NEWS UPDATE

"One day some men arrived. They accused us of supporting the guerrillas... They threatened my husband with a weapon in front of the children, and told us to leave by dawn. My children cried a lot. We were all very scared and so we did not take anything with us, concentrating only on leaving as fast as we could. That is why we are here." –An internally displaced woman living in Soacha, Colombia, tells an MSF aid worker why she fled her home.

This is just one of the millions of sad stories that have come out of Colombia, all in some way involving the forced displacement of civilians during the country's decades old civil war. Large numbers of people have flocked to Colombia's cities in search of new homes, and many of them now continue to live in cramped shacks on the outskirts of these cities with no electricity or clean drinking water.

A common sight is a rundown shack where ten people have to share a single room, with only two or three mattresses between them, and the rest sleeping on the dirt floor. The lack of access to affordable adequate health care compounds these problems for internally displaced Colombians.

Some children looking toward Bogota from a slum in Soacha. Photo © Gervasio Sanchez

Nowhere is this situation clearer than in Soacha, where MSF has provided medical services to the community since 2000. This slum on the outskirts of Bogotá receives more than a third of the people who have fled their homes in the Cundinamarca department, and sheds light on the health crisis affecting internally displaced people. According to independent estimates, there were three million internally displaced people throughout Colombia in 2004 and at least 17,500 of them lived in Soacha.

"These families have borne witness to massacres, detentions, and the disappearance of family members or their neighbors," explains one MSF aid worker*. "They have been harassed by armed groups, 'taxed' for money and property, and in some cases they have been forced to flee to save their children from forced recruitment."

Often forced at gunpoint to abandon most of their worldly possessions and their way of life, displaced Colombians have had to make a difficult transition to urban slums where poverty, disease, and violence make daily life extremely hard.

"Currently, we are living with my sister-in-law, who is also displaced," one Soachan resident told MSF. "She has five children. Her six-month old baby is sick–he has lost weight–and she does not work every day. We all sleep in the same room. There are ten of us and we pile on top of each other. The only one working, although intermittently, is my sister-in-law. She supports us all. Some days we have no food for our children and we just stay here looking at each other. I feel ashamed but I hope the situation changes. My sister-in-law has been displaced for two years and I came with my daughters a month ago and my husband followed a month later. We have been told we will receive some aid in a month's time."

Despite their poor living conditions, no access to health care, and little employment, most of the internally displaced people choose to endure impoverishment rather than risk the danger of returning to their homes. "We are here without work," laments a displaced man, "We don't know what we are going to do when we are told to leave. Our children don't go to school. To think that I once owned my own small business. But how can I even think of going back? It would be like a death sentence."

But ultimately no one sounds more desperate than a man who feels uncertain. "I recently sent my wife to see what is going on there," tells one man. "Let's see if we can go back to collect our crops. But it is difficult. Just imagine how much we left there, our lifelong work. There I was a farmer, but here there is nothing to do and our children starve. I am so desperate that I think the best thing to do would be to go to the front and fight and get killed."

Enduring Disease and Poor Living Conditions

Fear and the crowded living conditions have taken a toll on people living in Soacha. In 2004, during consultations in MSF's clinic in the Altos de Cazucá section of Soacha, MSF medical staff found that 29 percent of the children under the age of five were chronically malnourished compared with a nationwide level of nine percent. Twenty-six percent of the adults seen in the clinic suffered from respiratory illnesses, and the proportion reached 43 percent among children under five.

The other deadly killers in this area are parasitic and infectious diseases–which have affected 22 percent of the adults and 32 percent of children under five who sought medical consultations with the MSF. In 2003, half of the cases of hepatitis A, an indicator of poor access to potable water, in the Cundinamarca department (which includes Bogota) occurred in Soacha.

"We live very badly," says one displaced person. "We do not have access to water, so the water we get we keep in the jars to cook and everything else."

Struggling to Access Medical Care

The health situation shouldn't be so urgent in Soacha. On paper the internally displaced have been given medical rights and social benefits by the Colombian government. In practice, though, MSF has learned that fear, lack of knowledge, and a complex Colombian heath-care bureaucracy have prevented thousands of internally displaced people in Soacha from accessing medical treatment.

An MSF health care worker in consultation with patients in Soacha. Photo © Gervasio Sanchez

More than 60 percent of the patients surveyed in MSF clinics in 2004 did not know about the health agency in charge of providing social benefits to displaced people, and 88 percent had no knowledge of how to access the agency or find information about it.

"The most important problem faced by members of the community is their lack of knowledge about their rights regarding health and how to make a claim when those rights are violated," says an MSF aid worker in Soacha. "We even see people who come from other areas to ask for guidance."

MSF has also found that some of the people who know about the benefits available to them fear providing information on their own whereabouts. In order for an internally displaced person to qualify for benefits the government requires the confirmation of a person's identity both with the municipality of current residence and with the area from which they have fled.

For those who escaped persecution in former homes, like the woman whose testimony begins this article, authorizing the government to conduct a process of verification raises serious concerns. If the details of a person's whereabouts were to fall into wrong hands, it might endanger them. Thus, free preventive health care eludes thousands of displaced people who are wary of compromising their whereabouts to access medical treatment.

Even if a person is able to navigate the complex medical bureaucracy they still may not receive medical coverage. The government has not funded enough new quotas for medical benefits to meet the growing number of people who would qualify for benefits. In Soacha alone, there are 98,490 people who have been identified as poor by the government that are still waiting to receive the proper certification. The certification is required for them to start receiving health and other state-funded social benefits. Yet in 2004, there were only 3,000 new individual spaces open for people to receive full benefits, and partial benefits (coverage for prenatal care and high-risk diseases like HIV and cancer) was only available to another 42,200 people.

Receiving medical care in Colombia without health insurance is very hard, if not impossible. Most hospitals in the privatized health system instruct doctors to refuse treatment to patients who can't pay the bill. The consultation fees start from 900 pesos. Traveling to a medical clinic from the urban slums on the outskirts of the city costs 750 pesos, and the basic health care bill ranges around 8500 pesos; just one tablet of acetaminophen adds 500 pesos to the bill. The grand total comes to approximately 10,650 pesos–or $4.

For a population who survives, in many cases, on less than $1 a day, this price tag is immensely high. Many households in Soacha can only spare 1000 pesos a day to buy half a kilo of maize to feed a whole family, making medical care a luxury that remains out of reach for many.

(*)The majority of MSF's aid programs, including in Soacha, are run by Colombians. The names of MSF aid workers have been withheld in order to protect their identities and their safety.

© 2005 Doctors Without Borders/Médecins Sans Frontières (MSF)