C Components for the Future AKU
     
  C. I The Faculty of Health Sciences : Continuing Emphases and New Elements
     
  1.1 The Commission has assumed that the future AKU will continue with a strong commitment to the health sciences and that the Faculty of Health Sciences will continue as a major part of the University. The questions the Commission has needed to face are several:
     
    - What changes in the needs and demands for health care will appear in the coming quartercentury and what changes in the capabilities and practice of medicine and health care will come about ?
     
    - What changes, if any, in the character and emphases of the existing Faculty should be made ? What additions to its present scope ?
     
    - And how might AKU's work in the Health Sciences be strengthened and complemented by new components of the University ?
     
    In considering such questions we have benefited from the Strategic Planning Exercise now going on in the Faculty. We have also studied closely the report of the Medical Centre Committee and related our recommendationg to theirs. But we are taking a longer perspective and, being concerned with many fields, have not been able to concentrate our attention on the health field as MCC did. Our views are necessarily less fully worked out, but we hope they may provide helpful basic guidance in the future shaping of AKU's work in this field.
     
  1.2 There are perhaps no subjects of private and public concern that arouse more interest and debate at the present time than health and health care. And there is reason to believe that the crises of public policy that now preoccupy the United States, or scandalise Italy, or bring forth a World Bank Development Report trying to teach many governments the principles of sound health policy, are not transitory but becoming more and more world-wide. Future efforts to cope with new needs and demands, and to respond to new scientific and technical advances, may be more exacting in the health field than in others that governments and private institutions must face. It may indeed be more difficult than in other fields simply to foresee the situations AKU and other institutions may face a quarter of a century from now.
     
  1.3 We do not venture into a thorough analysis of why health and health policy should now be such daunting subjects. But one evident source is the growing and potentially unlimited demand for health care, as populations become more aware of possible treatments, and as equity principles reinforce the growth of demand. One aspect of the globalisation we have frequently recalled as shaping the worlds of particular concern to AKU is that it spreads both the demand for modern health care and a moral sense that it must be extended to all who need it. The danger that impossible burdens may be imposed on limited resources, even in the richest countries like the United States, is now vividly before the architects of health policy, and fearful talk of the necessity of rationing arises. "Solutions" to this situation are now a modern and very difficult Grail Search, which is complicated by growing awareness that the state of a population's health depends on more than the health care it has available. While we cannot foresee what solutions may be found, we can be confident that the pressures driving the search will not diminish in the next decades, as populations rise, their education and awareness increases, and fatalistic acceptance wanes.
     
  1.4 Whether driven by the search for more effective and affordable responses to rising demand or by the sheer fruitfulness of scientific and technical research, the practice of health care has been changing rapidly and may be expected to keep a fast pace of change in the next decades. The Economist recently ["Peering into 2010 : a Survey of the Future of Medicine", supplement, pp. 18, March 19, 1994] and somewhat breathlessly declared :
     
    "Biotechnology, faster and smarter computers, telecommunications and robotics are coming together to transform health care. New products are rolling out of laboratories at breathtaking speed ...
     
    "There will be drugs for hitherto untreatable diseases. There will be easy-to-use medical tests that predict a person's prospective state ofhealth throughout his lifetime so steps can be taken to prevent diseases. There will be surgical robots operating with a precision that puts their human counterparts to shame. Doctors, nurses, hospitals and manufacturers will all be linked through a network ofcomputers, telephones, opticalfibres and satellite link-ups that a patient can plug into. The entire health-care business will be automated and closely monitoredfor cost and efficiency.
     
    "The new generation of medical products will [make] it easier to measure health outcomes. Surgery will be less intrusive, less painful and safer ... Patients will recover more quickly and need less hospital care. Asfor drugs, biotechnology will reengineer them from mere palliatives into full-scale cures that tackle not just the ills of rich countries but those ofpoorer countries too."
     
    One need not be swept away by this enthusiastic set of prophecies in a respected journal to take it as fair indication that great and rapid changes are in prospect that will affect AKU's mission in the health sciences. AKU is committed to a field that is challenging in almost any part it may choose to take for its special efforts.
     
  1.5 In keeping with our general conception of the mission of AKU, its Faculty of Health Sciences should in the long run :
     
    - provide exemplary education to health a professionals, offering exemplary programmes of health care as well;
     
   

- contribute to the advancement of knowledge and policy through research and scholarship in its field.
     
    The translation of these general propositions into specifics will involve many steps in AKU's future, only some of which this Commission can foresee and propose. We assume that the Medical College and the School of Nursing will remain institutions of modest size, and hence that their distinctive contributions must come through the quality and the critical relevance of what they do. The competing tendencies and ambitions we have described in Section VI above impinge particularly strongly on the Medical College. It has no difficulty attracting far more highly qualified applicants for its classes than it can accept; it sets a valuable example in honest selection of the I in 35 or 40 applicants it can admit, and it offers those admitted a quality of education which is exemplary for Pakistan. It can already property claim influence on standards of medical education in the country. But much about the content and outcomes of the education AKUMC offers remains unsettled. What AKUMC medical education may contribute toward solution of the problem of balance between training of specialists and general practitioners of medicine remains unclear. A large fraction of the graduates now undertake specialty training, either abroad or at AKUMC itself, and there is concern that those training abroad may not return. AKUMC may indeed be threatened like other Third World institutions of superior quality (e.g., the Indian Institutes of Technology) with supplying more graduates to the brain drain than to national competencies. But we should remember that migration of talent is not simply a loss; for AKU as an international university we should expect some of its graduates to follow international careers, making their contributions in scattered places; and for some of its specially talented graduates migration may be necessary to fulfilment of their potential. As the Commission's work was drawing to a close we have had enthusiastic reports from the September 1994 meeting in Washington, DC of graduates from the Faculty now in North America. The meeting both confirmed the capacity of AKU graduates to meet high standards where they are residents in major medical centres, and the interest many have in opportunities to use their training and talents in Pakistan.
     
    The Medical Centre Committee was concerned with these matters and called for an "Educational Realignment" because "well trained, committed generalist physicians are badly needed to take leadership in dealing with [Pakistan's typical] health problems". The Faculty in its May 23, 1993 Commentary on the MCC Report argued that no such "realignment" was necessary, that the curriculum as it stood only needed to evolve rather than be realigned. But it did concede that more efforts were needed to develop community linkages and off-campus clinical sites for more immediate engagement with primary health care and community health needs. We take it that this exchange of views between the MCC Report and the Faculty Commentary may be typical of' those that will go on more or less constantly over the next years, as AKU assesses what it is achieving and where it is heading. We understand that the Strategic Planning Committee of the Board has been established as a standing venue for surveillance and debate on these matters. The contribution that this Commission may hope to make must be of a different sort, in one respect in defining long-term objectives that may guide year-to-year developments, and in another, viewing the health sciences in the full range of AKU's future activities.
     
  1.6 Just as we see AKU as a whole fated tostraddle objectives that are not always easily compatible, we believe that this must be true in its engagements with health and health care. The Faculty of Health Sciences declares commitments to education, service, and research. It cannot now turn away from any of these and it will not be able to do so in the future, however difficult it may be to sustain and balance all three. MCC, facing very difficult financial questions, considered for a time an option that would drop undergraduate medical education. It may be possible to envisage a future AKU in which its contributions might be greater by taking such a step. But we do not believe that it is a realistic option. We also stress that AKU must seek to become an institution doing world-class medical research, and this in more than token amounts. But this does not mean that its medical component can become primarily a research institute or a graduate research centre like the Rockefeller University. Quite aside from the financial and other resource difficulties in doing so, there are other constraints which mean that AKU's Faculty of Health Sciences is not free to focus solely on the advancement of knowledge.

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