"There is a fear that you will be attacked just for the act of working in health": a survey of experiences of violence against healthcare in Colombia.

BACKGROUND: Colombia has experienced decades of conflict between the government and non-state actors. Attacks on healthcare have been a grave but regular facet of that violence. In response, the Misión Médica (MM) program was developed to support, protect, and defend healthcare. Sporadic violence continues, with many recent attacks perpetrated not by armed actors but by residents. Given the history of conflict and ongoing violence, we sought to capture the perspectives of both healthcare workers (HCWs) and community members (CMs) regarding the characteristics and impacts of attacks on health in Colombia to gain insight into how to better prevent violence and mitigate its impacts. METHODS: A cross-sectional survey was conducted from January to March 2021 in seven departments in Colombia in regions that witnessed attacks on healthcare. Questionnaires were administered to HCWs and CMs via purposive sampling, probing their experiences with attacks on health with both closed and open-ended questions. The categorical responses were stratified by health worker vs. non-health worker and descriptively analyzed. Narrative responses were analyzed via a hybrid deductive/inductive thematic approach. RESULTS: Seventy-three individuals participated in the study (36 HCWs and 37 cm). Approximately 77% of HCWs believed that attacks on healthcare impacted health outcomes while 68% of CMs did not see a direct connection between violence against healthcare and poor health outcomes. Awareness of the MM program was significantly different between HCWs (83.3%) and CMs (37.8%). The survey responses explored the characteristics of attacks on health, compounded impacts of violence on the health system, personal impacts, and perspectives on mitigation efforts. CONCLUSIONS: The study demonstrates that: (1) attacks on healthcare are context-dependent and require a local lens for mitigation and management; (2) both HCWs and CMs have critical perspectives that must be considered, (3) the impacts of violence against healthcare are complex and compounded and (4) that awareness of the legal protections of the Geneva Conventions must be combined with education on the health impacts for robust protection strategies. Critically, Both CMs and HCWs experience fear and psychosocial ramifications of these attacks, suggesting the need for stronger protections and resources to support the health workforce and the local community.

La macroviolencia encubridora y la invisibilización de las víctimas del conflicto. Estudio etnográfico de la masacre de Cienaguita-Pita (Atlántico) / Macroviolence and the invisibilization of the victims of the conflict. Ethnographic study of the Cienaguita-Pita massacre (Atlántico) / Macro-violência e a invisibilização das vítimas do conflito. Estudo etnográfico do massacre de Cienaguita-Pita (Atlántico)

Este artículo argumenta que la macroviolencia ha invisibilizado buena parte de las masacres ocurridas en regiones donde el conflicto interno fue de menor intensidad, ha banalizado sus efectos en pequeñas poblaciones, y con ello, ha provocado una relación transaccional entre el Estado y victimarios con las víctimas de masacres de menor escala. Por esta razón, por medio de un estudio de caso, haciendo uso de entrevistas semiestructuradas, grupos focales y encuestas al universo de habitantes de Cienaguita-Pita (Atlántico), se ilustrará cuáles fueron los efectos de la masacre, las entradas diferenciadas del Estado y el acceso que tuvieron las víctimas a los derechos a la verdad, justicia, reparación, no repetición y dignificación. Por último, este artículo pretende visibilizar una de las masacres ocurridas en el Caribe, que ha sido oculta por cuenta de la macroviolencia que caracterizó a la región en las décadas de 1990 y 2000, y demostrar, además, que el Estado es quien ha asumido la carga de indemnizar a las víctimas y establecer algunos insumos para reconstruir la verdad en el conflicto armado.

This article argues that macro-violence has made invisible a good part of the massacres that occurred in regions where the internal conflict was of lesser intensity, has trivialized its effects in small populations, and with it, has provoked a transactional relationship between the State and victimizers with the victims of smaller scale massacres. For this reason, by means of a case study, using semi-structured inter-views, focus groups and surveys of the universe of inhabitants of Cie-naguita-Pita (Atlántico), we will illustrate the effects of the massacre, the State>s differentiated approaches and the victims> access to the rights to truth, justice, reparation, non-repetition and dignity. Finally, this article aims to make visible one of the massacres that occurred in the Caribbean, which has been hidden due to the macro-violence that characterized the region in the 1990s and 2000s, and also to demonstrate that the State has assumed the burden of compensating the victims and establishing some inputs to reconstruct the truth in the armed conflict.

Este artigo argumenta que a macro-violência tornou invisível uma grande parte dos massacres que ocorreram em regiões onde o conflito interno foi de menor intensidade, banalizou os seus efeitos em pequenas populações, e provocou assim uma relação transaccional entre o Estado e os perpetradores com as vítimas de massacres de menor escala. Por este motivo, através de um estudo de caso, utilizando entrevistas semi-estruturadas, grupos focais e inquéritos aos habitantes de Cienaguita-Pita (Atlántico), ilustraremos os efeitos do massacre, as abordagens diferenciadas do Estado e o acesso das vítimas aos direitos à verdade, à justiça, à reparação, à não repetição e à dignidade. Finalmente, este artigo visa tornar visível um dos massacres ocorridos nas Caraíbas, que foi escondido devido à macro-violência que caracterizou a região nos anos 90 e 2000, e também demonstrar que o Estado assumiu o ónus de compensar as vítimas e estabelecer alguns contributos para a reconstrução da verdade no conflito armado.

Trauma Craneoencefálico por Proyectil de Arma de Fuego: Revisión Temática / Traumatic brain injury (TBI) by a firearm projectile: thematic review / Traumatismo cranioencefálico por projétil de arma de fogo: revisão temática

Resumen El trauma craneoencefálico (TCE) por proyectil de arma de arma de fuego (PAF) es una condición severa producida por alteraciones mecánicas sobre el encéfalo. En Colombia, uno de cada cinco homicidios se produce a nivel craneal. Objetivo: Realizar una revisión de la literatura para identificar los aspectos médico-legales y clínico-quirúrgicos del TCE por PAF. Metodología: Revisión realizada por medio de búsqueda en bases de datos de literatura médica y recopilación de datos publicados por entidades gubernamentales. Resultados: El TCE por PAF, es un evento epidemiológicamente constante, cuyos patrones se relacionan con la presencia de conflictos armados. Se asocia con manifestaciones clínicas y complicaciones severas asociadas con variables como el tipo de arma y munición, sexo de la víctima, región principal de lesión y mecanismo de muerte. La mortalidad de este evento es muy alta si no se realiza intervención quirúrgica; y de hacerlo, las lesiones determinan la reducción de la expectativa y calidad de vida. Conclusión: El conflicto armado actual de Colombia, hace del TCE por PAF un tema de importancia criminológica, criminalística y médico-legal.

Abstract Traumatic brain injury (TBI) caused by a firearm projectile (FAP) is a severe condition produced by mechanical alterations on the encephalon. In Colombia, one in every five killings is produced at cranial level. Objective: to do a literature review to identify the medical-legal and clinic-surgical issues of TBI by FAP. Methodology: a review conducted by means of medical literature databases searching and data gathering published by governmental entities. Results: TBI by FAP is an event epidemiologically constant; and its standards are related to the presence of the armed conflicts. It is associated with clinical manifestations and severe medical complications connected with diverse variables such as type of weapons and ammunition, sex of the victims, main region of the lesion and death mechanism. If the surgical operation is not performed, the mortality in this event is very high, but if the surgery is carried out, the lesions determine the decrease of life expectancy and quality. Conclusion: the current Colombian armed conflict makes TBI by FAP a topic of criminological, criminalistics and medical-legal relevance.

Resumo O Traumatismo Cranioencefálico (TCE) por Projétil de Arma de Fogo (PAF) é uma condição severa causada por alterações mecânicas sobre o encéfalo. Na Colômbia, um em cada cinco homicídios é producido na zona craniana. Objetivo: realizar uma revisão de literatura para identificar os aspectos médico-legais e clínico-cirúrgicos do TCE por PAF. Metodologia: revisão realizada por meio de busca em bases de dados da literatura médica e coleta de dados publicados por entidades governamentais. Resultados: o TCE por PAF é um evento epidemiologicamente constante, cujos padrões relacionam-se à presença de conflito armado. Associa-se a manifestações clínicas e complicações graves vinculadas a diversas variáveis, como o tipo de arma e munição, sexo da vítima, lugar principal da lesão e mecanismo da morte. A mortalidade, decorrente desse evento, é muito alta caso não seja realizada intervenção cirúrgica. No pós-cirúrgico, as lesões determinam a redução da expectativa e da qualidade de vida. Conclusão: o conflito armado atual na Colômbia faz do TEC por PAF um tema de importancia criminológica, criminalística e médico-legal.

La guerra como desastre. Sus consecuencias psicológicas / War as a disaster. Its psychological consequences

En más de 100 conflictos bélicos que se han producido en los últimos diez años, más del 80 por ciento de las víctimas son civiles. Se ha producido un desarrollo acelerado en las investigaciones concernientes a las consecuencias psico-sociales de la guerra en la población civil, la cual es el blanco principal de las víctimas en la guerra contemporánea. Este trabajo constituye una revisión bibliográfica sobre la guerra como desastre, acerca de los conceptos “modernos” de “guerra total”, desastre y las consecuencias psicológicas de la guerra en la población civil, la utilización de los niños como soldados lo cual acarrea desórdenes mentales marcados y se aborda el problema de la violencia sexual como arma de guerra. Las mujeres, las jóvenes, e incluso niñas, son a menudo sometidas, violadas, secuestradas y forzadas a la esclavitud sexual o cualquier tipo de abuso sexual; son vejadas, humilladas y dañadas en lo más profundo de sus sentimientos psicológicos, y valores morales, lo que también trasciende al grupo social, comunidad, clase social o etnia a la que pertenecen. El deterioro o la destrucción de la infraestructura económica, social y política de las naciones en conflicto impide la atención de las necesidades básicas de la población. El trastorno por estrés postraumático es la entidad nosológica más frecuente en las víctimas de la guerra, pero existen otros trastornos mentales que hay que tener en cuenta.

In over 100 war conflicts that have occurred in the last 10 years, m ore than 80 percent of the victims were civilians. The scope of recent studies has been increasingly focused on psychological and social effects among civilians who are the target and main victims of contemporary wars. This article is an explanation of why war is considered a disaster, a revision of modern terms for war, disaster and the psychological effects of war on civilians, the training of children as soldiers, and the resulting mental disorders. It touches upon sexual violence problem as a war weapon. Women, adolescents and young children are often violated and forced into sexual slavery or any other type of sexual abuse, causing humiliation and psychological, ethical and moral damage, which can affect social groups, communities, social classes, or races. The deterioration or destruction of the economic, social and political infrastructure of the countries in conflict hinders the satisfaction of the citizens' basic needs. The most common psychological effect among war victims is posttraumatic stress, but there are also other mental disorders which must be taken into consideration.