Objectives: We examined the manner in which state public health agencies have organized their operations to accomplish the goals associated with emergency preparedness (EP) funds. We also examined the leadership challenges associated with the effective utilization of preparedness funds. Methods: The websites of all 50 state public health organizations in the USA were examined in order to determine the different approaches that states have used to organize for preparedness. Thirty-eight states provided sufficient information to allow for classification of their organizational approach to EP. Telephone interviews were conducted with representatives in three model states to obtain deeper insights into the organizational approach. Results: Three predominant organizational models were identified as a means to address the challenge of organizing for preparedness. The results confirmed the equifinality principle of organization (there may be more than one equally effective way to organize) and demonstrated that, contrary to the prescription of early management thought, there is no 'one best way' to organize. Leadership rather than formal management emerged as the primary contributor to perceived EP. Specifically, interviews with preparedness professionals indicated that they believed expert power was more important than position power and the ability to negotiate and influence through persuasion was more important than formal authority. Conclusions: All three models contained, to a greater or lesser degree, elements of matrix management with the associated leadership challenges for emergency preparedness (EP) directors. Recommendations were provided for successful leadership in the context of EP directors in state departments of public health. © 2006 The Royal Institute of Public Health.