Sending-Country Violence & Receiving-Country Discrimination: Effects on the Health of Colombian Refugees in Ecuador

Abstract

BACKGROUND

This study explored factors affecting the health and well being of recent refugees from Colombia in Ecuador. Data collection focused on how sending-country violence and structural violence in a new environment affect immigrant health vulnerability and risk behaviors.

METHODS

A qualitative approach included ethnographic observation, media content analysis, focus groups, and individual interviews with refugees (N=137). The focus groups (5) provided perspectives on the research domains by sex workers; drug users; male and female refugees; and service providers.

RESULTS

Social and economic marginalization are impacting the health and well being of this growing refugee population. Data illustrate how stigma and discrimination affect food and housing security, employment and health services, and shape vulnerabilities and health risks in a new receiving environment.

DISCUSSION

Widespread discrimination in Ecuador reflects fears, misunderstanding, and stereotypes about Colombian refugees. For this displaced population, the sequelae of violence, combined with survival needs and lack of support and protections, shape new risks to health and well-being.

INTRODUCTION

Colombia’s 40-year long armed conflict has caused a massive displacement of its population[1], which has been increasing in recent years[2] as paramilitary groups have become involved in drug operations and kidnappings to finance their activities[1]. Ecuador has been the most frequent country destination for Colombian asylum seekers and other refugees. The U.S. Committee for Refugees and Immigrants has reported that a total of 35,562 “registered” Colombians solicited refugee status in Ecuador through official channels between 2000–2006[3]. However, the local United Nations refugee office estimates that as many as 450,000 Colombian refugees currently reside in Ecuador[4]. Local and international sources agree that 700–1,000 Colombians illegally cross into Ecuador each month. They do so because they have been unable to obtain the official legal police document (pasado judicial) needed to cross the border or they do not know their rights[4].

Colombian refugees are increasingly female and young[5]. Three-quarters live in poverty and 50% in extreme poverty[6]. Household food insecurity and hunger are common, and fewer than one-fifth (19.4%) of Colombian refugees reported having sufficient food to meet their household’s basic needs[6]. Many also lack the economic and social support system normally provided by families.

Mobility and migration have been documented as contributors to the spread of disease and health vulnerability of individuals and communities[7–9]. New immigrants and refugees are frequently unprepared to deal with the challenges present in their new environment. Such changes influence social exposure, perceptions, experiences, and norms, all of which can affect health outcomes.

THE STUDY

The findings discussed in this article represent some of the rich, qualitative data from research funded by the National Institute on Drug Abuse (NIDA/NIH). Originally submitted as “Substance Abuse and Health Vulnerability: Colombian Refugees in Ecuador,” the study title and focus were modified in-country to address the concerns of advocacy agencies regarding the association of substance abuse with the refugees. The research addressed the need to reach a more complete understanding of the migration process and vulnerabilities experienced by refugees as they cross international borders, particularly in South America. Findings highlight the urgent need for identifying specific health risks experienced by mobile and displaced populations, underscoring the voluntary and involuntary risk behaviors shaped by the nature and reach of life and environmental changes.

The main objective of the study was to gather descriptive data on the characteristics of recent refugees moving from Colombia into Ecuador as a result of drug-related violence and how the conflict, displacement and a new environment affected their health vulnerabilities and risk behaviors. What emerged as most salient, however, were data on how the sequelae of violence, coupled with the stigma and discrimination experienced as refugees, affect all aspects of health, well-being, and survival of this population.

METHODS

The study employed a qualitative approach combining individual interviews, focus groups, ethnographic observation, and media content analysis. Ethnographic observations permitted an understanding of context and provided information on the characteristics of daily lives and behaviors. Members of the in-country research team carried out structured observations in the locations where refugees lived and worked. Data gathered from these activities complemented data obtained in the interviews with refugees and key informants. Observations were carried out by four team members in working-class neighborhoods, characterized by the large influx and settlement of refugee populations, including northern Quito, and the central and southern areas of the city. Team members also visited health and educational facilities, nightclubs, and drug treatment programs.

The focus of the media analysis was to identify the socio-historical and political contexts of the study. A content analysis of the written press coverage (108 articles published in four newspapers of national circulation) relating to the Colombian refugee issue in Ecuador was carried out from January 2009 until January 2010. The majority of the articles analyzed were brief press notes or journalistic accounts. Analyses identified three salient issues: the rupture of diplomatic relations between Ecuador and Colombia due to the Angostura bombing; the new Ecuadorian constitution approved in 2008, extending constitutional guarantees to all residents on Ecuadorian soil regardless of nationality; and the increased registry of refugees initiated in 2009.

Individual semi-structured interviews (n=96) were conducted with male and female refugees. This sample included: 75 men and women, 11 men who have sex with men (MSM), and 10 female sex workers. The interview instrument was designed to gather information on the a number of research domains: demographic characteristics, general perceptions of health, access to food, immigration and its relationship to current health conditions, mental health, social activities/networking, sexual and reproductive health, HIV/AIDS, and general perceptions of substance abuse among refugees including personal substance abuse. The sample criteria were: 18 years of age or older, born in Colombia, resident of Ecuador for at least three years, and reported to have left their country for matters related to violence and/or physical or emotional safety. For individual interviews and focus groups, snowball-sampling techniques were employed. Interviewees representing specific population characteristics and vulnerabilities related to health, violence, and behavioral risk were identified.

Interviews with key informants (n=21 plus 12 participants in the institutional focus groups) permitted cross validation and explanation as well as expanding the range and depth of the data set. In addition, interviews were used to address special issues and to address unexplained variants found in refugee interviews.

Five focus groups were carried out with individuals likely to provide different perspectives on the research domains: sex workers, drug users, male refugees, female refugees, and key informants/gatekeepers. Respondents were recruited by the collaborating NGOs. All interviews and observations served in the triangulation of data in the analysis process and provided a strategy of validity checks on data collected by each method.

The Institutional Review Boards (IRBs) of the University of Texas at El Paso (where the study was originally funded), New York University (where the study was transferred), and the Universidad Central de Ecuador approved the study. Informed Consent documents were written in Spanish, modified in-country, and adjusted to ensure they complied with all regulations of the IRBs of the US and Ecuadorian universities involved.

Limitations

The results of this study need to be interpreted with caution. Snowball sampling helped in meeting the challenge of engaging a population justifiably suspicious of researchers. Thus, because participants were recruited through peers and trusted NGO sources, this bias must be noted. In addition, the sample cannot be seen as representative of the general population of Colombian refugees in Ecuador, given that the participants were recruited only in urban Quito, nor does it capture the perspectives of refugees who were not connected with advocacy groups and providers in Ecuador. Finally, it is important to note that the information shared by participants needs to be situated in the larger context of how the Ecuadorian government and society have grappled with a complicated humanitarian issue despite the economic limitations of their country and the additional demands on scarce resources by an increasing refugee population. Our findings illustrate one perspective on a complex geopolitical situation, which includes ongoing efforts to address the needs of Colombian refugees, the history of diplomatic relations and tensions between the two countries, the history and dynamics of drug trafficking, and the related violence in both countries.

FINDINGS

Forced Displacement

Reasons for fleeing Colombia included pressure to join paramilitary forces, threats to members of their families, and violent disputes over properties or businesses that led to forced abandonment of homes and livelihoods. For young men in rural areas, recruitment by paramilitary forces was said to cause them to flee to Ecuador seeking refuge and protection.

The refugees also described direct threats from the police or armed forces, because they owned property, had money, had witnessed murders, or had refused participating in one of the groups. As one interviewee stated:

I am very worried, because the people who were persecuting us are quite dangerous and if they become aware that they are my family, they are going to kill them … (she cries) because they killed more than ten of us in a year. Every two, three months, they killed four, three families.

Another explained,

We came here … because of the pressure, and there was another incursion, they destroyed everything and they had orders to kill everybody—women, children, and the elderly, paramilitaries dressed as civil defense.

Needs and Resources for Support

Having fled the violence in Colombia, most respondents said they lived in Ecuador without friends or family. They identified a range of obstacles in daily life, which they felt they could not overcome due to financial or xenophobic barriers. Nevertheless, some social support networks and advocacy organizations exist, which provide important assistance to help refugees to deal with these barriers and the sequelae of violence and displacement.

Discrimination

Discrimination was identified as a major challenge of daily life, influencing access to food, housing, education, employment, and health care. As people experiencing forced displacement, the Colombian refugee population is adapting to new environments while at the same time trying to overcome barriers blocking their integration and adaptation. The battle against exclusion and misconceptions about them appears to produce high levels of stress, anxiety, and depression.

Daily Experience of Discrimination

Participants frequently stated that “they [Ecuadorians] treat us badly,” and reasons varied significantly from person to person. Afro-Colombians described “racism” in addition to being viewed as a Colombian and thus categorized as “violent and criminal.” The perception that Colombians were viewed as gang members, thieves, or guerrillas arose frequently in the interviews and focus groups. Participants noted that these stereotypes affected access to employment, housing, and services. Several participants suggested that the stigma surrounding Colombian identity affected them psychologically and significantly impacted their daily lives.

Social Isolation

Men and women who arrived in Ecuador with relatively few sources of support spoke about the difficulties in establishing new friendships precisely due to stigma and discrimination. They claimed not to be able to frequent bars or clubs for fear of being arrested and deported by the police. Few places in Quito were identified where refugee families felt they could get together to socialize. Many said they preferred to stay in their homes, exacerbating their isolation. Both the men and women interviewed said they felt punished and that they were seen with a negativity deserved only by a few criminal elements of the Colombian population. They described suffering emotionally as a result of being exposed continually to these attitudes, and feeling humiliated and ashamed at being rejected.

Effects of Discrimination on Women

Women respondents reported experiencing many of the same prejudices and stereotypes that affect the overall refugee population, but the gendered impact was seen as different. For example, one woman explained that "Here they all believe that everyone comes to do wrong, to take away the food from the Ecuadorians, that every woman that comes, we come to prostitute ourselves." Others added that they had heard Ecuadorian men and women saying that Colombian women are sexually easy. A number of the women also described sexual demands by potential employers in order to obtain work.

Discrimination and Violence

In many cases, prejudice was said to result in violence. Participants reported vandalism against their properties and being victims of robbery. They described unprovoked physical abuses and verbal assaults. Violence at the hands of the police was said to be common. Many interviewees shared that they had been stopped because of their accent or manner of dress without having committed any infraction, and that Ecuadorian police demanded bribes before releasing them. Some said, in addition, that police threatened refugees with deportation or invalidating their work or residency papers.

Discrimination and Employment

Another critical aspect of the discrimination described by Colombians was its impact on access and conditions of employment. A common concern related to deception in the work environment. Many participants reported that after having agreed with employers to a fixed rate or salary, employers refused to pay after work was completed, would pay less, or would threaten to turn them in to immigration authorities. Obtaining a work visa did not always solve the employment problem because even with legal status, many refugees suffered deception and mistreatment. For those unable to obtain jobs in construction or other sectors, work in the informal economy was often the only option.

Housing Insecurity

Participants reported Ecuadorians refusing to rent to Colombians because refugees were perceived as unable to meet payments. Unreasonably high rents, apartments in appalling conditions, and housing without basic infrastructure and services were described. Refugees perceived they were denied housing because of having too many children, lack of legal documents, lack of a stable job, not being recommended by an Ecuadorian, or not having the means to pay a three-month deposit and the first month’s rent.

Discrimination and Access to Health Services

Ethnographic observations revealed that health services are accessed at public health centers. Nevertheless, the utilization of emergency care and hospitalization appeared to be complicated by distances between where refugees resided and where services were available, as well as by the lack transportation. Observations also confirmed insufficient human resources to care for all patients seeking services. Under these circumstances, Colombian patients were often the last cared for or simply not seen in spite of a national constitution that states they have the same right to access the healthcare system as Ecuadorians. It was common to hear mixed views about the care received when seeking health services. Some said they were treated "sometimes well and sometimes badly.” It was, however, more common for those interviewed to describe being intimidated and facing obstacles, indifference, and even abuse while seeking health services.

Some refugees also stated that even when provided services, these services were incomplete (e.g. diagnosis, but not medications) and that they were charged higher fees. Several pregnant women, and women seeking reproductive health care, reported having been neglected or having been put into last place with preference given to Ecuadorian patients. Not having proper documentation to be eligible for health care was also noted in seeking pediatric services. This situation was exacerbated by the fact that parents fleeing their homes often did not take children’s vaccination or health history documentation with them, thus facing difficulties in explaining pre-existing health conditions. Several interviewees reported that their children were, in fact, treated quickly and efficiently depending on where they sought care. Participants also noted that health services tended to be more equitable in larger hospitals where patients, regardless of nationality, experienced fewer problems. In smaller clinics, it was not uncommon to be given appointments at dawn or be placed at the end of the line. While the refugees experienced a range of quality of care and levels of perceived discrimination, and differences existed between public and private services, it was noted that not all of the obstacles they experienced were due to discrimination; the inadequacy of health services, they suggested, affected everyone, regardless of nationality.

Sex and Drug Use as Health Risks

While some women who identified themselves as sex workers reported having come to Ecuador specifically to work in the sex industry, most refugees engaged in sex work felt that they had no other alternative for survival. Some acknowledged being at high risk for contracting HIV, but needing to support their families. Drug use was generally acknowledged by these women as a way to deal with the stress of sex work. As one woman explained, “it depends on your need for money, then you know you have to work hard, that you have to have at least ten clients, so you have to consume and consume to be ok.”

Significant alcohol consumption among the sex workers was described, as well as clients consuming large amounts of alcohol and drugs. Easy access of drugs in the streets and bars was said to include largely cocaine and marijuana.

DISCUSSION

The urgency of forced displacement to escape violence shapes the migration and adaptation of Colombian refugees in Ecuador. It is clear that not only do they deal with current and continuing fears relating to the reach of violence from sending communities, but daily stresses resulting from on-going confrontations with a society that at once fears and rejects them based upon associations with the drugs and violence from which they fled. Even given government mechanisms for refugee status and efforts to create a more positive climate for Colombian refugees, the reactions of the receiving community reflect fears, territoriality, and erroneous assumptions about Colombians.

Forced migration itself produces changes and tensions in social networks and, specifically, in the family. Reports of anxiety, frustration and “depression” permeated the interviews even before accounts of discrimination and the effects of isolation and rejection. Lack of basic survival needs and inadequate health services result in the poor health they describe, and the escape provided by drugs and alcohol for some.

Data analyses were focused on understanding health risks and vulnerabilities in a new receiving environment. Individual accounts of daily challenges clearly reflect the context of structural violence in which they now live as well as the potential or real physical violence that prompted their migration in the first place. This structural violence is manifested in the poverty, social and gender inequality, and racism and discrimination they describe.

CONCLUSION

Studies of immigrant health have historically focused on individual-level risk factors more than environmental/structural factors as salient mediating variables. Yet the epidemiological/public health trilogy of host-agent-environment is the recognized mechanism for disease transmission[10]. Clearly, research is needed to identify the geopolitical, historical and cultural factors that influence health and well-being. Understanding the impact of structural violence on these displaced and vulnerable populations as well is crucial to developing effective structural level interventions, e.g. policy responses, efforts toward community education and organization, and advocacy.