Unknown respiratory illness — how would you organize the first 48 hours?
"After leading the global eradication of smallpox, Bill Foege was asked what public health should tackle next. He replied: the eradication of bad management."
The hardest organizational decisions are made not when the picture is clear, but when it is not. This exercise places you in the role of a senior public health advisor in a country with no existing emergency operations center, facing an unknown respiratory illness on day one. You must make structural decisions before you have the evidence that would make those decisions feel certain.
This is the scenario in which organization matters most — because structure is what converts uncertainty into coordinated action rather than paralysis. You will first record your working assumptions about the outbreak, then build your IMS structure, then see how your assumptions should have shaped your choices.
Understand that IMS enables action before certainty is available. The value of organizational structure is not that it produces the right answer — it is that it produces a coordinated answer that can be revised as evidence arrives. Waiting for certainty before activating an IMS is itself an organizational decision, with costs.
Apply IMS principles under conditions of maximum uncertainty. An unknown pathogen forces you to build a structure that can accommodate multiple working hypotheses simultaneously. The functions you activate, and the order you activate them in, reveal which hypothesis is implicitly driving your response.
Distinguish between what structure enables and what information enables. Lagos succeeded because Nigeria activated structure on day one — before the full picture was clear. Structure does not require perfect information to function; it requires clear authority, defined functions, and daily accountability.
You advise the Minister of Health of a low-income country. The capital city has a population of 2.4 million. There is no existing emergency operations center. The national public health laboratory has limited capacity. International travel connections are moderate.
This morning, three hospitals in different districts reported clusters of severe respiratory illness — fever, cough, and in several cases rapid deterioration. Seventy-three patients are confirmed ill across the three sites; four have died. The pathogen has not been identified. Transmission route is unknown. No epidemiological link between the clusters has been established. The minister has asked you to advise on the immediate response.
How it works: Step 1 — record your working assumptions about the outbreak. Step 2 — build your IMS structure using drag-and-drop. Step 3 — see how your structure compares to the Lagos model, with annotation that cross-references your stated assumptions. Step 4 — debrief. Allow 15 minutes.
What are you assuming about this outbreak?
The pathogen is unknown. Before building your response structure, record the working assumptions you are acting on. Select one option in each category. These will be carried forward into the comparison.
These assumptions will be used to assess whether your IMS structure is internally consistent with what you believe about the outbreak.
Assign functions to your command structure
Drag response functions into your command structure. You do not have to use every function. If you are deliberately excluding a function, drag it to the Left out zone — this distinguishes a conscious decision from a function you have not yet considered. Be ready to explain what you left out and why, given your working assumptions.
From the functions placed in your structure, select the three you would act on first.
Your structure vs. the Lagos IMS model
The full comparison below shows every function — what you included, what you left out, and how it maps against the Lagos model and the adaptations this scenario requires.
How Nigeria organized its Ebola response
Unknown pathogen additions — beyond the Lagos baseline: Laboratory & diagnostics, Infection prevention & control, and Healthcare worker protection were not part of Nigeria's original Lagos IMS, which was designed for a confirmed contact-transmitted pathogen. These three functions reflect what an unknown respiratory illness requires beyond that baseline.
All international partners operated within this structure, not parallel to it.
What your structure reveals
Your working assumptions — revisited
What the Lagos response shows about acting under uncertainty
Nigeria did not wait for certainty before activating IMS. The EOC was operational the same day Ebola was confirmed — before the full picture of exposure was known. The organizational lesson is not about having the right answer, but about having a structure that can act on imperfect information and revise as evidence arrives.
Activating IMS is not a claim that you understand the threat — it is a claim that you have organized to respond to it.
The value of unified command is not that it produces the right decision — it is that it produces a single, coordinated decision that can be revised. A committee debating under uncertainty produces delay. A commander deciding under uncertainty produces action that can be corrected.
Every IMS encodes implicit assumptions about the threat — making them explicit is what allows the structure to be revised as evidence arrives.
If you assume airborne transmission, your IPC function must be resourced differently than if you assume droplet spread. If you assume nosocomial origin, hospital infection control is an immediate priority. The structure that served Lagos for a contact-transmitted pathogen may underweight laboratory diagnostics for an unknown one.
The first 48 hours are not about solving the outbreak — they are about building the organizational platform from which it can be solved.
In 48 hours: designate the incident manager, establish the EOC, assign functional ownership, activate laboratory for pathogen identification, begin epidemiological investigation of the three clusters, initiate IPC in all three hospitals, and open a communication channel to the public. Each of these is an organizational action, not a clinical one.
The absence of a pre-existing EOC means building structure takes longer — it does not mean IMS principles do not apply.
Nigeria's Lagos response had a pre-existing polio EOC to activate. This scenario does not. But the four IMS questions still apply: who is in charge, what are today's priorities, who is doing what, are we making progress? The difference is that answering them requires improvisation rather than activation — which is slower and more error-prone, and is precisely why the Lagos case argues for building the EOC before the crisis.
- You stated working assumptions before building your structure. Looking at your structure now — is it internally consistent with those assumptions? Where did your intuitions override your stated assumptions?
An assumption you stated but did not act on in your structure is analytically interesting. What does that inconsistency reveal — a gap in your structural thinking, a belief that the assumption was not actually decision-relevant, or evidence that the assumption was stated but not genuinely held?
- The scenario specified no existing EOC. How did that constraint shape your structure — and what does it tell us about what Quadrant II investment should look like for a country in this position?
The absence of a pre-existing EOC is not just a resource problem — it is an institutional memory problem. What specific capabilities does years of operating an EOC produce that cannot be replicated by improvising one during a crisis, and how would you make that argument to a minister who sees the EOC as an expensive insurance policy with no immediate return?
- The pathogen was unknown. At what point in the evidence development would you change your structure — and what specific new information would trigger each change?
This question is about the relationship between surveillance and organizational design. The SEE component of the formula is not just about detecting threats — it is about producing the information that allows the CREATE component to adapt. Design a specific decision rule: if the laboratory confirms airborne transmission within 24 hours, which function gets immediately resourced up, which gets scaled back, and who has the authority to make that reallocation?
- In Lagos, Nigeria maintained command of the IMS even while integrating international partners — WHO, CDC, MSF — within its structure. This country has no existing EOC and limited capacity. How do you prevent international partners from effectively taking over the response, even with good intentions?