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1 Investigación y Educación en Enfermería ISSN: Universidad de Antioquia Colombia Arias-López, Beatriz Elena Care and social suffering: nursing within contexts of political violence Investigación y Educación en Enfermería, vol. 31, núm. 1, 2013, pp Universidad de Antioquia Medellín, Colombia Available in: How to cite Complete issue More information about this article Journal's homepage in redalyc.org Scientific Information System Network of Scientific Journals from Latin America, the Caribbean, Spain and Portugal Non-profit academic project, developed under the open access initiative

2 Essay Ensayo Ensaio Care and social suffering: nursing within contexts of political violence Beatriz Elena Arias-López 1 Care and social suffering: nursing within contexts of political violence Abstract In light of the armed conflict and political violence in Colombia, the contribution of nursing professionals is fundamental in caring for individuals, families, and communities, whose experience because of these types of events has been devastating, not only for their physical health, but for their psychic and emotional stability. Due to this, we give way to some brief considerations on the armed conflict and political violence in Colombia. Thereafter, the notion of social suffering is included as a perspective that broadens the horizon of care within this context, then we review the elements that characterize the perspectives and domains of nursing and the possibilities offered by the new epistemological tendencies to reflect on life, as a central focus of care, from the proposals by Afaif Meleis; and, finally we discuss the role of nursing professionals in the restitution of the dignity of those who have experienced the consequences of the armed conflict. Key words: nursing care; violence. 1 RN, Ph.D. candidate, Professor. Universidad de Antioquia, Colombia. Article associated with the research: Violencia, Resistencia y Subjetividad. Violencia política en comunidades campesinas del municipio de san Francisco, Oriente Antioqueño, Colombia. Subventions: Universidad de Antioquia. Conflicts of interest: none. Receipt date: March 12 nd Approval date: September 19 th How to cite this article: Arias-López BE. Care and social suffering: nursing within contexts of political violence. Invest Educ Enferm. 2013;31(1): Cuidado y sufrimiento social: la enfermería en contextos de violencia política Resumen A raíz del conflicto armado y la violencia política en Colombia, es fundamental el aporte de los profesionales de enfermería en el cuidado de los individuos familias y comunidades, cuya experiencia por este tipo de eventos ha sido devastadora, no solo para su salud física, sino para su estabilidad síquica y emocional. Por eso, se da inicio con unas breves consideraciones sobre el conflicto armado y la violencia política en Colombia. Posteriormente, se incluye la noción de sufrimiento social, como perspectiva que amplía el horizonte del cuidado en este contexto, luego se revisan los elementos que caracterizan las perspectivas y dominios de la enfermería y las posibilidades que brindan las Invest Educ Enferm. 2012;30(3) 125 nuevas tendencias epistemológicas, para reflexionar sobre la vida,

3 como foco central del cuidado, desde los planteamientos de Afaif Meleis; y, finalmente se habla del papel de los profesionales de enfermería en la restitución de la dignidad de aquellos que han experimentado las consecuencias del conflicto armado. Palabras clave: atención de enfermería; violencia. Cuidado e sofrimento social: a enfermagem em contextos de violência política Resumo Este artigo procura gerar uma reflexão a respeito do potencial contribua dos profissionais de enfermagem, no cuidado dos indivíduos, famílias e comunidades, que experimentaram eventos tão devastadores como os derivados do conflito armado e a violência política. Para cumprir o propósito, dá-se início com umas breves considerações sobre o conflito armado e a violência política em Colômbia. Posteriormente, inclui-se a noção de sofrimento social, como perspectiva que amplia o horizonte do cuidado neste contexto, depois se revisam os elementos que caracterizam as perspectivas e domínios da enfermagem e as possibilidades que brindam as novas tendências epistemológicas, para reflexionar sobre a vida, como foco central do cuidado, desde as propostas de Afaif Meleis. E, finalmente se fala do papel dos profissionais de enfermagem na restituição da dignidade daqueles que experimentaram as conseqüências do conflito armado. Palabras chave: cuidados de enfermagem; violência. Introduction This theme has remained marginal in the research, practice, and teachings of nursing, not only within the local and national contexts, but within the global context, specifically in the West. 1,2 It is urgent to inquire for the pertinence of these social phenomena for our discipline, the role that concerns us in the recovery of the dignity of the subjects who have experienced them, as well as revising in care practices situations that through act or omission could generate for them new situations of violence. The International Nursing Council (CIE) declared in 1997, and ratified in 2007, its open opposition to all types of armed conflict, as well as its concern for the deterioration of health and the violation of basic human rights provoked against the civilian population, especially against women, the elderly, boys, and girls. 3 Nursing professionals, within our double condition as professionals and citizens, cannot evade these reflections, and more so within a context like Colombia. For purposes of this reflection, we initially address an outline of the characteristics of the conflict and political violence in Colombia. Thereafter, we present a revision of the damages and effects of the armed conflict and political violence from the perspective of social suffering. We will end with a review of the challenges of healthcare practices within this context, having as a reference the proposal by Afaif Meleis. A look at political violence in Colombia The academic and research production that has been developed around the topic of violence in Colombia is abundant; however, it does not seem to be reflected on the State or of the Colombian society that tends to maintain a simplistic vision of such, which reinforce polarities like good/bad, victims/victimizers, legality/illegality, among others. These polarities contribute to the perspective denominated enemy syndrome 126 Invest Educ Enferm. 2013;31(1)

4 though which we adhere to the stereotyped and demonized construction of an adversary against whom we have to struggle. 4 Nursing personnel has not been foreign to this stereotyped approach of the situation, nor as citizens, or from the professional practice. Molina proposes that, amid the polarities mentioned, it is necessary for civilian society, apparently not affected by political violence, to assume a more inclusive third place, which leads it to identify itself as offended by the damage, loss, and undermining of the dignity of those who have been directly affected by the armed conflict. 5 This inclusion obligatorily passes through recognizing and visualize said affectations and the context in which they are produced. Ignorance of the complexity of the armed conflict and its impact upon a large segment of the population, only perceived from the exposure made by mass communication media, merely contributes to the stereotyped and simplistic view previously mentioned. These are the reasons that justify the start of the reflection with an outline of what has occurred and has been occurring in Colombia, which is difficult to synthesize in a small section, given its dynamism and complexity, but without a doubt necessary for the purpose proposed. Political violence in the nation is a long-standing phenomenon, originating from the chain of wars during the 19 th century, 6 which are part of a global dynamic among European nations for territorial control and processes of emancipation of their colonies in the American territory. This derived by the 20 th century into internal processes of readjustment of the former colonial territories and into the consolidation of hegemonies, expressed during the two World Wars of the 20 th century. By mid 20 th century and until 1980 with the fall of Berlin wall, the Cold War was the global scenario, where economic, political, and military powers were at stake. Within the national and Latin American contexts armed guerrillas came to be, specifically in Colombia, the Colombian Revolutionary Armed Forces (FARC, for the term in Spanish), the National Liberation Army (ELN, for the term in Spanish), and the Popular Liberation Army (EPL, for the term in Spanish) among others. This world panorama shifted toward the consolidation and emergence of drug trade between the 1980s and 1990s, besides the strengthening of paramilitary armed groups, which in Colombia are denominated as the Colombian United Self-defense groups (AUC, for 4, 7-9 the term in Spanish). By 1989 eight armed conflicts were identified in Latin America of which, currently, only the Colombian conflict persists. 10 Experts on the topic indicate that in its undertone multiple explanatory causes are found. Some affirm that its origin is linked to problem of the use and access to land and resources, 6,11 while others stress upon the rupture of the institutional regulations and the loss of credibility in the legal order. 12,13 These situations, among others, consolidate the conditions for violence to become involved in the social fabric and turn into the privileged mechanism for the resolution of conflicts, both private and public. The millennium came to an end with a rate of 61 homicides per 100-thousand inhabitants, which almost duplicates the Latin American average (35 per 100-thousand inhabitants) and 12 times higher than the world average (five homicides per 100-thousand inhabitants). 14 The number of municipalities affected by violent actions went from 227 in 1993 to 498 in Forced involvement of boys and girls in the conflict came to fluctuate between and by 2005, 15 placing Colombia as the fourth country in the world with the highest number of boys, girls, and youth in armed groups. 16 Women occupied 12% of the paramilitary ranks and approximately 40% of the guerrilla ranks with its correlates in sexual violence and forced domestic servitude in said illegal armed groups. 17 The pressure exerted by these, along with the operations undertaken by the legal armed forces, have generated great forced displacement of population. Since 1985 until 2011, close to 5-million people have been displaced. 18 The balance from the last decade of the 20th century reveals that the civilian population has been increasingly involved in the war in our country, which is evidenced in one of the figures of infractions to International Human Rights (IHR), which almost double the figures Invest Educ Enferm. 2013;31(1) 127

5 from direct war actions among armed groups in confrontation, legal and illegal, like guerrillas, paramilitary groups, and the State s military and police forces. 4 Specifically, regarding the protection to the medical mission in connection with armed conflict, the Red Cross International Committee indicates that between January and September 2011, 39 cases of infractions were reported; more than double with respect to the same period for As can be noted, the figures are overwhelming. This set of facts and situations, which directly implicates over 10% of the Colombian population, cannot be ignored by the members of a discipline dedicated to caring for lives, such as nursing. Armed conflict and social suffering The incorporation of violence as a healthcare problem is relatively recent in the institutional agenda. The first studies, during the 1960s and 1970s, were associated to phenomena of family and gender violence, and was not until the 1990s that it became part of the official discourse of organisms like the PAHO and the WHO Institutional concerns and analysis have mostly revolved around aspects like morbidity and mortality, in addition to the analysis of the costs generated for healthcare systems. However, for political violence, besides these effects, violent action leads to effects of greater amplitude. Therein is produced the destruction of the material, social, and cultural infrastructure; altering the social fabric, forms of cohabitation, solidarity and cooperation networks, the dynamics of daily life, life stories, and systems of beliefs and values identity The substantiation and support systems of populations and whole communities are undermined, 27 which are not only the support of their ways of life, but which are also vital for coping processes and recovery from pain, suffering, and losses. Beyond the concrete expression on the bodies of individuals and the corresponding demand on emergency and traumatology services, said violence permeates, in hidden or manifest manner, cultural and social life, affecting interpersonal and community relations and emotional processes, and its possible expression on organic alterations. This broadened view of the alterations produced by political violence, which is consolidated in the notion of social suffering, contributes to overcoming the anatomopathological, physiopathological, and/or etiopathological view with which the biomedical model has operated, to understand and intervene the health disease processes. 28 From here, it is recognized that the effects of political violence and the armed conflict do not occur in isolation, on the contrary, they are part of a set of historical and social conditions, but, additionally, the possible somatic and/or emotional alterations are accompanied by loss of trust, reciprocity, and hence of the rupture of social ties with which people construct security in their lives. 29 For Kleinman, Das, and Lock, 30 social suffering refers to the result of the actions of the economic, political, and institutional powers upon people, as well as to the social responses these construct to cope with said powers and which involve diverse aspects related to health, welfare, morals, religiosity, and even legal aspects. As an expression articulated to the daily experience, it permits recognizing the cultural processes and practices that emerge among those sharing similar experiences, which not only refer to expressive forms of pain and suffering, but also to a variety of other manifestations that permit life s warp to again interweave. 31 The power of the notion of social suffering lies in its dialectic. Just as it recognizes the repercussion upon the bodies and the social fabric, it also claims recognition of a series of resistance methods visible on the body and on the language. 32 Understanding and incorporating the comprehension of social suffering as experience lived, articulated to day-to-day experience, permits a phenomenon as complex and broad, like political violence, to be understood within the particularity of life of an individual, a family, or a community, as well as incorporating the personal and social significance of the experience in the subsequent integration and recovery steps. 33 Care and social suffering In the interest of maintaining the guiding principle of the reflection made by this document, it is 128 Invest Educ Enferm. 2013;31(1)

6 important to recapitulate what has been developed until now. On the one side, we have presented a panorama of the situation of the armed conflict and political violence in Colombia, seeking to show that it is a sufficiently convincing situation to incite interest from a profession like nursing. On the other, the notion of social suffering has been indicated as a broad perspective, which permits recognizing the experience of those who have been affected, incorporating the particularity of their suffering, as well as their ways of coping and recovery processes. Now, we must focus on some elements of nursing that reaffirm the pertinence of incorporating the previous concerns and perspectives in its disciplinary and professional credit. To begin, it must be indicated that caregiving has been claimed as the main element that gives nursing the status of discipline and which also facilitates and guides the necessary knowledge for the professional practice. 34 Although there are diverse meanings or connotations of caregiving in nursing, it is possible to find as common point the identification of two dimensions of caregiving: a technical-scientific dimension related to processes and procedures and an emotional dimension related to the interaction among human beings. 35 Colliere integrates these two dimensions when stating that caregiving is above all an act of life, in the sense that caregiving represents an infinite variety of activities aimed at maintaining and conserving life and permitting such to continue and reproduce. 36 This statement, as complex as it is broad, invites us to explore inquiries of philosophical, ethical, and political nature of what is considered good and valid in the nursing practice, 37 which although not the central focus of this reflection, do constitute a fundamental reference point for it. Regarding the armed conflict and the derived social suffering, it triggers us to wonder for the life compromised therein and, consequently, for the nursing care deserved by the affected individuals, families, and communities so their lives can be maintained, conserved, continued, and reproduced. We consider it pertinent, in this sense, to bring onto the scene the contributions made by Afaf Meleis 38 on the perspective and domains of nursing during the dawn of the 21 st century. According to said author, nursing as a human science, is basically related to the human life experience in situations of health, disease, and death, which is expressed through symbolic responses. Nursing assumes the human being as a totality, but understanding his/ her particularities, whose specificity and sense is known as of a relationship of dialogue with those it cares for. Meleis states that the caregiving relationship between nurse and patient is, above all, a relationship between human beings, whose purpose is the preservation of dignity. The author, likewise, proposes that through caregiving processes the nursing personnel discovers the forces of health of individuals, contributes to their mobilization, maximizes the resources available, and empowers people to use said resources to achieve their wellbeing. This accompaniment integrates the set of values and beliefs of the subject benefiting from the caregiving to the healthcare system and to the professional practice. Being able to capture the significance of the experience lived is the basis for the care of individuals. When Meleis 38 analyzes the domains of nursing as those referring to theoretical body and its practical body, the author indicates that said domains include the sociopolitical and economic context and inquires on the contribution nursing personnel can make in the care of individuals who have experienced devastating events like wars and natural disasters, wonders about the processes that lead people to heal from the effects of said experiences and about the strategies we must implement from our disciplinary field to create a healing environment and accomplish wellbeing in processes of transition toward healing. The synchrony between the proposals by Meleis and the perspective that guides the proposal of social suffering derived from the armed conflict are resounding. Common points like the importance of the experience lived, its particularities, and the ethical horizon of the concern for dignity, recognition of the subject who suffers subject of care as a social and cultural producer and the incorporation of a cultural perspective in the Invest Educ Enferm. 2013;31(1) 129

7 process of accompaniment, leave no doubt that social suffering derived from political violence and the armed conflict constitute genuine concerns within the horizon of nursing care. In closing As can be concluded, nursing care is constituted within a potential field to explore, energize, and reorient the accompaniment we have been offering to individuals, families, and communities affected by the armed conflict. This contribution is strengthened inasmuch as nursing tends toward a process of (de)colonization of the biomedical model, of the patriarchal hierarchy, and of the prevailing institutional regulatory mechanisms that ignore the pertinence of caregiving, but likewise inasmuch as we remain open to diversity in using different paradigms to guide the development of the theory and research. Incorporating onto nursing research, teaching, and practice notions like those of social suffering allows us to approach the particularity of the experience lived, core of the disciplinary perspective in nursing, and in contexts of political violence, particularly, places us in an ethical perspective that claims life in dignity. If, as stated by Meleis, the caregiving relationships between nurse and patients are above all relationships between human beings, whose purpose is the preservation of dignity, then it is imperative to understand that we have a professional and citizen responsibility, in the sense of restoring the political sense of dignity, which as suggested by Blair, is no more than the decision to construct more dignified ways of ordering life together. 39 Nursing care, centered on accompaniment, recognition of the particularities, and on the subjective experience, is a privileged scenario for life to be recognized in its broader dimension, especially in contexts of political violence. The accompaniment nursing professionals offer and the seat we occupy in healthcare systems is a privileged place to bring us closer to the daily lives of individuals, families, and communities affected by the armed conflict. Both healthcare scenarios of greater technological complexity and first-level scenarios, in addition to the scenarios where daily life elapses: neighborhoods, schools, formal and informal social organizations of diverse nature, are a source of recognition of their needs, as well as of their resources. Individual and group expressions of human suffering claim our involvement in accompanying processes of reconstruction of vital individual and group projects and trajectories. However, this opening is only possible when we manage to recognize said suffering and, consequently, when we permit the production of the necessary cognitive aperture to feel challenged by it. 40 At this point, a range of multiple possibilities is opened for the contribution by nursing within contexts of violence and armed conflict through the construction and implementation of new caregiving strategies. Support to the recovery of processes of practical life that deal with family, socio-cultural, religious, and economic aspects; promotion and rehabilitation of social and community ties; recovery and strengthening of endogenous cultural resources; activation of support groups and social networks; among others, are some of the approaches we are in debt of exploring. Acknowledgments. The author thanks the rural citizens from the municipality of San Francisco (Antioquia) for the generous opening of their spaces and life experiences, for the possibility of marveling me with their capacity to withstand, and for being a source of inspiration for this reflection. Likewise, I thank the reading and contributions made by Dr. Elsa Blair (sociologist) and by Berena Torres (Master in Anthropology), both researchers at Universidad de Antioquia; Dr. Duncan Pedersen, researcher at McGuill University (Canada), by colleague Dr. Jane Georges, researcher at the University of California at San Diego (USA), and by Psychologist Nidia Montoya. References 1. Wright GM. La contribución de la enfermería frente al fenómeno de las drogas y la violencia en América Latina: un proceso de construcción. Cienc enferm. [Internet] Dec [cited 2011 Nov 28]; 8 (2). Available from: Invest Educ Enferm. 2013;31(1)

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