December 16, 2004

December 16, 2004
Caught in Colombia's Crossfire
This article appeared in New England Journal of Medicine, Number 25. All rights reserved. http://content.nejm.org/

By Brigg Reilley, M.P.H., and Silvia Morote, M.D.

It is an accepted part of a doctor's job to awaken at night to an emergency call. But in many parts of Colombia, such a visit is often reason for a doctor to shudder with fear. The people knocking on your door may wield guns as they summon you to tend to their ill or wounded compatriots. If you refuse, you might be killed. Yet if you go with them, another armed faction may kill you as a collaborator. If the government discovers you cooperated with any of them, you may be interrogated or detained. This is Colombia's "low-intensity conflict," where medical staff and civilians struggle to remain outside the violence.

The province of Caqueta is a current hot spot in the War on Drugs and the War on Terror. The small provincial airport now bustles with military transport planes, Humvees, and Blackhawk attack helicopters providing air cover for coca-crop fumigation. In this and other provinces, as villages change hands between the national army and various illegal armed factions, medical workers can be caught in the middle. Rather than being respected as neutral and impartial, health care and its providers are treated as strategic resources – and therefore targets. Recently, a health care worker in a rural area that is controlled by insurgents traveled to a referral hospital in a city firmly held by government forces. She was interrogated and released by the army. When she returned, the insurgents informed her that she was now considered a government spy. Suspected by both sides, she fled, becoming yet another of the "internally displaced."

Ambulances are also targets and have been attacked both in robberies and for military purposes. Ambulance crews have seen their patients forcibly removed and executed. Referring patients to a higher level of care is impossible with such overarching security threats. Recently, the army accidentally killed a family of five that was trying to get a child to the hospital for an emergency consultation.

Medicines are a strategic objective as well. Armed groups sometimes raid health posts or hospitals in order to get necessary medical supplies. To preempt such raids, the army may confiscate drugs from health centers. In either case, the community goes without. Treatment for cutaneous leishmaniasis, a disease that is endemic to Colombia, has come to have tactical military importance: because it primarily affects persons living in rural areas, the disease is viewed as a marker for possible insurgents or their supporters. As a result, the army may choose to detain a mobile clinic if it is carrying medications for the treatment of leishmaniasis.

Such conflict in Colombia is not new; it has been going on for decades. Today, official estimates put the number of persons internally displaced at more than 2 million – by far the largest number in the Western Hemisphere and the third in the world (after Sudan and the Democratic Republic of Congo). A Colombian saying has it that "a turbulent river benefits the fishermen" – in other words, the murky lawlessness and violence of the conflict benefit many interests. Some experts claim that the politics of the war have long since been diluted by pursuit of financial gain; the most notorious trade is in coca, but areas that are rich in petroleum, gemstones, timber, or other such resources have seen the heaviest violence. Other layers of the conflict involve ideological claims by various groups and efforts at "social cleansing" – the systematic killing of certain members of a community, such as homosexuals or homeless juveniles who are considered to be delinquents.

Colombia is a country of great contrasts and disparity, and not all segments of the population are affected equally, by either violence or a scarcity of health care services. In Bogota highly skilled surgeons transplant organs or delicately separate conjoined twins. Some cities are renowned for their numerous, high-quality cosmetic-surgery clinics. Yet nationwide, more than half of Colombians live below the poverty line. In some poor and rural areas, vaccine coverage dips below 50 percent, and the country recently struggled to contain a yellow fever epidemic that straddled areas controlled by multiple armed groups. Certain mortality statistics resemble those of a developed country – ischemic heart disease and cancer are among the leading causes of death – but the most common cause of death remains violence.

For outside groups seeking to provide medical aid to the Colombian people, access to a given area may be denied; if a mobile clinic gets through, it will be one of the community's only links to health care. Mobile clinics typically treat many respiratory, skin, and parasitic infections and provide vaccinations. In some cases, the physician in such a clinic is the first doctor the community has seen in well over a year.

The sustained conflict has taken a toll on mental health. A sizable proportion of patients at mobile clinics present with nonspecific headaches and generalized body pain. Mental health experts at such clinics have reported that such aches and pains are often the symptoms of people living in fear. Threats by armed groups, domestic violence, and sexual assault have been the primary issues addressed in mental health consultations. Some patients have walked for hours to a clinic, seeking acetaminophen for a headache, although they know the pills are available and affordable in their village. These consultations with a doctor are often preludes to discussions with a mental health expert that reveal the terrifying conditions of life in Colombia – inescapable insecurity and a struggle for day-to-day survival.

Many displaced people have fled to shantytowns on the outskirts of major cities. Here, poverty-related illnesses are common – mainly respiratory illness and diarrheal disease among children. In 2003, half of the cases of hepatitis A recorded in the capital city's province occurred in one such community, Soacha. The rate of chronic malnutrition among patients seen in the clinics is 30 percent, as compared with a national average of 8 percent.

Violence is at least as big a threat to health as infectious disease, since even here, civilians cannot avoid the conflict. Graffiti bearing names of one armed group or another is highly visible on many buildings in Soacha. Some houses are spray-painted with the word "capo," slang for informer. No one is a civilian in this conflict; everyone is considered a potential informer or collaborator. At night, these neighborhoods are plagued by threats and violence in an extension of the conflict the displaced have fled. Acts of violence intended to intimidate have been horrific – such as dismemberment by chainsaw.

The conflict has also inflicted collateral damage on the population, including avoidance of registration for health care benefits. Colombia's health care laws are progressive, and – on paper, at least – the benefits offered to the internally displaced are exemplary; but these theoretical benefits often remain unrealized. For example, registration for a government health plan requires detailed information to prevent fraud and abuse. This includes confirmation of identity by the local municipality as well as from the area that the person has fled. But if details of displaced peoples' current residence fall into certain hands, it can cost them their lives. Understandably, many opt not to enter the system.

Despite pervasive violence, however, not all health problems are directly linked to the conflict. Important gaps in access remain, and it is difficult to navigate the bureaucracy of the national health care system. Colombia has sought to increase the efficiency of the health sector through privatization, which has created incentives to avoid treating the poor or persons with costly illness, who can be turned away on technicalities. In rare instances, even in downtown Bogota, patients have died in front of a hospital where an exasperated ambulance crew left them after being turned away from several facilities. Hospitals, for their part, are struggling to survive, since if a patient cannot pay or be otherwise billed, the hospital or the doctors must pay the difference. Some months ago, the tertiary care facility in Cartagena, the referral hospital for the Caribbean coastal region, closed its doors, bankrupt.

In the end, a combination of obstacles related to the ongoing conflict and chronic problems with the medical system makes health care inaccessible for many patients and keeps them beyond the reach of doctors.

Source Information
From Médecins sans Frontières, New York (B.R.) and Bogota, Colombia (S.M.).