Academic health sciences centres in both the United States and Canada, once major "brokers" of medical and biomedical knowledge and other scare resources, are frequently depicted as "victims" of the environments in which they exist. While the national and local environments in which these organizations exist differ substantially, the integrity of AHSCs in both nations is threatened by a variety of emergent and continuing externalities. It is important that AHSCs develop a sufficient vision and market to be self-determining and successful in countering pressures that challenge their teaching, research and service activities. Leadership in both Canada and the United States must become much more skilled in strategic management to achieve this goal.

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