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Colombia continues to struggle with violence
World Report
Colombia continues to struggle with violence Although its homicide rate is down, falling from 64 per 100 000 people in 2001, to 38 per 100 000 people in 2005, violence remains a major public-health problem in Colombia and much of the Latin American region. Mike Ceaser reports from Colombia’s capital city, Bogotá.
www.thelancet.com Vol 370 November 10, 2007
100 000 rate seen in the USA or the even lower figure of 0·6 per 100 000 seen in England and Wales. Most of those killed are young men living in urban areas, but many died as a result of the country’s ongoing civil war. Colombia is the only country in the Americas that still has an ongoing armed conflict. Indeed, Colombia has had some sort of civil strife almost continuously since the end of World War II. Colombia was torn apart by a civil war that lasted from 1948 to 1956, leaving an estimated 200 000 people dead. The 1960s saw the rise of leftist insurgencies, which by the 1970s had forged links with murderous drug cartels. Over the same period, in response to the insurgencies and rising drug crime, the country saw the emergence of right-wing paramilitaries and police death squads. During the 1990s, according to a study by Richard Garfield and Claudia Patricia Llanten Morales published in the Pan American Journal of Public Health in 2004, homicide was the first or second most common cause of death for all age groups in Colombia except in children aged 0–4 years.
The recent drop in the country’s homicide rate has been attributed in part to the law-and-order policies of President Álvaro Uribe, who has beefed up police presence in the cities and military presence in the countryside, but also to social outreach programmes that have sought to engage marginalised youth and to reduce the country’s “culture of violence”. The Uribe government has also negotiated settlements with many of the paramilitary armies that, in return for reduced punishments for their crimes, have agreed to disband. Ironically, however, many of the thousands of ex-paramilitary fighters, with little education and few marketable skills besides killing, have reportedly turned to crime. The civil strife has also increased crime by forcing hundreds of thousands of people to flee their homes in the countryside and to settle in the nation’s already overcrowded cities. Over the past decade, close to 2 million people in Colombia have been forced from their homes because of the fighting. In 2004 alone, nearly 425 000 people were displaced by
Mike Ceaser
On a recent Friday night, Omar Suarez found himself in the emergency department of Bogotá’s John Kennedy Public Hospital, having his arm sewn up by a medical student. Suarez, an agronomical engineer, said three youths in their 20s attacked him, grabbing his mobile phone and slicing open his forearm. The Kennedy hospital is located in a sprawling, impoverished, and violent neighbourhood littered with chaotic avenues, dangerous alleys, and cheap nightclubs. Every night its emergency staff sees a steady stream of trauma and violence-related cases—victims of stabbings, shootings, and assaults, as well as alcohol-related injuries. Weekends, when the streets and bars are full of Bogotános flush with payday cash, are particularly busy. Emergency room physician Felipe Naranjo said the department will treat about 70 trauma cases on a typical weekend night. “60 to 70% are victims of aggression and fights”, he said, and the rest are victims of roadtraffic accidents, intoxication-related injuries, and a small proportion due to domestic accidents, such as falls. Suarez was lucky to have been slashed, said Naranjo, because in many cases muggers stab their victims instead, inflicting serious puncture wounds to the head, heart, lungs, and other organs. “Many times [the muggers] are under the effects of alcohol and drugs”, he says, “and they are not even aware of the injuries” they cause. According to a report released by the Pan American Health Organization (PAHO) in October, the murder rate in this nation of 44 million was 38 per 100 000 people in 2005, down from 64 per 100 000 people in 2001, but still far higher than the 5·6 per
Omar Suarez is treated for a knife wound after a violent mugging on the streets of Bogotá
1601
World Report
Panos Pictures
The printed journal includes an image merely for illustration Paramilitary groups have contributed to the high rates of violence in Colombia
violence. Every day an estimated 90 internally displaced people arrive in Bogotá, many of them settling in the Ciudad Bolívar district, which borders the Kennedy neighbourhood. This district, where right-wing paramilitary groups and leftist guerrilla bands vie for control of territory and the drug trade, has become notorious for violence. In its report, PAHO emphasises that violence is a public-health problem in much of Latin America. Although homicide rates have fallen in Colombia, Brazil has seen its rates rise from 11·4 to 28·5 per 100 000 people. “In 2000”, notes the report, “28% of all homicides in the Americas took place in Brazil”. Gang violence is a major problem, accounting for between 20% to 50% of all violent crimes. Gangs are prevalent in many major Latin American cities where young, poor men find themselves unemployed and marginalised and where drug trafficking is rife, guns are easy to obtain, and police are often either inefficient or corrupt. The “epicentre” of gang violence is El Salvador, Guatemala, and Honduras, PAHO says. Governments of these countries have adopted get-tough policies targeting crime and gangs with mixed results. El Salvador, for example, saw its homicide rates drop from 62·5 per 100 000 people in 2000, to 54·9 in 2005, but Guatemala has seen 1602
its rates rise from 20·0 per 100 000 people to 27·0, and in Honduras the homicide rate is nearly 53 per 100 000 people. Heavy drinking has long been an important part of male working-class culture in the region, and alcohol abuse, experts says, is another major contributor to the region’s violence problem. Most of the patients with trauma at the Kennedy Hospital were drunk when they were injured. After Suarez left the Kennedy Hospital’s emergency department, a 25-year-old man came in with a lacerated arm. He said that he had been drinking with his brother when he became angry over family tensions and smashed his arm through a window. This was not the first time he had injured himself while drinking. 3 years before, he said, he had been shot in the abdomen during a drunken fight. “I don’t take care of myself when I am drunk”, he acknowledged. According to the PAHO report, the contribution of alcohol consumption to mortality in Central and South American countries exceeds worldwide figures, accounting for 4·8% of all deaths compared with 3·2% worldwide. Although alcoholrelated disease rates were high, 60% of the estimated 279 000 alcoholrelated deaths in the region in 2000 were attributable to intentional and unintentional injuries, the report said. Efforts have been made to reduce alcohol abuse in the region including public education campaigns and changes in drinking laws, such as earlier closing of bars and other drinking establishments. Oscar Dario Reina, a retired Colombian police sergeant who served in both rural and urban areas during his 23-year career, said alcohol often lay behind the violence he saw. Once, when he was working in a small town there was a case in which one man hit another on the head while playing a drinking game. The next weekend, the man who had been struck killed the other man, sparking a feud between
five families that lasted for 7 years and killed dozens of men. The police could do nothing, Reina said, because none of those involved would cooperate. The killing ended, he said, only when all of the men in the families were dead. Reina says he has seen incremental improvements over the years. Publichealth programmes targeting alcohol abuse have successfully placed a stigma on drunkenness. In the past, country people were “happy to have” their children start drinking at a young age, he said, but “lately, there has been a tendency among country people to teach [their children] that alcohol is not good”. Timothy Ross, a Briton, worked as a journalist from 1973 to 1998, covering conflicts in Colombia and the region, before becoming qualified as a licensed nurse and working for the past 5 years in a Bogotá clinic for youths involved in prostitution and drug abuse. Stabbings, Ross said, were routine among the youths he attended because there is a culture of violence. “The level of latent violence is very high, very close to the surface”, he said. Ross says the culture of violence has roots going all the way back to the Spaniards who conquered the region in search of gold and other riches and the indigenous peoples who engaged in human sacrifice. The wars of the 20th century have only made that culture stronger, Ross says. Other nations, such as neighbouring Ecuador, have similar levels of poverty and social inequality but have never had the same rates of violence, Ross pointed out. “It is the acceptance of violence as normative, not as an aberration”, in some parts of Colombia’s society, he said. “On the contrary, if you are violent, you are not deviant.” But at the Kennedy Hospital, Fabio Barrera, the hospital’s director, is not concerned with such analyses. “When there is poverty, the disposition towards violence is much greater”, he says.
Mike Ceaser www.thelancet.com Vol 370 November 10, 2007
Colombia continues to struggle with violence Although its homicide rate is down, falling from 64 per 100 000 people in 2001, to 38 per 100 000 people in 2005, violence remains a major public-health problem in Colombia and much of the Latin American region. Mike Ceaser reports from Colombia’s capital city, Bogotá.
www.thelancet.com Vol 370 November 10, 2007
100 000 rate seen in the USA or the even lower figure of 0·6 per 100 000 seen in England and Wales. Most of those killed are young men living in urban areas, but many died as a result of the country’s ongoing civil war. Colombia is the only country in the Americas that still has an ongoing armed conflict. Indeed, Colombia has had some sort of civil strife almost continuously since the end of World War II. Colombia was torn apart by a civil war that lasted from 1948 to 1956, leaving an estimated 200 000 people dead. The 1960s saw the rise of leftist insurgencies, which by the 1970s had forged links with murderous drug cartels. Over the same period, in response to the insurgencies and rising drug crime, the country saw the emergence of right-wing paramilitaries and police death squads. During the 1990s, according to a study by Richard Garfield and Claudia Patricia Llanten Morales published in the Pan American Journal of Public Health in 2004, homicide was the first or second most common cause of death for all age groups in Colombia except in children aged 0–4 years.
The recent drop in the country’s homicide rate has been attributed in part to the law-and-order policies of President Álvaro Uribe, who has beefed up police presence in the cities and military presence in the countryside, but also to social outreach programmes that have sought to engage marginalised youth and to reduce the country’s “culture of violence”. The Uribe government has also negotiated settlements with many of the paramilitary armies that, in return for reduced punishments for their crimes, have agreed to disband. Ironically, however, many of the thousands of ex-paramilitary fighters, with little education and few marketable skills besides killing, have reportedly turned to crime. The civil strife has also increased crime by forcing hundreds of thousands of people to flee their homes in the countryside and to settle in the nation’s already overcrowded cities. Over the past decade, close to 2 million people in Colombia have been forced from their homes because of the fighting. In 2004 alone, nearly 425 000 people were displaced by
Mike Ceaser
On a recent Friday night, Omar Suarez found himself in the emergency department of Bogotá’s John Kennedy Public Hospital, having his arm sewn up by a medical student. Suarez, an agronomical engineer, said three youths in their 20s attacked him, grabbing his mobile phone and slicing open his forearm. The Kennedy hospital is located in a sprawling, impoverished, and violent neighbourhood littered with chaotic avenues, dangerous alleys, and cheap nightclubs. Every night its emergency staff sees a steady stream of trauma and violence-related cases—victims of stabbings, shootings, and assaults, as well as alcohol-related injuries. Weekends, when the streets and bars are full of Bogotános flush with payday cash, are particularly busy. Emergency room physician Felipe Naranjo said the department will treat about 70 trauma cases on a typical weekend night. “60 to 70% are victims of aggression and fights”, he said, and the rest are victims of roadtraffic accidents, intoxication-related injuries, and a small proportion due to domestic accidents, such as falls. Suarez was lucky to have been slashed, said Naranjo, because in many cases muggers stab their victims instead, inflicting serious puncture wounds to the head, heart, lungs, and other organs. “Many times [the muggers] are under the effects of alcohol and drugs”, he says, “and they are not even aware of the injuries” they cause. According to a report released by the Pan American Health Organization (PAHO) in October, the murder rate in this nation of 44 million was 38 per 100 000 people in 2005, down from 64 per 100 000 people in 2001, but still far higher than the 5·6 per
Omar Suarez is treated for a knife wound after a violent mugging on the streets of Bogotá
1601
World Report
Panos Pictures
The printed journal includes an image merely for illustration Paramilitary groups have contributed to the high rates of violence in Colombia
violence. Every day an estimated 90 internally displaced people arrive in Bogotá, many of them settling in the Ciudad Bolívar district, which borders the Kennedy neighbourhood. This district, where right-wing paramilitary groups and leftist guerrilla bands vie for control of territory and the drug trade, has become notorious for violence. In its report, PAHO emphasises that violence is a public-health problem in much of Latin America. Although homicide rates have fallen in Colombia, Brazil has seen its rates rise from 11·4 to 28·5 per 100 000 people. “In 2000”, notes the report, “28% of all homicides in the Americas took place in Brazil”. Gang violence is a major problem, accounting for between 20% to 50% of all violent crimes. Gangs are prevalent in many major Latin American cities where young, poor men find themselves unemployed and marginalised and where drug trafficking is rife, guns are easy to obtain, and police are often either inefficient or corrupt. The “epicentre” of gang violence is El Salvador, Guatemala, and Honduras, PAHO says. Governments of these countries have adopted get-tough policies targeting crime and gangs with mixed results. El Salvador, for example, saw its homicide rates drop from 62·5 per 100 000 people in 2000, to 54·9 in 2005, but Guatemala has seen 1602
its rates rise from 20·0 per 100 000 people to 27·0, and in Honduras the homicide rate is nearly 53 per 100 000 people. Heavy drinking has long been an important part of male working-class culture in the region, and alcohol abuse, experts says, is another major contributor to the region’s violence problem. Most of the patients with trauma at the Kennedy Hospital were drunk when they were injured. After Suarez left the Kennedy Hospital’s emergency department, a 25-year-old man came in with a lacerated arm. He said that he had been drinking with his brother when he became angry over family tensions and smashed his arm through a window. This was not the first time he had injured himself while drinking. 3 years before, he said, he had been shot in the abdomen during a drunken fight. “I don’t take care of myself when I am drunk”, he acknowledged. According to the PAHO report, the contribution of alcohol consumption to mortality in Central and South American countries exceeds worldwide figures, accounting for 4·8% of all deaths compared with 3·2% worldwide. Although alcoholrelated disease rates were high, 60% of the estimated 279 000 alcoholrelated deaths in the region in 2000 were attributable to intentional and unintentional injuries, the report said. Efforts have been made to reduce alcohol abuse in the region including public education campaigns and changes in drinking laws, such as earlier closing of bars and other drinking establishments. Oscar Dario Reina, a retired Colombian police sergeant who served in both rural and urban areas during his 23-year career, said alcohol often lay behind the violence he saw. Once, when he was working in a small town there was a case in which one man hit another on the head while playing a drinking game. The next weekend, the man who had been struck killed the other man, sparking a feud between
five families that lasted for 7 years and killed dozens of men. The police could do nothing, Reina said, because none of those involved would cooperate. The killing ended, he said, only when all of the men in the families were dead. Reina says he has seen incremental improvements over the years. Publichealth programmes targeting alcohol abuse have successfully placed a stigma on drunkenness. In the past, country people were “happy to have” their children start drinking at a young age, he said, but “lately, there has been a tendency among country people to teach [their children] that alcohol is not good”. Timothy Ross, a Briton, worked as a journalist from 1973 to 1998, covering conflicts in Colombia and the region, before becoming qualified as a licensed nurse and working for the past 5 years in a Bogotá clinic for youths involved in prostitution and drug abuse. Stabbings, Ross said, were routine among the youths he attended because there is a culture of violence. “The level of latent violence is very high, very close to the surface”, he said. Ross says the culture of violence has roots going all the way back to the Spaniards who conquered the region in search of gold and other riches and the indigenous peoples who engaged in human sacrifice. The wars of the 20th century have only made that culture stronger, Ross says. Other nations, such as neighbouring Ecuador, have similar levels of poverty and social inequality but have never had the same rates of violence, Ross pointed out. “It is the acceptance of violence as normative, not as an aberration”, in some parts of Colombia’s society, he said. “On the contrary, if you are violent, you are not deviant.” But at the Kennedy Hospital, Fabio Barrera, the hospital’s director, is not concerned with such analyses. “When there is poverty, the disposition towards violence is much greater”, he says.
Mike Ceaser www.thelancet.com Vol 370 November 10, 2007