Anajulia Caicedo and her two children fled 500 kilometers to Ciudad Bolivar, a huge slum outside Colombia’s capital city of Bogotá when fighting erupted in 2006 between the army and leftist guerrillas in her home village in the rural province of Meta. She has since built a small house and her own business, a small food stall. She also volunteers to help other families displaced by Colombia’s relentless warfare.
But six years after her flight, Caicedo continues to struggle for access to health care that is legally guaranteed for all Colombians.
Her case is not isolated. An estimated 30% of Colombia’s five million internal refugees lack access to government-run health services in the big city slums where they seek sanctuary, according to Amelia Fernandez Juan, director of the Institute for Public Health Promotion at Bogotá’s Pontificia Universidad Javeriana, a university founded by the Society of Jesus in 1623.
Their predicament, Juan and others argue, serves as a stinging rebuke to the Colombian government, which proudly boasts to have built a universal health care system, though it has been engaged in sporadic armed conflict with predominantly peasant guerilla groups such as the Revolutionary Armed Forces of Colombia and the National Liberation Army since the mid-1960s. An estimated 100 000 people are internally displaced each year as a result of that conflict, according to government figures.
Standing in the kitchen of her cinder-block home in the heart of the slum in which it has been estimated that 300 000 of 1.2 million residents are displaced Colombians, Caicedo says health care should have been available to her family within a month of registering her residency in the slum.
But the teary-eyed Caicedo says local health officials will not enrol her family for health care until officials in her hometown release her family’s health care files, which they have steadfastly refused to do. “This is a very common experience for displaced people here,” she says. “There is obvious discrimination against displaced people who seek health services.”
That seemingly mundane bureaucratic obstacle cost her diabetic brother his life, Caicedo asserts. “His blood sugar levels were not checked. Then he lost a leg in an amputation. At one point, he was denied care because I could not afford to photocopy a document for him. He eventually died — it was obviously due to neglect.”
An intentional and cynical policy toward the displaced?
Probably not, she murmurs. “It is probably just bureaucratic incompetence.”
Juan, who established a clinic in 1989 to provide free health services for Colombia’s internally displaced and since witnessed huge waves of people flooding out of war-torn areas into the ever-growing slum, takes a much tougher view.
Under pressure from the Constitutional Court of Colombia, the United Nations and various nongovernmental organizations including Médecins Sans Frontières to improve health services for the displaced, the government initially argued that they were economic migrants, rather than victims of ongoing conflict. But in 2006, it created Units for Care and Coordination specifically tasked with helping displaced people find health care, housing, education and social services.
That helped, Juan says.
But access to health care remains an obstacle, primarily because of red tape, she adds. “The municipalities control access to health care and they demand that displaced people show their documents.” Juan estimates that 75 000 residents in Ciudad Bolivar, and about one-third of Colombia’s estimated five million displaced people, are excluded from the health care system.
“There is no doubt that the officials responsible for this are doing it intentionally,” says Juan, who hopes government plans to replace local control of health records with national controls in 2013 will help ameliorate the problem.
The displaced are treated more badly than even the homeless, says Dr. Amparo Hernández Bello, an associate professor working with postgraduate students in health administration at the Faculty of Economic and Administrative Sciences within Pontificia Universidad Javeriana.
“These are the people who live on the margins of the margins in part because there is widespread belief that the displaced have been actors in the violence, and are not victims,” she says. “One result is that many young girls have a strategy to get pregnant and entitled to benefits as single heads of households. Otherwise they face multiple barriers to getting help.”
Back at Juan’s clinic in the slums, which is housed in a church basement, 12-year-old Vanessa Feriz has arrived with a month-old baby in tow for a checkup.
Her story was all too common: forced to flee from her family home in a small rural town after paramilitary threats were made against her brother, she arrived with her father in Ciudad Bolivar and soon became pregnant, which at least entitled her to health care under the government’s Families in Action program for mothers and children.
“The greatest health challenge here is pregnant adolescents, along with malnutrition, TB [tuberculosis], HIV, and other infectious diseases,” says Juan, who as a member of several national health advisory bodies has long argued that the government must acknowledge that the vast numbers of displaced people in Colombia are unlikely to ever return to their former homes.
The government adopted a “victim’s law” in 2011 aimed at encouraging such returns and set aside a $500-million fund to promote the cause. Colombian President Juan Manuel Santos Calderón recently handed out cheques on television to a few families who agreed to return to communities where massacres once occurred.
But most will not, Juan says, as she strolls through the vast slum, where seemingly endless mazes of temporary shelters are perpetually being patched piece-by-piece into permanent homes. “We see the health care needs of people now living here in Ciudad Bolivar as permanent needs,” she notes. “That is the reality the government finally needs to address.”
Editor’s note: Second of a three-part series on health care in Colombia.
Part 1: A system in crisis (www.cmaj.ca/lookup/doi/10.1503/cmaj.109-4124).
Part 3: The chronic disease burden (www.cmaj.ca/lookup/doi/10.1503/cmaj.109-4126).