“¡Se va a caer!  “She´s going to fall!” laughed Rosmira.  Precariously balanced on a long two-by-four board, Ana Felicia, a heavy-set Health Promoter is one of the Health Promoters being held, grasped and supported as she is passed from arm to arm to the front of the line.  Suggestions and encouragement are conveyed in the languages of Emberá, Spanish, and Wauunan.  Short-statured elderly Indigenous men support the deeply Afro-Colombian Ana Felica, as she is passed next to mestiza[1] young women along to middle-aged Afro-Colombian men.  All sweating in the tropical morning sun, all with the common goal of not letting Ana Felcia fall into the surrounding “water” and find her rightful place in the line being formed.  Ana Felicia does not fall, and arrives safely to the end of the boards without falling.  However, it takes the opinion of all involved to decide whether she is in the right order in the line.  Does Ana Felicia belong before Ana Elizabeth?  And what about Anival or Albenico? 

The objective of this game is to place everyone in alphabetical order without letting anyone fall; both tasks equally difficult in this first workshop of Health Promoters in the Lower Atrato River of Colombia.  Though some have graduated from the equivalent of 6^th grade, most have not.  At this point the deficiencies of their formal education becomes all too apparent.  The lack of government programs for education, health or social development becomes glaringly obvious in one small game.  Yet, this game has a very serious purpose.  The inability to implement such a basic concept as placing one another in alphabetical order makes it obvious that there it is impossible to look up a word in the index of their manual “Where There Is No Doctor[2].”  After the game, we head inside to continue applying our studies. 

The walls and floor of this three-room schoolhouse are made of rough boards, each board hand-hewn by chain saw.  The roof is made of laminated sheet metal that resound with a deafening roar when the afternoon tropical rains pass through.  There is neither electricity nor running water in the school.  We are fortunate to have the use of this building, one of the better locations around for gathering a number of people in an area removed from the active combat of Colombia’s civil war.  The afternoon heat, magnified by the corrugated metal roof, makes it mandatory for afternoon courses to be extremely active.  Sweat drips in sheets from ones entire body while trying to pay attention to either giving or receiving the course.  It is crucial to make these studies engaging and active.

Anatomy review is begun with a magic marker and Heberto, a volunteer from among the student Health Promoters.  With his shirt removed, I ask another Health Promoter to draw her perception of the lungs over the chest of the male volunteer.  The lungs are drawn in a small circle over what might encompass the right breast.  Asking the other promoters if they have a different perception of the size of the lungs, another draws the lungs a bit larger, with others providing their commentaries and input until finally, after many tries, the lungs, approximating their real size, are drawn over Heberto’s chest.

Laboratory and Diagnostic work

With the arrival of two other Concern America volunteers, we are able to provide more attention to the 32 health and lab workers who arrive from the villages.  “Lab workers” is a relative term in the context of the lower Atrato River basin.  A dozen villages were provided with microscopes by a project ten years ago, but there has been no follow-up for almost half of that decade.  There were no reagents for doing the stains necessary to detect malaria, tuberculosis, or bacteria.  All of the microscopes are outfitted with reflective mirrors for illuminating the slides, as there is no electricity in the majority of the communities.  During this course, for the first time many of the promoters saw the difference between gram-positive and gram-negative bacteria.  Most had never seen the cysts in stool samples that demonstrate the worm (helminth) infections that are almost ubiquitous in the children of this region.  Promoters learned to detect basic anemias by measuring the quantity of hemoglobin in the blood.  At the end of the course 10 communities had enough stains and training to do basic lab work to detect urinary tract infections, pregnancy, intestinal parasites, basic bacteria and malaria. 

We were also able to provide deeper clinical diagnostic techniques and treatment modalities to the promoters.  There had never been a course on the use of penicillins, although almost all promoters had experience injecting them in the communities.  One can, after all buy almost any medication over the counter, without prescription, largely due to free market economics here.  By the time we finished this course there was a new appreciation and understanding of the basics of this important, though at times risky, antibiotic. 

Among the various techniques used in this course were the use of a board game where the promoters took on the role of different parasites; there was practice of medical exam techniques; listening to tapes of different respiratory sounds; and a raucously competitive knowledge-challenge game at the end of the course. 

Displaced

Displaced…  a word that is an everyday term here, used all-too-casually to describe the tragedy of almost one in every ten Colombians.  It is a word that should evoke rage, sorrow, and grief for those who no longer have a place to be; for those have been forcibly removed from their home and their land.  Entire communities of people are in exodus during these years of war and violence.  To not leave is tantamount to suicide while the factions at war continue their agonizing process of eliminating those who live in these communities but do not participate in the divisions of the civil war. 

There are only two countries in the world reputed to have more displaced people than Colombia; these are Somalia and the Democratic Republic of the Congo.  Here in Colombia, with over 40 years of civil war, the scars of this conflict have touched almost every family in the country.  Many families have sons, husbands or fathers in both the guerrillas and the army or paramilitary.  When one of the armed factions takes over a community there are almost always reprisals and vengeance against those who have either supported another side or merely not joined up with the newly dominating faction.  The intertwining of personal and political affairs in these reprisals has lead to an extremely complex web of ties, betrayals, and subterfuge that break down the tenuous sense of community that would exist in any war situation.  These divisions are antagonized by those with money and power from the narcotics trade or the neo-liberal “free trade” that dominate people’s lives here.  To counteract these tendencies, our works of Health Promoter training and organizing are among the primary objectives of this project.  The formation of a Health Promoter association is building bridges among these communities that have not been felt for years.

The risks of providing decent health care

Dedicated to Mario Flores, M.D., Medical Director of the Murindó Hospital.

Colleague, companion in service to those in need, and friend for all too short of a time.

In June, “Oliverio[3]” the Parish priest at a local Catholic Church was getting into his boat to 8-hour trip upriver.  We hadn’t had a chance to talk about much except the most urgent of details; the guerrillas pressuring in this river valley, the army attacking and killing a young man in that one.  Where are there more malnourished people right now?  Which community hasn’t had a medical visit for months, if ever?  The cord on the boat’s motor is pulled, the putting sound of the 25 hp engine is warming, and last messages and greetings to others are exchanged.  I asked of Oliverio, “Please send my warmest greetings to Mario, the director of the hospital in Murindó.” 

From the very first time I met Mario I was impressed.  He was one of the only Colombian medical doctors I met who was willing to work in the remote and conflictive zone of the Jiguamiandó River basin.  As director of the Murindó Hospital he certainly had more than enough work to keep him busy without leaving that small town where he lived.  But Mario was all too aware of the very real needs of those who could not make the nine to fourteen-hour hike to the hospital.  So, several times a year, he would enlist the aid of one of the other two M.D.s at the hospital to accompany him on visits to these communities at risk.  He lived life in these difficult areas like everyone else; bathing in the river, sleeping on the hard wooden floors with barely a mat to cushion him, and enduring the stifling heat and clouds of mosquitoes during extremely long days of medical exams.  We often met on these long, difficult excursions and immensely enjoyed our mutual commitment to heal in these zones and we often conversed about professional cases as well as about our personal lives.

Oliverio’s quizzical look had me concerned immediately.  “Mario Flores?” he inquired.  “Yes.” I replied, “I haven’t seen him since I returned.  He doesn’t even know I’m in the country yet.”  As he softly started his response I felt I could no longer hear, my ears and face became hot as the blood rushed to my head, I found it hard to breathe without sobs welling up as I fought tears that would pour out later when I could hear and register…  “So, you haven’t heard….”  At the moment I could hear only selective words to confirm the worst, “terribly tortured, mutilated”, “almost a year ago”, “paramilitary”, “accompanying Maria’s deaf-mute nephew”, “tragedy”, “I’m sorry, I know…” 

Later, when Maria confirmed the gruesome details of Mario’s death I was able to grieve more fully.  What Mario’s primary “crime” was, why the paramilitary decided to kill him, I still do not know.  Possibly it was due to his visits to the communities, perhaps he cured the “wrong” person who was seen as an enemy of the para-military or army, or perhaps he had pushed the government too far in his fervent efforts to end corruption and to appropriately fund the hospital and public health programs he was associated with.

Taparal

Deep, obscure water flows slowly from the mouth of the narrow Domingodó River, with a depth belying the appearance of tranquility.  Life giving vegetation, normally above the shoreline in the all-too-short dry season, now slowly decays under the river surface.  The almost impenetrable sheen on the oily dark surface allows one to see the world reflected as inversely as society itself functions here. 

Waves from our four wooden longboats break the placid reflection of trees and surrounding brush as over two dozen members of the Chicao community head upriver, accompanied by several members of a Peace and Reconciliation team, religious members of the Catholic Church, and myself.  Our boats are all flying white flags to demonstrate the civilian nature of our mission.  These flags are in dramatic contrast to the official army and marine boats we have just passed.  They uniformly fly the skull-and-crossbones flag, reminiscent of the pirate age they all too aptly symbolize.  The flags skull eyes are painted in deep red. 

We haven’t gone more than a couple of kilometers[4] before we have our first of many encounters with the paramilitary on this trip.  The “Para” military are Colombia’s version of the death squads made famous in Central America in the 1980s.  Working hand-in-hand with the government and army they are the judge, jury and executioner of the local populace.  Anyone perceived as not conforming to their brutal tactics, their social/military project or their promotion of the narcotics trade is seen as enemy.  In fact the flight of the entire village of Taparal was due to the paramilitary attacks on their village. 

The killing of “Chanana,” a Health Promoter in Taparal had been the last blow for the people there.  Chanana was intimately involved in the lives of the people of his community.  When one neighbor was picked up by the paramilitary and taken to their nearby encampment, Chanana trusted that he could negotiate for the release of his neighbor.  He was wrong.  After paddling downstream in his dugout canoe to the paramilitary encampment he explained that his neighbor was not involved in the insurgency and should be released.  Instead, Chanana himself was accused of being involved with the insurgency as well, and was killed alongside his neighbor.  Several days later the entire village fled into the jungle.  For the next half year people struggled to stay alive under the dense jungle cover, unable to plant, harvest or fish with any regularity.  Their children virtually starving, they contacted Catholic Church members to help get them out of the river basin where they had fled.  Still, half of the community stayed behind, preferring a precarious life, with implicit hunger and lack of even the most basic services, to the life in Río Sucio with the paramilitary watching their every move.  Now, the community who relocated to Río Sucio has returned to re-clear their land in the hope of returning there by the end of 2004. 

The water is murkier as we climb further upstream, ever farther even from the remote town of Río Sucio.  The faster current mixes in mud now, making the water impenetrable and obscuring stinging “toadfish” and freshwater stingrays lurking below.  Community members are all aware of the dangers of this water and this environment.  So, fear is palpable as we pass each of the checkpoints of the paramilitary forces, omnipresent in this river basin.  The gun holsters on the hips of these deadly serious soldiers each display the classic “U.S.” lettering of previous U.S. military use.  In one way or another, the $2,000,000 U.S. tax dollars sent daily for military support is deeply felt, and blatantly obvious in its intent.  We continue to pass paramilitary soldiers as they stand quietly on the shore, as they look out from their tents and as they dry their uniforms drying in hot, humid air.  We pass them in the village of “La Madre” their armed presence the only evidence of life in this previously active town.  We stop only when they insist on questioning our presence and purpose.  On the boats, people are uncharacteristically quiet. 

After a five-hour struggle of cutting through logjams, shoving boats over lowspots in the river, and answering to paramilitary harassment, we arrive at the shore of Taparal.  Trees have grown up to 30 feet tall and homes now hide behind the overgrowth of weeds.  As the first men disembark onto the muddy riverbank, their machetes are out, clanging with a metallic ching, each stroke bringing down a swath of overgrowth.  Within the first hour there is a clearing to the first line of houses on the bank.  Meanwhile two of the houses are organized for cooking and sleeping.  Wasp nests are cleared away, floors are swept, and food is prepared for the evening meal.  I look for an appropriate site to do medical exams from.  The health post had been used by the paramilitary as a latrine.  The floor is covered with feces.  I decide to work out of the building we will stay in.  Violent and pornographic graffiti is painted on almost all the homes.  Pseudonyms of paramilitary fighters “The Nazi”, “The Tiger” and others sign the walls, overtly taking credit for previous killings and attacks in the zone, as well as threatening for the future.  Over the next days, the entire town is cleared of overgrowth, and the homes are once again cleared for possible occupation in the future. 

While clearing of the land occurs in Taparal, I take the opportunity to visit surrounding the Indigenous villages of Pichindé, Jagual and Marcial.  The Indigenous villages did not flee either the guerrilla nor paramilitary incursions, however they suffered even worse in some ways.  The armed forces effectively blockaded this river over the last years, ensuring a lack of economic participation, guaranteeing worsening malnutrition and poverty.  The Wauunaan and Emberá people here are in as desperate conditions, or more so, than those who fled. 

The two dozen families who inhabit the tiny community of Mamey Dipurudú contend with nightly paramilitary fighters occupying the village.  The armed troops insist on staying in the houses of the Indigenous inhabitants, violating what is a basic constitutional guarantee in the U.S. and most civilized countries.  One can barely imagine this amendment being violated even under George Bush’s version of the national security / anti-terrorist state.  On this July night, paramilitary soldiers stormed into the village of only a dozen families, yelling epithets and making threatening gestures.  Only when one of the priests and I illuminated ourselves with flashlights did the soldiers stop their aggression.  One soldier approached us to announce they were going to stay in the village due to the inclement weather on this night.  When we challenged their assumption to place the community at risk by staying in the limits of the village, one of the soldiers clarified that they usually “only stay in the school.” We pointed out the school is still located within the village and is still an absurdly inappropriate place to locate armed troops.  They eventually stayed the night in people’s homes. 

Medical Challenges

Work and life are a mix of brief glimpses of the positive working against the enormous swath of negative, as death tries to overshadow life, war dominating as much as it can over peace.  Still, the light in the world is ever-present...

I saw it in the face of Guille (pronounced Ghee-yeh), a 62-year-old Afro-Colombian man, and a catechist for most of his life, dying of cancer.  The first time I met Don Guille we had wonderful interchanges that brought an immediate bond between us.  His spirit of humor, reverence and appreciation for life were very apparent in his cachectic face and alertly deep-set eyes.  "So, Don Guille, how old are you?"  I asked.  "Ayyyeee...." came his Afro Colombian drawn out response indicating forever, more or less.  "More than 200 years old?" I asked.  "More than 300," he replied.  "So, you knew Christopher Columbus?"  I had to ask.  "When he was just a young lad" came the immediate reply.  Guille was given Acetaminophen (Tylenol) at the hospital to relieve the excruciating pain of his metastatic cancer even as he became unable to walk or sit.  Thankfully, I was donated some morphine and fentanyl patches so that his last days became gratefully less excruciating. 

It is quite an ordeal to get to where Done Guile’s "house" of rough-hewn boards among the other thousands of displaced in the town of Rio Sucio.  His house is raised on poles above the 3 feet of murky, stagnant lagoon water.  Water rains in through the leaky corrugated aluminum roof.  To get to the house one has to walk from board to board stretched between the houses extending into this marsh.  The boards bounce up and down as I traverse them, and I've fallen in more than once.  Beautiful purple flowered water lilies bloom along the way. 

When I told Don Guille that I was leaving for these days to Apartadó he acknowledged this, replying; "Well then, so I'll see you there.  I’ll be waiting there for you."  We have had a lovely meeting of spirit and I knew immediately what he meant.  He passed away quietly in his sleep two days later. 

So, how to sum up even a day where Don Guille was one of a dozen people I was fortunate enough to be touched by and to touch?  The medical care I provide is minimal at times.  I have no lab work or diagnostic methods other than what I can carry in my bag, which is to say it is woefully inadequate.  And that is still more than most people here have ever had.  It is such a privilege to be with people in these places and conditions!

There is so much more to recount of the lives and deaths, and near-deaths of people here.  I intensely feel the lack of medications and resources.  Treating a young, violent schizophrenic man with the old option of Haloperidol; sweating through an acute asthmatic crisis with a woman with a syringe of adrenaline and a metered dose inhaler of Albuterol; struggling with an infant whose respiration is three times as fast as it should be from pneumonia; making clinical calculations on what type of malaria I should be treating for when the patient in front of me has a 103° fever.

The day-to-day life here is inspiring as the Health Promoters in their villages begin to organize for the right to have vaccines instead of bullets, medical training instead of military training.  They are attempting to heal in the midst of absent or incapable government services.  They provide a front line of non-violent, constructive presence for those who sorely lacking in hopeful options.  It is a gift to share a bit of the life and light here with those of you taking the time to read and hear a bit of the lives of those who touch mine.  Thank you for your efforts to be a healing and positive force in the world.  We will overcome.

En Paz y Servicio,

Curt Wands

(Alan “Curt” Wands practices spirituality as a Quaker and healing as a Physician Assistant in northwest Colombia.)

Alan (Curt) Wands
Pastoral Social
Calle 105, 95-20
Colonia La Chinita
Apartadó, Antioquia
Colombia, South America

Tel:
Casa Apartadó:    (57)(4) 826-2172 / 826-6090
Casa Río Sucio:    (57)(4)  681-0012
Fax:                         (57)(4) 828-4786
email:                      cwands@igc.org
www:                      http://home.igc.org/~cwands/