Report: Colombia: In the shadow of the peace process

Executive Summary

This report highlights the consequences of violence on the health of people living in the Colombian municipalities of Buenaventura, in Valle del Cauca department, and Tumaco, in Nariño department. International medical and humanitarian organization Doctors Without Borders/Médecins Sans Frontières (MSF) is currently providing health services to victims of violence in these areas. Colombia is experiencing a new political and social reality in the so-called post-conflict era, a period that began with the signing of a peace accord between the government and the Revolutionary Armed Forces of Colombia—People’s Army (FARC-EP) in 2016. However, an analysis of activity in Buenaventura (Valle del Cauca) and Tumaco (Nariño) reveals that violence remains a problem, despite the end of the conflict with the FARC-EP.

In fact, these areas have seen an increase in the presence and influence of criminal organizations and other armed groups. At the same time, Other Situations of Violence (OSV)—including threats, selective homicides, kidnappings, disappearances, harassment, extortion, and restriction of movements—have become a day-to-day part of life for many people.

Read the Full Report in Spanish: A la sombra del proceso: Impacto de las otras violencias en la salud de la población colombiana

This violence has had a clear impact on the physical and mental health of the people of Buenaventura and Tumaco, according to data collected by MSF psychologists in 2015-2016. Because of exposure to violence and risk factors, people assisted by MSF suffered from a variety of conditions. These included depression (25 percent), anxiety (13 percent), psychological disorders (11 percent)—including schizophrenia, childhood psychosis, bipolar affective disorder—and post-traumatic stress disorder (8 percent). Although the situations and needs of the people assisted by MSF in Tumaco and Buenaventura cannot be directly extrapolated to the rest of the country, the description provided by the report can be considered a plausible approximation of the situation in the urban and rural areas of many departments of Colombia.

The report shows a lack of institutional mental health services available at the primary care level, despite the significant needs of the population and the existence of a legal framework for care, assistance, and comprehensive reparation for victims of violence (Law 1448 of 2011). This is also true for mental health care, which is protected by the provisions of Law 1616 of 2013. This law affirms mental health care as a fundamental right and regulates the obligation of the State to guarantee the promotion, prevention, diagnosis, treatment, and rehabilitation of all mental disorders.

The report also reveals a failure to educate communities about proper responses to sexual violence. The analysis of medical data shows that only 9 percent of survivors of sexual violence seen by MSF were treated within the first 72 hours, a critical period in which to receive effective medical treatment and reduce the risk of sexually transmitted diseases and unwanted pregnancies. Many victims believe they must file a complaint with the authorities to receive medical attention—a false belief reinforced by the treatment of victims by public institutions. The data makes it clear authorities need to communicate these messages more effectively: sexual violence is first and foremost a medical emergency, and survivors of sexual violence need be treated within 72 hours.

MSF is calling on the Colombian government to continue to move forward with legislation to ensure the effective implementation of mental health care and care for survivors of sexual violence. MSF recommends the following actions:

1. Mental health services should be decentralized and made available at the primary care level to guarantee timely and quality assistance to those in need, and to provide clinical care in hospitals and health centers as well as through outreach activities. MSF suggests that psychologists be hired to provide clinical care at the primary care level and that their efforts not be limited to advocacy, as is currently the case.
2. Psychologists should be hired—at least seven in Tumaco and 25 in Buenaventura—to provide clinical care. This recommendation is based on data collected by MSF in 2016 in both municipalities where, on average, three percent of the population suffer from mental disorders requiring attention.
3. Primary care physicians should receive training on the World Health Organization (WHO) mhGAP strategy to facilitate the diagnosis and appropriate treatment of mental illness, thereby facilitating access to mental health care.
4. Better permanent psychiatric services should be guaranteed, with at least one permanent psychiatrist in the municipality of Tumaco and one in Buenaventura.
5. Public services and institutions should reinforce their messages on sexual violence to ensure the issue is understood as above all a medical emergency. Sexual violence must be treated as a public health problem and priority should be given to medical care for survivors.
6. Timely and quality efforts should be made to address alerts and emergencies related to the confinement or displacement of populations. This will prevent the aggravation of symptoms of mental disorders and the generation of chronic disorders.

Introduction

Since 1985, MSF has provided health care to those most in need in Colombia, primarily in areas most affected by armed conflict. The dynamics of the conflict and the forms of violence have changed, and MSF’s medical interventions have been adapted to respond to changing humanitarian needs.

Since 2014, MSF has focused its efforts in the country on victims of Other Situations of Violence (OSV) in the urban areas of Buenaventura and Tumaco. In Tumaco, MSF professionals operate directly out of national health system buildings, while in Buenaventura, teams work out of their own offices. In both cities, MSF coordinates with the national health system for referrals and counter-referrals as well as for trainings and workshops for patients. MSF uses a psychosocial strategy to reach people who need care, inform them of the availability of care, gain their trust, and encourage them to seek care. This program includes raising awareness and promotion of medical services, and helps people to recognize both their symptoms and the need for professional assistance.

This report is based on a quantitative analysis of the medical records as well as on a context analysis carried out by MSF programs in 2015 and 2016 in Buenaventura and Tumaco. The report also draws on medical data from 39 emergency interventions carried out by MSF in 2016 in seven departments in the country.

In total, MSF analyzed data from around 6,000 people who participated in mental health consultations in 2015 and 2016. MSF studied the pathologies, the procedures performed, and the challenges these participants faced in accessing health care. The report also includes patient testimonies, which describe the difficulties affecting this population. These personal stories were collected by MSF staff outside of the doctor-patient relationship, and in all cases respect the rules of confidentiality and medical ethics. Although the interview subjects agreed to share their experiences, their names have been changed to ensure their safety.

The report aims to highlight the humanitarian needs stemming from the violence that continues to affect the people of Colombia, and to warn of the impact of this violence on their mental health. The report is structured in three sections: the first presents the context documented by MSF in 2015 and 2016 in Buenaventura and Tumaco, as well as MSF’s response to emergencies in other areas of the country; the second describes the most acute health needs; and the third focuses on sexual violence in Buenaventura and Tumaco from a public health perspective.

Read: Colombia: “Violence isn’t only something out there; it also exists within the home”