Colombia is a thriving country with a lively culture and growing level of progress. It has modern cities, flourishing scientific and education centres, and the global aspirations of a decidedly developed country. Behind this upbeat image, an extremely violent internal conflict has carried on unabated for four decades.
Fuelled by drug trafficking and foreign military assistance, the struggle by guerrillas, paramilitary groups, and government forces to control territory and resources continues to take a high toll on the civilian population. The human cost is immense. Violence is the leading cause of death in Colombia.
During the last decade, the annual homicide rate has been approximately 60 per 100,000 inhabitants. In 2000, the world's average homicide rate was 8.8 per 100,000 inhabitants, meaning Colombia's rate is roughly seven times greater than the global average. Today Colombia has one of the highest homicide rates in the world.1
Massacres, selective killings, and constant fear have become an unavoidable part of everyday life for people caught in areas where different armed groups vie for control. This violence most affects males between the ages of 15 and 44.
The Colombian Ministry of Health and the Pan American Health Organization reported a homicide rate of 221 per 100,000 for males within that age range.
The percentage of female victims of violence has also been on the rise during the last 20 years. For women between 15 and 39 years old, violence is the leading cause of death (17 per 100,000). Violence kills twice as many women as the second leading cause of death — complications from pregnancy and childbirth. Even children cannot escape the violence. Violence is the second leading cause of death for boys and girls between the ages of five and 14.2
Violence is arguably the most urgent public health concern in the country. However, the impact of violence cannot be reduced to a simple body count. For every person killed a family is left behind: children without parents; parents without children; a wife without a husband; families without an income or a home. For every person who dies as a result of violence, many more struggle to survive it, often burdened by a range of physical and mental health problems.
In addition to the direct physical and mental trauma of victims, this violence has a devastating impact on the health status of millions of people who are confined to conflict zones by armed groups or forcibly displaced by massacres and threats. Both confinement and displacement result in an impoverishment and lack of access to the most basic medical services, making people extremely vulnerable to a wide variety of diseases that could otherwise be prevented or treated.
Médecins Sans Frontières (MSF) teams providing health services are direct witnesses to the suffering caused by the conflict in Colombia. This report is an attempt to raise awareness of the human cost of the conflict by giving a voice to those who bear the brunt of its harsh consequences.
The structure of this report This report is structured as a journey through the three stages of the cycle of violence and forced displacement.
The opening section describes the first stage, which plays out in isolated rural communities located amid struggle for control by different armed actors. In these areas, people live under unbearable pressure — they face threats, fear, and levels of violence that take a distinct toll on their physical and mental health. More importantly, the violence confronts members of rural communities with stark, if not impossible, choices. Should they stay home and continue to live under a constant threat of being killed? Or should they try to flee, seeking safety in bigger cities where most end up living among other displaced people in squalid sprawling slums?3
The second stage of this journey deals with the arrival of those who flee to bigger cities, and their struggle to adapt and survive in urban slums under extremely harsh conditions.
Medical data collected by MSF teams working in such areas show how people struggle to cope with violent incidents and mourning, and how the conflict violence continues under different forms.
Finally, after a period of time, sometimes years, of enduring misery in slum areas, some of those who have fled the countryside decide to return "home". The third section of this report completes the cycle by describing the dilemmas faced by those who try to return to their original communities and rebuild their lives.
Personal accounts and MSF's medical data suggest that even after people return, they still find themselves vulnerable, reliving their past traumatic experiences and lacking control over their own future.
When Colombians refer to displacement, they never use the phrase "estar desplazado" meaning being temporarily displaced, something that can be reversed, and something that will eventually end. Whether consciously or not, Colombians have adopted the phrase "ser desplazado", which means a permanent displacement, a way of life, a condition that is a lasting part of someone's identity.
Much more than just a semantic curiosity, this particular wording emphasizes the realization among Colombians that displacement is a lasting condition, scarring the individual for the rest of his or her life. This ongoing drama of displacement is a daily reality for the approximately three million Colombians who have been forced to flee the violence of a conflict that has ravaged their villages for more than four decades.