A Forgotten Population

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As the recipient of the 2015 EMRA Global Health Initiative Award and as the senior teaching assistant of Post-conflict Colombia and Public Health: A Project of the Open Hands Initiative and Harvard Humanitarian Initiative in Collaboration with the Universidad de Antioquia, I had the pleasure of working directly with the internally displaced population (IDP) of Medellin, Colombia. Through this incredible opportunity, I witnessed the raw complexities this forgotten population faces on a consistent basis.

Internal displacement was once described by Former Secretary-General of the United Nations, Kofi Annan, as “the great tragedy of our times” and IDPs “among the most vulnerable of the human family.”1 As of 2014, there were 38 million IDPs in the world, nearly twice the number of refugees – and 77% of this population lived in just 10 countries: Syria, Colombia, Iraq, Sudan, Democratic Republic of Congo, Pakistan, South Sudan, Somalia, Nigeria, and Turkey. The current conflict in Syria and the ongoing crisis in Colombia account for one-third of the world’s displaced, with 20% and 16% of the world’s IDPs living in each country, respectively.2

One important distinction is that, unlike refugees, IDPs are not bestowed a status that allows them explicit or specific international protection or assistance. According to the United Nation’s (UN) Guiding Principles on Internal Displacement, “internally displaced persons are persons or groups of persons who have been forced or obliged to flee or to leave their homes or places of habitual residence, in particular as a result of or in order to avoid the effects of armed conflict, situations of generalized violence, violations of human rights or natural or human-made disasters, and who have not crossed an internationally recognized State border.”3 Drafted in 1998 by the late Sergio Vieira de Mello, UN Under-Secretary General for Humanitarian Affairs and Emergency Relief Coordinator, The Guiding Principles identify the guarantees consistent with international human rights and humanitarian law that protect civilians but focus on the particular basic rights of IDPs. They have since become the minimum standard of the treatment of IDPs applied during displacement as well as during return or resettlement and reintegration into society .3,4 Although IDPs do not lose the right afforded to those nondisplaced under national or international law, they do not have additional protection and assistance created by their needs and vulnerabilities.5 Because IDPs remain within their sovereign state, they are often at the mercy of a government that may have been the cause of their displacement and thus be unable or unwilling to protect them. Since 2006, the United Nations High Commissioner for Refugees (UNHCR) has assumed the lead agency responsibility for the protection, emergency shelter, and camp coordination and management for IDPs under the UN’s cluster approach.4,6

IDPs are uprooted from their homes due to armed conflict, generalized violence, or human rights violations, but may also be displaced due to natural disasters.4-7 Armed attacks, family separation, sexual and gender-based violence, arbitrary deprivation of land, and, at times, displacement into inhospitable environments are common exposures. Once they leave their community, it is often impossible to attempt to return to their homes, which are often destroyed or occupied by the violent criminal groups that compelled them to leave in the first place.6 Figure 1 outlines the major challenges and barriers faced by IDPs.

At times, even when agencies are willing to provide aid, physical restraints, lack of security, and/or refusal of access by governments or local rebels make it impossible for IDPs to receive assistance.4 When IDPs are able to cross national borders on a large scale (and gain refugee status), a domino effect is often created in the region – resulting in further instability and violence.2 Moreover, the very programs that are designed to offer relief may complicate possible asylum procedures for some when asylum claims are rejected on the basis of internal flight alternative.6  They are among the most vulnerable of populations regardless of whether they cluster in camps or informal settlements, escape into the countryside, or submerge into the community of the poor.7

Post-conflict stabilization and progress is measured by the return and reintegration of IDPs to their native land and communities. Resettlement is an exceptionally delicate process that also creates disparities and disagreements among factions.4 It is because of these obstacles during and after displacement that protracted displacement for 10 or more years is not infrequent. The year 2014 saw a 15% increase in IDPs globally, averaging 30,000 people being displaced per day. Because a large number flee to urban areas and live among the urban poor and in ongoing violence, they are largely invisible, and the true magnitude of this problem is difficult to measure.2 This phenomenon described exactly my experience with the IDP community in Medellin, Colombia.

The conflict in Colombia has been in existence for more than 50 years. Since the 1960s, violence between the government and the two main guerilla groups, the FARC (Fuerzas Armadas Revolucionarias de Colombia) and ELN (Ejercito de Liberación National) have produced a high level of both civil and political unrest that produced a significant movement of the population.  This tremendous population shift, in addition to the urban drug violence of the 1990s, produced one of the largest and longest cases of protracted displacement in the world. By 2015, the ongoing crisis had produced six million IDPs, making up 12% of Colombia’s population, with 300,000 new IDPs displaced each year since 2000.8-10 Meanwhile, 50% of Colombia’s IDPs live in unauthorized urban settlements and contend with demobilized guerillas, re-emerging paramilitary groups, and criminal gangs who continue to battle over urban territory while terrorizing local communities with killings, extortion, and sexual violence. With no access to adequate housing, resources, or public services, 92% and 33% of IDPs live below the poverty line and in extreme poverty, respectively.2,8

Road to Recovery

In 1991, Medellin peaked as one of the most violent cities in the world, with a homicide rate of 380 per 100,000 persons, contributing to one of the biggest displaced, disenfranchised, and migratory populations in the country. Medellin is Colombia’s second largest city and one of the top three cities with the highest number of IDPs.11-13 In spite of this staggering history, the Urban Land Institute named Medellin the “Innovative City of the Year” in 2013. Led by former mayor Sergio Fajardo, internationally-acclaimed architect and planner Alejandro Echeverri, and a group of civically focused leaders representing an array of the city’s stakeholders, the city transformed through social urbanism – a strategy of innovative cultural, economic, environmental, educational, and technological initiatives.  This concept connects and integrates Medellin’s poorest neighborhoods to the city by establishing affordable public transit and placing the municipality’s most beautiful and striking artwork, parks, and libraries within them.14-15 The result conjoins the less advantaged communas with the tools of opportunity, raising the welfare of all its citizens.

Critical to the peace process, the Colombian government passed Law 1448 – the Victims and Land Restitution Law – an attempt at social reconciliation and transitional justice for those affected by the internecine violence. Its aim was to “dictate measures for the consideration, and the provision of assistance and restitution to the victims of the internal armed conflict.”16 The objective was to demonstrate peace and progress towards rebuilding and reintegration by returning stolen or abandoned land to IDPs and providing reparation. However, only a small fraction of cases were ruled upon due to forced evictions, infrastructure obstacles, and violent opposition resulting in more than 200,000 additional displacements.2,8,16 In 2012, the Government of Colombia entered peace negotiations with the FARC, the country’s largest guerilla group. Even with this progress, hostile acts continue and will continue, albeit diminished in number and intensity, until a final accord on a bilateral ceasefire is reached.10,17

However, as I witnessed the unbelievable progress the city has made in the past 20 years, along with the honor of intimately learning from this resilient community, I remain optimistic. Despite inconceivable horrors, they continue to fight for their rights and for the prospect of a better life. Their spirit is inspiring. As we face the new IDP crisis in Syria, we must look at the challenges and successes of Medellin and use them to improve care for this vulnerable population of our human family.

 

References

  1. Egeland J. Guiding Principles on Internal Displacement. 2nd ed. New York, NY: United Nations; 2004.
  2. Bilak A, et al. Global Overview 2015: People Internally Displaced by Conflict and Violence. Rep. Geneva: Internal Displacement Monitoring Centre; 2015.
  3. Commission on Human Rights (1998). Guiding Principles on Internal Displacement (U.N. Doc. E/CN.4/1998/53/Add.2). New York, NY: United Nations.
  4. Internally Displaced People: Questions and Answers. UNHCR: The UN Refugee Agency, 2007. Geneva, Switzerland: UNHCR Media Relations and Public Information Service.
  5. Hugh G. The Peacemaker’s Toolkit: Integrating Internal Displace in Peace Processes and Agreements. United States Institute of Peace and Brooking Institution, 2010. http://www.unhcr.org/50f94e689.html.
  6. Handbook for the Protection of Internally Displaced Persons, Global Protection Cluster. UNHCR: The UN Refugee Agency, June 2010. http://www.unhcr.org/50f94dcc9.html.
  7. On the Run in Their Own Land. The United Nations High Commissioner for Refugees. UNHCR, n.d. http://www.unhcr.org/pages/49c3646c146.html.
  8. Colombia: Internal displacement in brief. Internal Displacement Monitoring Centre. Norwegian Refugee Council; 2013. http://www.internal-displacement.org/americas/colombia/summary.
  9. 2015 UNHCR country operations profile – Colombia. The United Nations High Commissioner for Refugees. UNHCR; 2015. http://www.unhcr.org/pages/49e492ad6.html.
  10. Colombia: Displacement Continues despite Hopes for Peace. Rep. Internal Displacement Monitoring Centre; 2014. http://www.internal-displacement.org/americas/colombia/2014/displacement-continues-despite-hopes-for-peace.
  11. Lowenthal A, Mejia P. Medellin: Front line of Colombia’s Challenges. Americas: Politics, Business and Culture In Our Hemisphere. Voices From The New Generation; 2010.  http://americasquarterly.org/node/1310.
  12. La Crisis Humanitaria En Colombia Persiste. CODHES: Consultoría para los Derechos Humanos y el Desplazamiento, 2010. (Documentos CODHES Nº26). Bogota: CODHES.  http://www.abcolombia.org.uk/downloads/Informe_Desplazamiento_2012_La_Crisis_Humanitaria_.pdf.
  13. Occidente del país concentra al 58% de desplazados. El Tiempo; 2014. http://www.eltiempo.com/politica/justicia/unidad-de-victimas-y-codhes-entregan-informe-sobre-desplazados/14106956.
  14. Starkey M. Medellin Voted City of the Year. Urban Land Institute; 2013. http://uli.org/urban-land-magazine/medellin-named-most-innovative-city/.
  15. Nolen S. ‘Social urbanism’ experiment breathes new life into Colombia’s Medellin. The Globe and Mail. 2014. http://www.theglobeandmail.com/news/world/social-urbanism-experiment-breathes-new-life-into-colombias-medellin/article22185134/.
  16. Cortes P. The Victims and Land Restitution Law in Colombia In Context: A analysis of the contradictions between the agrarian model and compensation for the victims. Berlin: FDCL and TNI for the Hands off the Land Alliance, December 2013.
  17. Why Colombia’s Negotiators Couldn’t Manage a Cease-Fire by March 23. Colombia Peace: Monitoring Progress in Peace Dialogues. Washington Office on Latin America (WOLA); 2016. http://colombiapeace.org/2016/03/23/why-colombias-negotiators-couldnt-manage-a-cease-fire-by-march-23/.
Nirma D. Bustamante, MD

Nirma D. Bustamante, MD

International Emergency Medicine Fellow Brigham and Women's Hospital Boston, MA
Nirma D. Bustamante, MD

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P. Gregg Greenough, MD, MPH

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Christian Arbelaez, MD, MPH

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