The Caquetá Department, in the south of the country, has historically been one of the hardest-hit areas in the conflict, particularly, the Caragena del Chairá y San Vicente del Caguán Municipalities. Caquetá was one of the areas in the country where the Patriot Plan was implemented. In early 2004, a military offensive was launched against subversive groups also covering the Meta, Guaviare and Putumayo Departments. Since then, the guerrilla has withdrawn to rural areas and Florencia, the department’s capital city, and the municipal administrative centres are under military control. And the civilian populations in rural areas, about 250,000 people, find themselves caught between the conflict with limited access to healthcare. Serge Le Duc has just returned from Caquetá, where he has been working with Médecins Sans Frontiéres (MSF) for two years. Next, he talks about MSF activities in the area:

Currently, what projects is MSF running in the Caquetá Department?

MSF has been present in the Caquetá since 1999. In eight years several projects have been implemented both in rural and urban areas. In Florencia, the department’s capital city, in 2005, MSF opened a mental health centre (MHC) that is still operational. Primary healthcare mobile teams, integrating a mental health component, started in July 2007 in the north of the department (Cartagena and San Vicente municipalities).

Why a mental health project in Florencia?

We decided to open a mental health centre in Florencia because we realized that there were many needs related to this issue mainly due to the vast number of internally displaced persons (IDPs) arriving in the town because of the conflict. Out of a population of 120,000 people, between 15 and 30% are IDPs (between 20,000 and 40,000 people). Besides, the arrival of IDPs is ongoing. According to the UAO (Unidad de Atención y Orientación or Guindace and Care Unit), in charge of recording newly displaced people so that they are entitled to government aid, every week Florencia sees the arrival of 50-60 families fleeing from the conflict.

The Florencia Health Centre offers care to those without social benefits. At the beginning of the project, we decided not to limit healthcare just to IDPs in order to prevent stigmatisation and also because most of the host population in the department, even if not displaced, also endures the conflict. However, IDPs account for 60% of the patients coming to the MSF health centre. Curiously enough, the pathologies we see are rather common — mainly depression, anxiety, bereavement or adjustment syndromes — and not so much post-traumatic stress as we had initially thought. IDPs arriving in Florencia first look for job and shelter before caring for their mental health, which they do not prioritize until after they come to the MSF-run MHC.

Measuring the impact of a mental health project is always difficult, yet the acknowledgements from our counterparts and the success of our health centre have proven the relevance of this programme.

Does the population in Caquetá have access to health care?

In urban areas, the population has relative access to health due to the complex and exclusive Colombian health system. In Florencia, the Maria Inmaculada hospital, the only secondary level facility in the department, has recently faced major financial constraints. It used to take in for free both IDPs and vulnerable populations, however in the past few months it has decided to no longer accept them due to lack of resources.

In rural areas, access is much more restricted. The population there is very scattered, spreading across a very vast area. Caquetá covers an area twice the size of Switzerland. The State has a network of health promoters in the department but needs far outnumber the government’s response. In addition, there are large areas to which access is not possible due to the conflict. These are precisely the priority areas where we aim to develop our projects.

How does MSF work in rural areas?

In 2004, an MSF team was detained by the guerrilla for one week and there were several security incidents. As a result, we had to interrupt our mobile medical teams in rural areas.

In July 2007, we managed to regain access to rural areas and successfully organise our first mobile clinic integrating a mental health care.

How does a mobile clinic work?

We always go to places where we have certain assurances: an invitation from the communal board representing the population in the area for instance. This means that tacitly and through the community we also have the green light from the guerrilla.

We start work at eight in the morning. Based on the needs of the population we distribute tokens: to see the doctor, the vaccinator, the nurse in charge of monitoring child growth and development, the psychologist, etc. For the psychologist at nine there are no longer any tokens left, as we cannot see more than 12 people a day and there are many people seeking to see our mental health specialist. We were surprised by the success of mental health care in rural areas; we had feared that the psychologist would be frowned upon by the guerrilla or that people would think that the psychologist could only help those who are “insane”. In the mobile medical teams, there is a clinical psychologist that sees people in the clinic and a social psychologist that stays outside and explains what mental health is to the population; for example, the counsellor explains that crying when one has lost a loved one is normal but that if the person cannot manage to move on, seeing a professional is important. People rapidly understand that this is something that can help them and ask to see a psychologist.

Mobile clinics last between two or three days in the same place and they are made up of a team of about 10 people. Whenever possible, due to security reasons, we take with us MoH professionals in order to involve local hospitals so that they can later replace us, also seeking to upgrade their knowledge too.

How have you selected the places where to organise mobile clinics?

Since July 2007, we have been conducting exploratory missions in various areas within Caquetá. This is the best and safest way to work in the country. What we normally understand as rapid assessments — fast and not offering any services other than gathering information — are not possible in this context due to obvious security concerns for the teams involved. This means that we have been little by little gaining access to isolated and complicated areas, organising there our mobile clinics while assessing the situation the population endures as well as the relevance of our intervention in these areas.

We try to enter the most relevant places where the population is caught in the middle of the conflict. In rural areas, the population is very isolated (transport is scant and costly mainly by boat along the river) and besides many times people need to request permission from the guerrilla to leave, a permit that is only given for a certain number of days.

For mobile clinics, we have chosen the San Vicente and Cartagena municipalities, in the north of the department where about 90,000 people live. These two municipalities pose many problems in Caquetá as it is from this area where most of the IDPs fleeing the fighting between the guerrilla and the military come from. The civilian population stays trapped in the middle of the conflict enduring the consequences and falling prey to abuses perpetrated by both warring parties. Many times, they are accused by FARC of being military spies and by the military of being rebels. Many people flee to Florencia and if they still feel threatened move to Bogotá or further away.

What are the main challenges for the work MSF is to carry out in the coming months?

So far, we have chosen four places where to organise mobile clinics on a quarterly basis. This will enable us to have an impact on these populations’ public health. In addition, we will always work with government’s health promoters. In each place, we will work with the same health promoters in order to train them and better prepare them to properly perform their tasks. Besides, if necessary, we will rehabilitate the health centre where they work.

A special feature of this project was our decision to keep room for these mobile clinics in other places where, according to the evolution of the conflict, there might be a need for them. The conflict in Colombia is very volatile and our main challenge is that we want to be flexible and be ready to respond to the arising needs.

The release of those kidnapped, the military offensive against the FARC and the Hugo Chávez’s mediation attempts have again drawn media attention on the Colombian conflict. In Caquetá, have all these events had a bearing on our operations?

I don’t know if it is related to the kidnapping but it is obvious that in Caquetá for the past six or seven months military operations and combats have intensified in areas where MSF is or was present, which obviously has had an impact on our activities. For example, a mobile medical team in Llanos del Yarí, a part of the San Vicente municipality, emblematic for being one of FARC’s strongholds. It was a very relevant place to provide mobile clinics; the population in the area had not seen a doctor for years. After a few months ago, Chávez proposed to Marulanda a meeting there, we have no longer been able to return to the area as military pressure has increased.

Also after the death of Raúl Reyes, due to security, we had to cancel a mobile clinic that was planned. Lately the conflict has worsened in the Caquetá, thus making our work more difficult yet more relevant as well.