The Peruvian Truth Commission's mental health reparations: Empowering survivors of political violence to impact public health policy

Health and Human Rights

Volumn 9, Issue 2, 2006, Pages 136-163

  Laplante, Lisa J ^a   Rivera Holguin, Miryam ^b,c  

^a Praxis Institute for Social justice   (Peru)

^b European Union   (Belgium)

^c Truth and Reconciliation Commission   (Peru)

Author keywords

[No Author keywords available]

Indexed keywords

HEALTH CARE; HEALTH POLICY; HUMAN RIGHTS; MENTAL HEALTH; POLITICAL VIOLENCE; PUBLIC HEALTH;

ARTICLE; ATTITUDE TO HEALTH; BEHAVIOR; HEALTH CARE DELIVERY; HEALTH CARE POLICY; HUMAN; MENTAL HEALTH SERVICE; ORGANIZATION AND MANAGEMENT; PERU; POLITICS; POVERTY; PUBLIC HEALTH SERVICE; SURVIVOR; VIOLENCE; WAR;

HEALTH KNOWLEDGE, ATTITUDES, PRACTICE; HEALTH POLICY; HEALTH SERVICES ACCESSIBILITY; HUMANS; MENTAL HEALTH SERVICES; PERU; POLITICS; POVERTY AREAS; POWER (PSYCHOLOGY); PUBLIC HEALTH ADMINISTRATION; SURVIVORS; VIOLENCE; WAR;

EID: 33846925122     PISSN: 10790969     EISSN: None     Source Type: Journal    
DOI: 10.2307/4065405     Document Type: Article

References (117)

1. The author's observations shared in this article arise out of their sustained field work and participant observation during their work with the TRC as well as with victims-survivors, as well as through the funded research studies mentioned in our acknowledgments.
2. For the purpose of this text, "this population" is understood to pertain to victims-survivors' the majority of whom are poor, rural farmers.
3. See for example, I. Martín-Baró, Psicología Social de 1a Guerra (San Salvador, El Salvador: UCA Editores, 1990).
4. L. E. Fletcher and H. M. Weinstein, "Violence and Social Repair: Rethinking the Contribution of justice to Reconciliation," Human Rights Quarterly 24 (2002): pp. 573-639.
5. A. Allan, "Truth and Reconciliation: A Psycholegal Perspective," Ethnicity & Health 5 (2000): pp. 191-204, at 191.
6. Ibid.
7. Peruvian Truth and Reconciliation Comisión, Hatun Willakuy: Versión Abreviada del Informe Final de la Comisión de la Verdad y Reconciliación (Lima, Peru: 2004): p. 18.
8. K. Theidon, Entre Prójimos:El Conflicto Armado Interno y la Política de la Reconciliación en el Perú (Lima, Perú: IEP, 2004): p. 174.
9. Peruvian Truth and Reconciliation Commission, Final Report (Lima, Peru: 2003). Available at: www.cverdad.org.pe.
10. Ibid.
11. Ibid: "Psicosocial Secuela," Vol. VIII, p. 167. (Translation by author).
12. Ibid: p. 169.
13. Ibid: p. 354.
14. Personal Interview with J. B. Choque Q., President, Asociacion de Heroes Civiles Fundadores y Protagonistas de la Pacificacion del Peru (October 1, 2006).
15. TRC, Hatun Willakuy (see note 7): p. 355. (Translation by author).
16. Ibid;
17. and Psicosocial Secuela, TRC Final Report (see note 11): p. 167.
18. Seminar, Salud Mental en el Proceso Post Comision de la Verdad y Reconciliación (CVR) (Asociacion Peruana de Psicoterapia y Psicoanalítica de Niños y Adolescentes, Lima, Peru: October 4, 2006). [Hereinafter, Lecture Vivi Valz Gen].
19. TRC, Hatun Willakuy (see note 7): p. 355. (Translation by author).
20. J. S. Castillo, "Estudio Epidemiológico en Salud Mental en Ayacucho," Anales de Salud Mental XX (2004): p. 29.
21. While more marked in rural villages, the authors have encountered these challenges in urban centers especially in communities composed entirely of people displaced by the war.
22. Fletcher, "Violence and Social Repair" (see note 4): p. 564.
23. Castillo, Estudios Epidemiológico (see note 19): p. 29.
24. TRC, Hatun Willakuy (see note 7): pp. 22-3.
25. Instituto Nacional de Estadística e Informática, Conso Nacional de Población y Vivienda (Lima, Peru: 1993). The United States State Department estimates Peru's total population to be 27.2 million, according to a 2006 census. See Bureau of Western Hemisphere Affairs, available at: http://www.state.gov/r/Pa/ei/bgn/35762.htm;
26. Instituto Nacional de Estadística e Informática, Compendio Estadístico Departmental (Lima, 1995-96).
27. Peru's situation fits into a general regional pattern as passionately detailed in the classic E. Galeano, Open Veins of Latin America: Five Centuries of the Pillage of a Continent (New York, NY: Monthly Review Press, 1997).
28. L. J. Laplante, "On the Indivisibility of Rights: Truth Commissions, Reparations and the Right to Development," Yale Human Rights and Development Law fournal (forthcoming May 2007).
29. Ibid.
30. Committee on Economic, Social and Cultural Rights (ESC Committee), General Comment No. 14, The Right to the Highest Attainable Standard of Health, UN Doc. E/C.12/2000/4 (2000), para. 59.
31. The Court held that the right to health requires not only that the State refrain from putting a prisoner's health at risk but also that it "provide adequate and appropriate medical attention." Sentencia Tribunal Constitucional del Perú, Expediente, 1429-2002-HC/TC, paras. 13-15. (Translation by author).
32. See website of the Peruvian Minister of Health, available at: http://www.minsa.gob.pe/portal/.
33. For further examination of these mechanisms, see R. Castellon and L. J. Laplante, Los Afectados por el Conflicto Armado Interno del Peru: Exigiendo el Derecho a la Salud Mental (Lima, Peru: Consorcio de Investigaciones Económico y Social, 2005): Ch. 2. Available at: www.consorcio.org/observatorio.
34. M. Rivera, A. Reyes, and R. M. Cueto, Ayacucho: Personas en una guerra, Apuntes desde salud mental (Ayacucho, Peru: 2003). (On file with author).
35. The authors thank Jocelyn Getgen, Masters Candidate at Johns Hopkins Bloomberg School of Public Health, for providing assistance with this research. The archives mentioned are currently stored at the Information Center for Collective Memory and Human Rights of the Ombudsman's Office (Centro de Información para la Memoria Colectiva y los Derechos Humanos) in Lima, Peru.
36. For fuller discussion on the framework for analyzing the violation of the right to mental health, see L. J. Laplante and R. Castellon, "Expanding the Definition of the Right to Mental Health: Attending to Victims of Political Violence and Armed Conflict in Their Communities of Origin," Essex Human Rights Review 2/1 (2005): pp. 38-56.
37. The analysis in this section is based predominantly on interviews with local mental health professionals, representatives of the public health sector, and human rights professionals working with this population. While an exploration of these issues should be conducted in more depth with victims-survivors themselves, the observations of third party observers shed important light on some of the more subtle obstacles to a culture of rights with respect to health that run along a continuum and are interrelated.
38. See for example, S. E. Merry, "Rights Talk and the Experience of Law: Implementing Women's Human Rights to Protection from Violence," Human Rights Quarterly 25/2 (2003).
39. For a full discussion of the right to mental health, see Laplante and Castellon, Expanding the Definition (see note 33).
40. For example, I. Coral, who developed a program in reparations for survivors of the conflict for the Prograrna de Repoblamiento y Apoyo a Zonas de Emergencia (PAR) (Program of Repopulation and Development) of the Peruvian Minister of Woman and Development, indicated that she frequently received written requests for attention in mental health from the 163 victims organizations working with PAR. She said that the requests were based on complaints that their mental health problems prevented them from having a normal life. Personal Interview with I. Coral, current Director of Centro de Promoción y Desarrollo de la Mujer (CEPRODEP) (Center of Promotion and Development of Women), (Lima, Peru: September 9, 2004). (Transcript on file with authors).
41. Interview with D. Fernández, Coordinator of the Proyecto Fortalecimiento Institucional. para la Protección de los Derechos Humanos en Salud (Institucional Strengthening for the Protection of Human Rights and Health Project), Peruvian Ombudsman's Office (Lima, Peru: September 27, 2004). (Transcript on file with authors).
42. Interview with M. E. Planas, Professor, University Cayetano Heredia (Lima, Peru) and civil society representative, Multi-Sectarian Committee of Mental Health of the National Council of Health of the Peruvian Minister of Health (Lima, Peru: October 12, 2004). (Transcript on file with authors).
43. For further discussion on the frequency of psychosomatic expressions of mental suffering observed in this population, see Theidon, Entre Prójimos (see note 8).
44. Interview with A. M. Rabasa, Executive Director, OXFAMPeru (Lima, Peru: September 14, 2004). (Transcript on file with authors).
45. Interview with Dr. A. Perales, Coordinator of the Masters in Bioethics of the Universidad Nacional Mayor de San Marcos (Lima, Peru: September 23, 2004). (Transcript on file with authors).
46. Interview with Sister Victoria, the Commission of Health of the Archdiocese in Ayacucho, Peru (Ayacucho, Peru: November 24, 2004). (Notes on file with authors).
47. D. Summerfield, "A critique of seven assumptions behind psychological trauma programmes in war-affected areas," Social Science & Medicine 48 (1999): pp. 1449-62.
48. Interview with Dr. D. Fernandez (see note 39).
49. For discussion see, Grupo de Trabajo de Salud Mental of the Coordinadora Nacional de Derechos Humanos, Salud mental comunitaria en el Peru: Aportes temáticos para el trabajo con poblaciones (Lima, Peru: AMARES, 2005).
50. Lecture Vivi Valz Gen (see note 17). Valz Gen's perspective follows a growing trend in Latin America to challenge traditional psychoanalytical approaches.
51. See also N. C. Hollander, Love in the Time of Hate: Liberation Psychology in Latin America (New Brunswick, New Jersey: Rutgers University Press, 1997): p. 17.
52. I. Martín-Baró, "Toward a liberation psychology" in A. Aron and S. Corne (eds), Writings for a Liberation Psychology (New York: Harvard University Press, 1996): p. 125.
53. For discussion see, P. B. Hayner, Unspeakable Truths: Confronting State Terror and Atrocity (New York: Routledge, 2001);
54. R. G. Teitel, "Transitional Justice Genealogy," Harvard H. R. J. 16 (2003): p. 69.
55. "Programa Integral de Reparaciones" in TRC, Final Report (see note 9): Vol. IX, sec. 2.2: 142-3.
56. The TRC uses the framework of human rights to substantiate its legal arguments for reparations. Although the right to reparations exists within the framework of International Humanitarian Law (IHL) which applies during conflict, this argument was not used by the TRC, no doubt due to the fact that there was still controversy on whether to denominate the political violence in Peru as an internal conflict. This article focuses thus on the right to reparation within human rights law, although encourages further development of jurisprudence on the right within international humanitarian law. For a full discussion on the right to reparations, see L. J. Laplante, "Bringing Effective Remedies Home: The Inter-American Human Rights System, Reparations and the Duty of Prevention," Netherlands Human Rights Quarterly 22 (2004): pp. 347-88, at 347, 351-61.
57. Here, the TRC invoked both national and international law. TRC, PIR (see note 50): pp. 141-2.
58. Ibid: p. 157. (Translation by author).
59. Specifically related to health, PIR speaks of the need to respond to the "state of distrust, fear, insecurity, paralyses and pain generated by the violence." Ibid: p. 168.
60. Ibid: p. 146. However, the TRC makes clear that even if PIR alleviates some of these problems, it does not seek to resolve entirely the problems of poverty, exclusion, and inequality that arise out of economic and political structures, since these are problems that must be addressed through institutional reform and social development designed to "attack the roots of poverty and inequality" as recommended in other parts of the TRC Final Report.
61. Ibid: p.148.
62. For further discussion see, Laplante, On the Indivisibility (see note 26).
63. See A. R. Chapman, "A 'Violations Approach' for Monitoring the International Covenant on Economic, Social and Cultural Rights," Human Rights Quarterly 18/1 (1996): pp. 23-66.
64. Ibid.
65. V. Gauri, "Social Rights and Economics Claims to Health Care and Education in Developing Countries," World Bank Policy Research Working Paper 3006 (March 2003): p. 12.
66. Ibid.
67. R. D. Glass, "On Paulo Freire's Philosophy of Praxis and the Foundations of Liberation Education," Educational Researcher 30 (200 1): pp. 15-25, at 15;
68. Paolo Freire, Pedagogy of the Oppressed (New York: Seabury) 1970: pp. 12 & 21;
69. and Martín-Baró, Writings (see note 49): p. 125.
70. Fletcher, "Violence and Social Repair" (see note 4): pp. 623, 633.
71. A. E. Yamin, "Defining Questions: Situating Issues of Power in the Formulation of a Right to Health under International Law," Human Rights Quarterly 18/2 (1996): pp. 398-438, at 402.
72. Ibid.
73. Sub-Commission on the Promotion and Protection of Human Rights, The Social Forum: poverty, rural poverty and human rights. Background note by the Office of the High Commissioner for Human Rights, U.N. Doc. E/ CN.4/Sub.2/SF/2004/2 (23 June 2004).
74. According to a study conducted by Oxfam in Peru, during the two-year term of the TRC, 40% of the approximate 120 victims associations in Peru formed specifically to present their demands to the TRC, including mental health. R. P. Ruiz, Mapeo De Las Organizaciones de Afectados por la Violencia Política en El Peru (Lima, Peru: Oxfam, 2004): p. 33. (Working document on file with authors).
75. Author Laplante began observing ARIL in 2002, continuing until the present time of writing. Her observations of the group arise out of participant observation and from attending their weekly assembly meetings. In addition, she has conducted in dept interviews with as well as surveys of its members. The results of this study can be found in Chapter 4 of Castellon and Laplante, Los Afectados (see note 31).
76. While ARIL's members reside in urban Lima, many come from the rural setting and/or share the types of characteristics described earlier in terms of their passivity in demanding their rights.
77. The Peruvian government began to implement reparations in health for members of ARIL following the work of a special commission whose recommendations preceded the TRC but which TRC folded into PIR. For more information see, Defensoría del Pueblo, La Labor de La Comisión Ad-Hoc a Favor de los Inocentes en Prisión (Lima, Peru: 2001).
78. Loayza-Tamayo v. Perú, Reparations, I/A Court H.R., Series C No. 42 (November 27, 1998).
79. Decreto Supremo No. 015-2006-SA, El Peruano (July 22, 2006): p. 325619.
80. Resolución Ministerial No 591-2006-MINSA, El Peruano (June 29, 2006).
81. M. R. Garate, "Sensibilización del Personal de Salud Para la Atención de Casos de Violencia," in A. M. Guerrero (ed), Derechos Humanos y Salud: Encontrando Ios Lazos (Lima, Peru: 2002): pp. 74-6, at 74.
82. TRC, PIR (see note 50): p. 157.
83. Ibid. (Translation by author).
84. Ibid: p.140.
85. General Comment No. 14 (see note 28): para. 11.
86. World Health Organization (WHO), 2001 World Health Report Mental Health: Now Understanding, New Hope (Geneva: WHO, 2001): p. 3. Available at:http://www.who.int/whr/2001/en/.
87. See for example, M. Minkler, and N. Wallerstein (eds), Community-Based Participatory Research for Health (San Francisco, California: Jossey-Bass, 2003).
88. Ibid.
89. E. Villar, "Empowering The Poor: The Politics of Health and Poverty Reduction Programmes," Development 47/2 (2004): pp. 109 -14, at 110.
90. Salud Sin Limites, Modelo de Atención de Parto con Adecuación Cultural (2003). (Unpublished document on file with author).
91. A. E. Yamin, "Empowering Visions: Toward a Dialectical Pedagogy of Human Rights," Human Rights Quarterly 15 (1992): p. 653.
92. Only recently have local groups like ForoSalud, the Coalition of Health, the Peruvian Ombudsman's office and CarePeru, who have experience empowering grassroots rights movements in other areas of health, begun to examine the issue of mental health in this population in response to the recommendations made by the TRC. In fact, these various groups commissioned the study conducted by the authors that led to some of the observations being shared in this article for the purposes of informing their own development of programs on mental health, especially related to the victims-survivors of the war.
93. C. Hollander, Love (see note 48): p. 143.
94. Fletcher, "Violence and Social Repair" (see note 4): p. 633.
95. Yamin, Defining Questions (see note 62): pp. 425, 415.
96. TRC, PIR (see note 51): pp. 157, 170, 174.
97. Ibid: pp. 141, 157. (Translation by author).
98. TRC, Hatun Willakuy (see note 7): pp. 367-8. (Translation by author).
99. Personal Conversation with C. M. Beristain (Lima, Peru: March 25, 2005). (Notes on file with authors).
100. S. E. Alvarez, E. Dagnino, and A. Escobar, Cultures of Politics, Politics of Cultures: Revisioning Latin American Social Movements (Boulder, CO: Westview Press, 1998): p. 5.
101. Freire, Pedagogy (see note 60): pp. 12, 21.
102. Center for Economic and Social Rights, Economic, Social and Cultural Rights: A Guide to the Legal Framework (New York: CESR, 2002): p. 10.
103. A. E. Yamin, "EDHUCASALUD, Derechos Humanos y Salud: Encontrando los Lazos," in Guerrero, Derechos Humanos y Salud (see note 72): pp. 15-9, at 18.
104. P. Freire, Teachers as Cultural Workers: Letters to Those Who Dare Teach (Boulder, CO: Westview Press, 1998): pp. 50-1. (Translated by Donoldo Macedo, Dale Koike, and Alexandre Oliveira).
105. Ibid.
106. S. C. Wright, D. M. Taylor, and F. M. Moghaddam, "Responding to Membership in a Disadvantaged Group: From Acceptance to Collective Protest," Journal of Personality and Social Psychology 58 (1990): pp. 994-1003, at 995.
107. CESR, Economic, Social and Cultural Rights (see note 93): p. 11;
108. A. G. García, "La Sociedad Civil y el Derecho a la Salud," in ForoSalud, La Salud: Un Derecho para Todos (Lima, Peru: 2003): pp. 80-5, at 85.
109. The Ottawa Charter for Health Promotion, First International Conference on Health Promotion, WHO/HPR/HEP/95.1 (November 21, 1986).
110. These types of civil society power struggles are not unique to Peru. See Alvarez et. al., Cultures of Politics (see note 91): p. 17.
111. J. Urrutia, former President of the Comisión Multisectorial de Alto Nivel Para la Seguimiento de las Recomendaciones de la Comision de Verdad y Reconciliación, "Reconciliación y Democracia" (Conference convened by the Instituto de Democracia y Derechos Humanos and the Pontificia Universidad Catolica del Peru, Lima, Peru Noviembre 30, 2004). (Notes on file with authors).
112. Yamin, Defining Questions (see note 62): p. 436.
113. Ibid: p. 432.
114. Freire, Pedagogy (see note 60).
115. Yamin, Defining Questions (see note 62): p. 413.
116. Martín-Baró, Writings (see note 49): pp. 215-6.
117. A. Mahtani, "The Right of Refugee Clients to an Appropriate and Ethical Psychological Service," The International Journal of Human Rights 7 (2003): pp. 40-57, at 51.