The armed conflicts and the violence are a public health problem that not only has a direct effect on various health aspects (illness, death and disability) but also an indirect effect on the health and wellbeing of individuals, families, and communities [1]. The indirect causes of this violence are those associated with different war circumstances such as attacks on medical missions, price increases and difficulties in public transportation and food production, land mines, kidnappings, torture, and threats, among others [2]. These war events cause disability and trigger the spread of diseases among populations and make it difficult to carry out: emergency surgeries; care for non-communicable diseases; vaccination to prevent infectious diseases (polio, measles, whooping cough, and others); treatment of chronic diseases that require medications, personnel, and operational infrastructure (diabetes, cancer, and kidney failure); reproductive health and pediatric care services (to reduce maternal and child mortality); and mental health and nutritional care, to mention just a few [3].
In Colombia, the armed conflicts and violence are frequent in economically poor territories where public assistance is scarce, despite having valuable natural resources such as rivers, deserts, mountains, jungles, oceans and being positioned in geographically strategic areas as they are located within the country’s border. Unfortunately, these areas are also used for the growth, production and transportation of narcotics. It is also common to find human trafficking, recruitment of illegal armies, forced labor, land dispossession, enforced disappearance, illegal mining, and violent disputes between illegal armed groups in these abandoned and violent territories [4]. One of these critical regions is the Colombian Pacific region, which is made up of territories from the departments of Choco, Valle del Cauca, Cauca and Narino, with San Andres de Tumaco (Tumaco, Narino) standing out as one of the most violent municipalities [5]. In 2019, Tumaco was the Colombian municipality with the largest number of coca plantations, occupying 16,036 hectares. This has become a growing phenomenon given its geostrategic condition, as Tumaco is located on the border with Ecuador, which has been exploited by different armed groups. In addition, this municipality has an extensive humid jungle, several rivers (Patia, Telembi, Rosario, Mejican, Chagui, and Mira) and access to the Pacific Ocean. Finally, Tumaco has paved roads that connect it to the Andean and Amazon regions and it is the second most important seaport of the Colombian Pacific coast [6] (See Map 1).
The Afro-descendant (Afro-Colombian or Afro) population from the Colombian Pacific coast identify themselves as Black [7]. At the national level, 40% of the Black population has had some kind of deprivation, 30.2% has fallen behind in school, and 37.5% has been displaced because of violence. In Tumaco, 81% of the population is Black, 54% lives under multidimensional poverty, 66% inhabits in rural areas with precarious living conditions and poor public services coverage, e.g. 79% of the population has electricity, 47% gets their garbage collected, 32% has drinking water, 8% has internet access, and 5% has a sewage system [8].
Black and Indigenous communities have historically been affected by the Colombian armed conflict as well as by all types of violence [9]. As of February 2024, 9,659,204 people have registered as victims of the armed conflict in Colombia, based on the Comprehensive Assistance and Restitution of Victims Unit (UARIV, from the Spanish “Unidad para la Atencion y Reparacion de Victimas”), of which 434,239 belonged to the Narino Pacific Coast population. This population number is distributed in the municipalities of Barbacoas (44,315), El Charco (51,059), Francisco Pizarro (7,427), La Tola (10,414), Magui Payan (18,860), Mosquera (7,335), Olaya Herrera (32,364), Ricaurte (18,201), Roberto Payan (26,042), Santa Barbara (15,531), and Tumaco, which has almost half of the victims (202,701) [10]. In 2021 alone, there were 8 massacres with 38 fatalities in Tumaco [11]. The homicide rate in the Pacific coast is high as shown by the figures from 2021, which indicate higher homicide numbers in Olaya Herrera (78.5), Barbacoas (82.9), and Tumaco (75.9), per 100,000 inhabitants. These are worrisome statistics since they are three times higher than the national homicide rate (25.4), and it got worse in 2018, when Tumaco had a homicide rate of 117.1 [12].
The most relevant health-related events associated with victimizing circumstances of the armed conflict in 2022 in Tumaco were the cases of HIV (51.7 per 100,000 inhabitants), tuberculosis (29.9 per 100,000 inhabitants), gender-related violence (151.9 per 100,000 inhabitants), suicide attempts (43.1 per 100,000 inhabitants), and acute respiratory infections in children under 5 years of age (25.4 per 100,000 inhabitants) [13]. All of these figures were avoidable and exceptionally higher in this region in 2022, as compared to the rest of the county.
This study identified the direct and indirect effects of violence on the health of the Black population of Tumaco, as this municipality is one of the territories most highly affected by the Colombian armed conflict. This relationship between violence and health has not been studied deeply in Colombia, i.e., there is no scientific evidence but only dissimilar reports and records from non-governmental or state entities. Hence, the Commission for the Clarification of Truth, Coexistence, and Non-Repetition (CEVNR, from the Spanish “Comision para el Esclarecimiento de la Verdad, la Convivencia y la No Repeticion”), one of the three entities created by the Peace Agreement with the FARC-EP guerrilla (From de Spanish “Fuerzas Armadas Revolucionarias de Colombia – Ejercito del Pueblo”) in 2016, together with the Missing Person Search Unit (UBPD, from the Spanish “Unidad de Busqueda de Personas Desaparecidas”), and the Special Jurisdiction for Peace (JEP, from the Spanish “Jurisdiccion Especial para la Paz”) proposed in their final report that it was necessary to investigate and understand the impacts, copings, and resistance of the victims of the armed conflict [14].
Another reason to conduct this study was the concern about the persistence of violence and its effect on the health of Tumaco’s population. Although the number of homicides has decreased slightly during the last five years, in 2019 it ranked first as the cause of death, with a gross rate of 77.3 per 100,000 inhabitants, which was seven times higher than the national rate (23.4), and two times higher in male victims (142.9 per 100,000 inhabitants) [15]. In addition, violence is a key factor associated with increases in the cases of maternal and infant mortality, depression, anxiety, tobacco and psychoactive substance abuse, malnutrition, disability, teenage pregnancy, sexually transmitted diseases, acute diarrheal disease, and vector-transmitted diseases. The reason behind these increases is that violence makes it difficult for people to obtain access to health services, health professionals, medicines, infrastructure, and technology [16].