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Hope in healing scars

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At the age of 17, Edilson was a gang member in Cali, Colombia. Constantly at 'war' to defend his zone in the town, he was caught one night by a rival gang. He was shot in the back and in the skull. At the hospital, doctors could not operate and he was told he would never walk again.

Two years later, after going for treatment at the Médecins Sans Frontières (MSF) rehabilitation ward in the heart of one of the most difficult areas of Cali, the Aguablanca district, Edilson is walking again on his own.

Edilson remembers the night his life changed. "The guy who shot me belongs to a gang that operates were I used to steal," says Edilson. "We steal from neighbouring suburbs; we go there and they come here. We try to make others respect our territory… its like everything… isn't it?"

On that particular night, Edilson ran into his enemies who then surrounded him and threatened him with a gun and a "chupasangre" (a home-made weapon, literally meaning "blood-sucker" and they demanded he hand over his running shoes. "I heard them say, Kill him!!, Finish him off!!" said Edilson. "I heard the shot and then everything turned black."

Since 1998, over 2,700 patients like Edilson, have received free of charge comprehensive attention in physiotherapy, psychology, nursing, transport and social services at the MSF facility in Cali.

By the end of the year, MSF will have handed over the programme to local health authorities.

The 18 MSF staff and 35 community volunteers will be saying goodbye to what is "their" rehabilitation centre in the District of Aguablanca. Most have worked at the centre since its creation in 1998. MSF is leaving the District and has transferred the Program model to a City Council's public health structure. This means that in the coming months, the Aguablanca compound is not accepting new injured people; they will directly go to the nearby Marroquin Cauquita hospital. To ensure that the same integral approach, that has formed the basis of some 34,000 consultation sessions, is guaranteed, the MSF team has been training doctors and nurses during the last four months.

"I was on my way home when I was mugged by some guys." The attack left him with a bullet lodged in the top of the spine and in a wheelchair. The doctors told Hamilson that he would never be able to walk again. "

As MSF's Head of Mission, Antonio da Silva explains, "We believe that, by making use of our experiences, the City Council's has taken on its responsibility to ensure that more people can access the type of care we have provided. This model can be applied in all health settings around the globe where urban violence is considered a public health problem".

The hand-over has been possible because there has been financial and political commitment from the local authorities. They have nominated 12 public health employees to be the Rehabilitation Program staff and MSF is provided them with four months of in-house training, from April to July.

The local authorities have demonstrated their commitment to a four year plan  by investing $90 million in modifications to the local health centre.

"This unique model of intervention in Colombia for victims of urban violence and their families has demonstrated that the health sector has a very important role in reducing the physical, psychological and social effects of violence in the cities," said Antonio da Silva.

In Colombia, urban violence is the first cause of death in men between 14 and 44 and is a particular public health issue for Cali, the third largest city in Colombia. In the first six months of 2004, an incredible 1,225 murders were registered in the city. These figures do not include deaths related to Colombia's continuing armed conflict.

In the outskirts of most cities in Colombia, many young people belong to organised gangs who define "territories", with invisible frontiers known only among themselves and their "enemies". For them, the rules are clear, and to venture beyond these safety zones could have fatal consequences.

"Most of our beneficiaries are male between 14 and 25 of age. All present either a knife or a gun shot wound and most frequently they are repeat offenders and gang members", says de Silva.

But not all victims are gang members. Many are innocent victims who have been in the wrong place at the wrong time. Their injuries are often severe and many patients at the MSF facility have come from the emergency ward of local hospitals.

On December 1, 2003, Julian was leaving a party to return home when "a group of young guys who were fighting nearby shot at me. I had nothing to do with their fight."

Jennifer Espinosa and her baby daughter, Daniela, were severely injured when someone threw a grenade into a birthday party. Just 18 years old, Jennifer was left in a wheelchair with a near useless arm. Her child limped badly and required surgery. After extensived treatment at the MSF facility, Jennifer no longer uses a wheelchair and has regained the use of her arm.

Brayan Perez, 10, was shot by another boy the same age who was playing with his father's gun. Brayan was in a wheelchair when he was brought to the MSF facility and was emotionally devastated. After one month of treatment, he was walking again.

These cases are seemingly miraculous recuperations. However not all the patients are able to walk again. Injuries are often too severe.

"18% of them present a permanent disability as a consequence of their injury: paraplegics or quadriplegics," explained Justine Simons, Coordinator of the Aguablanca project.

"If the rate of urban violence injuries continues in the manner it has been during the past six years, Cali could become one of the cities of the world with the highest rate of disability," said Simons.

The MSF rehabilitation program was set up to respond to the lack of integrated care for people injured in urban violence after they have received medical emergency treatment. When they left the hospital, there was no follow-up.

"We were enjoying the party when a group of guys tried to barge in the house (gate-crashers). I ran upstairs to the third floor with my baby. I heard (a sound) like someone threw a rock, but it was a grenade." The 18 year-old arrived at the MSF Rehabilitation Project in a wheelchair with very little mobility in her arm and leg.

At the same time, there has been a general lack of interest in the well-being of this particular group.

MSF beneficiaries who have come from local hospitals have frequently complained about the attitude of hospital staff and have heard comments such as, "Oh, he must be a gang member or something of the sort, so when you clean his wound, make sure you rub it hard so it hurts him bad".

In the new venture, much of the training is for staff at 11 health centres in Aguablanca and in the hospitals in Cali. This training will continue until November this year and includes; staff-patient relationships and their connection to patient recuperation; the importance of active listening and the direct relationship with patient recuperation; the importance of multi-disciplinary approaches to patient health-care

The MSF team has also created a video to help educate people about the human side of those affected by violence. The team is constantly training community volunteers. In 2003-4, 120 were trained and 33 of these volunteers are currently active with Rehabilitaion Program patient support. In 6 years, MSF has trained more than 200 publilc health staff.

The principle of treatment, not judgement, has been key to the success of the programme. Providing professional medical care of the highest standard is essential in the patient's recovery. The idea is to treat them as people in need of care – not as gang members who need to be punished.

"The degree of physical and psychological recovery depends almost entirely on the quality of attention provided to the people," explained Juan Carlos Torres, one of the MSF psychologists. The entire team shares this vision.

"When I was in the morgue, they had me down on the metal bench, and it was when they were just about to strip me open to do the autopsy, that I moved my fingers. I don't know how I got out alive."

Roger Micolta, the physiotherapist said, "We know the limitations the injury brings and we can define part of our work from that. But how the patients reacts, how they choose to fight back and help themselves in their recovery, this is something that is much harder to identify"

In many cases, the success of recovery has been surprising. Two years after his injury, Edilson went to a New Year's Eve party and on his way home, was injured a second time. He was hit hard and has scars across his face and head to prove it, but once more, against all odds, he came through.

As Justine Simons states, "The main achievement of this project is the confidence and proximity gained with a traditionally suspicious and inconsistent population. This becomes clear when you look at the commitment of beneficiaries to comply with a long-term treatment process."

The MSF project has sometimes been the place where "mortal enemies" have crossed paths but, inside, the fights are over. "Opponents have never resorted to aggressive behaviour in our presence or in our building. If enemies come across each other, the staff coach them to find their own solutions, rather than telling them what to do This strategy has always proven to be effective. The rivals request to change the timetable in order to avoid meeting each other or they negotiate a 'peace zone' at the MSF project site. They have always understood the logic of our non-weapon policy", states Justine Simons.

Stivenson is an example, like many, whose experience at the MSF rehabilitation centre was life-changing. He arrived at the centre for the first time in February 2003.

"I met the MSF team after an accident. I was shot at while I was at home. It was a stray bullet, aimed at another guy who while running away came into my house for refuge; during the chase they shot my leg. I was really bad. Depressed. My leg was stiff, but everyone at MSF helped me a lot."

Today he is one of the people who volunteer in the physiotherapy department. During his rehabilitation process, Stivenson won a scholarship to study physiotherapy and for a few months he did his in-house training at the MSF centre.

"In my family, I am the only one who has studied. It has been a really nice experience because I give the other patients hope. The others know I was also injured, but seeing me gives them hope to strive ahead. My dream is to become a professional physiotherapist so I can help people, just as I was helped, without caring for the persons' origin or race. My pride is to help people like me."