Perspectives in Health Magazine
The Magazine of the Pan American Health Organization
Volume 7, Number 1, 2002

Seeing the Whole Child
by Isabel M. Estradas-Portales

In 1999, six years after IMCI was first introduced in the Americas, the Pan American Health Organization (PAHO), in collaboration with ministries of health in Latin America and the Caribbean and other international and national agencies, launched a new effort to promote the strategy under the rubric Healthy Children: Goal 2002. The initiative set the goal of saving an additional 100,000 children's lives (beyond the progress already achieved with IMCI) during 1999-2002, by stepping up implementation of the strategy throughout the Region. The target population was children under 5, and efforts were focused on areas having the highest infant mortality rates, that is, in excess of 40 per 1,000 live births.

At a meeting at PAHO headquarters in Washington, D.C., last November, proponents of the initiative announced the preliminary results. Using 1998 as a baseline, they reported an estimated 33,735 fewer childhood deaths--a 6.4 percent decline--from all causes in the Region during 1999, the initiative's first year. Looking only at deaths from causes targeted by IMCI--a more targeted focused indicator of the initiative's success--the decline was 15.4 percent, representing an estimated 24,276 lives saved. This effectively put the initiative on track to achieve its four-year goal.

Overall, 17 Latin American and Caribbean countries, accounting for 52 percent of the under-5 population in the Region, have now adopted IMCI, supporters noted at the PAHO meeting. Yet they emphasized the need to expand the initiative even further. "It is important that 17 countries are already applying the IMCI strategy, but the region has almost 50 countries and territories, and perhaps the countries that are still missing also have high mortality rates," said PAHO Assistant Director Dr. Mirta Roses. [AU: Per PAHO Web site, full name is Mirta Roses Periago. Add "Periago"?] "It's good...that we have heard so much good news, but a great deal remains to be done."

(Photo ©Alejandro Marín) "Is the doctor in?" The Child Life Unit in Turbo, Colombia, was established in 2000 by Dr. Carlos Alberto Bernal and colleagues from Antioquia University's medical faculty. IMCI serves as the unit's guiding strategy, and in its two years of work, the clinic has gained wide respect and a steadily growing clientele through word-of-mouth.   One day not long ago, a mother showed up at the clinic looking for a "Dr. Yepes" to examine her son. The receptionist told her they had no such doctor, but the mother insisted that there must be; she had been told that Dr. Yepes was "the best for treating children." After a moment's confusion, one of the clinic's staff realized that the woman must be referring to the Spanish acronym for IMCI, which is AIEPI (pronounced "ay-yeh-pee"). Says Bernal: "Dr. Yepes turned out to be AIEPI, the best for children."

Mesa, of Bogotá's Ciudadela Medical Center, believes the strategy is best taught at the end of the pediatrics rotation of medical and nursing students. "Graduate students in pediatrics should be fully capable of applying the strategy in an integrated fashion, since they will undoubtedly be the second or third level of care that receives referrals, and they must understand, reinforce, and, above all, respect the decisions of their colleagues at the first level," she says.

Integrating IMCI into the classroom is proving to be a gradual process. This is in part because, according to some supporters, teaching physicians tend to resist change. Other supporters note that practical application of the strategy during training is essential, but that many academic institutions lack sufficient links with the kinds of health services in which students can do this type of practice.

If the strategy takes time to be accepted in academic settings, it has also encountered resistance in physician's offices, according to Mesa and other supporters. Doctors may complain about the time required for examinations using the IMCI protocol, which usually takes longer than traditional exams.

"The feeling is that a consultation that includes all aspects of the strategy--for example, counseling for the mother and instructions on how to administer drugs--takes quite a while. In many institutions, the time available for a consultation is often extremely short," notes Bernal.

Yet IMCI offers its own built-in solutions to such problems, notes Dr. Juan Carlos Bossio, IMCI adviser to PAHO's Division of Disease Prevention and Control. By pPromoting teamwork-, assigning responsibilities and functions to different categories of personnel,-- it makes up for the greater time spent on actual exams.

"Nurses, auxiliary personnel, and even administrative or general staff can contribute to the application of IMCI, supporting it in pre- or post-consultation," says Bossio. "The time of each staff member is therefore utilized more efficiently, and the entire health team works in a coordinated manner with an eye to care, treatment, and protection of health."

Meanwhile, as a growing number of the Region's health professionals receive training in IMCI, and as improving mortality and morbidity statistics seem to prove its effectiveness, the strategy is winning more enthusiastic supporters. Mesa sees this phenomenon in her trainees, who she says have not only embraced IMCI for pediatrics practices, but have "extrapolated" elements of the strategy for use with other patients. "They often say...that there should be an IMCI for adults."

Back to Index