Part 1: Cycles of violence in Honduras

MSF psychologist Christian Ramírez Medrano poses in a consultation room at the Center for Maternal and Child Health in Choloma, Honduras.
HONDURAS 2017 © Dominic Bracco
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This article is part of the Fall 2018 issue of Alert that highlights the urgent medical aid our teams provide to people on the move through Central America and Mexico.

Tegucigalpa

There’s no avoiding violence in Honduras, even at home. The streets of major cities like Tegucigalpa and San Pedro Sula are gripped by crime and conflict. Domestic and sexual violence are also widespread, with women and children bearing the brunt. Corruption, fear of retribution, and limited access to essential health services often leave victims with no protection and few choices but to leave home.

To address these issues, MSF launched its servicio prioritario, or priority service, to offer emergency medical and psychological care to victims of violence. In cooperation with the Honduran Ministry of Health, this free and confidential service has treated patients at two health centers and Tegucigalpa’s main hospital since 2011.

In late 2017 a study by the UN Refugee Agency estimated there were 174,000 internally displaced people in 20 of Honduras’s main municipalities. The factors that have contributed to their flight are easily visible in Nueva Capital, a community on the mountainous outskirts of Tegucigalpa. A maze of low buildings along vertiginous unpaved roads, Nueva Capital was originally settled in the late 1990s by people displaced by Hurricane Mitch, the same storm that drove thousands of Hondurans to claim temporary protected status, or TPS, in the US. (The Trump administration’s decision to end TPS for Hondurans living in the US, effective January 2020, threatens to send these people back into the violent conditions so many of their compatriots are desperately trying to flee.)

Nueva Capital, self-organized into five neighborhood “sectors,” has become one of the most dangerous settlements in the area. Sector one, at the base of the mountain, and sector five, near the top, are entirely controlled by maras. Most people in Nueva Capital live in deep poverty, without even basic government services like water, sanitation, and electricity.

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MSF recently rehabilitated a clinic originally built by members of the community in Nueva Capital’s sector two. Now, a team provides primary and mental health care to as many as 60,000 people from the region. At 9 a.m. on a Monday in early July, the clinic’s waiting area is already thronged with people who have come to receive free care. Most are women and children—some very young—but there are a few men among them as well.

MSF doctor Eva Hazel Banegas Reyes consults with a patient at the Center for Maternal and Child Health in Choloma, Honduras
© Dominic Bracco/MSF

“There’s a big need for psychological services here,” says MSF psychologist Brenda Villacorta. “If you come with a gunshot wound we can treat the injury, but you don’t always see the psychological wound associated with that. I see issues with unresolved grief, anxiety and depression disorders, [and] sexual and domestic violence.” In Nueva Capital, violence is a fact of life. Many people in this community, if they are lucky enough to find work, commute to jobs in Tegucigalpa—risking mugging, kidnapping, or worse on the way.

Today, 54-year-old Ilma has come to the clinic with stomach problems. She has lived in Nueva Capital since 2004, when she and her husband left their home in Honduras’s La Paz department and came to Tegucigalpa looking for work. He eventually found a job as a security guard. “At the beginning life was easy for us,” she says. “We got married and had a child. Then things got bad. My husband was shot and murdered by men trying to rob the business he was guarding. Now I live with my son alone.”

Ilma’s son, now an adult, does accounting work for a factory in Tegucigalpa. She fears for his safety as well. “It’s difficult to live in Nueva Capital,” she says. “My son has been assaulted many times. Most times he’s left without even enough money for transport. He wants to go back to La Paz; it’s safer there but the economic situation is not good.” With few options, Ilma and her son, like many others in Honduras, are trapped in a cycle of violence and exclusion. Despite the risks, she has considered making the journey north to build a new life in the United States. “I know about the dangers of traveling to the USA, and as poor people we don’t have the means to go in a legal way,” she says. “But I don’t feel safe in Tegucigalpa.” 

In order to adapt services for people on the move, MSF is implementing a new survey at its projects in Honduras to screen for people who have been forced to leave their homes and to assess their medical and psychological needs. When they arrive for their appointments at MSF clinics, patients are asked to complete an anonymous questionnaire about their displacement status. Together with demographic data, the results of the survey will help MSF teams to tailor health services to those who need care the most.

Though the survey has just begun, MSF psychologist Jorge Alberto Castro, who works at the MSF clinic within Tegucigalpa’s Alonso Suazo Health Center, believes that displacement related to violence is on the rise in Honduras. “The number of internally displaced people is growing,” he says. “These people need to move—if they don’t, they’ll go through the same traumas again and again and again.

Choloma

Northwest of Tegucigalpa, near the industrial hub of San Pedro Sula and the border with Guatemala, lies the city of Choloma. Choloma is the third largest city in Honduras, with an official population of some 250,000 people, though the actual figure is likely much higher. Home to many factories, known locally as maquilas, the city attracts people from across the country who come here looking for work. But low wages and abysmal working conditions mean that many still live in poverty.

Crime is both endemic and rampant in Choloma, and, as in Tegucigalpa, women and girls are often most at risk. Here, too, MSF teams offer mental and sexual and reproductive health care services, with a focus on care for survivors of sexual violence. In spring 2017 MSF teams began supporting a local Ministry of Health clinic in Choloma that was struggling with budget and staff limitations. The facility now provides sexual and reproductive health services and emergency care, and helps pregnant women avoid overcrowded public hospitals. Elsewhere in Choloma, MSF outreach teams provide preventive and curative services, including health education and counseling, twice weekly at another clinic in the La López neighborhood. 

The sky over the La López clinic is clearing after torrential rains as MSF psychologist Ámbar Assaf gazes out through the bars of the heavy iron gate to the street beyond. At the edge of the clinic’s sandy parking lot, chickens scratch in the wet grass by the fence. Assaf is here to work her afternoon shift at the clinic, but fears that the storm might keep patients away. 

“People here are deeply affected by violence, especially women,” she says. “The patients I see are mostly young women between 15 and 35 years old. Physical violence, psychological violence—sexual violence is extremely common. I see a lot of women who suffer from depression because they’ve experienced violence and normalized it as a defense mechanism.”

MSF in Honduras in 2017

6,800
antenatal
consultations
2,300
individual
mental health consultations
600
patients
treated after incidents of sexual violence

Assaf and her team work with patients to help them process their experiences and regain some semblance of control over their lives. But the pervasiveness and intensity of the violence in Choloma can leave deep scars. “One of the cases I remember most was a family,” says Assaf. “A pregnant woman with two kids, one six years old and one eight. One day the husband didn’t come home.” Neighbors later found his body lying in the street and went to tell the woman. “She took her kids, and they saw—he was killed in a hit, strangled, and the body was in really bad shape. The kids saw everything. You see cases like this all the time in this area.” 

The family was referred to a witness protection program and moved to another town two hours away, joining the ranks of the thousands who have become internally displaced in Honduras. But even with the move, they still don’t feel safe, says Assaf, and being forced to leave the city has also cut them off from social networks and economic opportunities. “The mother will give birth in one month. And she’s considering returning to Choloma, because there are no jobs in the town where they fled,” she says.

The MSF outreach team worked with the children to provide emotional support and build coping mechanisms as they mourned the loss of their father. But the family is still faced with an impossible choice, one familiar to many people in Honduras: Stay and risk your life at home, or risk your life on the move, gambling on a better future. “There are so many needs in this area,” says Assaf, who lives in nearby San Pedro Sula. “The more we work, the more needs we see. We’ve all seen people killed in the streets. We can’t change the situation here, but we can support people who have to live with the violence.

Forced return

A Honduran man at the Senda de Vida migrant shelter in Reynosa, Mexico. He and his wife fled threats in Honduras.
© Dominic Bracco/MSF

Many people who have been repeatedly displaced within Honduras eventually make the desperate choice to travel north, through Guatemala and Mexico, in an attempt to reach the United States. 

Large numbers continue to make the journey even as the route north becomes more treacherous and the likelihood of deportation from the US becomes higher with the Trump administration’s “zero tolerance” policies to restrict migration. The heightened risks have actually empowered people-smugglers, or coyotes, who organize transportation for migrants traveling through the Northern Triangle and Mexico. The going rate to travel with a coyote from Honduras to the US has risen sharply, from around $6,000 to as much as $10,000—and many have begun offering “packages” of three chances to reach the US. But the violence and despair are so great that many displaced people still consider the US the only alternative, and the coyotes their only option for help crossing the border. 

Thousands are caught anyway in Guatemala or at the US-Mexico border and deported back to Honduras. Every week, hundreds of these men and women pass through La Lima Centro de Atención del Migrante Retornado (CAMR) at Ramón Villeda Morales International Airport in San Pedro Sula. Families and children are processed at Belen, a separate facility. Opened in 2000, today the La Lima migrant center is run by a Catholic sisterhood known as Las Hermanas Scalabrinianas in partnership with the Honduran government. When planes carrying deportees arrive from the US or Mexico, the team here welcomes them and distributes coffee, snacks, and hygiene kits. At the center they have access to basic triage to evaluate the need for medical or psychological care, legal immigration services, and limited assistance finding a place to stay if they don’t have a home to return to

An MSF psychologist, social worker, and doctor augment the scant medical and mental health services on offer at La Lima. On the morning of July 13, a group comprising MSF’s project coordinator, mental health referent, and medical and psychological staff visit the center to assess the needs of deportees from the US scheduled to arrive by plane. The center receives seven to eight specially chartered flights from the US every week, each carrying an average of 80 to 90 passengers. Eighty four people will be arriving on today’s 10 a.m. flight.

 

MSF staff members at the bus station in San Pedro Sula, Honduras.
© Dominic Bracco/MSF

The reception room at the airport has the false cheer of government offices everywhere—its yellow walls lined with photographs showing off the country’s progress: thriving coffee plantations, construction projects, ribbon-cutting ceremonies. 

A bus pulls up on the tarmac outside, and men and women file off. Some joke and laugh with each other; most are silent. They’ve only recently been released from the shackles they were forced to wear on their ankles and wrists during the flight. As they are seated in rows of folding chairs, their belongings—confiscated during incarceration and packed in white polypropylene bags—are unloaded by volunteers. A representative of the hermanas speaks over a PA system, welcoming the arrivals and explaining the procedures.

“Life’s short, bite hard,” reads the back of a young man’s t-shirt advertising a restaurant. When he sits down to listen to the speaker, only the first words remain visible across his narrow shoulders: “Life’s short.”

Flight crew members carry medical records and sometimes medications for the people who arrive on the flights. There is a small medical office at La Lima where deportees can get basic care and referrals for illnesses like tuberculosis or HIV. Some people also arrive with injuries, particularly those deported from Mexico. They are given referrals for medical care and encouraged to stay in San Pedro Sula if they are local. 

Many people who arrive at La Lima after being deported have nowhere to go. A recent arrival found that his whole family had left the city while he was away. An 87-year-old man deported from Guatemala had no relatives to care for him and was placed in an assisted living home by the hermanas. Others have been living in the US for 10 years or more and have lost contact with family and friends in Honduras. The hermanas estimate that some 40 percent of deportees who arrive at La Lima will try again to reach the US, even though it’s common knowledge that deportations are on the rise and many of these people have already suffered horrific violence, kidnapping, or worse during earlier attempts. In the first six months of 2018 the center has already received 3,500 more deportees compared to the same period last year. Some people have passed through La Lima as many as five times in a single year.

After receiving their belongings, people line up to make a free phone call. As they wait, some pull on confiscated belts or freshen up. Many carry emergency supplies—water, bandages—for the journey still ahead. Anyone without a home in San Pedro Sula receives a bus ticket through agreements with Honduran transit companies. They are bused from the airport to the main terminal, from which they can catch buses onward. Many of them travel immediately back into Guatemala to points north—and back into uncertainty

>> Part 2: Tending deep wounds in Mexico