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How Should Health Systems Help Clinicians Manage Bias Against Ex-combatants?

Learning Objectives
1. Explain a new or unfamiliar viewpoint on a topic of ethical or professional conduct
2. Evaluate the usefulness of this information for health care practice, teaching, or conduct
3. Decide whether and when to apply the new information to health care practice, teaching, or conduct
1 Credit CME
Abstract

Clinicians in postconflict health care settings can be tasked with caring for patients who are ex-combatants. This commentary responds to a case of a health worker with duties to care for ex-Revolutionary Armed Forces of Colombia combatants. Specifically, this article considers clinical, ethical, and legal demands of reincorporating ex-combatants in compliance with a peace agreement on systems and individual health workers.

Case

CH is a health worker who has long served rural community members of Vista Hermosa, Colombia. CH travels to veredas (remote, limited-resource clinical settings) as an employee of a local health organization's outreach program, without which, hundreds of people—including ex-Revolutionary Armed Forces of Colombia (Fuerzas Armadas Revolucionarias de Colombia, or FARC) combatants—would lack access to clinical evaluations and health services. CH is haunted by having been kidnapped by FARC members years before. “It was horrible,” CH relates. “They kidnapped and held us for 3 days without food or water. We had no idea when we would be released. They are overtaking our hospitals and have more rights than their victims.” Despite a peace agreement, CH and other health workers traumatized by years of conflict struggle to maintain clinical neutrality and execute professional duties to care for all patients their hospital serves.

Commentary

Until 6 years ago, FARC was a guerrilla group that had operated in Colombia since the 1960s and had been known to kidnap health care workers for ransom or medical assistance.1 In 2016, Colombia and FARC signed the Acuerdo Final para la Terminación del Conflicto y la Construcción de una Paz Estable y Duradera (peace agreement),2 ending the longest conflict in the Western hemisphere and reincorporating 13 000 ex-combatants into society. With the agreement, FARC ex-combatants were guaranteed access to services, including health care.3 However, as ex-FARC members began accessing health care, CH and others felt that victims of FARC actions and members of marginalized communities were left behind, while ex-FARC patients received care. CH seems to feel burdened by an obligation to care for ex-FARC patients, whom CH still remembers as violent perpetrators.

Although the peace agreement was a revolutionary approach to peace building, ethical questions that arose during its implementation are common in postconflict clinical encounters. Quiz Ref IDTwo key issues were (1) resource allocation equity among perpetrators and victims and (2) supporting health workers with duties to care for members of both groups, despite their own personal trauma experiences. This article describes the Colombian approach to health care reincorporation, focusing on the ethical values of restorative justice and subsidiarity in resource allocation decision making, and considers strategies for supporting health workers struggling with how to cultivate and maintain clinical neutrality, especially when caring for ex-combatants.

Peace and Public Health

The Colombian peace agreement guaranteed ex-combatants access to health services, including government-subsidized insurance, and immediate attention in encampment zones where FARC disarmed.24 In health care, the ethical values of restorative justice (ie, engaging each actor of conflict to repair and build relationships)5 and subsidiarity (ie, decentralizing and sharing governance responsibilities with local organizations) can be expressed in inclusion, forgiveness, making amends, mutual healing, reintegration, and equity and can be implemented in processes of reconciliation. Restorative justice has proven effective in improving health outcomes among participants in other conflict-affected populations.69Quiz Ref IDSubsidiarity was implemented by Colombia's Ministry of Health insofar as it relied on municipal-level public hospitals to provide health care for ex-combatants in reincorporation camps and for all Colombians in surrounding communities. This strategy aimed to strengthen long-term investment in local public health capacity.10

Caring for All Colombians

Implementing government-subsidized health care in encampment zones risked the perception that ex-FARC patients were being favored. Although most FARC ex-combatants lacked clinical records, they needed to be integrated into health service provision streams. Quiz Ref IDVia decree, the Colombian government integrated 10 836 ex-FARC combatants into the Colombian universal health insurance system in 2017.10,11 The opportunity for ex-FARC members to access the same health benefits as other Colombians helped avoid conflicts stemming from perceived favoritism. Gradual integration of encampment zone-based health service provision streams into those of the general Colombian health system also facilitated ex-FARC members' access to services available to all Colombians.

Subsidiarity also empowered hospitals to allocate resources, manage decisions, and implement nondiscrimination policies locally. The Colombian Ministry of Health's 2018 peace agreement accountability report documented 11 827 consultations, 63% of which were for Colombians who were not FARC ex-combatants,12 and this number increased to 70% in 2020.13 In other words, what started as a strategy to reincorporate FARC ex-combatants into Colombian society became a vision to benefit all Colombians in well-integrated, locally administered rural health programs.

Peace Requires Clinical Neutrality

While the peace agreement addressed the need for local resource allocation and management of risk of perceived favoritism, it lacked guidance for health workers with duties to care for all patients, including FARC ex-combatants. One study found that 22.6% of Colombian physicians were affected by the FARC conflict and, like other clinicians, seemed to share experiences like CH's.14Quiz Ref IDThe Geneva Conventions and Colombian law affirm a universal right to health care,15,16 so helping clinicians manage affective negative bias that could undermine what they think a patient deserves from them is ethically, clinically, and legally important and could determine whether and to what extent the health provisions of a peace agreement will succeed.

Health workers like CH share accountability for equitable national health care provision.17 Human rights law specifies that all “persons deprived of their liberty” deserve to be treated humanely due to their status as a “human person” with “inherent dignity,” and the Geneva Conventions include clear provisions about the care of persons in enemy hands.18 Although less has been written about health rights of ex-combatants in postconflict settings specifically, it seems reasonable to interpret both Colombian and international law as protecting them. Therefore, it is of utmost importance to understand the nature and scope of a national health system's obligations to traumatized health workers struggling to care for all patients in postconflict settings.

Peace requires health workers like CH to be agents of peace in practice by expressing ongoing, steadfast commitment to collaborative, communal healing. Official policy tasked the Colombian Ministry of Health to develop guidelines for health workers caring for FARC ex-combatants.19Quiz Ref IDWe suggest that such guidelines continue to be implemented with a focus on restorative justice, which can promote healing through ownership of one's roles in past atrocities, ownership of one's own responses to past atrocities (eg, feelings like those experienced by CH that could undermine clinicians' neutrality), and participation in exchanges and discussions that motivate reconciliation and build trust.20 For example, because engaging with ex-FARC patients could be harmful to patients or to health workers,18 CH needs and deserves support from the Ministry of Health in navigating trauma from CH's past in order to be positioned, now and in the future, as someone who can operationalize clinical neutrality in practice. With proper support, health workers caring for FARC ex-combatants can address their tendencies toward negative bias and discrimination against ex-FARC patients so that these patients have access to the equitable care the peace agreement promises.21

Onward

Restorative justice centers relationships and trust building. The Colombian peace agreement was innovative in its reliance on health workers to express and implement restorative justice values and to promote health-system level attempts to make equitable health care key to postconflict life in urban and rural communities. To increase the rural health care workforce, in particular, hundreds of ex-FARC members with combat nursing experience became certified as auxiliary nurses through capacitation programs.22 Hiring has been regionally dependent, but organizations working with ex-FARC nurses could reduce turnover, since ex-FARC health workers tend to remain in rural areas and have unique knowledge of the regions and communities they serve. Colombia's approach offers lessons and strategies that other countries can draw upon to reintegrate ex-combatants into postconflict health care schemes and to help health workers address the ethical dilemmas they face in such scenarios.

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The AMA Journal of Ethics exists to help medical students, physicians and all health care professionals navigate ethical decisions in service to patients and society. The journal publishes cases and expert commentary, medical education articles, policy discussions, peer-reviewed articles for journal-based, video CME, audio CME, visuals, and more. Learn more

Article Information

AMA Journal of Ethics

AMA J Ethics. 2022;24(6):E483-488.

AMA CME Accreditation Information

Credit Designation Statement:

The American Medical Association designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME Disclosure Statement:

Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

Editor's Note

The case to which this commentary is a response was developed by the editorial staff.

Conflict of Interest Disclosure: The author(s) had no conflicts of interest to disclose.

The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.

Author Information:

  • Christopher W. Reynolds is a third-year student at the University of Michigan Medical School in Ann Arbor. He received a Fulbright US Student Program grant in 2019 to study the health care access barriers and experiences of FARC ex-combatants in Colombia. His research interests include health care access in humanitarian settings; Camilo Sánchez Meertens, MPP is a political scientist who earned his undergraduate degree from the Universidad de los Andes in Bogotá, Colombia, and a master of public policy degree from the Hertie School in Germany. He has worked for Colombian independent research institutes, the United Nations, and the Colombian government, including the Ministry of Health and Social Protection and the Office of the High Commissioner for Peace, and has been directly involved in the 2016 peace agreement implementation.

References:
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Santos Calderón  JM, Jiménez  T.  Acuerdo Final para la Terminación del Conflicto y la Construcción de una Paz Estable y Duradera.  November 20 , 2016. Accessed February 25, 2022. https://peacemaker.un.org/sites/peacemaker.un.org/files/Colombia%20Nuevo%20Acuerdo%20Final%2024%20Nov%202016_0.pdf
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Gaviria Uribe  A; Ministerio de Salud y Protección Social.  Decreto numero 1937 de 2016.  Accessed July 28, 2021. https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/DE/DIJ/decreto-1937-de-2016.pdf
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 Presidencia de la República decreto ley número 899 de 2017.  República de Colombia. May 2017.
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McEvoy  K, Shirlow  P.  Re-imagining DDR: ex-combatants, leadership and moral agency in conflict transformation.  Theor Criminol. 2009;13(1):31–59.Google ScholarCrossref
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Clark  JN.  The three Rs: retributive justice, restorative justice, and reconciliation.  Contemp Justice Rev. 2008;11(4):331–350.Google ScholarCrossref
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Redacción.  Así será el acceso a la salud para los miembros de las FARC.  El Tiempo. January 25 , 2017. Accessed July 20, 2021. https://www.eltiempo.com/salud/salud-para-los-guerrilleros-de-las-farc-28119Google Scholar
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