Imagine the reaction if the state of Pennsylvania had held back using $2.8 million it received to help prevent AIDS, immunize elderly people against the flu or discourage children from smoking.

That's what the state Health Department has done thus far with its funds to address compulsive gambling, spending barely 12 percent of the amount it has been given from two years of casino revenues.

The 2004 slots legislation dictated that a minimum of $1.5 million annually be funneled into treatment, prevention and awareness programs. It was at least modest recognition that the gambling expansion could harm the 1 percent of adults who are considered pathological, while also jeopardize at least twice that number at risk with less severe gambling problems.

Of the $1.5 million allocated to the health department in 2007-08 and $1.7 million more in 2008-09, the department's Bureau of Drugs and Alcohol Programs reports it spent $388,000.

The biggest portion of that was for specialized training of therapists and to launch a system in October for addicted gamblers to get state-paid counseling.

But no money has been spent to advertise the program. Fewer than 50 gamblers have used it, though nearly 800 are on the state's self-exclusion list as admitted addicts and statistics suggest 90,000 Pennsylvania adults are pathological gamblers.

Relatively few compulsive gamblers want to enter treatment, but those seeking it in Pennsylvania could find themselves as lost as a casino first-timer dazed by the lights and sounds of the slots.

"The vast majority of people in Pennsylvania don't know anything about problem gambling," observed Joanna Franklin, education coordinator for the private, nonprofit Council on Compulsive Gambling of Pennsylvania. "Where are the public service announcements? The bought TV time? The ads in newspapers? There is nothing."

Instead, state officials say the unspent funds will roll over and supplement another $2.4 million allocated for the current fiscal year, based on growth in slots revenue anticipated through new facilities like the North Shore's Rivers casino.

How and how soon that growing pile of anti-addiction cash will be used is uncertain. Officials from the Bureau of Drug and Alcohol Programs expect treatment needs to grow and intend to launch advertising and awareness initiatives, but nothing is formalized yet.

The lack of spending and programming has drawn nary a peep publicly, even from legislators who raised the most fears about excess gambling as a result of legalizing slots. Rep. Paul Clymer, R-Bucks, an outspoken gambling critic, was unaware so little had been spent.

"This just shows irresponsibility," he said. "You know the people [needing help] are already there. ... You mean to tell me it's taken us five years to get where we are? It's like a slow boat that just doesn't seem to have any motor to it -- it's all just paddles."

Health department officials offer the following explanations for the tentative approach to their mandate thus far:

• They viewed therapeutic treatment of problem gamblers as the No. 1 goal for the allocated funds and didn't want other use of the money to preclude that.

• They needed time to create a system in which clinicians statewide had specialized training in gambling addiction.

• They didn't want to spend money advertising help for the gambling problem until they could serve those seeking assistance.

• There has been little to indicate that the opening of nine casinos in the past 34 months has exacerbated compulsive gambling problems.

Since October, the state has covered counseling for 47 gamblers and nine family members of addicts.

Gamblers are considered among the toughest to get into treatment, because the disorder is so hard for others to detect. It often takes a financial crisis for the addicts to admit their problem, and it can take years of excess gambling that amasses debt before that occurs.

"Within the first two to three years of a program, lots of times utilization is low," based on other states' experience combatting gambling ills, said Robin Rothermel, director of state drug and alcohol programs.

At the same time, the state is nowhere near enrolling the hundreds of providers of treatment it would like -- Ms. Rothermel hopes for at least one in all 67 counties -- in the event people learn they exist and want to get to them.

The state reimburses therapists $65 an hour for up to 20 sessions for patients meeting financial criteria, a status not hard to achieve for someone who has lost all his money gambling. Barely 40 providers have signed on, a small fraction of the number who have been through gambling training or who participate in the state's drug and alcohol programs.

Providers are certified for state reimbursement in just 17 counties, with Allegheny and Washington counties having the most. But Erie County, which also has a casino, no longer has a single counselor participating after an addiction clinic there shut down in June.

"One of the things we've heard from providers is, 'We don't have that problem here,' " Ms. Rothermel said. "I think some of the providers are waiting to see if individuals present [gambling problems] in that area. It's a little bit of a Catch-22."

Others question if the Catch-22 is in a different form for which the Bureau of Drugs and Alcohol bears responsibility.

With no public advertising, there's no direct way people know help with gambling problems can be obtained. The Pennsylvania Gambling Control Board requires casinos to widely post 1-800 numbers that can be called for problem gambling information, but those brief ads omit any mention of certified gambling counselors offering state-paid treatment.

Information is posted on the Health Department's Web site, but not prominently: The link to "gambling addiction information" is one of 22 items running down the left side of the screen.

"It's just not that easy to find help," said Brent Olean, a licensed social worker in Cranberry certified to treat gamblers. "Why don't they put up billboards about it? They could put daily or weekly ads in newspapers within range of a casino saying gambling is OK for some, but there are those who need help, and here's what to do."

Ms. Franklin, a national consultant considered a leading trainer of gambling treatment clinicians, said of the health department's overall approach: "There have been incredible delays. It makes no sense to me."

Ms. Rothermel said discussions of advertising are in the works.

Her bureau has also begun awarding community education grants, five thus far totaling $17,344, to agencies and individuals for public presentations about gambling problems. That's out of 24 grant requests received.

In addition, the drug and alcohol bureau also is preparing to award a contract to the private compulsive gambling council to enter schools in the Philadelphia, Pittsburgh and Allentown areas to educate youngsters about gambling risks. That would be the first prevention-oriented program attempted by the state.

There is no one correct way for a state to establish a problem gambling program, say those who run them elsewhere. Programs with more experience tend to spend more and attract more people.

A chart from the Association of Problem Gambling Service Administrators for 2007-08, when Pennsylvania funding was at the $1.5 million level, showed the allocation was 14th highest among 31 states spending money on the issue. But it was only 20th of 31 on a per capita basis, and it failed to take into account the lack of actual spending.

"A lot of states focus on bringing up treatment services to meet people with the most immediate need, and then after the infrastructure is built, do more of the prevention and education things," said Tim Christensen, head of Arizona's Office of Problem Gambling.

But it is also essential, he and other officials say, to develop a multi-faceted approach

If the sole focus is on treatment, said Mark Vander Linden, coordinator of the $4.3 million Iowa Gambling Treatment Program, "I think that's missing out on a large segment of the population that could be at risk. ... I'd much rather provide prevention."

West Virginia, though much smaller than Pennsylvania, allocates more than $1.5 million to an 8-year-old program that runs a hot line, connects callers to 110 certified clinicians, funded 46 educational conferences last year and spent nearly $500,000 on media advertising.

Oregon devotes more effort to the issue than any other state, with a $6.2 million budget that includes a separate Web site and funding of one 11-bed residential center. Last year, 1,749 Oregonians received state-funded outpatient treatment and 85 benefited from a 30-day or longer residential stay, said Paul Potter, the state's problem gambling service manager.

Residential treatment is funded in several other states also but is typically reserved for the most severe cases. No plans have been developed for it in Pennsylvania.

One reason for no residential treatment planning is the same one Ms. Rothermel gives for the slow pace of state spending: There's scant evidence of any surge of gambling problems.

While fewer than 50 Pennsylvanians have been treated in the state program, those are not the only gambling addicts seeking help. Mike Chevalier, president of Preferred Systems, an Erie-based company that has done gambling training of therapists, said many people in that county and elsewhere are still receiving counseling.

That's because clinicians can treat gambling as a co-disorder with a client's other substance abuse or mental health issues, and bill an insurer for coverage that might not be provided for gambling addiction alone. They have done that in the past and continue to, but no statistics are kept on that secondary treatment.

Other service providers just haven't seen the incentives of entering the gambling field, including Mercy Behavioral Health, which operates its Reedsdale Center office directly across the street from the Rivers casino. It has drug and alcohol and mental health and retardation programming, but nothing for gamblers.

"It didn't feel like anything we should rush into and spend time and effort on unless somebody is really saying we have a big demand for it," said Jane Miller, Mercy Behavioral Health's communications director.

Two separate gambling help lines can be used by state residents. One, at 1-877-565-2112 under a Bureau of Drug and Alcohol Programs contract, received all of 73 phone calls in 2008 from people in need of help out of 205 overall inquiries.

The phone line, minimally advertised to the public, was created under a three-year contract costing the bureau $102,000, one of its few expenditures outside of training and treatment. The state was thus paying someone $34,000 last year to handle fewer than two serious calls a week.

Officials from the private Council on Compulsive Gambling of Pennsylvania view the state's phone line as a waste of money, because they have been operating a better-known help line for years. Accessed by 1-800-GAMBLER, as well as other advertised numbers, it rings to a national call center in Louisiana where the staff has Pennsylvania-specific information.

Jim Pappas, the state council's executive director, said monthly calls from Pennsylvanians have risen to about 1,300, compared to 1,000 in the dawn of the state's casino era. But only about 10 to 20 percent relate to serious problem gambling needs, he said. The volume of those calls actually declined in Western Pennsylvania between the first quarters of 2008 and 2009.

Norm B., a spokesman for the Pittsburgh-based chapter of Gamblers Anonymous, said there has been a small increase in attendance at its 27 area meetings since the casinos opened, but nothing to create a need for more sites.

In fact, when a longtime drug and alcohol service in Stowe known as Clean and Sober Humans Association Inc. opened a transitional housing service specifically for gambling addicts last year, it found few takers. Again, it suffered from minimal advertising, but Executive Director Panfilo DiCenzo said only two residents ever used it, and the site can't even support a GA meeting.

The lack of visible gambling problems is a curiosity to many, but gambling addiction is also known as a well-hidden, slow-building illness. Those treating gambling think it's just a matter of time before they are busier -- with or without better advertising.

Ivan Lambert, a counselor who does work in both Washington, Pa., and Dormont, has had four gambling clients, though none now. Just two of those were drawn to area casinos.

"I find it real interesting that any type of people looking for help has dropped off," he said. "Pretty much any indication throughout the country where casinos opened up, it's been just the opposite.

"Maybe we're in the calm before the storm."

Ms. Rothermel also believes those numbers will increase, and the overall state effort to address it will build, given more time.

"Would I rather have 200 people in treatment? Absolutely," said Ms. Rothermel. "Right now the important thing is we're not turning anyone away because we don't have capacity."