Survivors of the genocide
by Dr Peter Hall
1. A general health questionnaire carried out on 248 survivors of the genocide in July 1994;
2. An assessment of the psychological distress factors experienced by survivors of the genocide;
3. Information on the work of the UNICEF Trauma Project in Rwanda.
1. GENERAL HEALTH QUESTIONNAIRE
Physicians for Human Rights (UK) spent 2 weeks in July 1994 in Rwanda. As well as fact finding, one of the objectives of the mission was to carry out a survey of psychological morbidity among survivors of the genocide using the Self Report Questionnaire. This screening instrument was developed for use in primary health-care situations in the Third World by Harding et al in 1980 as part of the WHO Collaborative Study on Strategies for Extending Mental Health Care. It consists of 20 "non psychotic" and 4 "psychotic" items each of which requires simply a Yes or No response. In the administration of the survey, we omitted the "psychotic" sub scale as the questions were inappropriate to the prevailing conditions in Rwanda - one being, for instance, "do you think someone is trying to harm you".
These are the questions:-
Do you often have headaches?
Is your appetite poor?
Do you sleep badly?
Are you easily frightened?
Do your hands shake?
Do you feel nervous, tense or worried?
Is your digestion poor?
Do you have trouble thinking clearly?
Do you feel unhappy?
Do you cry more than usual?
Do you find it difficult to enjoy your daily activity?
Do you find it difficult to take decisions?
Is your daily work suffering?
Are you unable to play a useful part on life?
Have you lost interest in things?
Do you feel that you are a worthless person?
Has the thought of ending your life been in your mind?
Do you feel tired all the time?
Do you get uncomfortable feelings in your stomach?
Are you easily tired?
The Questionnaire was translated into Kinyarwanda and then subject to independent "back translation". It has previously been used in a number of studies in Africa and elsewhere. Despite some criticism about the cultural relevance of some questions in some cultures, it has proved reasonably robust. Caseness levels vary in different settings, which makes interpretation of the results difficult. Normally one would expect to administer a battery of other tests, to establish a cut off score. Clearly this was not possible with our extremely limited resources. Nonetheless, we felt it worthwhile to attempt the exercise.
We undertook the survey in the towns of Rwamagana and Gahini, which lie southeast of Kigali. This area was chosen as representing one of the more settled parts of the country. The massacres had persisted here for only two weeks and it had been free from the conflict for nearly three months when we arrived.
Over the course of 3 days we collected responses from 248 adults and adolescents of whom 11 were RPF soldiers, the remainder being civilians, either displaced persons or inhabitants of the two towns. With only a handful of exceptions, the respondents were born within Rwanda. Few had travelled any distance prior to the onset of the genocide or the preceding conflict. We were unable truly to randomise the sample, but tried by a variety of means to obtain a representative selection.
Sixty four and a half per cent of those questioned were women, 22.2% were widowed (male & female), 48.4% were single. We believe that these proportions, which at first sight may seem very unusual, reflect the aftermath of war and genocide. From our own observations, both in the sampling area and in the other parts of Rwanda we visited, they reflect the remaining adult population well. We should stress, however, that the vast numbers of displaced traumatised children are not represented here. This is only because of the very real problem of finding a suitable instrument. It is reasonable to assume, we believe, on the basis of what we saw and heard, that they are, if anything, even worse off.
Despite a strikingly small positive response to questions about suicide and feelings of worthlessness, the overall scores were high with a mean of 9.66. Many respondents reported various somatic symptoms, with headache and GI symptoms being prominent. Others reported cognitive disturbances. Whilst the instrument does not enquire about nightmares, many reported them either spontaneously, or on further questioning about their responses. Probably the least useful questions were about work related problems. The high non response rate reflects the profound breakdown of civil society. Very few people had any opportunity for any kind of useful work, let alone the chance to pursue their previous occupation. Some comment on the overall level of psychological morbidity ought perhaps to be attempted, despite the problems sketched out above.
Throughout Rwanda, the impression was of a people still stunned by the ferocity and scale of the killings. If one assumes a cut off score of 7, which has been used in some other African setting, one is left with a caseness rate close to 77%. In other words over three quarters of survivors tested had a significant psychological and/or physiological disturbance. This finding has implications for the future of Rwanda. Before the war there was only one specialist psychiatric hospital. Whilst physical needs must obviously be met, it is possible that unless resources are found to address the psychological needs of this profoundly traumatised society, further bloodshed may ensue.
2. THE EFFECT OF THE GENOCIDE ON SURVIVORS
It is difficult to envisage a more terrible and frightening experience than being a Tutsi in Rwanda between April and the end of July 1994. But it may be wrong to see the psychological stress of the genocide as a discrete episode. The distress that the survivors suffered and in many cases continue to suffer both preceded and followed the genocide. The intimidation of Tutsis started long before the Habyarimana plane crash. Leading up to the slaughter there had been a sequential ratcheting up of ethnic antipathy in a country where the killings of Tutsi men, women, and children carried out in 1963-64 matched the brutality and horror of the 1994 genocide. Bertrand Russell, the most famous pacifist of his day, called it then "the most horrible and systematic human massacre we have had occasion to witness since the extermination of the Jews by the Nazi." Nor does the ending of the conflict resolve many psychosocial factors that conspire to delay full resolution of any symptoms - full recovery may rely upon the reconstruction of social and economic network, cultural institutions, and justice.
The main factors contributing to psychological stress in the survivors are, in three parts, intimitation before genocide, suffering during the genocide, and suffering after the genocide
INTIMIDATION BEFORE GENOCIDE
the ethnically targeted killings and political murders in the years before the genocide, such as the massacre at Bugesera
belonging to a well defined, disdained and discriminated against minority group
the ongoing requirements of employment quotas - the so called ethnic balance
the easy accessibility to the ethnic identification section of the identity card - you could not disguise your ethnicity
the demonisation of the RPF and Tutsis in general, especially through radio propaganda via RTLM and newspapers
SUFFERING DURING GENOCIDE
the horror of witnessing the deaths of friends, relatives and loved ones,
the fear and expectation of probably being murdered and of loved ones, especially children, suffering in the same way
the terrible brutality of the methods of murder
the intimacy of the relationships between victim and perpetrator
the scale of the killings
the inability to grieve properly for dead relatives because there was no time or opportunity
the inability to properly bury their murdered relatives in a culture where burial ceremonies are important
the inability to find any identifiable body of a murdered relative
the threat that the targeting of the whole of a population to which a person belongs represents to individuals within that population
the hopelessness of the predicament - it must have seemed that death was inevitable and that nothing could be done to avoid it
the absence of loved ones to provide support
the loss of sanctuary traditionally provided by the church
the abandonment by the international community, the sense of not mattering to the rest of the world
SUFFERING AFTER THE GENOCIDE
continuing bereavement - the loss through death of a loved one, especially if sudden or violent is one of the most severe psychological stresses an individual can undergo. Vulnerable people are at risk of developing psychiatric problems and almost any psychiatric disorder can be precipitated by bereavement.
anxiety about missing relatives and the absence of news (are the dead, are they injured?)
the loss in confidence in human beings in general and particular social pillars such as priests, doctors, nurses and teachers - the professions were well represented amongst killers
the loss of identity that results from the loss of and breakdown of previous social networks.
by the poverty of existence - many survivors experience a sharp drop in social circumstance
the lack of basic necessities
the absence of counselling
the response to the Rwandese predicament by the world
any social stigma associated with wooded, being raped, having children outside marriage,
being dependent on others
the uncertain future in personal terms
the actuality or prospect of living cheek by jowl with perpetrators
the threat posed by living among people who have murdered
the uncertainty that justice will be meted out
the threat posed by the polarisation of society
the possible loss of religious conviction
typical Rwandese stoicism inhibits demonstrative
3. THE WORK OF THE UNICEF TRAUMA PROJECT IN RWANDA
(with grateful appreciation to Dr Leila Gupta, the project officer)
UNICEF TRAUMA PROGRAMME.
The UNICEF Trauma Programme was set up in August 1994 at the request of the Ministry of Rehabilitation and Social Reintegration following the massacres between April and July 1994.
The trauma team consists of 3 national staff and one expatriate:-
a teacher and
a project officer.
The initiative of the Ministry of Rehabilitation and Social Integration is a pioneering enterprise considering the absence of child psychiatry in Rwanda before the genocide. There has now been a shift in emphasis such that now doctors are being trained in child psychiatry and an Italian NGO training medical students at Butare University.
The remit of the UNICEF TRAUMA PROGRAMME is four fold:
1. Provision of technical assistance for government officials, NGO's and local agencies.
2. Strengthening of national capacity among Rwandese social agents so they can train others to alleviate war trauma/grief among children.
3. Dissemination of information/mass media campaign to sensitise the public about the impact of war trauma on psycho-social development.
4. Establishment of a National Trauma Recovery Centre in Kigali for training, information, research and treatment of severely traumatised children.
The centrepiece of the trauma recovery programme is the strengthening of the national capacity among Rwandese para-professionals by training them in basic trauma alleviation methods. To date approaching 4,000 Unicef Centre care-workers, NGO staff and religious or community leaders have been trained and 72,000 children helped.
The principle object is to teach them definitions and symptoms and sign recognition, and what they can do about it.
Children tend to want to express what they have experienced. The drawing of pictures can be an effective way for them to relate what is important to them. Others write essays perform psychodrama (theatre is culturally important in Rwanda), talking to God through prayers or writing poems.
Children cannot talk about it all the time. In school for instance teachers are advised to set aside one hour a week. In the first session children are asked to describe life before the genocide. In the second they concentrate on what happened during the genocide but not necessarily their worst experience. There are no rules, so no child has to draw anything if they do not want to, or the drawing could be locked away without anyone seeing it.
The concept of continuity of their life is very important. In the 3rd week they are asked to consider the future and they are shown that life has not come to a stop because of the genocide. This is often their first opportunity for expressing their experiences. Many children live with parents or relatives who have their own grieving and.or post-traumatic-stress-disorder problems. Children are very skilled at picking up non-verbal cues, especially orphans who are cared for by relatives, and they may avoid the risk of irritating the care-giver.
Making use of radio (Radio Rwanda) has allowed the message to be passed on to families who may be illiterate or who would otherwise be inaccessible. It is important to de-mystify any abnormal behaviour some children exhibit--they must not be labelled as crazy. The response is normal--it is the genocide which is abnormal. By using a series of vignettes of actual post-traumatic-stress-disorder (PTSD) cases with UNICEF staff play-acting as parent and child the public can be informed of real-life situations and learn how to respond. The community has received the series of vignettes very well.
Seven trauma advisors, one for each prefecture have been intensively trained over a 6-week period. They will act as gate-keepers and screen for severely affected children referred to them who may benefit from attending the trauma centre but they are not accepted without the presence of a care-giver.
Lastly, here are some examples of some provisional results of an assessment of trauma exposure experienced by children during the genocide, carried out by the UNICEF Trauma Project Team.
1. Nearly 40% of children had experienced both parents being killed.
2. 95% witnessed violence and 70% witnessed someone injured or killed, and over half saw many people killed at once (massacre). Nearly one third witnessed sexual assault;
3. 60% were threatened with death and 90% expected to be killed. Nearly all had hide at some stage - half of them hid for 4-8 weeks.