Describing+people,+places,+organizations,+practices,+events

Juan Carlos, a farmer from the Cali region of Colombia, stepped on a landmine while herding cattle on his own property. Juan Carlos laid in his field for eight hours until a nearby neighbor finally found his body and rushed him to the local clinic. Thought to have planted by the FARC, the landmine that Juan Carlos stepped on was likely some twelve to fifteen years old, originally planted in the early 1990s to deter movement from competing narco trafficking groups across and important thoroughfare. Juan Carlos survived the devastating injuries and blood loss, but was left without one leg above the knee and much of his other foot. For a farmer who relies on his gait for income, this was worse than being dead, for the victims death claims are much more straightforward to complete than those for landmine injury.
 * Describing People**
 * People as Parts**

In Colombia, to receive compensation for landmine injury, the subject must present his body to the Medical Board whose members will determine his degree of injury and consequent disability based on a grid of percentages that correlate with body part and capacities lost (i.e. lost arm = 20%, lost leg = 30%, lost eye = 10%). To obtain an evaluation from the Medical Board, the subject must fill out paperwork and attend a series of appointments. Frequently his wishes are deferred or rejected if incongruent with stringent deadlines and protocols. For those subjects who obtain an evaluation from the Medical Board, they often feel that they were evaluated unfairly, given a low percentage of disability, and therefore low or no income compensation. The subject does all this in order to make his claims and have his injury and suffering recognized and compensated. If he is rewarded compensation, the claimant must agree to meet standards of rehabilitation and use prosthetic objects even when they cause him pain and further injury.

Among soldiers and civilians, the Medical Board review was controversial. People attested that while the grids used to determine income compensation seemed objective, or rational, one’s status and personal connections actually informed Medical Board decisions. If civilians are not given at least 50% disabled status, they will not receive income compensation. Some civilians who were missing multiple body parts reported they did not make the 50% mark, while they knew that other people missing only one limb would be given a 70% mark.Through percentages, the human figure is reified, that is it is reduced to its parts and the accompanying capabilities and powers associated with those parts. The grid conceals what is openly known: the claims do not establish equality, but rather reproduce social hierarchies.

Luis describes his ill-fitting prostheses to me in hushed tones while sitting on the physical therapy mats in the small military rehabilitation hospital in Medellín. “I know that I should not complain,” he starts, “but they hurt.” Gesturing to several red, angry sores where his prosthetic sockets meet his kneecaps, Luis, like Freud, clearly has prostheses that “still give him much trouble at times” despite the common Colombian sentiment that soldiers with prosthetics are “removing the limits to their functioning…prosthetic god(s).” Luis outlines for me how cycles of reinjury have come to define healing within the hospital, with his stumps being both the site of injury, as well as the site of intervention.
 * Describing Place**
 * Place of Injury/Site of intervention**

Each time Luis attempts to walk using his prostheses, they push into the bony prominences of his residual limbs, painfully breaking through the skin. Each time this happens, Luis must wait for the wounds to heal before wearing the prosthetics again. And when he is able to put them back on, the same cycle perpetuates. For Luis to learn to walk, he must push himself. But to push himself means for his prosthetics to wear holes in his skin, which, if he “endures” without complaint like a “good soldier” result in dangerous infections that compromise what limb he does have left. Prosthetic sockets, the unforgiving wood or carbon fiber buckets that surround the distal portion of the residual limb, must fit snuggly in order to achieve optimal function of the hardware. This insistence on a tight fit means that prostheses often cause pain for the wearer, and further, a functional but notably painful socket is sign for the prosthetist that he has crafted a perfect device. The same device that is intended to make the body “whole” and facilitate a return to a prior, normal state of functioning is now extending the experience of enduring violence onto the body, albeit in a more controlled and less overtly violent manner than the initial amputation. But this departure from extraordinary traumatic violence into a festering violence of the everyday sounds quite similar to how we’ve come to understand the fluctuations of intensity within the Colombian conflict. In thinking about how chronic states of disability are experienced in Colombia, we must understand the political histories that inform both the underlying injuries and the medical and social systems in which they operate.

Not unique to the Colombian or even military amputee populations, these patterns of reinjury are seen as being part of the necessary physical and social initiation of the amputee into prosthetic culture, one that glorifies often conflicting notions of “overcoming” and “enduring” the realities of living with disability. Beyond the physical actualities of donning prostheses, the social expectations associated with prosthetics are also rife with contradiction, especially within the Colombian context.

Luis is left in a position where he is told that he is “lucky” to be the recipient of prosthetic limbs, but they are not working for him. Even more, they are causing him pain and further harm. But to Colombians, prosthetics engage the imagination in a narrative of going beyond a human state, one that is not constrained by the limits of the “natural” body.

Las Madres Caminar por la Verdad (Mothers Walking for the Truth) sit wearing hard hats on the ridge overlooking La Escombrera in Comuna 13, in the northwest corner of the Medellín valley. La Escombrera, a privately owned landfill, is thought to have the remnants of more than 300 people deposited by a right-wing paramilitary group during one of the darkest periods in the early 2000s. In June 2015, the government of Antioquia agreed to start excavating a very small area of the landfill where a prominent paramilitary leader claimed to have deposited bodies. Las Madres started self-organizing immediately after their children were “disappeared” and are now permanent fixtures along the peripheries of the landfill site. They stand guard over the site, ensuring that no garbage is dumped into the excavation region, as the rest of the landfill is still actively in use. Driven by the burial traditions of the Catholic Church, the mothers express that they cannot begin the mourning process without the bodies of their children. In order to begin the process of remembering in order to eventually forget, they must literally re-member their children from their pieces. This focus on the materiality of the body, particularly on recovering and reassembling the whole body, sheds light onto the ways Colombians, and medicine more broadly, locates explanation within the body itself. In order to come to terms with the loss of their children, Las Madres feel as though they must recover the majority of the physical body, a materially and forensically challenging task. A representative of the mayor’s office tells me, “to them, an ear, a leg, a tooth is not enough—if only a small piece is unearthed, that gives them even more reason to think that they may still be alive, out there (gesturing to the mountains).” Making the task even more challenging is the shifting landscape, ecologically and politically. While the recovery team was initially able to use the presence of proximate artifacts to determine whether biological artifacts were in fact from the period of disappearance in question (for example, the presence of a milk container with an expiration date of 2002 located next to biological remains), the location of the landfill on the edge of a mountain means that the land is constantly shifting. This movement of the geologic material unsettles and rearranges the possible biologic evidence, calling into question whether there is even really a “right” place to excavate. A shift in political power also leaves Las Madres and the recovery team in a state of uncertainty, with the question of whether funding to continue the effort will be renewed each fiscal year. Just as medical bodies are subject to the forces of environment and politics, efforts to recover the lost face similar challenges, both medicine and recovery reliant on the presence of the body.
 * Describing Organizations**

Dr. Carlos Valderrama resects the tissue around the distal end of the soldier’s residual limb to expose the jagged edges of the femur. After grinding the bone down with a saw that looks like it belongs on a construction site rather than an operating room, he proceeds to describe for me how //his// technique for amputation surgery allows for “a perfect marriage” of body and machine, making reference to the eventual promise of utilizing a prosthesis for this patient. In order to ensure that this patient would have the best physical chance of adapting well to a prosthetic limb, Valderrama reshapes the bone and soft tissue of the limb to be as uniform as possible with muscle contorted around the bottom of the limb to allow for comfortable weight bearing. He demonstrates how he severs the nerves of the upper limb in efforts to prevent the formation of neuromas, bulbous tumors that commonly grow on the ends of severed nerves in amputated limbs. Valderrama closes his eyes and blindly fishes for the sciatic nerve under the patient’s exposed muscle. Once he has the slippery nerve grasped, he opens his eyes and pulls the nerve distally until taut, at which time he quickly slices through the nerve where it exits the residual limb and it recoils back into the body. Valderrama tosses the excess nerve to the side and explains that allowing the nerve to naturally recoil after being cut under tension embeds the nerve deep into the muscle where it will (hopefully) not be irritated by the pressure of the prosthesis which aids in the growth and development of neuromas. Knowing that Valderrama’s non-military amputation patients at the public hospital typically present with more varied reasons for amputation than the military personnel who we are attending to today, I’m curious if he approaches all conditions with the same technique he just demonstrated. When I ask if Valderrama uses this same technique with his patients at the public hospital, he answers with a laugh and gestures with his index finger as if firing a gun. Recognizing my distress at what I imagine to be an allusion to some sort of violence even more extreme than what is happening on the operating table between us, Valderrama clarifies, “I staple them closed.” Still not understanding what exactly he is attempting to convey, I ask for him to elaborate. “They will never wear a prosthesis. They will never have a prosthesis. Stapling is quicker. Less pain. I don’t have to cut the muscle and wrap the skin. I just close them.” While I was well aware of the disparities between military and civilian populations in access to prosthetic care and components in Colombia, I never imagined that it would inform early stage treatment decisions on part of the surgeon.
 * Describing Practice**

Sitting on a rooftop in Envigado, a suburb of Medellín, I prepare myself for the impending toll of midnight. Alborada, “the dawning of the lights,” has become an annual event in Medellín, tracing its roots to the 2003 demobilization of 849 members of the Cacique Nutibara paramilitary unit. After these members were demobilized, they detonated illegal fireworks from their homes in order to provide visual proof of where members were now embedded in neighborhoods. The illegal fireworks dot the sky over much of the city until dawn, though the event no longer is practiced solely by the paramilitary groups, with others citing the night as the unofficial commencement of the Christmas season. Still, the history of the event is readily ostensible, with different militant groups bearing different colors of firework, the sky becomes a temporary map of the division of the land that is not readily apparent to the unaided observer in the daylight hours. The contrast of the light against the dark backdrop of the sky brings me back to an interaction at the Hospital Pablo Tobón Uribe the day prior, during which the contrast dye of a CT scan also created a map of concern, one in which the areas of invasion lit up white against the black backdrop. Coming from the neighboring village of Marinilla, Maria had been unable to make the trip to the city since discovering the lump in her breast some three years before. Now, even to the unaided and untrained eye, it was obvious that she had a quite serious cancer, with her left breast appearing hardened and discolored. After finally obtaining an appointment and being immediately admitted to the hospital, Maria’s CT indicated that the cancer had metastasized to her spinal column, the white spots of brightness radiating out from her chest serving as a roadmap of the cancer’s non-adherence to boundaries.
 * Describing Event**