 live in the four o'clock block on a given Monday. This is transitional justice. And we're talking today about health and peace building. This is very important, not only in Columbia, that's where we're gonna focus, but everywhere, health and peace building, it's kind of like infrastructure, okay? And our special guest is from Columbia, but he's actually at Northwestern University, taking a PhD in sociology. His name is Alejandro Castillo. We've talked to him before. Hi Alejandro, how are you? Thank you for joining the show. Hi Jay, it's a pleasure to be here. I'm doing well, thank you. So, you know, one of the things that I get out of the write up on this is that, although we thought a deal had been made with the FARC in Columbia, it's not perfect. And it requires further attention. And part of that attention is health services. And you worked on that in Columbia. Can you talk about it? Absolutely Jay. So I completely agree. I don't think there's a perfect deal as many lawyers would agree on, I guess. The only Columbia had very strong features, but its implementation has hit some rocky spots, in particular with what is related with physical security of the former combatants of the FARC. That would be one of the main concerns and also like violent threats or life threats against the social leaders and social movements that are still ongoing or rampant in some areas of the country. However, in many other areas, implementation has been robust and it's ongoing. And as with everything in transitions, you know, it's a continuous challenge. And I think that everybody involved is doing their best. Yeah, you say transitions. And indeed, you know, the subject, the title of our show, our series is transitional justice. But it occurs to me talking to you that life is transition. The only thing that's permanent is change. And transition is changed. Transition is changed in Columbia, it's everywhere. And certainly it moves faster. The changes are more profound, sometimes more deadly elsewhere to it, you know, Ukraine. But there's always change. And so I guess my question is, if I were to find an imperfect move to democracy in Columbia, and I wanted to help make it more perfect, a more perfect union, if you will. I've heard that. So, and I knew something about healthcare, healthcare services, doctors, medicine, hospitals, you know, healthcare infrastructure, if you want. Would that be a salient piece of improving the deal with the FARC or bringing the FARC more to the table of having greater concessions with them and improving, thus improving the democracy as it is in Columbia? So I think this is a very good question, Jay. And I wouldn't really focus it on how to improve the deal with the FARC, which has been signed and it's being implemented. But I would focus on how you can deploy health services and improve the robustness of health services in rural areas, in remote areas of the country where conflict has been traditionally present and where in some results it still is even after the mobilization of the FARC as an armed group. Actually, some years ago, the Ministry of Health in Columbia launched this new initiative called Special Model for Despair's Rural Areas, M-I-A-S in Spanish. And the bed under, like that had, like the underpinning bed of the model was to understand that in these remote rural areas you can't really hope that health is gonna work as in urban areas where if you have a health condition you go to the hospital and then or you go to a physician's office and you help, you hope to get treated. In these very dispersed areas, what you need is more of the state coming to the people because these are people that live eight, 10, 12 hours away from maybe in some cases a couple of days away from the nearest urban outpost. And so you're not gonna go there to get your, I don't know, health pressure checked up. You're not gonna go there for a mild pain because it's too far away, it's expensive, it's risky sometimes, but instead you could have brigades of public health company like physicians and teams that could like do rounds on the territory reaching this far away communities. And this has two impacts, one obvious one, health but it has a democracy enhancing impact as well because these communities, they don't interact much with the state, you're building state presence in this area. And in the few instances where they do interact with the state, it is often with the military which is not the best way to engage with state services. So having health professionals, health teams that go to them and give them a different vision of what the state can do for them and give them a sense of inclusion, give them a sense of building trust. It's not only crucial for improving any public health indicators but it's crucial for improving the state of democracy. So I would tell you that if I had to do a bet it would be on deploying rural health teams on the most like remote areas of the country. You know, we've talked with one Pablo Tello, do you know him? He's a lawyer in Bogota. And his thing for his law firm is to build infrastructure. He organizes public-private partnerships. He brings in capital from a lot of places in the world and he creates what we call legal structures to build infrastructure in the notion. It's an important notion that you can improve the country you can improve the country, the democracy in the country by improving it's what you were saying a minute ago by improving the infrastructure. So for example, if I have government services that I want to deliver on a show the people in the hinterland and in the far reaches of the country that, you know, in the jungles and the mountains whatever it is, then I have to get there. So I need roads, I need airports and I need telecommunications. You know, I need to have security and that means I suppose the army. But I also, and I guess what I'm getting out of this is I need healthcare because that will show people that I care, it'll show people to the government. Yes, the government can help them live a better life, not die, provide life-saving, you know, things. And so it falls right within one Tello's program of improving the country by improving the infrastructure. I mean, and the general rule would be better infrastructure, better economy, better country and healthcare is part of that. So you agree? I agree with the main premise that improving infrastructure is crucial but I would maybe also reframe it in the current discussions that are happening and or had happened in the past months in the US around the infrastructure bills that were presented by the government for Congress and it's to maybe de-emphasize the notion that infrastructure necessarily means bricks. The necessarily means building like roads or building buildings. Infrastructure is also public, like public services including health services, of course. It's not only, it's not about building hospitals because I used to think similarly to like this brick-centered way of infrastructure and what I quickly realized what I was working with the Ministry of Health in Columbia is that even if you build a hospital in these faraway regions, it's gonna be very difficult if not impossible to find doctor, nurses and a whole set of staff that will permanently be there because it's so far away that people don't stay. And even if they state their density of population is so small that the health outpost would be empty most of the time, if not pretty much all the time. So infrastructure is crucial, I agree with you but it doesn't mean building hospitals or building operating rooms. Infrastructure in this case in this very remote isolated regions means first and foremost deploying services making the professionals get there. And they don't have to be there permanently because you don't go to the doctor every day. If it's a community of 50, 150 people you can have a health team, a brigade that goes for three, four or five days everybody gets a checkup, everybody gets their medicines everybody gets their prescriptions. And then you need to, I agree with you deploy the infrastructure so that medicines come like the needed medicines, the prescribed medicines get to the remote outpost on a frequent basis. But it's not only about building bridges or building hospitals in this case it's also about thinking of infrastructure as services and in this case human service. Yeah, I take your point, absolutely. And in the case of health you wouldn't build a hospital that'll service 5,000 people when there's only 50 people in the village. You have to adapt it to the community that you're serving and you can't have a formula that applies to one without thinking of the other what you're really applying it to. So that takes me to a question to connect your sociology which I dwell on as social psychology myself and democracy. So here I have a person who lives in a village and his family for generations has died from the stat the other thing because they haven't had healthcare. They haven't had these services period. And so now the government in Bogota says we wanna deliver healthcare services because we want them to believe in the country to believe that we here in the capital of the country can do our doing something for them. So that's the intention. And then the people at the other end in the little village they are getting the healthcare call it infrastructure if you want the healthcare services. So query what is the psychological sociological connection between those services and the way those people in that village see the capital in Bogota the way they see the possibility of democracy. Well, I think this are very complex questions and I can't venture to know exactly what's going on in the minds of this populations but what I can tell you from my experience and having visited some of these regions is that it is all like feedback cycle. These people many times like voting is either like abstention is very high or voting behaviors respond to very clientelistic relationships with politicians and often with frustration and disillusionment because their votes did not get translated in better presence from the state in their home communities. So providing services, providing health services is a way of breaking these cycles that feed themselves in a circular manner. Providing health services is a way of changing the idea that the state does not care about these communities and does not come to these regions and that the state has something to give and hopefully that will mean that also these communities will feel more engaged and willing to give themselves in terms of state building and recognition of the state's authority. Yeah, but there's also this kind of representative thing. In other words, if I'm in the clinic, call it a clinic in this little village and I say to the doctor or the healthcare worker, we need more widgets here. We need you to do this, that's the other thing maybe we could use this kind of medicine. Maybe you should come on Tuesdays and Fridays instead of Mondays and Wednesdays, that sort of thing. And the staffer says, yes, thank you. We take that point. We are completely sympathetic with your wishes here. Now that may not be like voting, okay, but it is responsive that it is caring about the individual in the small town and it is a kind of democracy, at least to the point that the individual who makes the request and has his request granted can say, gee, they actually respond to me. We're in a kind of arrangement where I'm not just being handed something. I absolutely agree with this perspective. And of course, all of these tasks are very challenging and these areas are not easy to access and easy to deploy services in those areas. So it's also getting to get everybody on board with the fact that not everything will be able to be solved in place. So many times the communities will be like, well, I need a surgery and I can't have my surgery here or you need an ICU or you need more complicated procedures, but just the scale and the staff is not available to be in those regions. So what do you need is robust evacuation routes and robust logistical chains that will allow you to identify early any potential complicated cases in the remote area and be able to tram it them through the appropriate routes to larger urban outposts. But it's not only about the surgery because many times you get an insurer that's there to pay. In Colombia, we have a national insurance health system. It's not very like the US in that sense, but that's only the beginning because even if these people are making it to the city to get the surgery, then they need to go to the follow-up appointment with the doctor three, four days afterwards and they don't have a place to stay. And these are very remote rural, often poor communities. They don't have also the money to pay for a place to stay three, four days in the city for the follow-up checkup with the doctor. They don't know what bus to take, how taxis work in that city. They don't know the addresses. They feel lost many times in this context. It's not their hometown, completely understandable. And it's all of those support services that are crucial for health services to be successful. We live the same experience when we were doing the transition with the FARC. They signed the peace agreement and then all of a sudden, we had thousands of former combatants. They were concentrated upon 26 different encampments around the country. And as a government, we had the responsibility to provide them with health services, health services that they hadn't had access for for decades because they were rebellious against the state in an insurgent armed conflict. So many times we found them the doctors. We found them the hospital to go to, but they didn't have a way to get there. Also because in a transition, you have a bunch of additional hurdles which is their mobility to move is restrained because there is international observers missions that are supposed to check the fulfillment of the agreements and the actual demobilization. There's limitation, there's security threats. So you can't freely move former combatants around the country to a hospital without thinking of potential security implications for their own lives. They're being targeted by many rival groups or people who they've wronged during the many years of conflict. It's a very complicated scenario. So I just wanted to underscore the importance of not only health and health, not understood necessarily as the building, but as the service, but then all of these ancillary services that are often challenging in hospitable conditions, like geographic conditions, like what happens in Columbia during the demobilization phase of the park. Well, I mean, it does sound very complex in a very complex environment, but it sounds to me that also that the government is saying, we will move you. We will find a hospital for you and we will take you there. I mean, assuming there are no security implications, we will take you there and we will have you meet your appointment and follow up as necessary and have the benefit of the original operation, have the benefit of the healthcare that our system can provide. And correct me if I'm wrong, and that you do this without distinguishing between a member of the FARC and a member of the village, everybody gets the same. Am I right? That's absolutely right. So these former combatants were moving into regions to settle down and demobilize where there were some local communities that they themselves had very scarce access to the state infrastructure, the state health services because these were remote areas. So we did not want to create new inequities. We did not want to create new wedges between the communities. So the services that we had to deploy had to be equal for everybody. And it was like a beautiful metaphor if you think it in a way like these were combatants that have fought the state for close to 60 years. For them, the state was something or someone that wanted to kill them. And now the state was there to actually save their lives, to take them to a hospital to give them a different image of what the state was to them. And that was like beyond the health, like the immediate health benefits of providing healthcare that was one of the big strengths of providing a comprehensive healthcare approach to the early demobilization phases because it allows you to completely reshape and resignify for the former combatants who were what the state is and resignify that relationship between the now demobilized combatants and the state who used to be the enemy. It's beautiful. It really is. And furthermore, I would make a guess and say that this was an important part of the effort to bring the FARC in to society because that is the kind of experience that people remember, FARC people remember for the rest of their lives. And they also think it's a beautiful thing. Am I right? Did it have a salient effect? Do you have a metric on how many people bought into that and accepted it and were positively affected by it? So I think that you're right in the sense that these are the kinds of experiences that people will remember and that they're so powerful that they will shape their image of the state. However, here I wanna maybe highlight the risk and it's that if you do it well then it plays out wonderfully because you're gonna remember a good experience. You're gonna remember the state of somebody who came to help with an efficient service. However, if you do it poorly because perhaps you didn't consider this was an important, like you're doing a peace process. You're thinking of guns. You're thinking of not committing any more crimes. You're thinking of transitional justice. You're thinking of the victims. You're thinking of many things but often you're not thinking of, oh, what about the health services for the former combatants? Many times that's not in the top of your list. And so if things go well this can be a beautiful experience that will be signified in a positive way the relationship with the state because it's one of the first and early ways in which they engage with the state after demobilizing. But if you don't do it correctly if the services are delayed or if there are no services or things don't go as planned then it will be memorable. It will be a bad outcome in terms of health. But not in the way you wish. Yeah, well, yeah. I mean, it's the old story. You bring the magic of modern medicine somebody who has no clue on how it works or the risks involved. You do an operation that fails and this individual dies on the table and his family and friends or her family and friends are gonna say, hmm, this didn't work at all. We are really ticked off at you. And I wouldn't wanna be the doctor in that circumstance. So yeah, you know, it's a matter of giving informed consent and all that. So I wanna shift. We have a few minutes left and I do wanna shift for a minute to the news that occupies us all these days and that is Ukraine. And I know you're not an expert in Ukraine and I'm not either except that I read about it. But I wanna see if any of these principles would apply or could apply to the, what do you wanna call it? The peaceful transition. The transition that we know must come in Ukraine because it's being destroyed. And on the health side, that's where I wanna talk to you. On the health side, we know the Russians have destroyed most of the hospitals. And we also know that they wounded and killed and maimed an enormous number of people which they are continuing to do today while we speak. And so the question is, and I've asked a lot of architects and engineers about this. I've asked contractors and builders. I had not asked a sociologist yet. You're the first one. When you take these principles of sociology and you try to knit back together a culture and a country, a society that has been damaged to this effect and whose healthcare system has been damaged if not destroyed. How do you do that in a way that works? Where do you start? And can you be successful at all? In a pile of rubble? I think it is important to consider the health effects beyond the, of course, tragic loss of life, the health effects that war has. It also, it is important to acknowledge that here like the Ukrainian case poses a very different scenario in the sense that it is an interstate war or conflict. And so after the aggressions end, what you would hope is you're not looking for victims and aggressors to live together in the same country. That is not the outcome that you're looking for, which is the most typical outcome in an internal conflict in a civil war. The communities that were adversaries in the past need to find ways to build a future together. This is not exactly the same logic with interstate wars. So that's the first difference that I would call, but what we know is that beyond the loss of life, any war, interstate or internal, has a public health on desirable outcomes, not only in terms of those who die or are directly wounded, but in terms of those who lose access to health infrastructure, those who have high tension, chronic illnesses, those who have preventable conditions that are no longer preventable anymore because they don't have access to different healthcare. It's a- Say nothing of infectious disease and exposure on an immune system basis. Absolutely. And here it's important to think of maybe a good analogy. It's COVID and schooling. We know that there are gonna be lasting effects to children's schooling outcomes because of COVID, not because the days of school that they already missed, it's gonna mark them for life. It's similar in a war context with populations that even if they're not directly affected by the violence of the war in terms of being injured, they are losing access, they're losing access to school, except in this case, access to healthcare. And that is gonna leave profound marks in the Ukrainian population. So it's, of course, building back hospitals and doing it fast is gonna be crucial, but it's not only thinking of the day zero and forward, it's thinking of the scars in terms of physical health and mental health that such a crude conflict can leave for an entire country. It's also a self-image thing, isn't it? I always think that if you look at one individual person, you can do a kind of clinical analysis of where he or she is and whether he's happy or not, depressed or not, what have you, that's for the moment, the private moment with the psychologist. But you take that one experience, that one lack of optimism, depression, and you multiply it by say 40 million. And now you have a country where nobody believes they're gonna be healthy anymore, where nobody believes that their life expectancy will be anywhere near as long as it was, where nobody believes that the daily life on the planet will be as pleasant and productive, and the same with their family, their kids, their spouses. So that becomes more of a sociological, psychological question. You take a culture of people who are all kind of pessimistic about their own health, life expectancy, quality of life. What happens? I think you're highlighting a very important point. And this is one of the big challenges of any big shock or a big event. It could be war or it could be a pandemic. And it's how it reshapes the way our social relationships are built, how it reshapes our long-term expectations. And to be honest, Jay, I don't think that we have satisfying answers to how to go back to the previous stage, because the previous stage is not attainable. Maybe that's not even the right question. It's acknowledging that we're not gonna go back. We have to go forward. And forward is gonna look hopefully better than what it is right now, but it's not gonna be exactly the same as what it used to be. It's gonna be like a new set of interactions, a new set of social rules, expectations, behaviors that are gonna come out of, well, history, long history from a national perspective, and then how that history is shaped and impacted by a horrible shock, in this case, the Ukrainian Conference. Trauma. Trauma. I'm thinking of the word trauma, but I'm not thinking of it in terms of the emergency room. I'm thinking of it in terms of trauma to an entire population, to millions actually, directly and indirectly, millions of people. And that has an effect. So what you've learned, okay, in Bogota, in Columbia, and in sociology and your PhD, where does the issue of healthcare fall on the list of priorities, assuming that we all have, and I say we, I mean, the whole Western world, has in terms of trying to rebuild Ukraine, is it the top, is it the very first priority, or is it not the first priority? In my experience, health services are often not at the top of reconstruction efforts or the agendas for transition. There's just an internal conflict, there's justice concerns, there's economic rebooting or economic launch initiatives. There's maybe building hospitals, building infrastructure, but not necessarily thinking on what those hospitals need to do. That comes as a second order priority or something that is often not looked at. So I would call for anybody who's thinking about these problems in Ukraine and elsewhere to bring back health to the center, not only because health is important in and of itself, but because health, and I'm taking a sentence here from the PAHO, the American Health Organization, health is a bridge for peace. Health can build peaceful relations and can resignify and knit community relationships back when they were severed. This were some examples that they did during the Central American transitions in Nicaragua and Salvador, which we were inspired by and we researched on when we were designing our approach in the Colombian transition with the former combatants of the park. Health is a bridge for peace. What a wonderful idea. If you achieve it. Well, at least it's vision, at least you want to achieve it, which takes me to my last question to you, Alejandra. So there you are, working for the government in Bogota. They were bringing health services to people around the country. And that's altruistic in the sense that the government needed to do that and there was a positive effect of it. And then next time we look, we find you're in Northwestern sociology. So connect it up for me. Why did you lead healthcare services in Colombia and study sociology? What is it about sociology that makes you want to take study it and that is consistent with what you were doing before? And what do you want to do with it when you finish your PhD? By the way, somewhere in your answer, tell me what you're writing about your PhD. Absolutely, Jay. So I think the thing that connects both of these things is that both policy and academia and in particular sociology seek to understand how the human relationships work and how we can improve them, how we can improve the lives of entire communities or countries, hopefully. And being in the policy making fear, I felt that sometimes we are so concerned with what we need to do now to solve very urgent problems that we lack distance and space to step back and really think or look from a 10,000 feet view how these problems are shaped. That's what moved me into wanting to do a PhD in sociology. And hopefully my hope is that I can engage in public debate and maybe back in policy, hopefully one day once I've completed my PhD and use my research in ways, leverage my research in ways that will shape and improve the lives of many, that's the hope. And to close to your question, I'm right now just focusing on studying the relationships between the pharmaceutical companies and physicians here in the United States and how those networks of influence between companies and physicians are created and change over time over the years based on different types of shocks. So it's not just sociology, it's much more than that. Absolutely, let's hope so. One of these days, Alejandro, you're gonna get a call from the White House. They're gonna wanna tap your thinking about these things, especially about the drug companies or the relationship of the drug companies to the state of mind of the community. There's so many problems to work out, but I think you're in a place where you can actually have an effect and your healthcare and sociology combination is really powerful stuff. So, but I would hold up on moving to Ukraine just now, okay? Absolutely, and well, thank you for your good wishes, Jay, and I hope they're all true. Yeah, thank you, Alejandro Castillo, who joins us from Chicago and who is from Columbia, from Bogota and part of or at least familiar with Project Expedite Justice. Thank you so much. Appreciate you being on the show, Alejandro. Thank you, Jay, have a good day. Aloha.