nowhere near where we want to be," says John Agwunobi, Florida's health secretary.
Both Florida and North Carolina passed the grade in nine of the 10 categories that the Trust for America's Health (TFAH), an independent research group in Washington, used to assess each state's public-health readiness. In 2003, Florida scored seven out of 10. The state has scored highly, Mr. Agwunobi says, largely because of the strong public-health infrastructure it has developed, which maximizes resources.
Among such achievements is the state's coveted "green" status relating to the Strategic National Stockpile of the Centers for Disease Control and Prevention. It means that Florida, the first of only five states to achieve such a grade, is deemed adequately prepared to distribute vaccines and antidotes in the event of a mass disease outbreak.
Last February, health personnel from each of the 67 counties took part in a large-scale exercise that simulated air passengers with bubonic plague arriving at various places in the state. The distribution test was passed.
Officials also point to the state's five-year public-health plan, which calls for additional resources to counter bioterror threats. For example, in the event of a biological, chemical, or radiological attack leading to mass casualties, Florida's hospitals will be able to manage emergency treatment for 500 people per 1 million of population, and they will be able to admit 50 patients per 1 million. Florida has almost 17 million residents.
In addition, each region will be able to isolate 10 patients showing symptoms of diseases like smallpox.
"Many states, if not most, don't have our kind of infrastructure," Agwunobi says. "We have been working on this for 20 to 30 years, and over time our legislators have come to realize it is a jewel in the crown."
Agwunobi says that maintaining a strong response capability in Florida's Public Health Department laboratories has also been a priority, and the state has upgraded much of its equipment. Only one-third of states were judged to have enough scientists to be able cope with a bioterror attack. Florida expects to be able to call on help outside the public-health structure. "We are working on a plan that will allow our labs to call on community partners," says Lindsay Hodges, spokeswoman for the state's Department of Health.
One key concern of health officials has been a possible flu pandemic, especially with a nationwide shortage of vaccine earlier this winter. A worst-case model suggests as many as 16,667 deaths and 66,447 people hospitalized in the state, according to the TFAH. Yet again, Florida is well placed, Agwunobi says.
"We have a strong and robust pandemic plan, which we couldn't afford to build on the premise that there would be adequate vaccines," he says. "We have been able to fine-tune our plans with many training sessions."
Other steps forward include the setup of an Internet-based instant-warning system that allows doctors and health workers to report suspicious disease symptoms to their colleagues statewide at the push of a button. Florida already has some of the strictest reporting requirements in the country, requiring immediate notification of any disease of "public-health significance" to Agwunobi's department.
Overall, Florida's spending on public health has increased from $1.73 billion in the 1999-2000 fiscal year to $2.17 billion in 2004-05.
"Florida has recognized the importance of an integrated public-health system," says TFAH spokesman Michael Earls, co-author of the report. But he notes that other states have a crucial role to play too: "Neighboring states such as Georgia and Alabama did not score so highly, and it's important to realize that different health threats don't stop at a state's borders."