MSF
July 2010

Three time
victims
Victims of violence,
silence and neglect
Armed conflict and mental healthin the department of Caquetá,
Colombia

Contents

4

1 Introduction

6

2 The armed conflict in the department of Caquetá

7

3 The work of MSF in Caquetá

7

4 Violence, conflict and health9

5 Victims of violence directly related to the armed conflict
5.1 Risk factors
5.2 Diagnoses
5.3 Clinical outcomes16

6 Victims of silence and stigma. Cultural violence18

7 Victims of government neglect and institutional
ineffectiveness. Structural violence
7.1 Lack of recognition
7.2 Contradictory legislation and lack of expenditure24

8 Conclusions

25

9 Appendices

2 MSF

Three time victims

“Every day, when I start seeing patients, I try to understand
why our country has been plunged into this sea of violence forover five decades. Today, nearly three years after I started
to work on the mental health program run by Médecins Sans
Frontières / Doctors Without Borders for people affected by
the armed conflict and forced displacement, I realise just
how futile this chronic violence is. All of the life stories I haveheard in my office revolve around the same issue: stories ofpain, death, despair and fear, fragments of lives soaked ina violence so irrational that it shows our fellow human beings
are dehumanised and have a cruel nature.”
Mario A. Ibáñez Suárez, psychiatrist for Médecins Sans
Frontières / Doctors Without Borders in Florencia, Caquetá(Colombia). July 2008.

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1Introduction

Colombia

Florencia
Curillo

Departmentof Caquetá

San Vicentedel Caguán
Cartagenadel Chairá

The department of Caquetá, the country’s southern gateway to
the Colombian Amazon, has been one of the focal points of theColombian conflict. The historical presence of the guerrilla andof paramilitary groups, combined with a strong presence of themilitary in recent years, has seen the area turn into a geostrategic“battlefield” over the control of transport and of the land itself,
which is particularly rich in natural resources and has large areasof illegal crops. The consequences for the civilian population are
vast. Threats, murders, forced disappearances and displacements,
confinement and restrictions on movement are just some of thedangers that the inhabitants of Caquetá are faced with.
However, the civilian population not only endures the violencecaused by the armed conflict. It also faces additional violenceon two different levels: the neglect and ineffectiveness of theinstitutions that ought to tend to them, as well as social silenceand stigmatisation. These three levels of violence have a serious
impact on the mental health and the quality of life of the individuals
and communities which are exposed in one way or another tothe conflict. These multiple forms of violence are the atrocious
reality that a large part of the people of Caquetá has to live
with, making them triple victims of the conflict.
The consequences of this violence include a series of mental healthdisorders, both on an individual and on a family and community
level, which overwhelms the population’s coping mechanisms andcauses severe emotional and psychological suffering which theauthorities ought to respond to.
Médecins Sans Frontières / Doctors Without Borders (MSF) has
been working in the department of Caquetá since 1999. In 2005,
the organisation began to implement a mental health project totend to the victims of the Colombian conflict and to provide aservice that was not being adequately supplied by government
health structures.
This report is based on data compiled from 5,064 patients
who were provided clinical care by MSF from March 2005 to
September 2009. 65% of the patients were female and 35%
were male. Ages ranged from 1 to 89, although patients mostcommonly belonged to the 19-45 year age group. Additionally,
60% of the people were seen in Florencia, the capital of thedepartment, and 40% were seen in rural areas.

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Through the statistical data collected and the accounts provided
by its patients, MSF wishes to make known the suffering that theviolence is causing among the population. The mental health profile
recorded among our patients demonstrates the direct impact of
the armed conflict on the mental health of the population, which
the country’s mental health services fail to cover due to theextent of the problem.
Finally, this report seeks to demonstrate that mental health services
can indeed be provided in conflict situations, even with limited
resources, and that they can effectively benefit patients.

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2
The armed
conflict in thedepartmentof Caquetá

The department of Caquetá is a geostrategic region which a numberof armed groups have fought to control for decades. Since the1980s, the Revolutionary Armed Forces of Colombia (FARC) haveexerted a strong social and military influence in the region, whereparamilitary groups are also present.
The peace process between the FARC and the Government broke
down in 2002. The subsequent suppression of the “demilitarisedzone” 1 brought a dramatic deterioration to every aspect of theconflict. In addition, the militarisation of department has increased
further due to the Patriot Plan launched by the Government in 2003
to regain control of the area.
This situation is compounded by extremely high displacement rates.
According to government sources, in 2009 Caquetá was one of theColombian departments where most people – over 7,600 – weredisplaced 2. Furthermore, the annual homicide rate almost doubles
the nationwide average. In 2009, 265 3 people were murdered in thedepartment, and there were 130 4 incidents involving undetonatedanti-personnel mines and other ammunition, which killed a further
20 civilians. One of the reasons for such a high level of exposure toviolence of the civilian population is that the parties in the conflictseek to involve them in different ways in an effort to either gain or
maintain their influence in the region.
As a result, not only is the population of Caquetá significantly
exposed to the dangers inherent to the war, but through the years it
has also been subjected to direct and continued interaction with thearmed factions and has lived in permanent fear. The situations thepeople are most commonly exposed to include: direct and indirect
threats, murder of relatives, neighbours or friends, massacres,tortures, forced disappearances, kidnappings, arbitrary detentions,landmines, fighting, terrorist attacks, crop eradication, restrictions
on staple food supplies and other basic survival items, confinementof communities, sexual violence and forced recruitment, sometimes
including minors.
1

Some of the municipalities of the department of Caquetá fell within thedemilitarised zone established by the Government from 1999 to 2002 tomove peace talks with the FARC guerrilla leaders forward. When negotiations
broke down, the Army launched a large-scale offensive forcing the FARC towithdraw, although the guerrilla group preserved its military capacity.
2

The departments where most inhabitants were displaced in 2009 wereNariño, Antioquia, Cauca, Tolima and Caquetá, accounting for 51% of
the total number of forced displacements recorded during the year.
Colombian Presidential Plan on Human Rights and International
Humanitarian Law. Indicators on human rights and IHL in Colombia. 2009.
http://www.derechoshumanos.gov.co/observatorio_de_DDHH/documentos/
Indicadores/obs_indicadores_dic2009_100503.pdf (in Spanish)3

Op. Cit. Footnote 2.
4

Op. Cit. Footnote 2.

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3
The workof MSFin Caquetá

MSF has been working in the department of Caquetá since 1999,
and has been implementing specific mental health activities since2005. The organisation’s teams currently visit the district capitals of
Cartagena del Chairá, San Vicente del Caguán and Curillo regularly
to carry out mental health promotion and prevention activities andto provide regular consultations at local hospitals. Mental health isalso one of the components that MSF mobile primary care clinics
provide in the rural areas around Cartagena del Chairá and San
Vicente del Caguán. In addition, MSF also worked for four years
in a mental health clinic in Florencia, the department capital. In
May 2009, the mental health activities performed in this clinic werehanded over to the country’s Universidad Nacional Abierta y a
Distancia (Open University).
As part of its mental health project, MSF provides individual,family and group psychological support, as well as psychosocial
activities (informative talks, psycho-educational workshops, basic
mental healthcare training, etc.). In addition, the organisation has
established community networks to ensure that care is delivered tothose who need it most.
The organisation’s activities are implemented by clinical and social
psychologists, and by prevention and promotion technicians. From
March 2005 to September 2009, MSF provided care for 5,064
people in the department of Caquetá.

4
Violence,
conflicts
and health

The World Health Organization (WHO) defines violence as “theintentional use of physical force or power, threatened or actual,against oneself, another person, or against a group or community,
which either results in or has a high likelihood of resulting in injury,
death, psychological harm, maldevelopment, or deprivation”.
As in many other conflicts, the physical and verbal violence inColombia is self-evident, but the structural and cultural forms ofviolence, which are no less serious, are harder to perceive. (Seefigure 1, page 8 5).
5

See Johan Galtung, Peace by peaceful means: Peace and conflict,development and civilization, London, SAGE, 1996; particularly its firstpart, Peace studies: basic paradigms. See also, Conflict transformation by
peaceful means, by the same author. Geneva, United Nations, 1998.

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Adaptation of the Galtung
triangle, 1996a) Direct violence. Violence overtly and specifically applied to aperson or group, within a specific timeframe, with visible intentions
and results. It is understood as bodily, physical and/or psychologicalharm which is verifiable and, in principle, evident.

DirectViolence

Many MSF patients in Caquetá declare to have been subjected todirect violence, such as threats, beatings, rape, displacement or
restriction on movements.

VisibleInvisible
CulturalViolence

Estructural
Violenceb) Structural or indirect violence. Violence exercised by institutions
operating in the social environment. In principle, its impact is lessevident. This category includes violence owing to political and economic
structures that cause segmentation, social fragmentation, exclusion
and/or marginalization.
For example, even though Colombian law ensures free service
provision for displaced peoples, it is rarely fulfilled and the population
is often subjected to humiliations when trying to exercise their rights.
c) Cultural violence. Refers to the cultural aspects of a groupthat are used to reinforce and/or legitimise direct and/or indirect
violence, through religious (holy war, inquisition, etc.), ideological(demonization of opponents, perceiving AIDS as a type of
punishment) and linguistic (racist terminology) mechanisms, either
through the media or through educational and/or socialization
mechanisms.
As an example, civilians from the demilitarised zone of Caquetá arestill systematically depicted as guerrilla collaborationists simply
because they live in that area.
The interconnection between these three levels of violence in armed
conflicts has been widely described, and it has been proven that they
are exacerbated when people become accustomed to them 6 7 8.
This interrelation can be clearly seen in the armed conflict inColombia, where as well as the direct violence, the victims arealso faced with structural violence on behalf of the institutions,while living in a society in which violence is validated, accepted andpromoted by all of the parties that aim to profit from it.

6
WHO, World report on violence and health, Washington, D.C., 2002.
7
Ascher, William. “The moralism of attitudes supporting intergroup violence”.
Political Psychology. Vol. 7. No. 3 (1986). 403 - 425.
8
Ferme, Marianne. “The violence of numbers: consensus, competition, and thenegotiation of disputes in Sierra Leone”. Cahiers d’Études Africaines. Vol. 38.
Nº. 150 / 152. (1998). 555 - 580.

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Due to these close links between the forms of violence found inarmed conflicts, the consequences and effects on the psychologicalbalance of individuals are endured not only by those who are
confronted by direct violence, but also by the general population of
conflict zones.

5
Victimsof violence
directly related
to the armed
conflict

The data analysed below have been compiled from 5,064 patients 9
who were provided clinical care by MSF from March 2005 until
September 2009, regardless of whether the organisation classified
their exposure to the conflict as direct or indirect. The consultations
were provided both at the mental health centre in the town ofFlorencia and in the municipalities of Curillo, San Vicente del Caguán
and Cartagena del Chairá.
Using the data compiled by the project, we performed descriptive
analyses and comparisons between the risk factors 10 that the
population was exposed to and their clinical diagnoses.
The direct violence related to the armed conflict affecting ourpatients can manifest mental health disorders or disturbances
within a specific range of clinical diagnoses 11, which are described infurther detail elsewhere in this paper. In addition to the behaviouraldisorders that are normally associated to armed conflicts, patients
attending MSF mental health services frequently showed adjustment
problems and a greater degree of exposure to other forms of violence(familial, sexual or social), which is typical of armed conflict contexts 12.
Furthermore, the direct violence associated to the armed conflict
can also be observed in the personal accounts provided by ourpatients, which regularly include acts of violence such as threats,
injuries, forced recruitment, displacement, kidnappings or murder.

965% of the patients seen were female and 35% were men. The most common age
group was 19-45 years, accounting for 54.9% of all patients.
10
A risk factor is any circumstance or situation that increases a person’s chances ofcontracting an illness.
11
Exposure to the stress generated by war can cause mental disorders such as posttraumatic stress, major depression and generalized anxiety disorder, as well as otherforms of anxiety.
12
Hynes, Michelle; et al. “A determination of the prevalence of gender-based violence
among conflict-affected population in East Timor”. Disasters. Vol. 28. Nº 3.
(2004). 294 - 321.

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49.2% of the 5,064 patients seen by MSF had been directly
exposed to the internal armed conflict, having been affected byfighting between armed factions and other acts of violence. The
following accounts illustrate some of the episodes of violence enduredby MSF patients:“Things were going well [at the farm]. My wife and I weremaking progress and our children’s needs were covered, despite
living very far away from the town. But then things started to get
ugly: they increasingly put pressure on us and demanded bigger
quotas for the people in the bush, and things got worse when they
started to take teenagers and sometimes even kids away.
Then they tried to take my 13-year-old daughter away, but I could
not allow that to happen and I got her out of the village. Thenthey told me they had to get even. They told my wife not to follow
them and to wait for three days before going to fetch me. Theybound me to a tree and hit me on the head so hard that I fainted.
I don’t know how long I was unconscious or why they didn’t kill me.
Three days later, my wife was allowed to go and fetch me, and she
found me covered in ant bites, because they had stripped me down
to my shorts. They told her that they didn’t want to see us everagain in the area and gave us three hours to leave the farm.”
50-year-old man from a rural area in Caquetá“You know doctor; a year ago those people killed my son. He was
25 and was my right hand man for everything. He used to worry
all the time about me and about my mother, who’s very old andvery sick. His little brother loved him too. He used to help him withhis homework and taught him the jobs we did on the farm. I knowthat they killed him because he refused to join them and because
he didn’t listen to them when they told him to leave the area. He
wanted to stay with us; he was a good boy who didn’t like to get
mixed up in funny business. But they took him away from me.”Female patient from a rural area of Caquetá“Things changed very suddenly. We started to see strangers withvenom in their eyes. Ever since the rumours about them being in
the vereda, we had been gripping ourselves for whatever might
happen... but we could never have imagined what happened
eventually.

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One night, the dogs were barking a lot. We got up to find out
what the fuss was about and saw a group of men in combat
clothes and armed to the teeth who were leading two men who
were bound up and gagged. Even though it was dark, we could
see the feeling of fear and anxiety in their eyes, as if they were
aware of their fate. After a while, two gunshots snapped us out of
our astonishment. From that moment on we were unable to sleep;
we were petrified by the sound of a chainsaw.”
A 50-year-old displaced woman in Florencia

5.1. Risk factors
MSF psychiatrists found that the vast majority of patients seen had
been exposed to more than one risk factor. The most common risk
factors were: family dysfunctions or problems in primary support
networks (54.3%), forced displacement (38.7%), financial problems
and housing (36.6%), direct exposure to armed conflict (22.9%)
and death of a family member or significant other (19.1%). In
addition, child abuse was recorded in 11.3% of the cases, violenceagainst women in 10.7% and sexual violence in 9.69% 13.
9,7 %

10 %

10,7 %

20 %11,3 %

30 %

19,1 %

40 %

22,9 %

50 %

36,6 %

38,7 %

60 %

54,3 %

Most common risk factors

Sexual violence

Violence against womenChild abuse

Death of a family member
or significant other

Direct exposure to
armed conflict

Financial/Housing problem

Forced displacement

Family dysfunction or primary
support network problems

0%

It is important to point out that MSF patients are simultaneously
exposed to several risk factors and that some of these factors are
directly related to others. As a result, it is not easy to draw clear
lines between the direct effects of the armed conflict and otherrisk factors observed. This can be clearly seen, for example, inthe case of “family dysfunctions or problems in primary support
networks”. This risk factor is defined as: “The individual is in asituation in which s/he has scarce support from her/his next ofkin, communication is inadequate, relationships between family
members are conflictive or the family structure is seriously disrupted(traumatic separation, sudden changes in family dynamics, etc.)”.
In a large number of cases in which this risk factor was recorded,
the source of the dysfunction was found to lie in life events typical of
conflict dynamics: families split up due to displacement or absence(temporary or definitive) of some of its members, which disrupt
family dynamics or require an untimely redistribution of family roles.

13
Percentages represent how often each risk factor was observed in all MSF patients.

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“I was at school with my sister and my mother was back on thefarm with my little brother. When we got home, he was crying andmy mother wasn’t there. We asked him why he was crying andwhere mummy had gone, but he couldn’t answer. So I searched
the house and that’s when I found her. I shouted at her to wakeup, but she couldn’t hear me. Then some neighbours who had heard
gunshots arrived and they told me my mother was dead.
A few months earlier, my mother and sister were on a bus that
was attacked by armed men. There was a gunfight and my little
sister was shot in the head. Luckily, they were able to remove thebullet at the hospital, but now she is in constant pain. After mymother was killed, some men from the authorities took us to livewith some relatives because we were minors. But I’m very sad,because my mother is no longer with me and because we left thetwo dogs we used to play with down by the stream and a cockerelthat a friend had given me behind. I don’t know what I’m goingto do. I used to go to Florencia every weekend with my mother tosell banana leaves, which people ordered to make tamales, and we
also took yuccas, pineapples, bananas and other things from thefarm, and then my mother would use the money we made to do
our own shopping. We can’t go to school any more and my father
isn’t here to keep us company. They told us they’ve called him butthat he’s a long way away and that it’s going to take him a longtime to get back.”
14-year-old displaced boy in Florencia

Similarly, a closer look at the cases involving other risk factors, suchas sexual violence, family violence or exposure to other forms ofviolence, reveals that the armed conflict is also behind many of thesesituations, which include single-parent households, overcrowdingof displaced populations in precarious socioeconomic and security
conditions or minors in the custody of extended family members.
A similar reading can be made of other factors that, despite not being
directly linked to the conflict, are deep-rooted in the conditions it
creates, such as “problems in social support networks”, defined as:“Situations in which the individual has scarce support from friends,
acquaintances, neighbours, community groups and organisations,due to isolation, peer rejection, discrimination or difficulty adjusting
culturally”.
In such cases, it is not hard to establish the relation between the
problems and dynamics of social fragmentation and polarization,
fear and mistrust which are typical of internal armed conflicts and/or the social and cultural uprooting inherent to forced displacement.
Such is the case in the following account given by a 52-year-old
woman who was forced to leave her home in the countryside after

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she was threatened by one of the armed factions. Since the army
helped her family to escape to Florencia, they are now accused ofbeing informers and have lost part of their social support network.
“We hardly go out any more. We are afraid because those people
are everywhere, not just out in the bush. When we do have togo out and we meet people we know from back home, they ask
us whether the army is really helping and protecting us, and wetry to explain that all they did was get us out of there. But therumour has gone around the entire area, so we have no hope ofgoing back or sending someone to recover some of our belongings,
because this time they would undoubtedly kill us.”52-year old displaced woman in Florencia

5.2. Diagnoses

Principal diagnoses

Other*
24,52%

Adjustment
disorders
18,7%
Relational problems
and problems related
to abuse and neglect
17,6%

*

For other diagnoses, see table in Appendix 2.

Other mooddisorders
8,29%
Grief
8,9%
No disorderobserved
10,66%
Major depressive
disorder, single
episode.
11,33%The typical clinical diagnoses in war contexts, such as grief ordepressive disorders, were common among the 5,064 patients thatMSF treated. In addition, it is important to note that the stressinherent to armed conflict situations can also serve as a facilitator
for other more serious clinical conditions apparently unrelated tothe conflict, such as psychotic disorders 14. At the MSF project inCaquetá, up to three non-exclusionary diagnoses were recorded foreach patient. The one considered most significant in each patient
was recorded as the principal diagnosis.
Overall, the five most common principal diagnoses among MSF
patients were 15: adjustment disorders (18.68%); relational
problems and problems associated to abuse or neglect (17.55%);
major depression – single episode (11.3%); grief (8.9%); and othermood disorders (8.29%).
The five most common diagnoses observed imply that over 65% of
the people seen did not have a serious or chronic disorder as such,
but rather an intense response indicative of acute psychologicalsuffering requiring therapeutic treatment, triggered or closely linked
to devastating external life events. This is coherent with the armed
conflict setting in which MSF was working, with normal, albeit
intense reactions to abnormal or extreme circumstances, where
therapeutic approaches are essential both to contain and cope withthe situation and to prevent more severe and chronic disorders.

14
A clinical diagnosis defined by the existence of disorganised behaviour,
hallucinations and delusion.
15
As per the categories established by the ICD-10 (International Statistical
Classification of Diseases and Related Health Problems). For definitions,
see Appendix 1, page 25.

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“That’s why I’m here [at the Care and Counselling Unit for
displaced populations]; because I was told that they could help us
here. I came on my own because my husband is ill and my son isafraid to go out. I am also afraid, but I have no choice. You know,
doctor, I haven’t slept for several nights now. In my dreams in I
see the heads of my neighbours. I see them crying, begging formercy. I wake up in tears. I start thinking about the farms, about
my vegetable patch, my chickens and livestock, and about thedogs that tried to follow us until we had to throw stones at themto scare them off.
I’d never felt like this. I’d never seen my husband so quiet; I’d neverseen him cry in silence. And what can I say about my son, he’s not
the boy he used to be. There’s no tenderness in his eyes any more,
there’s anger and there’s hatred. I don’t know what will becomeof us now; I only know that we still have God and that our lives
will never be the same because now we are displaced people.”
50-year-old displaced woman in Florencia.
When an armed group came to her village, she heard them kill and dismember
some men, who she was then forced to bury. Finally, when her son was
threatened they had to flee their home and escape to Florencia.

Other conditions included behavioural and/or emotional disorders
in children (5.76%) and other anxiety disorders (4.28%). 1.5%of the diagnoses were for post-traumatic stress, with acute stressaccounting for 1.38%. 10.66% of the patients were not foundto have any disorders, which has been described as normal in thesetting of mental health consultancies in armed conflicts. It is
important to note that patients in whom disorders are not observed
are not necessarily healthy.
The above data coincide with other Colombian 16, 17 and international
studies 18 on the impact of armed conflict on the health of people inwhom there is a predominance of depression and anxiety disorders,
as well as emotional and behavioural disorders, as was the casein our project. Other common problems include those related to
exposure to all forms of violence, to abuse or neglect and disorders
specifically affecting children.

16
Londoño N, et al. “Salud mental en víctimas de la violencia armada en Bojayá(Choco- Colombia)”. Revista Colombiana de Psiquiatría. Vol. XXXIV. No. 004.
(2005). 493-505
17Pérez- Olmos, I; Fernández Piñeres, P; Rodado Fuentes, S. “Prevalencia del trastorno
por estrés post-traumático por la guerra, en niños de Cundinamarca – Colombia”.
Revista Colombiana de Salud Publica. Vol. 7. No. 3. (2005) Pág. 268-280.
18
Peña, Y; Mena, M; Hidalgo, T; Mena, N; Adan, E. “La guerra como desastre. Sus
consecuencias psicológicas”. Interpsiquis. (2007) http://www.psiquiatria.com/
articulos/psiq_general_y_otras_areas/psiqsocial/28872/?++interactivo(Accessed on: 19/11/09)

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Our data analyses revealed that post-traumatic stress disorderwas 3.6 times more common among people exposed to risk factors
directly related to the conflict than in those who were not. Similarly,
acute stress disorder was 2.6 times more common and grief was 2.5
times more frequent among the former group. Adjustment disorders
and single episodes of major depression were also more common –1.6 and 1.3 times, respectively – in people who had been directly
exposed.

Analysis of associations between risk factors directly linked to the armed
conflict and principal disgnoses. Caquetá mental health project, Colombia.
2005 - 2009.
Diagnosis

Prevalence
Rate

ConfidenceInterval

MantelHaenszel chisquare test

P value

Major depression,
single episode

1.27

1.09-1.48

9.20<0.0024181

Acute stress disorder

2.59

1.55-4.34

14.17<0.0001672

Post-traumatic stressdisorder3.60

2.10-6.16

25.14<0.0000005

Adjustment disorder

1.60

1.42-1.80

62.46<0.0000000

Grief

2.45

2.02-2.98

88.99<0.0000000

Sourse: MSF – España databases

5.3. Clinical outcomes
An analysis of the project’s clinical records reveal that 56% of the
5,064 patients treated by MSF, both in rural and urban settings,
showed clinical improvement compared to their baseline condition
before consultation.
It is important to note that the presence of several active armed
factions in Caquetá makes it impossible to guarantee the continuityof mental healthcare provision in the department’s rural areas.
MSF teams therefore chose a single-consultation strategy in orderto improve the therapeutic impact of the care provided, since thelikelihood of seeing patients after their initial consultation was scarce.
A formal evaluation performed by MSF on the immediate effect of
the therapeutic single-session intervention revealed that 94.4%
of the patients considered that the approach had been useful tohelp them address the issue for which they had sought help. The
psychologist working on the project considered this had occurred in
92.8% of the cases. This positive perception was shared by bothpatient and psychologist in 86% of the cases.

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6Victims ofsilence andstigmatisation.
Culturalviolence

As previously established, not only is the armed conflict in Colombia
a risk factor for mental health in itself, but it also creates theconditions for other risk factors that contribute towards thedeterioration of the health and quality of life of the people andcommunities involved.
In addition to the consequences of direct violence, the victims of theColombian conflict also endure the consequences of indirect violence,
including social stigmatisation and silence, which increase thevulnerability of the victims and hinder their emotional recovery.
The stigmatisation surrounding the victims of the conflict inColombia forces them to bear their situation and suffering in silence,both for fear of the armed factions and the lack of protection they
are given when threatened, or due to the shame of acknowledging
their situation, since society tends to blame them for their own
suffering and considers them responsible for the appalling situations
that they are subjected to.
“I now live in a shack in a dangerous neighbourhood. In themornings I sell bananas off a cart and in the afternoons I work
as a loader at the market. But that doesn’t cover all my expenses.
Things are very different here. Some people look at you as if you
were from another planet; they think that if you’ve been displaced
you must have done something wrong. They probably even think
you deserve it, but they never ask what they did to you or why you
had to come here.”
Displaced man in Florencia
He was forced to flee after witnessing fighting between armed factions in his
village. When one of the groups finally occupied the area, he witnessed a person
being murdered and dismembered.

“Some time ago, I had to flee to Bogotá. We left the vereda
where we used to live close to Florencia when my brother was
murdered. He was tortured; they tied him up and they burned his
face with acid. I recognised him in the morgue because he was
wearing a shirt I had mended for him. He was so young, he was 25
and his girlfriend was expecting a child.
We suffered a lot in Bogotá. Life is very difficult there, people
look at you is if you were from another planet, but we put up with
it because there was nothing else we could do.”
Displaced woman in Florencia
She moved back to the countryside from Bogotá to work in the fields, but thepresence of armed groups forced her to flee again, to Florencia this time.

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The above is illustrated by the analysis of the data from the Caquetá
mental health project, as 33% of the displaced people attending
consultation were not registered as such 19. One of the reasons forthis sub-registration is that some of the people displaced are afraid
to speak publically about their situation, leaving them to face theirsituation without any government support.
The victims of the conflict also have to live with the labels they
are given by their original or host communities. On the one hand,
they are stigmatised in relation to the conflict: “they are guerrilla
members”, “collaborators”, “informers”, “they must have done
something”, etc. On the other, they are perceived as a threat or asa problem, and people link them to crime or other social problems:“thieves”, “drunkards”, “they’re taking our jobs”, etc.

“I worked a farm for 13 years. I had a lot of animals and worked
the land. They were good times but, you know, the blasted war
came along and ruined it all. In the countryside, we don’t slamour doors in anybody’s face – armed groups arrive and, withouteven asking, they stay as long as they like and use everything as
if it was their own, and then they leave. Another group comesalong as soon as the previous one has left – it’s almost as if thedevil had tipped them off. And that’s where the problem starts.
They accuse you of being a collaborator. When you ask how you
can be a collaborator if nobody asks your permission. They are
fully aware of how things work, but they don’t want to know,
they just tell you to drop everything and leave. It’s the last straw;
they even ask you if you want to die. At that point, you remember
what happened to so many people you knew; you know they mean
it and that your only choice is to get out. You can’t reason withthem and you choose not to put your life on the line.”
Displaced man in the municipal capital of San Vicente del Caguán

19
It is the Government who decides which people are considered displaced. The problem isthat the complexity of the system, the fear of those eligible to request displaced status
and the Government requisites– which are often oblivious to the reality of the conflict–create a sub-registration of displaced people and leave many to cope without any
government support whatsoever. In order to be granted displaced status, a person must
provide an account of the events that caused his/her displacement before one of theestablished state bodies (legal registry, ombudsman, etc.). In turn, these bodies send theinformation to the Presidency of the Republic’s Social Action department, which
examines the report and decides whether or not to grant the person and his/her family
displaced status. People ‘certified’ as being displaced are entitled to support such as
humanitarian relief aid and are awarded priority in certain government programs
concerning education, employment or housing for example, and are automaticallyprovided free access to healthcare. Uncertified displaced persons who do not comply withgovernment criteria face a long and complicated process during which they are denied
health coverage, compounding the vulnerability to which they are already subjected to in
the towns they have fled to.

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Silence and stigma bar any chance the victims have of having theirstatus recognised by society, preventing them from developing
any sense of belonging or identity. Since social integration is nonexistent, they are unable to adjust to the environment or overcome
the traumatic events they have experienced. The poverty in whichconflict victims – particularly displaced persons – are forced to live inthe host cities makes them extremely vulnerable. The lack of social
integration further complicates access to employment, housing,education and healthcare and makes them lose any hope of being
able to restore their social, financial and emotional status one day.

7
Victims ofgovernment
neglect andinstitutional
ineffectiveness.
Structural
violence

The way in which the institutions treat the victims are proof of
their exclusion by the government. This is apparent in the subregistration of forced displacement in Colombia, the lack of specificgovernment welfare and healthcare services for the victims of thearmed conflict and the scarce allocation of government expenditure
to address the issue.
7.1. Lack of recognition
The Colombian Government refuses to acknowledge the armed
conflict itself and prefers to speak of a complex emergency or ofan anti-terrorist struggle, and this denial also implies its lack ofrecognition for the victims.
As a result, despite the tremendous problems posed by the forced
displacement and other forms of victimization caused by the armed
conflict, there is considerable controversy regarding the number ofdisplaced persons, and efforts are made to justify and conceal
the problem.
One of the direct results of this failure to recognise the armed
conflict and its victims is the lack of social spending allocated tohelp them, which translates into a lack of adequate and appropriate
government response systems.

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Three time victims

In the department of Caquetá, these deficiencies are made obviousby the state of the main government office for providing assistanceand guidance to displaced persons – the Unidad de Atención yOrientación 20 (UAO). Here, displaced persons have to provide adeclaration, an account of the events that led to their displacement,
which is a requisite for them to be granted access to Government
support programs, including free healthcare. The deficiencies ofthis government office are apparent in both the qualitative andquantitative aspects of its infrastructure and its human resources.
The facilities are small, lack privacy and are located in a buildingthat is not even owned by the town council, meaning the council
cannot invest in improving them, despite the fact that several NGOs
have offered funding. The inadequacy of the facilities and poor
staff profiling, overworked personnel or the mere fact that they
do not perform the tasks they ought to, mean that the services
provided re-victimize the subject. Victims lack any form of privacy
when providing their accounts and are submitted to an undignified
treatment during the long wait required before being granted accessto the services.

“This is extremely hard. I arrived at 3 a.m. to queue up for adeclaration form, but at eight o’clock they told us that they would
not hand the forms out today. I have to try again in eight days’
time. Well, I suppose I don’t have a choice, but I have been trying
unsuccessfully for 20 days now.
It’s an absolute nightmare. Twenty-four days ago we were forced
to flee our home along with seven other families because we had
all been threatened. What you see now is all I have – nothing –because we weren’t allowed to take anything with us. We had a
farm, animals and crops growing in the fields and we had to leavethem all behind.
But the saddest thing of all is that they killed my 21-year-old son.
He was a good boy, not because he was my son, but because hereally was, he loved to work with the community.”
Displaced man in Florence

20
These units were created under Law 387 of 1997, with the aim of improving thequality of services provided to displaced persons by: facilitating access to local
government services offering comprehensive assistance (education, health, housing
and employment, among others); to facilitate access to comprehensive, clear andtimely information; and to provide personalised and humanised assistance. This UAO
ought to comprise a number of government bodies such as the Mayoralty (who is
responsible for its running), Social Action, Registrar, Ombudsman or the Solicitor’s
Office. In addition, there are sporadic visits from the Servicio Nacional de Aprendizaje(National Further Education Service) and the Instituto Colombiano de Bienestar
Familiar (Colombian Family Welfare Institute). Visits to the Florencia UAO by
representatives of these institutions are extremely irregular.

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Many of the people who visit the UAO are in extreme need. They areoften forced to flee suddenly, and are not even given time to collectthe basic items they need to survive. In addition, they are often
explicitly warned not to report the situation.
The lack of political will to respond to the needs of the conflictvictims is also reflected in the lack of health services adapted to thereality of the town of Florencia, the department’s main host town
for displaced people.
There is only one government-run psychiatry unit in the entire
department of Caquetá (404,896 inhabitants 21). The María
Inmaculada secondary level hospital in Florencia has a mental healthunit with just one psychiatrist and 20 beds for hospitalising acutepatients until they are stabilised (maximum stay 30 days). This meansthat all the unit can do is stabilise chronic psychiatry patients during
acute stages; interventions are basically psychopharmacological, andpatients are discharged without medication. Other than the limited
psychiatric care provided at the María Inmaculada hospital, mental
health prevention and promotion services and psychotherapeuticcare (which is more appropriate for addressing the psychosocial
consequences of the conflict) are nonexistent, underlining the factthat the conflict’s consequences on the mental health of the
population are systematically ignored and neglected.

“I had not felt well for some time. Whenever I managed to see
the doctor, all he did was prescribe pills. That’s all. One day I
went to the village next to the river to see the doctor there.
He examined me and told me I had a mental health issue that
required psychological help. I had to come to terms with the factthat I might never be able to go to see a psychologist, because
I couldn’t afford it.”
Displaced woman in Florencia

Government bodies often argue that they do not provide mental
health services for the population in the areas directly affectedby the armed conflict either because their teams cannot accessthose areas or because the rural population is unaccustomed to
psychological care and would reject the services.

21
2005 Population Census, National Administrative Department for Statistics ofColombia, 2005.

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The data compiled by MSF in Caquetá prove the opposite.
Psychological care is indeed well accepted by the rural population
affected by the conflict. MSF saw 5,064 patients during the study
period. Almost 40% of all consultations were provided in rural
areas by mobile clinics deployed every 5-6 weeks.
It is logical for the population affected by the conflict to be waryof talking about their experiences. Their silence and distrust are
survival mechanisms used in response to the general climate of
suspicion surrounding the conflict. Nevertheless, our experience inthe field has demonstrated that there is indeed a high demand formental health services and that the strategies used must be
adapted to the complexity of the context.
Considering also that the analysis of our clinical records revealed
that the clinical condition of 56% of the patients treated by MSF
improved, we can conclude that the chosen approach is indeed
feasible and that the provision of mental health services forrural populations affected by the war should be encouraged
and expanded.

7.2. Contradictory legislation and lack of expenditure
Colombian legislation aimed at responding to the needs of thevictims is fragmented and diffuse. This is compounded by the factthat its health-related aspects often contradict the global social
security and healthcare framework set establish in Law no. 100
of 1993. As an example, many of the benefits granted to female
victims of sexual violence or forced displacement through current
legislation or by Constitutional Court rulings cannot be delivered
because they are not included in Law no. 100. Furthermore, thelegislation in place can barely be implemented due to the lack ofresources allocated to this end.
“I didn’t want to demand my rights as a victim of displacement
before because I didn’t think it was important, but now I realisethat I can and that, as a health worker, I can expect to be
granted certain assurances. But it’s extremely difficult, especiallybecause I was displaced several years ago and these claims are
subject to legal impediments and deadlines.
At least I’ve applied now, but it’s been very difficult because
there has been no stability at all down the years. We are now
fighting for my daughter to be granted medical services and tobe admitted to a Family Welfare program, but it’s been very
complicated because she was born several months after we weredisplaced and it’s almost impossible to add her to the family groupin our declaration of displacement. I’ve had to submit several
Petitions of Rights [a specific request made to a public body,

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Three time victims

either in the personal or public interest] because the institutions
that are supposed to compile the information on displaced
populations refuse to do so and ignore their responsibilities
towards displaced persons. Fortunately, I’m aware of how thesystem works, but I often think about all the country folk who canbarely read and are scared to speak to the authorities. I can’t
imagine how they treat them considering how they treat people
with formal qualifications.
Now, I am submitting an Acción de Tutela [a writ requesting
the protection of a constitutional right] because my son is being
refused an operation at the hospital. Every time we go, they comeup with something new, saying he needs a certain examination, orthat the doctor’s out, or that we have to pay, or go to a specificoffice, that the surgeon is not under contract... They make up allsorts of excuses to bore you into giving up, but I know that they’reviolating his right to healthcare, so I won’t give up.”
Displaced man in Florencia

The situation is particularly critical in the field of mental health,which has been neglected for years. This can be seen in the lackof mental health interventions provided for in Law no. 100, whichemphasises acute care for chronic disorders and ignores specificactions to provide for the psychosocial needs of populations
submitted to armed conflicts. Such is the case of this 52-year-old
woman who had to leave her home after being threatened by anarmed group.

“I became ill – maybe because of all the anxiety of feeling hunted
like an animal, of knowing that I had lost everything – even myclothes – and of thinking that they could find me at any time. My
nephew urged me to see the doctor, but the doctor couldn’t see theproblem, he said: ‘No dear, there is nothing wrong with you – youneed a rest.” And I could not tell him about my problem. It’s hardly
surprising that I felt so bad, is it?”52-year-old displaced woman in Florencia

The current legislation clearly excludes all individual psychotherapy,
psychoanalysis or prolonged psychotherapy except for individual
supportive psychotherapy during the critical or initial phase of thedisorder. The critical or initial phase is defined as lasting a maximum
30 days as of the onset.

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Uruguay: 8 %Percentage of South American health budgets
allocated to mental health 2005*

10,0 %
9,0 %

1,0 %

Chile: 2,3 %Perú: 2 %2,0 %Bolivia: 0,2 %3,0 %Colombia: 0,1 %4,0 %Paraguay: 0,1 %5,0 %Argentina: 2 %6,0 %Brasil: 2,5 %7,0 %Surinam: 4,2 %8,0 %All of the above problems can be found in the implementation of mental
health policies in the department of Caquetá, which fail to provide
any real individual or relational emotional support during a crisis.
Comparing regional expenditure, it is particularly striking that thecountry that allocates the smallest portion of its resources to mental
health is the only one where there is an active armed conflict.
As a result, the capacity of the department of Caquetá to respondto the population’s mental health needs is clearly insufficient due topoor legislation, poor implementation of national policies and to thelack of political will, funding and qualified staff.

0%*

Policy Committee of the Colombian
Association of Psychiatry. “National Policyin the Field of Mental Health: The Driving
Force for National Development andEnsuring Rights” (in Spanish). Ministry forSocial Protection. General Directorate for
Public Health. December 2007. Pg. 26.
http://www.psiquiatria.org.co/
BancoMedios/Documentos%20PDF/
politicanacionaldesaludmental.pdf

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8Conclusions

Médecins Sans Frontières / Doctors Without Borders is a direct
witness of the impact of the armed conflict on the mental healthof the population of Caquetá. Based on its experience in the field,
MSF has reached the following conclusions:• The epidemiological profile 22 of the patients treated at the MSF
mental health project in Caquetá, based on the diagnoses recorded,
is typical of a country in armed conflict.
• MSF patients who had been directly exposed to risk factors related
to the armed conflict were more liable than other patients to present
diagnoses typically found in war contexts, such as depression,anxiety disorders or grief.
• 49.2% of the patients seen at the project had been directly
affected by the conflict. The armed conflict also generates risks forthe mental health of the rest of the population.
• Not only is the armed conflict in Colombia a risk factor in itself
for the people exposed to it, but also creates conditions for the
emergence of other risk factors that contribute to deteriorating thehealth and the quality of life of the affected people and communities.
• In armed conflict contexts such as the one in Colombia, the links
between direct, structural and cultural violence cannot be
overlooked, since these forms of violence feed into each other andare interconnected.

All of the above highlights the significant need for specialised
mental health services for the population directly or indirectly
exposed to the armed conflict. Based on its findings, MSF
asserts that:• It is possible to gain access and effectively provide quality mental
health services to the population affected by the conflict.
• Regardless of whether or not the continuity of the provision oftherapeutic services can be guaranteed due to the restrictions onaccess linked to the armed conflict, there is evidence that they havea positive effect on patients’ mental health.
• Our project recorded a high demand for mental health services, bothin the population affected by the conflict and in other vulnerable
groups. This demonstrates that the need for this type of care is
not being addressed by the public structures in the area.
There is a clear need for mental health services that areboth accessible and adapted to the conditions and needs of a
population submitted to the hardships of the armed conflict.

22
An epidemiological profile is a collection of conditions and ways of life of a populationgroup that leads to a series of diagnoses, which in turn establish the main causes ofmortality and morbidity among that population.

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9Appendices

Appendix 1: Definitions for the five most common principal
diagnoses. (Based on ICD-10 classification)
Adjustment disorder. This disorder is characterised by the onsetof emotional or behavioural symptoms in response to an identifiable
stressor within a 3-month period after the stressful event. Its
clinical manifestations are greater-than-expected distress in
response to the stressor and a significant deterioration of social
activities or daily routines.
Relational problems and problems related to abuse or neglect.
Relational problems include patterns of interaction between or
among members of a relational unit that are associated withclinically significant impairment in functioning, or symptoms among
one or more members of the relational unit, or impairment in
the functioning of the relational unit itself. These problems canexacerbate or complicate the treatment of a mental disorder orphysical illness of one or more members of the unit; they can becaused by a mental disorder or by a medical illness; they can be
independent from other disorders in the same subject or can occur
without any other concurring disorder.
Problems related to abuse and neglect include categories that areused when the subject of clinical attention is a person seriously
abused by another, either through physical abuse, sexual abuse orneglect, both in adults and in children.
Major depression, single episode. Characterised by the presence,
for at least two weeks, of at least 5 of the following symptoms:
depressed mood, dysphoria or irritability for most of nearly every
day; anhedonia or a marked decrease of interest or pleasure innearly all activities, for most of nearly every day; loss or gainof weight or appetite; difficulty resting properly, either throughsleeping too much or too little; agitated or retarded motor activity;
fatigue or weakness; recurrent feelings of self-worthlessness or guilt;
reduced intellectual capacities; recurrent thoughts about death or
suicidal ideas.
The above applies in the absence of criteria for mixed affective,schizoaffective or schizophrenic disorders. The condition has negative
repercussions on the patient’s social or working life or other personalfunctioning. The symptoms are not explained by the intake of toxic
substances or medication or by an organic disease. The disorder
cannot be explained by grief in reaction to the loss of a person who
is significant for the patient.
Grief. Normal bereavement initiates due to the death of a loved
one, either immediately or several months after the event. Its mostcommon signs and symptoms are: sadness, persistent memoriesof the deceased person, crying, irritability, sleeping disorders anddifficulty concentrating. It does not normally last longer than 6months, though duration varies from one individual to another.

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In some cases, normal bereavement processes can lead to major
depressive disorders.
According to ICD-10 classification, bereavement reactions are
only classified as adaptive disorders when their duration, intensity
or content are not normal; otherwise the reaction is classified as
normal grieving.
Mood disorders. The main disturbance in these disorders is achange in mood or affections, normally tending towards depression(whether or not accompanied by anxiety) or euphoria, usuallyaccompanied by changes in the person’s general level of activity(vitality). Most other symptoms are secondary to these changes
in mood and vitality or are understandable in that context. The
majority of these disorders tend to be recurrent and the onset ofeach episode is generally related to stressful situations or events.

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Appendix 2: Table of diagnoses

Principal diagnoses in the Caquetá mental health project in Colombia. 2005 – 2009.
Type of diagnosis

Main (n)%Major depression disorder, single episode

574

11.33

Recurrent major depression disorder

50

1.00

Bipolar disorder

48

0.94

Other mood disorders

420

8.29

Acute stress disorder

70

1.38

Post-traumatic stress disorder

76

1.50

Panic disorder (anxiety) with and without agoraphobia

15

0.29

Other anxiety disorders

217

4.28

Adjustment disorder

946

18.70

Somatoform disorders

16

0.31

Dissociative disorders

1

0.01

Factitious disorder00.0Childhood behavioural
and/or emotional disorders

292

5.80

Specific developmental disorders

95

1.87

Pervasive developmental disorders

2

0.03

Childhood anxiety disorders

30

0.60

Mental retardation

89

1.75

Schizophrenia and other psychotic disorders

47

0.92

Organic mental disorders

33

0.65

Substance-related disorders

29

0.57

Sexual identity and gender disorders and paraphilias

19

0.37

Eating disorders

3

0.05

Sleep disorders

12

0.23

Personality disorders

5

0.10

Impulse control disorders
not classified in other sections

8

0.15

Drug-induced disorders

3

0.05

Grief

451

8.90

Relational problems and problems
related to abuse or neglect

889

17.60

Suicidal ideation/gestures and attempts

4

0.07

Other problems potentiallyrequiring clinical care

35

0.70

Unspecified mental disorder

25

0.50

Other disorders(e.g.: Axis III medical conditions)

20

0.40

No disorder observed

540

10.66

5,064

100.00%Total
Source: MSF – España Databases

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