From codes to language: is the ICF a classification system or a dictionary?

Abstract

Monitoring disability across the world: is the ICFthe answer?In a recent international seminar held in Rome [1], anexperts’ meeting explored the suitability of the Interna-tional Classification of Functioning, Disability, and Health(ICF, [2]) as a tool to implement the Convention on theRights of Persons with Disabilities [3] passed by the UnitedNations General Assembly in 2005, and now being aninstrument of international law valid in many States acrossthe world. The reader of this issue of BMC Public Healthhas the unique opportunity to get an overview of success-ful applications of ICF, but also of emerging concerns anddifficulties. The ICF was introduced in 2001. Its historydates back to its progenitor, the International Classifica-tion of Impairments, Disabilities, and Handicaps, pub-lished in 1980 [4]. The ICDH conceptual framework wasquite revolutionary: the “consequences of the disease” atorgan, person, and person-community levels were givenan official conceptualization (impairments, disabilities, andhandicaps, respectively), and were coded according to ataxonomy independent of the old established taxonomy ofdiseases issued by the World Health Organization (Inter-national Classification of Diseases, ICD). “Symptoms” like“difficulty walking” became a condition worth coding (andthus, studying and treating)“per se”. “Phenomena” wereupgraded to “reality” rather than being underestimated as“appearance” [5]. Rehabilitation became an autonomousform of medical care at any stage of the disease or the dis-ablement process, and thus a respected Specialty: it wasno more bound to a palliation coming after“true” carebecame ineffective. The new ICF model emphasizedthe value of the individual from a societal perspective:“disability” was up-coded (actually, sidelined) to a generic“umbrella term”, under which a positive gradient towards“enablement” was placed. Activity replaced disability, andparticipation replaced handicap. Whatever a disabled per-son can achieve “in the context of health experience” isnow better than nothing, rather than being less than anideal standard. The bidirectional flow from organ impair-ment to person’s performance, to his/her social participa-tion actually became a 3D space expanding along twomore axes, through the interactions with individualdiseases and individual living environments, respectively(see ref. [6], Fig.1). “Limitations” and “restrictions” wereseveredfromthe“intrinsic” person’s status and wereascribed to the community context. Personal bad luck wasobscured, and responsibilities of policy makers werespotlighted.Yet, something went wrong with this otherwise suc-cessful project: the philosophic and ethical constructgained an enthusiastic consensus, while the codingstructure of the model is still awaiting for wide accep-tance and routine application across the health careworld [7].Specialists in Physical Medicine and Rehabilitation(I am one of them) might be considered biased towardsa medically oriented view of disability. On the otherhand, bio-medicine considers us, the physiatrists, toomuch biased towards a social view of diseases [8,9]. Thisentitles me to express some opinions and commentswhile claiming for a decent neutrality.International experiences: successes and concernsThe successes emerging from the set of articles are wellrepresented by the paper by Kostanjsek, a WHO officer[6]. There have been plenty of applications of the ICFmodel and coding system in fields like legislation, healthcare planning, disability surveys and policy monitoring.