Orphans of the Mexican drug war: insights on a public health challenge/Huerfanos victimas de la lucha contra el narcotrafico en Mexico: apreciaciones sobre un reto en materia de salud publica.
In Mexico, the armed conflict between the government and the drug cartels has directly affected numerous families (3), with children paying the highest price. The drug war in Mexico began in the 1970s, but took on new dimensions in 2006 when the government headed by President Felipe Calderon decided to face the drug cartels with military-based strategies. This approach contributed to a significant increase in violence. An estimated 50 000 children lost either one or both parents or guardians, and a growing awareness of orphans as a public health issue followed (4).
Additionally, given that drug cartels not only resist the government, but also fight among themselves to claim market share, thousands more have been killed, leaving even more children in vulnerable situations. This particular type of OVC is referred to as "narco-orphans."
Parental loss not only harms the affected families, but takes a toll on society as well. The costs to society are both direct and indirect. Direct costs include those related to maintaining a system for investigating and responding to allegations of maltreatment, abandonment, and orphanhood; operating costs of judicial law enforcement; and health systems. Indirect costs include long-term economic consequences of orphanhood, such as juvenile and adult criminal activity, mental illness, substance abuse, domestic violence, loss of productivity due to unemployment or underemployment, special education services, and health care system (5). A study of OVC in the United Kingdom estimated a total indirect cost in that country of US$ 1.2 billion annually (6).
In addition to these costs, failing to effectively take care of the OVC directly undermines the Millennium Development Goals, mainly those pertaining to education, health, nutrition, and poverty reduction (7, 8). If "public health" is defined as "any activity directed to improve or maintain the health status of a determined population" (9) and a "problem" is defined as "a matter or situation regarded as unwelcome or harmful and needing to be dealt with and overcome" (10), then can OVC be considered a public health problem and not just an economic issue? The situation of these children has unwelcome consequences, not only for them as individuals, but also for the entire population, and potentially for the country's economy and stability.
Mexico has both private and public health services; however, most of the population utilizes the public network. Private services tend to be expensive and are completely out of reach for the 51.3% of the population that is at or below the national poverty line (11). The public programs rely on the budget of the "Seguro Popular" (Common Insurance), a financial system in place to protect people with low or no resources from catastrophic expenses for basic and extended health care (12).
Mexico has a paucity of research on the topic of narco-orphans as a public health issue, possibly due to the sensitive nature of the topic (13). For instance, there are high rates of drug-cartel violence against journalists investigating drug-related issues, a universal freedom of expression indicator (14). Due to the lack of reliable information, the magnitude of the problem and the steps to mitigate it are not clear. Further study is required. This gap has created what Tversky and Kahneman term the "representativeness effect" (15), that is, when little is said about a problem, the assumption is that its incidence is low. The inverse is also typical; however, these measurements are wrong most of the time.
The objectives of the present study were to describe how the Government of Mexico and other direct stakeholders perceive children orphaned by the drug war, to determine the current measures addressing this as a public health problem, and to compare these measures to international frameworks so that relevant recommendations can be identified.
MATERIALS AND METHODS
This was an exploratory, descriptive case study using qualitative methods based on grounded theory (16). The study was conducted in June 2013.
All of the states within Mexico were considered for the study. Based on levels of safety, of the known magnitude of the problem, and expected access to information, the State of Mexico was chosen. Despite the fact that drug-related conflicts do occur within the state (17), they occur in specific, mostly isolated areas, and so safety was not jeopardized. Also, in the State of Mexico, information was available and accessible due to the presence of several NGOs and several public management ministries' headquarters, as well as some of their dependent offices, clustered in Mexico City within the state.
Due to the limited number of stakeholders with in-depth knowledge of the problem and the topic's sensitivity, a snowball sample technique was used (18). The principle study method was semi-structured interviews. In addition, the researcher kept a reflective journal and field notes, adding rigor to the qualitative inquiry (19).
Semi-structured interviews were conducted in Spanish using an interview guide (Table 1). The average interview required 120 minutes.
Key informants were included in the study if they met at least one of the following criteria:
* Three or more years of experience in health policy development directly or indirectly related to OVC care
* Responsible for, or holder of, a key role in health policy and/or program formulation/implementation in the area of OVC care provision
* Management of a unit within the public health structure, NGO, and/or related institutions addressing the OVC challenge
A total of 10 stakeholders from 10 different institutions with legal or contractual responsibility to provide services to OVC were interviewed. These were either federal, state, or private/NGO institutions. During the study, one interviewee decided to remove his data from the study due to the sensitivity of the topic; all the information from his interview was destroyed, therefore only nine sets of data were analyzed. The institutions included were private or public, plus one NGO. Eight of the study participants were in direct contact with OVC: six out of these eight were direct service providers and the other two were managers of the institutions. The ninth person was a private stakeholder working as a consultant for a private OVC service provider.
The data was coded and analyzed using the qualitative software program, Dedoose (SocioCultural Research Consultants, LLC, Manhattan Beach, California, United States of America). The analyses obtained were then compared to find salient and commonly identified themes in all groups. The main coding for data analysis are presented in Table 1. The resulting themes were further augmented with the available, officially-published documents containing laws, policies, guides, and regulations on this matter, and then compared to the relevant international frameworks.
International frameworks for OVC
Three international frameworks relevant to OVCs were compared: the World Bank Framework (7, 20); the United Nations Framework (21); and the HIV/ AIDS Framework (8). The documents were read several times and key concepts emphasized by all three documents were identified.
Ethical approval was obtained from the Ethics Committee of the University of Heidelberg (Heidelberg, Germany). All participants were informed of the research scope and limitations, as well as of their right to refuse participation or withdraw later. Participants were ensured that any identifying data would be excluded, unused data would be destroyed, and that anonymity would be maintained through the use of password-protected devices. Those willing to participate signed a consent form.
The study results are presented following key themes that emerged.
Public health structure for OVC
According to current Mexican law, the decentralized organization called the "Desarrollo Integral de la Familia" (Integral Family Development, DIF) is the only institution charged with caring for this type of vulnerable population (22). DIF has three levels of authority, i.e., federal, state, and municipality; however, each is independent from the other, and in all cases, each reports directly to a different executive chairperson, i.e., the President of Mexico, its respective state governor, or its municipality president (Figure 1-A). Legally, the DIF can coordinate its actions and programs with any relevant entity in the private or public sector (23). The law also states that DIF is not only responsible for planning and promoting care provision, but also for developing a national information service on social assistance. A court determines the children over whom DIF has legal custody; after or during this procedure, DIF can delegate some responsibilities and activities to the private sector to meet its protection and provision goals, but the legal custody of the children always remains with DIF. In order to coordinate this external assistance, the DIF relies on each state's Private Assistance Board (Figure 1-B).
Interviewees consistently perceived that the DIF is clearly the leader and regulator of OVC affairs. Nevertheless, many spoke of a lack of coordination among the assistants and the leader.
Defining narco-orphans as OVC. None of the participants addressed these children as "narco-orphans." Despite the fact that the concept was known to them, they always clarified by making a statement such as "we don't call them 'narcoorphans.' To us they are all orphans and vulnerable children." However, there is no agreed upon definition of "orphan-hood," e.g., whether a single or both parents must be deceased or missing and what the age range is. Most used a broad "vulnerable children" concept adapted to their specific context. One of the interviewees, a private health provider, stated: "For us, OVC means female children up to 18 years old, with or without parents sent here by the DIF, because those are the children we are interested in."
The stakeholders stated that they do indeed collect and record the cause(s) that led to orphanhood and vulnerability, but they do not share the information outside of their own organization; therefore, it is not being used to adjust the public health programs to the actual needs. Despite the fact that there is no national or local register (database) of OVC, the interviewees spoke of their willingness to share their information in order to design more effective strategies. The study respondents from both the public and private sectors have observed a considerable increase in vulnerable children during the past 6-10 years.
The public sector interviewees said they exchange information on strategies to tackle the OVC problem mainly with other states within the nation; whereas, those from the private sector exchange information with both national and international bodies through the Private Assistance Board. No interviewee, private or public, was able to identify any international frameworks that might assist in developing a strategy.
According to the interviewees, there is one main reason behind the increase in OVC, and it is not the drug war, but rather the loss of family cohesion due to issues such as poverty and cultural changes. A perceived consequence of these was that family members get involved in destructive activities such as drug trafficking and violence. For instance, the interviewees identified that the main problems faced by OVC are domestic violence, psychological trauma or distress, abandonment, and involvement in illegal activities.
The DIF and its support institutions endeavor to maintain the children at their home or with their biological families; when there is no other option, the children are institutionalized in family-like settings where they receive education and training.
The private sector stakeholders perceive that the law is impeding them from doing a better job and that it is "impossible to change," whether it is about adoption procedures, making official the legal status of the individuals, or providing training and life skills to OVC.
The respondents identified the program "Seguro Popular" as playing a dominant role in the improvement of the children's accessibility to health care services and in reducing their own operating costs.
International framework comparison
Table 2 compares the three frameworks to the study results. Three criteria are consistently included in all the frameworks and emphasized by the study participants: involvement of stakeholders; community solutions that play a major role; and the use of simultaneous preventive programs. In addition, all frameworks recommend setting an agreed-upon, broad definition of OVC, to avoid stigma, as a first step to ad dressing the OVC problem. Though all three frameworks agree on this, they also emphasize that the means for identifying OVC should be context-specific.
It is clear that in Mexico, OVC are a public health problem; however, due to the lack of reliable, national, official data on its extent and an absence of research, it is hard to measure the problem's real magnitude. Based on evidence from the United Kingdom, where information on cost of OVC has been collected (6), the cost to Mexico may be quite considerable.
The consequences to society and especially to the children growing up in this conflict can be, among others: erosion of the adults' capacities to care for, nurture, and protect children; increasing levels of deprivation; frequency of dysfunctional families; incidence of sexual abuse; widespread stigmatization that acts as a barrier to health policies; and breakdown of family (3).
While states with a higher presence of narco-trafficking commonly refer to these OVC as "narco-orphans" in the media, this study's results indicate that the term most commonly used among the key informants from the State of Mexico is simply OVC. This does not mean that the drug conflict and its consequences are not present in the State. It provides information about its inhabit ants' perception and the possible representativeness effect (15), that is, the lack of accurate data being both the cause and effect of the little attention that the topic of "narco-orphans" receives in the State of Mexico.
The international frameworks (7, 8, 20, 21) recommend setting an agreed-upon and broad definition of OVC as a first step to addressing the problem. As the present study indicates, there is no such consensus on the definition in Mexico. This needs to be addressed urgently since it impacts the number of children estimated to benefit from the public health programs; affects plans to address their specific needs; and determines monitoring and evaluation of program effectiveness, including related budgets and services.
In this regard, all of the interviewees stated that they are unaware of any official OVC information or register/ database and most of their organizations do not have their own counting or estimation system. When the organizations do any quantitative analysis, it is usually used to make decisions related to their own facility's capacity. These in-house figures, or estimations, are not shared outside their organization in any formal or coordinated way; this precludes compiling any accurate statistics on any increase or other trends among the OVC population. However, based on their own observations and on the occupancy rates at their facilities, the study participants perceive a significant rise in the number of OVC in recent years. According to Subbarao and Coury (7), around 95% of the orphans are being cared for by their extended families and communities, an estimate that provides an alarming indication of the real extent of the issue.
Of great value would be a shared database since the DIF has overall responsibility for OVC and the private sector's role is only as an assistant. Therefore, the information collected in the private sector should flow throughout the system, mainly from bottom to top, and should be used to design public programs. Failing to compile OVC data can result in pulling in different directions, wasting resources, and losing efficiency. Sharing information and having a common database would benefit both sectors, as it would be easier to dynamically determine the most appropriate form of care (21). Substantial effort is being made to provide care and services to OVC, however, the efforts are independent and would benefit from wider coordination. An indicator of the fragmentation is evident in the variety of definitions of "orphan" used by the interviewees.
It is remarkable that the interviewees did not attribute the OVC increase to the drug conflict, but rather to a loss of cohesion within the families, brought on by poverty and cultural changes. Since orphans are mostly being cared for by their extended families and communities, it is absolutely justified to invest in family-strengthening strategies, and stakeholders should not hesitate in doing so. It is also important to maintain and expand the Seguro Popular program in this specific population since it plays a major role in enhancing accessibility to health. Furthermore, accurate information on the reason behind the loss of cohesion is essential to understand and combat the origin of the problem and develop preventive strategies (21). Thus, further research is recommended.
Additionally, the interviewees perceived the current laws as a barrier to doing a better job. But in this case, the interviewees will see a chance at change and progress due to the recent introduction of the 'General Law of Victims' (24). This new law provides a sound legal framework for initiating coordinated actions to construct a common front and favors coordinated changes, such as the development of a common database with stakeholder involvement.
All of the frameworks' strategies for improving the OVC situation require strong leadership to be successful (6) and to ensure the integration of the whole society into a single effort, enhancing not only family cohesion--the main perceived cause of OVC--but providing more and better education, guaranteeing access to basic services, employment, health, and other elements considered critical (7, 8, 20, 21).
Since all of the interviewees expressed a willingness to change their current methodology and procedures to obtain better results, integration and coordination may come relatively easily (7). Further research on the management of such an integration is strongly recommended.
By its own nature, a convenience sample easily incurs selection bias. To reduce this limitation, most of the stakeholders groups were included in the study, but clearly there were individuals and groups that may have been excluded. Therefore, the study sample does not represent the entire population of stakeholders. Due to the topic's sensitivity, some of the study limitations were low participation; emotional responses that may have biased the research; incomplete or inaccurate information from participants concerned with protecting themselves; and/or a general reluctance to describe feelings, thoughts, and opinions, among others.
As this was not a multi-state study, extrapolation of the study results to other states is limited. Further research is strongly recommended.
The three essential areas highlighted by the study results are also aligned with those of the international frameworks: stakeholder involvement; leveraging community solutions; and using simultaneously preventive and corrective programs.
A new common front involving all stakeholders is needed. It would improve efficacy by harmonizing the concepts and programs already in place and would encourage continuous learning through the sharing of information and experiences among its members. This common front should be composed of multisectorial and multidisciplinary groups, where the larger groups (federal programs) learn from smaller ones (community-based approaches). Work among these diverse groups is imperative to solving multidimensional problems (25), such as those faced by OVC, and could be a template for facing future challenges.
Leveraging community solutions
Mexico already has a strong, established health system infrastructure that includes community-based solutions that can be leveraged by both sectors to meet the needs of the OVC. The elements missing are coordination, integration, a constant flow of information, and well-determined actions.
Simultaneous preventive programs
Preventive programs, such as those that strengthen the family, must accompany all the tackling strategies. Further research is needed on the advantages of acknowledging a "conflict status" and its consequences on the public health management of orphans. Additional lessons learned from the international scenario under this specific status, for example the conflict in Rwanda, could enrich both the tackling and preventive strategies.
Despite the fact that more research is needed to better understand the correlation between the social determinants of health and the drug conflict, these study results already point to an area for further exploration: the loss of family cohesion as a possible root cause of the increase in orphans.
According to the study results, a great opportunity in the near future is offered by the General Law for Victims, which favors most of the elements pointed out by the international frameworks and the stakeholders. It is up to the latter to either take advantage of it and overcome most of their perceived barriers or to maintain the status quo with their independent efforts. Either decision will have a repercussion on the Millennium Development Goals and a direct impact on the lives of orphaned and vulnerable children.
Acknowledgements. No funds were received for this study. SC received a grant from the German Academic Exchange Service (DAAD) for his Master's studies at the Institute of Public Health at the University of Heidelberg, Heidelberg, Germany.
Conflicts of Interests. None.
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Manuscript received on 31 March 2014. Revised version accepted for publication on 5 August 2014.
Salvador Camacho,  Olaf Horstick,  and Sylvia Sax 
 Institute of Public Health, University of Heidelberg, Heidelberg, Germany. Send correspondence to Salvador Camacho, firstname.lastname@example.org
TABLE 1. Semi-structured guide for interviewing stakeholders at organizations charged with caring for orphaned and vulnerable children (OVC), with related qualitative codes used for analysis, State of Mexico, Mexico, 2013 Question Main qualitative analysis codes A. General perception How does your institution * Private stakeholder define an "orphan"? * Public stakeholder Do you consider the OVC to be * Orphan definition a public health problem? * OVC definition How do you measure the breadth * Measure systems. Does they of the problem? have a system for tracking What kind of structure does and collecting data or not? your organization use in this * Perception of accurate and OVC case: household-base care reliable measuring systems (extended family) or * Who takes care of the institutional care (community, orphans? public health organisms)? * Identified causes of And which is, in your opinion, orphanhood more common in the Mexican culture? Has your institution noticed * Increase of orphans perceived an increase of orphans in the * Identified causes of last 6 years? orphanhood * Correlation between increases and cause Has the information about the * Officially released info correlation between the cause about orphans and the consequence been publicly or officially released? B. Issues identified and current measures Has your institution * Public health problems identified some public health specific to orphans issues regarding these orphans, both in the short- and mid- to long-term? How is your institution * Programs specifically focused currently facing or planning on orphan health to face these identified issues? Why is it important for your * Current measures to tackle institution to tackle orphan problems these issues? What other institutions, both * Coordination with third public and private, are parties committed to these issues * Shared information that specifically affecting shapes programs the orphans? * Proposed improvements What is the legal frame of * Legal frame obstacles reference regulating these * Ways to tackle legal problems Institutions, their * Proposed improvements interactions and their scopes? C. Lessons learned in other countries * Knowledge of international Do you know of any measures successful strategies taken by other countries with * Main obstacles similar orphan problems? * Perceived willingness to adopt new strategies * Other obstacles impeding a good job * Proposed improvements TABLE 2. Comparison of international frameworks for addressing the issue of orphaned and vulnerable children (OVC) and study stakeholders interviewed and their OVC recommendations, Mexico, 2013 [up arrow] Strong emphasis Recommendations in the World United international frameworks Bank Nations Determination of the [up arrow] [left and magnitude of the problem, right arrow] needs and risks with context specificity Involvement of [up arrow] [up arrow] stakeholders Planning actions and [up arrow] [down arrow] interventions using existing, ongoing solutions Community solutions [up arrow] [up arrow] playing a major role Financial assistance [up arrow] [left and for caregivers right arrow] Choose cost-effective [up arrow] [down arrow] interventions to scale up Monitoring and evaluation [up arrow] [left and right arrow] Use of simultaneous [up arrow] [up arrow] preventive programs Thorough public policy [left and [up arrow] revision right arrow] Ensure access to basic [left and [up arrow] services right arrow] Training of third parties [down arrow] [up arrow] to help detect problems and vulnerabilities [left and right [down arrow] arrow] Medium Low emphasis emphasis Study findings: Recommendations in the HIV/AIDS Stakeholders international frameworks Framework recommendations Determination of the [down arrow] [left and magnitude of the problem, right arrow] needs and risks with context specificity Involvement of [up arrow] [up arrow] stakeholders Planning actions and [left and [left and interventions using right arrow] right arrow] existing, ongoing solutions Community solutions [up arrow] [up arrow] playing a major role Financial assistance [up arrow] [up arrow] for caregivers Choose cost-effective [down arrow] [up arrow] interventions to scale up Monitoring and evaluation [left and [down arrow] right arrow] Use of simultaneous [up arrow] [up arrow] preventive programs Thorough public policy [up arrow] [up arrow] revision Ensure access to basic [up arrow] [down arrow] services Training of third parties [up arrow] [down arrow] to help detect problems and vulnerabilities Source: Developed by the authors based on the information contained both in the references 7, 8, 20, and 21 and from the interviews.
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|Title Annotation:||Original research/Investigacion original|
|Author:||Camacho, Salvador; Horstick, Olaf; Sax, Sylvia|
|Publication:||Revista Panamericana de Salud Publica|
|Date:||Aug 1, 2014|
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