Cholera in a port city — how would you organize the response?
"After leading the global eradication of smallpox, Bill Foege was asked what public health should tackle next. He replied: the eradication of bad management."
Knowing that organizational structure matters is different from being able to apply that knowledge under pressure. This exercise asks you to make concrete structural decisions for an outbreak you have not seen before — then examines your choices against the evidence from Nigeria's Ebola response in Lagos.
It works whether you have already studied the Lagos case or not. If you have, treat it as a transfer exercise — can you apply IMS principles to a different pathogen and context? If you have not, treat it as a preparation exercise — build your own model first, so the Lagos comparison lands with more force.
Apply IMS principles to an unfamiliar scenario. The Port Cartier cholera outbreak shares the organizational challenge of Lagos but differs in pathogen, transmission route, and context. Applying the same structural logic to different conditions tests whether you understand the principle or just the case.
Understand why organizational structure is a precondition for action, not a backdrop to it. Lagos succeeded not because Nigeria had better drugs or more money, but because it activated a clear command structure before doing anything else.
Distinguish between what structure enables and what individual talent enables. When Nigeria replicated its Lagos response in Port Harcourt with a different team and the outbreak was again controlled, that replication settled the question: structure — not exceptional individuals — was decisive.
A cluster of severe watery diarrhoea cases has been reported at the city's main port hospital. Within 48 hours, laboratory results confirm Vibrio cholerae O1. Port Cartier is a mid-sized city of 800,000 — a major regional hub for cross-border trade, with significant populations of migrant dock workers, an informal settlement adjacent to the port with limited sanitation, and a porous land border 40 km away through which several hundred people pass daily.
The city's health department has confirmed the outbreak. The national Ministry of Health has been notified. International partners are offering support. No emergency operations structure has been activated yet. No one has been formally designated to lead the response.
How it works: Drag response functions into a command structure and select your top three priorities for the first 48 hours. Then see how your structure compares to the Lagos IMS model, with annotation explaining what each structural choice enabled or risked. The debrief closes with questions for reflection or class discussion. Allow 10–15 minutes.
Assign functions to your command structure
Drag each response function from the bank on the left into the appropriate position. 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.
From the functions placed in your structure, select the three you would act on first — in order of urgency.
Your structure vs. the Lagos IMS model
The Lagos response was not built for cholera — it was built for any outbreak. Your structure is compared below against the IMS Nigeria activated when Ebola arrived. The goal is not to find the single right answer, but to examine what each structural choice enables or forecloses.
How Nigeria organized its Ebola response
All international partners — WHO, CDC, MSF — operated within this structure, not parallel to it.
What your structure reveals
The four questions IMS answers every day
These are operational questions — not administrative ones. If any one cannot be clearly answered at any moment, the response fragments.
This is the single decision that makes every other decision faster.
Unified command means one person is accountable for all functions. Without it, every decision that crosses agency boundaries requires negotiation. In Lagos, the incident manager was designated the same day Ebola was confirmed — before any other action. That single decision is what made parallel operations possible.
Priorities shift as an outbreak evolves — only a commander can reallocate without triggering inter-agency conflict.
In a cholera response, week one focuses on case finding and WASH; week two may shift to border control and community engagement. A committee must negotiate each reallocation. A commander decides.
Clear functional ownership is what makes parallel operations possible rather than sequential ones.
In Lagos, logistics, epidemiology, laboratory, and communications ran simultaneously — not sequentially — because each had a named owner. Without that clarity, functions wait for each other and the outbreak grows in the gaps.
Data used as a management tool — not a reporting obligation — is what separates adaptive responses from ones that repeat the same mistakes.
Daily situation reports in Lagos were used operationally to reallocate staff and resources in real time. The same principle applies whenever response data is reviewed not to satisfy a reporting requirement but to make the next decision better.
The Port Cartier complications — what Lagos did not face
The cholera scenario introduced features that require IMS adaptation beyond the Lagos model.
Surveillance that covers only the city is surveillance with a structural blind spot built in.
A 40 km land border means contact tracing must coordinate with a neighbouring jurisdiction. The IMS must include a border health function and a mechanism for cross-border data sharing — neither of which existed in the Lagos outbreak.
Treating cases without controlling the water source is managing the symptom while the cause continues operating.
Cholera spreads through contaminated water and food, not contact. WASH must be an operational function equal in priority to case management — not a downstream advisory role. IMS structures historically designed for contact-transmitted diseases systematically underweight this.
Community engagement here is not communications — it is the precondition that determines whether any other function can reach its target population.
The most vulnerable population is the one most likely to distrust government health interventions. Without trusted community intermediaries active from day one, WASH cannot be deployed, contacts refuse home visits, and symptomatic individuals avoid the health system.
- Review the structural choices you made. Which decision are you most confident about — and which would you change now that you have seen the Lagos comparison?
What does the gap between your intuitive choice and the evidence-supported one tell you about how organizational design decisions get made under pressure in practice — and what institutional conditions would need to be different for the evidence-supported choice to be the default response?
- The Lagos IMS was built for polio and repurposed for Ebola. Port Cartier has no equivalent pre-existing infrastructure. What is the minimum organizational investment a city like Port Cartier should make before the next outbreak — and how would you make that case to a minister who has no current crisis to point to? This is Covey's Quadrant II: the work that is important but not urgent, and therefore systematically underfunded.
- IMS is an emergency tool. But the four questions it answers apply equally to programs that run for years. Consider a public health program you know — one tackling a chronic condition or a sustained epidemic. Which of the four IMS questions is hardest to answer in that program — and what organizational change would be needed to answer it clearly?
The organizational logic underlying IMS — identify the rate-limiting step, measure it, redesign around it — applies as much to long-running programs as to acute emergencies. Apply this diagnostic to Port Cartier: if it were to build a standing Emergency Operations Centre over the next three years, what would the rate-limiting step be — and what organizational redesign would remove it?
- Cholera is a disease of systems failure — inadequate water, sanitation, and housing. The IMS organizes the emergency response. What does it not — and cannot — address? What does that limit tell us about the relationship between emergency response and the structural determinants that made the outbreak possible?
Apply the four IMS questions to a long-term WASH infrastructure program in a city like Port Cartier. Which of those questions is hardest to answer — and why? What does that tell you about the organizational preconditions for sustained investment in systems that prevent the next outbreak rather than respond to the current one?