Ely Cossio*

Versión en español aquí.

Exceptional times require extraordinary measures; however, there are places in Colombia where the lack of essential services would make any extraordinary measure be considered meager given the marginality and the historical backwardness in the country. The negligence of the central government is the common denominator of the formerly called territorios nacionales[1], but only in the Department[2] of Chocó this feature is epitomized in absolute terms.

Seen in the light of the ability to cope with a virus as deadly as COVID-19, which to date has claimed the lives of nearly 400,000 people worldwide, the forecasts in the department of Chocó are terrifying. To this date, the people of Chocó lack the readiness and the human, technical, and financial resources necessary to face an epidemiological event of this kind.

The Department of Chocó, located in northwestern Colombia, is a place full of contradictions. A region rich in natural resources but dying amid so much shortage of basic services and opportunities. It has an approximate population of 515,145 inhabitants of which 82.1% are black Afro-Colombian, 12.7% indigenous, and 5.2% white and mestizo. According to the National Administrative Department of Statistics, 79.7% of the population has unsatisfied basic needs, it is one of the regions with the highest multidimensional poverty rates, and 61.1% of its inhabitants live with less than $2 USD per day.

In terms of health, the only hospital of medium complexity, that is, with the possibility of hospitalization and specialized care for people with complex diseases, is in deplorable conditions, without financial resources, without health personnel and partially sealed due to the presence of rodents in the emergency room. In the face of a health emergency like the current one, the Afro-descendant and indigenous communities of Chocó are in the line of greatest vulnerability and risk in confronting of the spread of the coronavirus.

The April 28 statement of  the  Inter-American Commission on Human Rights (IACHR) calls member States to “guarantee timely access to public health, through measures of prevention, mitigation, and treatment of [COVID-19], under conditions of dignity, equality, and non-discrimination for all Afro-descendant persons and tribal communities”. In this context, it is important to showcase the conditions of fragility and vulnerability of the Afro-descendant and indigenous communities of Chocó and to demand the national government to take «positive, real and tangible» actions to prevent the loss of lives because of the pandemic.

The right to health as a human right

According to the Constitution of Colombia, one of the essential purposes of the State is to guarantee life. The effective satisfaction of the right to life, enshrined in Article 11 of the Constitution as a fundamental right of citizens, depends on the effective assurance and protection of other rights, including the right to health.

Constitutional jurisprudence has recognized the right to health as a fundamental right. This implies that there is a notion of defense, respect, and a guarantee of it by the State. In virtue of International Human Rights Law, the right to health relies on obligations that are the exclusive responsibility of the State of Colombia, acquired by the ratification of international treaties on the matter.

Under General Comment No. 14[3] on the right to the highest attainable standard of health, «health is a fundamental human right indispensable for the exercise of other human rights,» therefore, health is an indicator of the success or failure of any policy or action aimed at guaranteeing the human dignity of an individual. The UN Committee on Economic, Social and Cultural Rights (UN-CESCR) has stated that the right to health supposes the existence of four Interdependent elements: availability, accessibility, acceptability, and quality.

While availability includes the existence of programs and health infrastructure in excellent conditions suitable for decent health care; accessibility means that health services must be accessible to all people without discrimination. In addition, accessibility has four dimensions of which two are of particular importance in the case of Chocó: (a) physical accessibility and (b) economic accessibility. These dimensions reflect the physical and economic suitability of health facilities, goods, and services for a given population, especially for vulnerable groups such as Afro-descendant and indigenous communities. Acceptability, on the other hand, refers to the cultural adequacy of goods and services. Lastly, quality implies, among other things, the existence of trained medical personnel, the standard of medicines, services, and hospital equipment, as well as clean and safe drinking water.

A snapshot of the health system in Chocó

With 295 confirmed cases and 11 people dead, as of the first week of June 2020, the Chocoan health system has already collapsed, showing signs that the department of Chocó is not prepared to control the outbreak and to respond quickly and effectively to the increasing demands. At first glance, taking as a reference the list of essential elements that compose the right to health, we can observe that, under normal circumstances, none of them are satisfied.

Regarding the element of availability, the health infrastructure aiming to serve a population of approx. 520,000 inhabitants, is not in any condition to receive patients with complex diseases. The coronavirus crisis outstrips the department’s institutional capacity due to the alarming poor condition of the only public hospital, which in regular operation does not have an intensive care unit or enough bed capacity. The remaining capacity consists of few private clinics with three intensive care units and 27 beds already occupied.

With reference to accessibility, both geographical and economic accessibility are major challenges. The absence to ambulances, the exacerbation of the armed conflict, and the insurmountable distances between some municipalities and a health center are just some of the obstacles faced by Chocó’s rural communities. Consequently, the population does not have decent and reliable access to health care services.

Concerning acceptability, it is clear that the health system in Colombia does not have an ethnic differential approach[4] that recognizes the specificities of the regions and their peoples. Therefore, the health of Chocó is a reflection of national assessments based on insufficient data on the social dynamics of Afro-descendant and indigenous communities inhabiting the department.

As to the quality, most of the health personnel have not received wages for more than eight months, and the hospital does not have access to regular water, its equipment is corroded, and there are no protocols for the disposal of contaminated material. Adding to this, the administration closed it temporarily, after confirming the infection with SARS-COVID 2 of health care workers, which places the burden of the response on private clinics without the capacity to offer affordable quality services.

Moreover, risk factors that make evident the unprecedented crisis are pre-existing conditions such as hypertension, diabetes, and ischemic heart complications, which are the major cause of mortality in women and men from the region. These conditions are conducive to a higher level of risk of dying from COVID-19. According to the US Center for Disease Control and Prevention (CDC), in places like Chicago and Louisiana, African Americans make up 70% of COVID-19 deaths. This situation is not only the result of health systems inequalities reflected on the discrimination in the practice of tests to detect the coronavirus, the lack of health insurances and access, but also due to the fact that African Americans suffer the highest rate of diabetes within the US population.

Lastly, the department of Chocó does not have laboratories for the diagnosis of COVID-19, with samples being sent to other cities such as Medellín and Bogotá. Because of this, the turnaround of results and notifications are delayed for up to 40% of the tests carried out so far, affecting the level of response by local authorities and highlighting the racial inequalities of the health system in Colombia. Likewise, critically ill patients must be transferred to Medellín due to the lack of medical tools and specialized health workers able to treat them.

The fight for the dignity of Chocó is still alive

As established by international and national law, the right to health is a legal asset that can be demanded to the State. Given this, Colombia is obliged to respect and guarantee the highest level of health. Therefore, the national government must take urgent, effective, and necessary actions to guarantee the right to health to the population of Chocó.

As for urgent measures, medical equipment such as artificial respirators, beds, diagnostic imaging equipment, electrocardiogram machines, sterilizers, among other essential equipment for the normal and effective operation of health centers, are needed. Furthermore, the Microbiology laboratory of the Technological University of Chocó needs to be allowed to carry out the COVID-19 diagnostic test, as well as the training of health workers on biosafety protocols.

In the long term, the department requires public health policy that includes, among other things, a tertiary health care program, which implies the creation of adequate infrastructure capable to provide specialized care for diseases that are not currently being treated at the department’s health centers. Also, it is necessary to implement special educational programs that allow Afro-descendant and indigenous people to be trained on health disciplines.

All of the above is framed within the 2030 Agenda for Sustainable Development and its policy of ‘leaving no one behind’. In this regard, Sustainable Development Goal No. 3 is clear: «Ensure healthy lives and promote well-being for all at all ages” through the access to «universal health coverage, quality essential health services and a substantial increase in health financing and the recruitment, development, training, and retention of health personnel in developing countries.»

Finally, let us not forget that the best way to honor the victims of this pandemic is to effectively guarantee the right to health for all Colombians, especially those who live in the historically marginalized and forgotten Colombia.

*Consultant, DPLF

[1] Between 1843 and 1991, the “territorios nacionales” were a set of regions characterized by being located far from Bogotá and by being marginal regions with economic, social backwardness and without the capacity for self-government.

[2] Equivalent to a State administrative division in a federal system.

[3] UN Committee on Economic, Social and Cultural Rights (CESCR), General Comment No. 14: The Right to the Highest Attainable Standard of Health (Art. 12 of the Covenant), 11 August 2000, E/C.12/2000/4, available at:
https://www.refworld.org/docid/4538838d0.html [accessed 3 June 2020]

[4] According to the  Ministry of the Interior of Colombia, the differential approach can be understood as “the set of actions that, by giving differential treatment to some population groups, contributes to reducing the gap between the different segments of the population and ensures that exclusion, political marginality, economic inequality, the special condition of vulnerability and the risk of these populations in the face of armed conflict, are overcome. ”

Photo: Department of Chocó