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A Word from the President: Capacity Building in a True Health Care Armageddon

AAMC President and CEO, Darrell G. Kirch, M.D.

Last month, as some U.S. lawmakers were proclaiming the health care bill to be "Armageddon," one nation was beginning long-term recovery from a true Armageddon the January 12 earthquake in Haiti. The widespread devastation that tragically claimed an estimated 230,000 lives also damaged nearly half the nation's hospitals, left an astounding number of traumatic injuries, and rendered the country even more vulnerable to communicable disease.

As many of you know, our institutions were among the first to treat Haitian evacuees with these injuries and many have continued to send highly skilled teams of specialists to Port-au-Prince (see www.aamc.org/haiti). Their tremendous efforts to provide and coordinate acute care in the earthquake's aftermath should make us all proud. Today, however, we face a new question: Does our responsibility as a community end with the provision of acute medical care? If not, how, and to what extent, should we contribute to the rebuilding of Haiti's medical education and health care delivery systems?

To help address these questions, the AAMC participated in a meeting of U.S. and Haitian medical education representatives convened by the U.S. Department of Health and Human Services. While the meeting initially focused on rebuilding capacity for medical education and training in Haiti, participants also discussed the urgency of preparing a wide array of health care professionals particularly nurses and public health personnelto meet Haiti's basic health care needs in the long term. It became apparent from this meeting and other follow-on discussions that our assistance not only was needed acutely, but was critical to future capacity building.

I believe that our participation in this effort is vital and is the right thing to do. Our involvement in the rebuilding process is consistent with the strategic priorities set by our governance. It also provides an extraordinary learning opportunity, particularly as we seek to identify guiding principles for AAMC international engagement. Four factors will be critical to our success.

The first critical factor is cultural competence; i.e., the recognition that everyonepatients, educators, cliniciansis shaped and influenced by his or her experiences, expectations, and beliefs, and that these attributes affect social interactions. At the most fundamental level, rebuilding a health care "system" in a nation of extreme poverty will take some of us far away from our comfort zone. In addition to the physical challenges posed by lack of basic infrastructure (e.g., clean water, sewage, housing), those who choose to assist will be continually challenged to approach teaching, training, and patient care in a way that meets the Haitian people's specific needs and cultural expectations.

For example, rather than simply "export" current U.S. health care practices, educational techniques, and technologies, the AAMC and other partners will take a different approach. As an initial step, we are seeking guidance from experts familiar with Haiti's unique demographics and culture so that we might align our efforts accordingly. As we go forward, we will need to keep in mind that redevelopment must take place in a step-wise fashionthat is, in coordination with ongoing efforts to rebuild the country's social and public utility infrastructures. Further, we must be sure to engage Haitian community leaders in all these processes and be careful not to be perceived as taking control.

Similarly, we must recognize and acknowledge our limitations and constraints. While we cannot do everything, the AAMC can catalyze some key activities that will, in turn, support the evolving medical education infrastructure. A good example is training Haitian doctors to train other doctors. Lifelong primary care is best managed by those who will be in Haiti for the long term. As United Nations Secretary- General Ban Ki-moon recently observed about the overall restoration effort: "At the end of the day, only Haitians can build Haiti back better."

Third, we must maximize our role in building collaborations. Already, other stakeholder groups (e.g., nursing, pharmacy, dentistry, and other health professions associations) have expressed a desire to be active partners. We also have been communicating with our colleagues in the Canadian Association of Faculties of Medicine to explore possible coordination of efforts.

Finally, we must recognize that we, too, are learners. By collaborating with Haitian educators and clinicians, we will develop an evidence base for what works, and what does not work, in knowledge transfer and training. Through this partnership, we also will develop a "template" for mobilizing more quickly in the wake of future international disasters and guidelines for helping rebuild medical education, research capacity, and clinical care. Additionally, as eyewitnesses to the rebuilding effort, we will be able to study the interrelationship between health care and local economies. A strong health care system in Haiti will not only provide medical care to the country's citizenry, but also will provide stable jobs and careers for the nearly 50 percent of the Haitian population currently under the age of 20.

These efforts, when combined with our immediate response to the Haitian earthquake, will stand as a vivid illustration of our social contract and what academic medicine can contribute toward building a better world. Further, to the extent this new experience pushes us beyond our comfort zone, it is integral to the culture change academic medicine is undergoing. Ironically, we may find that a small nation devastated by natural catastrophe provides one of the most fertile learning grounds of all.

Darrell G. Kirch, M.D., AAMC President and CEO