What to do in La Guajira?

The media have already sufficiently dealt with the problem of La Guajira. The analysis has gone through different phases: denial of the problem, minimization of the problem, institutional blaming, recognition of the problem, delegation of responsibility to the Wayúu people, monocausal hypotheses of the problem - corruption, paramilitarism -, and more recently, we are becoming aware of the number of factors and variables that are playing a role in the crisis in La Guajira. The latter, in terms of Public Health, means that the situation is the result of multiple determinants - ecological, social, economic, cultural, etc. -, which is why it is a challenge. -, which makes it a challenge.

My interest is to move from diagnoses to proposals, the what and the how, to face the situation in this department, as well as in other territories that are in similar situations. To this end, I take up a document recently published by the Interfaculty Doctorate in Public Health of the National University of Colombia, which summarizes the determinants of the situation, as well as the lines of action. Three of the latter are proposed: actions to address the humanitarian emergency, intersectoral intervention, and the development of a specific model of social security in health for the region. The following is my vision of the what and how of each of these points.

Attention to the Humanitarian Emergency

This is the most critical point at this time. Once the news began to spread, multiple governmental, non-governmental, religious, and multilateral organizations, among others, rushed to the territory and began an intervention in multiple areas, of which there is no information available. It is necessary for the department and the nation to be clear about who is in the region, what they are doing, and how they can effectively contribute with solutions. It is necessary to act by establishing strategic alliances as a form of solution.

Along with this process, attention must be given. To this end, I propose the following:

• Territorialize the department. Throughout the crisis, we have been learning that there is not only one Guajira but multiple. We already know that there is a Baja, a Middle and an Alta Guajira, each with very different ecological and socio-demographic characteristics, which imply particular challenges and problems. However, we must go further. I take as an example the municipality of Manaure, which has at least five territories - El Pájaro, Musichi, La Carretera, La Sabana and the urban center - each with differentiated characteristics, which imply important logistical challenges. Something similar is found in Uribia, Maicao and other municipalities.

  
  

• Form interdisciplinary teams according to the territory. The participation of multiple professionals is required, since the idea of this humanitarian care effort should be to make a diagnosis not only in health but also very quickly in other areas. In addition to doctors, nurses, assistants and nutritionists, there should be another series of professionals who will make it possible to think of solutions for basic sanitation, food security, drinking water, etc. in the territory. Solutions must be sought locally and with the participation of the people.

• Consultation and agreement. Although there is an enormous eagerness for attention, this cannot be done ignoring the minimum guidelines of respect and participation that indigenous peoples have. To this end, it is necessary to clarify that the levels of consultation and agreement are diverse among the Wayúu people, since their representativeness is diverse. As mentioned above, the basic social unit in La Guajira is the ranchería, which is why the family authority, the basis of the ranchería, is the central axis. But there is also the grouping by rancherías, known as community, which has its independent leaders; the grouping by communities, with its usual political leader; and the resguardo, with its specific characteristics. The interdisciplinary teams should be able to carry out these processes in the field, according to the scope of their intervention.

• Adequacy of interventions. This is probably the greatest challenge, as it requires very important strategic thinking. There is a level of adaptation of the intervention itself, which involves the use of Wayúunaiki, the most widely spoken language in Alta Guajira; the recognition of the cosmovisions and their effects on the subject of intervention; the recognition of the particularities of the life cycle and the roles of each of the cycles in daily life; the role of palabreros, women, wise men and leaders on the decision of care, not only individual but also social; recognition of traditional diets and their nutritional possibilities; an assertive communication in interculturality by the interdisciplinary teams and the population; and the involvement of the population in the solution of problems and difficulties. At the level of operational adequacy, aspects such as time and space of the intervention must be considered. In La Guajira, providers have opted for a daily brigade model - one or two days, one community - which does not necessarily work in all circumstances. Areas such as the Sabana de Manaure, Bahía Honda and Bahía Hondita in Uribia, and the transition between this and Nazareth, for example, require more of a commission model - several days - to ensure a more systematic development of actions.

• Strategic Management. Humanitarian care should also serve as an experience in the administration of resources of the General Social Security Health System. Not only financing but also logistical processes are an excellent starting point to get an idea of how much it may be worth to guarantee the right to health. Transportation costs - 4x4 vans and tanker trucks, for example -, of traditional care agents - piaches, midwives -, maintenance of brigades and commissions, equipment and technology according to the environment - based on solar or wind energy, for example -, generate an interesting challenge that must be assumed with the utmost responsibility. Here, technical capabilities are a crucial point.

• Support Measures. It is necessary to guarantee the support measures according to the balance in the field and the adequacy. In areas such as Cabo de La Vela, fish and shellfish provide an important nutritional contribution; goats and rams are kept in a very important part of ranches and communities: there is no single solution. Support must be provided according to the need, with the participation of the population in defining the most appropriate strategy, and bearing in mind the operational and logistical aspects. An example of the latter is the use of tanker trucks to carry water in the middle of the desert, which often get buried in the sand in the face of blizzards, being more favorable to use vans or smaller trucks.

Intersectoral Intervention with Resources from the General System of Participations and Royalties

I agree with the proposal of intersectoral intervention, which is not only a necessity but also a pending debt with the department and the population. However, this intersectoral intervention is not only an exercise of territorial authorities but also of the population. We must remember the processes of autonomy of indigenous peoples, so it is essential not only to generate the intervention but also the local capacity for the development of subsequent interventions, administration of those already made, and local oversight and monitoring. Corruption, which has attracted so much attention, must be confronted at this level, in the generation of capacities, which is why it will always be necessary to count on the local level.

Some fundamental intersectoral interventions are:

• Guarantee the electrical interconnection or availability through an alternate source in the greatest possible number of rancherías in the department. Energy is a very important resource in the desalination of water from wells, in the management of dietary aspects - boiling, cooking - and, of course, in the generation of social fabric.

• Guaranteeing water fit for consumption. Wells, water trucks and other alternatives should go hand in hand in the guarantee of appropriate water.

• Guarantee proper communication. Improve telecommunications coverage, either through cellular or satellite telephony, shortwave radios in communities and ranches, which allow direct communication with the institutions. Also, improve roads, recognizing that in many cases the territory is an important challenge for Colombian civil engineering.

• Production Chains. The Wayúu have been characterized as a trading population since time immemorial. Along with production - which implies a supply chain of inputs, generation of irrigation districts for cultivation, use of technology appropriate to the environment - there must be marketing chains. Weaving, fish and seafood, goats and rams are a starting point for many things that can be explored with the population.

• Intercultural education in basic, secondary, technical and professional aspects. This is a great challenge. A smaller percentage of the Wayúu have undergone professionalization processes, which should be taken advantage of. However, there are also training processes that do not take into account the fact that a large part of the professional practice will take place in the territories of this population. It is necessary to incorporate basic competencies in the training curricula.

• Strengthening of territorial capacities for male and female leaders. Training and generation of local capacities should be contemplated in order to be able to manage strategically and with intercultural sense the initiatives, processes, institutions, among others, that the autonomy of the indigenous people requires. We do not want to reproduce the welfarism of other times.

I believe that the above elements constitute a starting point for overcoming unsatisfied basic needs, which in some sectors can be 90 percent or more, as well as a necessary action to increase the local human development index.

Social Security Health Model

Health care models are not new. In Colombia, based on the 1978 Alma Ata post-conference movement, some important advances were made in the construction of these models in dispersed rural areas, which is not a novelty. The novelty lies in the fact that we have to think of them under the current model of social security in health, which constitutes the framework of the Indigenous System of Proprietary and Intercultural Health - SISPI (this is still under discussion, but the so-called Autonomous Decree expresses it).

Health care models imply to solve a first question: What health care should be part of the model? There are multiple forms of care. The general system of social security in health recognizes the biomedical system, the traditional system and some complementary ones. However, issues such as self-care, self-care, self-management, among others, have not been taken seriously.

Once there is social agreement on the types of care involved in the model, some clarifications are needed: the context in which the model will operate; the agents involved and their short-, medium- and long-term objectives; the competencies of each of the agents involved; and the needs and gaps to be resolved in all respects.

With this, it is possible to begin to discuss the actual financing (access, scope, supply, demand), management (knowledge, ethical and cultural conflicts, intersectoral, institutional/organizational action), provision, and finally, follow-up, monitoring and surveillance. Each territory will have to find the way that best harmonizes the elements in favor of guaranteeing Health, and in the case of indigenous peoples, Good Living.

By: Pablo Andrés Martínez Silva, Coordinator of Primary Health Care at Sinergias ONG.