In the fall of 2005, US President George Bush unveiled a federal initiative to ready the country for a looming danger: the possibility of a severe worldwide influenza pandemic. At the same time, Bush called on state and local governments, private industry, and private citizens to do their part to prepare. Between the lines of the President's call to arms was a stark truth. If the flu pandemic were to come-and the experts said it would-it would quickly sweep the entire country. The federal government could provide information, advice, technical assistance, and probably-a few months into the crisis-a cache of vaccines tailored to protect against the pandemic flu virus. But short of sending in the military to quell riots and enforce quarantines, the federal government would not be able to help with the crisis on the ground.  Each state would have to come up with a plan to take care of its own. 

But preparing for an influenza pandemic was a tremendous planning challenge for several reasons.  For one, the magnitude of the crisis in a pandemic was uncertain but might be huge; as much as a third of the country's population might fall ill and millions might die.  For another, responsibility for coping with the pandemic was divided among hundreds of government agencies, hospitals, health care providers, social service providers, first responders, etc. No single agency or entity could dictate to the others what to do.  At the same time, no single agency or entity could act independently in such a crisis without being overwhelmed.  A lone hospital, for example, could implement an emergency plan, but could not, on its own, create a system of triage or change standard patient care requirements without the risk of substantial liability.  In addition, there was general agreement that there would be a need for some kind of alternative care centers to take care of the thousands of patients the hospitals could not accommodate. There was no general agreement, however, about what agency or organization, in either the public health or health care systems, should establish, manage and operate such centers.   

This case tells the story of how the State of Ohio-and, in particular, the Ohio Department of Health-analyzed the problem and organized itself to meet the extreme planning task.  It provides an excellent example of a classic challenge in government-how an agency can play an effective leadership role to meet a mandate that far exceeds its direct authority.