Perspectives in Health Magazine
The Magazine of the Pan American Health Organization
Volume 7, Number 1, 2002
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Perspectives in Health Magazine |
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Seeing the Whole Child
by Isabel M. Estradas-Portales
 IMCI promotes a holistic view of the child, as a means of better ensuring good health in the first 5 years of life. (Photo ©Armando Waak/PAHO) |
For doctors and other health professionals, saving the lives of young patients means learning new ways of looking at children, parents...and themselves.
It was a follow-up visit, not just for the 7-month-old baby who had been diagnosed previously with pneumonia, but also for the doctor examining her. The young pediatrician had recently received training under an innovative international public health strategy known as Integrated Management of Childhood Illness (IMCI).
Dr. María Lucía Mesa, director of the Ciudadela Medical Center in Bogotá, Colombia, was making her rounds to observe the clinic's newly trained staff when she joined the exam in process. "The baby had arrived with her mother, and she was in a very good general state: smiling, good color--she really looked happy," says Mesa. "The doctor carried out a thorough IMCI check-up and found that the baby's respiratory rate was elevated. She then checked to see if the baby's breathing was labored, and it was, though slightly. She referred the baby immediately to the clinic. Once the child was gone, the shaken pediatrician told us, `It was only because you were here that I took her respiratory rate, and that led to the complete exam. IMCI saved this baby from being sent home. Who knows what could have happened....'"
Throughout Latin America and the Caribbean, medical students and experienced pediatricians alike are learning the virtues of IMCI as a protocol for pediatric exams, one that dramatically reduces the chances of missing something that may be wrong with a child. Launched in 1996 by the World Health Organization (WHO) and UNICEF, IMCI is today being implemented throughout the developing world to promote healthy growth and development in children under 5 and to reduce mortality and morbidity from the principal causes of childhood illness. In Latin America and the Caribbean, the strategy has been expanding its influence for the last six years.
Mesa and other supporters in the Region have no doubt that IMCI improves children's health and saves lives, because they have seen it happen. Yet not all their anecdotal evidence is so sanguine. Mesa also recalls a 2-year-old boy who visited her clinic, was examined under IMCI, and was diagnosed with pneumonia. "He was given ambulatory treatment and clear instructions about when to return. When he didn't get better and started to have labored breathing, his parents took him to a second-level facility, which had not received IMCI training. They sent him home. He died after three days in intensive care in that same institution."
According to UNICEF, more than 10 million children under 5 die each year from illnesses that can be readily prevented or treated, including dehydration, acute respiratory infections, measles, and malaria. In half these cases, the condition is complicated by malnutrition. In the majority, the child's illness cannot be attributed to a single cause. Thus, the creators of IMCI conceived a broad, intersectoral approach to childhood health.
The strategy is challenging but straightforward. It takes advantage of a child's visit to a health center to assess his or her general health status and identify any problems that may be present. Health workers first identify seriously ill children who require hospitalization and refer them to more specialized care. For less serious cases, health workers must focus on treating the whole child, assessing not only the problem that prompted the consultation but also any signs of other common childhood illnesses or conditions.
Continuing with a comprehensive assessment, the health worker evaluates the child's nutritional status, vaccination record, growth pattern, and the quality of care received at home. Finally, he or she ensures treatment of any and all detected health problems and--equally important--provides information to parents, other family members, and caregivers about proper prevention strategies and child care at home.
Seemingly simple and even commonsensical, the strategy nevertheless entails what is often an important redirection of emphasis. It calls on mothers or other primary caregivers to participate more actively in consultations and to be better observers of their children's health. It assigns doctors and community health workers new roles as social communicators and educators, who must teach parents how to promote and monitor key aspects of their children's physical development. Most important, it calls upon physicians to invest the extra time and effort necessary to make a thorough, holistic assessment of each small patient's health.
A different focus
 Teamwork is strongly encouraged by IMCI as a way to ensure quality health services and use time and resources more efficiently. (Photo ©Armando Waak/PAHO) |
Dr. Gonzalo Franco Ramírez, professor-in-chief of pediatrics at the Clínica Corpas in Bogotá, has seen IMCI training have a profound impact on his staff. In the past, he says, physicians tended to focus almost exclusively on analyzing and treating children's immediate symptoms. He attributes this to traditional medical education, which places greater emphasis on diseases that, "while not very prevalent, made an impression on the students," citing as examples malignancies, immunological disorders, and endocrine diseases. For Franco, IMCI's "holistic, biopsychosocial view of the child" is a welcome and needed change.
"Traditional training emphasized only clinical training in the prevalent pathologies," concurs Dr. Jaime Tellería Guzmán, a physician working in Bolivia's Ministry of Health. He notes that areas such as acute respiratory infections, acute diarrheal diseases, breast-feeding, tuberculosis, nutrition, and growth and development have generally been taught separately. "The IMCI strategy has made it possible to integrate these programs and use systematization to comprehensively address the main problems, linking prevention, treatment, and counseling for caregivers," he says.
Tellería also points out that, although IMCI's integrated approach requires doctors to spend more time with patients, it means less time in training than traditional disaggregated learning, which required health professionals to be absent from their clinical jobs for extended periods. "This has saved economic resources and time," he says.
The strategy also runs counter to the "specialize or die" trend in professional development in medicine. "Under the old system, it was believed that to be a better physician one had to practice a subspecialty--a vision that is disjointed, in many cases, even totally fragmented," says Mesa, who trains colleagues in the IMCI strategy.
Dr. Carlos Alberto Bernal, a Colombian pediatrician, received training in IMCI after more than 20 years of pediatrics teaching and practice, specializing in diarrheal diseases. At the Children's Hospital of Medellín, where he worked, "we had an oral rehydration ward for children with diarrhea...and right next to that room was the unit for children with respiratory infections. Training in IMCI gave me the opportunity to work in a more integrated fashion and pursue teaching and research activities in areas other than diarrheal diseases."
 Health workers trained in IMCI learn to view mothers as the best source of information on their children's health. (Photo ©Armando Waak/PAHO) |
"Traditional education has always sought to emphasize the taking of a good clinical history," notes Bernal. "This includes a review of systems, similar to the search for related problems in an IMCI consultation. But in practice, attention has often focused very narrowly on the reason for the consultation. IMCI represents progress in that it permits systematic exploration of the most prevalent problems, including important aspects of nutrition, vaccination, and good treatment." He adds, "It also provides for careful management of some good techniques for communicating with mothers, which may be the most innovative feature of the strategy."
Indeed, IMCI's emphasis on the role of mothers or other caregivers and their relationship with of health workers with them is for many supporters a key advantage. Franco, of Clínica Corpas, says that before receiving training in IMCI, health workers "placed little value on dialogue with the mother." They also tended to overlook what he terms "basic aspects of daily practice with the child...such as vaccination, growth, nutrition, and simple indications of simple problems that the mother might be experiencing when it comes to her child's health."
With training in IMCI, "Wwe saw a radical change in student attitudes," says Franco. "This has led to better relations with mothers and improvements in their behavior and the management of childhood illness." The change has proved beneficial for the clinic, Franco notes, in that better doctor-patient relations have attracted more users.
From a trainer's perspective, Mesa says she has observed that IMCI's "module" on counseling mothers seems to have a particularly strong impact on professionals taking her course. "The common denominator here is that career programs in medicine and other health professions have not stressed communication, an aspect that is key to achieving what we want."
At the Ciudadela Medical Center, the only health center in Bogotá where all staffers follow the IMCI strategy, director Dr. María Lucía Mesa has seen changes in attitude in physicians and students alike. She notes that the center's general practitioners regard IMCI training as professional updating that "makes them more secure in their decision -making and furnishes them with arguments to explain to mothers or other caretakers why they do or do not prescribe drugs."
A different focus
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."
