Background

Rwanda was, and remains, one of the poorest nations on the planet. Land-locked, deforested and underfunded, the land has known mass slaughter before. Any attempt to understand what happened in 1994 requires knowledge of the country's history (Box 1, Rwanda website).

The population of Rwanda falls into three groups: Hutu, Watutsi (Tutsi) and Twa pigmies. Hutu and Watutsi are, however, not really single unified groups. Inter-ethnic antagonisms are the pernicious legacy of colonialisation. The Belgians created a Tutsi élite, which eventually led to revolt by Hutu and the first diasporas of Tutsi to Uganda, Burundi and Tanzania. The Rwandan Patriotic Front (RPF) recruited from the Tutsi diaspora in Uganda and invaded Rwanda in 1990 and 1992, resulting in the 1993 Arusha power-sharing accord. This was, in effect, the death warrant for President Habyarimana, who was assassinated by extremist Hutu in 1994, the event that signalled the start of the genocide.

A cabal (the Akazu) was created by President Habyarimana's wife. Its aims were to gain control by decimation of their ‘enemies’, primarily Hutu dissidents and, subsequently, Tutsi. The Azaku hoped that mass killing would bind the perpetrators to their leadership and instil fear and submission into the population. The events of 1994 were not a simple flare-up of inter-ethnic tension: the killings were planned years in advance. Between 10 000 and 150 000 Rwandans became involved in the slaughter, either by coercion or choice (Reference SmithSmith, 1998; see also the Belgian Senate Inquiry into Rwandan Genocide website (Box 1)).

Of the survivors, 70% were women. Many had been raped and left with unwanted children. Many had lost children. Many had been widowed, with minimal or no property rights. By the end of 1994 over 100 000 children had been orphaned. The Hutu diaspora went to Zaire (1 million people), Tanzania (500 000) and Burundi (170 000). The morbidity and mortality in these groups was extremely high (Anonymous, 1996a ).

Rehabilitation of civil society

War damages the very fabric of society. This damage relates to its physical structure (buildings, homes, sanitation), its institutions (judicial, educational, medical, religious), its social fabric (families, communities), its environment (mines, defoliation, pollution, corpses, disease), its communications (roads, railways, postal and telecommunication services, radio and television) and the normal structure (routine) of life.

Ideally, any psychosocial intervention should follow a thorough sociocultural analysis of the country's culture, traditions and institutions (including any regional variations), in order to identify social differentiations and who will benefit from what and how (Box 2). In 1994, many such interventions were insensitive to Rwandan culture, economy and politics. In addition, they lacked coherence and coordination between, and within, humanitarian, military and political endeavour (Reference PottierPottier, 1996; Reference Gracia Antiquera and Morales Suarez-VarelaGracia Antiquera & Morales Suarez-Varela, 1999; Reference Banatvala and ZwiBanatvala & Zwi, 2000).

Social and economic planning go hand in hand. Local needs must be assessed in partnership with the intended recipients of aid. Priority should be given to medium- and long-term rehabilitation programmes that foster social cohesion. Solidarity of communities should be fostered and toleration of cultural, ethnic and religious diversity encouraged.

Economics

The post-conflict government in Rwanda had serious credibility difficulties both within and outwith their borders. Following war, the costs of restructuring and rehabilitation are astronomical, yet in Rwanda severe financial constraints were put on the new government and reconstruction was hampered by the significant reduction in population resulting from the diaspora, the decimated infrastructure and inadequate statistics from which to work.

Rwanda's debt situation remains unsustainable, being five times the value of its export revenue. Repayments absorb 30% of foreign exchange earnings and 25% of government revenues. The health ramifications are enormous and prioritisation of resources is inevitable. Poverty levels have increased (70% of Rwandan households live below the poverty line and more are living in poverty now than 10 years ago). Health care and education systems have collapsed: more is spent on debt repayment than on basic services. Worst of all, Rwanda continues to face serious security concerns and violent clashes continue (Box 1, Oxfam website).

Failure of reconstruction exacerbates social tensions, increases poverty and insecurity and raises the likelihood of intensified conflict, with all its attendant miseries. Sustainability is problematic and, following war, the capacity of a population to sustain itself, let alone develop, is severely limited.

Justice and human rights

The key to rebuilding a society is that justice exists and is seen to work. Human rights almost invariably require advocacy and strengthening. Appropriate United Nations (UN) human rights activities should be selected and advanced (e.g. training the police and military in their roles and responsibilities, educating survivors through schools and the media and tracing displaced persons). Rebuilding the fabric of Rwanadan society will be difficult, given the level of complicity by priests and nuns, government officials and medical staff. Some of those involved in the killings live in the same locations and are known to survivors, whom they may intimidate or who may kill them in revenge. Apportioning blame to ‘collaborators’ is an area fraught with difficulties.

The war in Rwanda effectively destroyed the criminal justice system. Is is said that 125 000 individuals are in prisons and detention centres, many held without charge, and of the 1420 tried, at least 180 have been sentenced to death. Amnesty International has raised concerns about the ‘fairness’ of the trials in Rwanda, stating that there is hostility towards defendants, who seldom have access to defence counsel (Box 1, Amnesty websites). Although it is to be deprecated, it is hardly surprising that those within Rwanda are hostile to defendants and perceive unfairness when those charged with war crimes are tried outside Rwanda. Amnesty International believes that some individuals are being forcibly repatriated and a number are ‘disappearing’. Rwanda's prisons are grossly overcrowded and unsanitary. Many men, women (with their infants) and adolescents are said to die while awaiting trial.

The International Criminal Tribunal (ICT) for Rwanda (Box 1, website) sits in Arusha in Tanzania and a steady trickle of individuals indicted for genocide end up there.

Women

Women suffer greatly during and after conflicts, yet they are the key to the survival of families and communities. When their partners and children go off to war women's roles change. They may become the head of the household or the breadwinner, some turning to prostitution to earn a living. War disrupts family and community networks and loss of family members is likely. Women are often the target of rape and other violence, putting them at risk of sexually transmitted diseases (STDs). Their impregnation may be encouraged by some combatant groups as a deliberate attack or defilement of their cultural or religious status. Indeed, rape has now been made one of the indictable offences of genocide. Such enforced pregnancies are likely to be unwanted. Women may lose property and possessions, and in many countries widow's rights are not strong. Some will have collaborated to save themselves or their families and their reception back into their communities may be problematic.

They should be encouraged, supported and intimately involved in reintegration at all levels of public life (Box 3; Reference OmorodionOmorodion, 1993; Reference Van der Straten, King and GrinsteadVan der Straten et al, 1995; UN Department for Economic and Social Information and Policy Analysis, 1996; Reference Richters, Bracken and PettyRichters, 1998).

Children

The war's effects on Rwanda's children were appalling (Table 1). One hundred thousand were orphaned or separated from their families (Reference GuptaGupta, 1996): using photographs and radio (there is virtually no TV in Rwanda) the International Committee of the Red Cross undertook their largest tracking of displaced individuals (90 000–115 000) since the Second World War. Of the 125 000 individuals detained, there were 1800 children (mostly boys aged 14–18) held on charges of genocide. Other children, many under 3 years old, were there simply because their mothers were awaiting trial (Reference GuptaGupta, 1996). The Intrahamwe (Hutu ‘death squads’) targeted children, maiming males and raping females. Some children were forced to kill relatives or other children.

The majority of surviving children live in the districts in which atrocities took place. Damaged landscapes, sites of execution (often churches), maimed and disabled civilians and veterans, the continued presence of armed soldiers all act as potent reminders of the genocide. The children's losses include loss of faith, of normal parenting, of trust (seeing parents killed or seeing them kill others) and of boundaries (killing others themselves). Interventions to provide safety, routines and normality offer the best hope of rehabilitation. Unemployment, poverty, and continuing political and military uncertainty will all undermine any such work.

Although delayed psychological problems are possible, they are not inevitable, as children's reactions are complex and interpretive. They may have been victims or pupils of war and may understand clearly what they were caught up in. They will require education (at an appropriate time) to aid their understanding and contextualisation of what happened to them and their families. Workers in Uganda and Mozambique report little clear evidence that violence breeds violence in these circumstances, and this gives hope for the future. Violence has been described as a drug that assuages hopelessness and the grief of loss. Those pupils of war who have been socialised into an aggression that has provided them with a raison d'être may now be more susceptible to dropping out of society and falling into (or continuing) substance misuse and gang and criminal behaviour. Child soldiers require a step-by-step ‘detuning’ of aggression and violent behaviour through specific programmes. The importance of women in the reintegration process cannot be overstated.

Children affected by war require general psychosocial support (United Nations Children's Fund, 1986). But children should not be seen merely as passive victims: their active participation is required to help communities heal the wounds of war.

Child care in Rwanda

There is a Rwandan tradition of caring for children other than one's own. In 1992, apparently, one in two families included a child from an unrelated family (Reference SmithSmith, 1998), so surrogate mothers or families may fill a void. Orphanages are common but of variable quality, understaffed and often overcrowded. If not competently staffed and administered with enough (basic) equipment to undertake educative tasks and evaluate their outcomes (social and educational), they have the potential for worsening children's problems. Cultural and local beliefs, attributions and understandings about death, community, family, spirituality, disability, memory and illness should all be used to aid assimilation and accommodation to the new realities.

Children should be provided with the means to express their emotions if they wish to. Play is important and includes art, drama, storytelling, fairy tales and myths, dance and holding and touching games. No fixed time-scales should govern whatever is offered, as individuals deal with bereavement and its attendant rituals at their own pace.

Refugees

In addition to obvious material and cultural losses (‘cultural bereavement’; Reference EisenbruchEisenbruch, 1991), involuntary refugees suffer loss of dignity and of occupation. Their problems are legion and stem from the damage war inflicts on the social fabric of their country as much as on them individually.

There may be no real safety in refugee camps. Individual refugees have different vulnerabilities and resources, and are exposed to different risks. However, the capacity to draw on social customs and religious beliefs, and a cooperative effort and solidarity, can bolster physical and psychological defences in even the most extreme situations. Passive waiting can lower self-esteem and lead to apathy, anonymity and exposure to abuse and exploitation.

In Goma, refugees found themselves not only in unsanitary and overcrowded camps, facing infectious diseases and inadequate feeding; they were also subjected to intimidation and extortion by the Intrahamwe in their midst. Furthermore, aid efforts were inefficient, poorly coordinated and occurred in the context of chronic and constant structural deficiencies. The mass movement of people that created this acute situation made the planning for long-term needs difficult, but all interventions must nevertheless consider the impact of short-termism and plan for the medium- and long-term from the outset.

Demobilisation

Veterans have special needs that require close attention. Ex-combatants may be local (adults, adolescents and children) or expatriate. Most cope adequately. They do, however, raise particular issues for politicians, funding agencies, receiving communities and the police. Any problems with ex-combatants will be compounded if inadequate effort is put into demobilisation, as so often happens.

Social reconstruction is slow, especially for men (and women) of action. Promises are frequently broken and a sense of disappointment, even of bitterness, resentment and anger, can pervade the minds of veterans and increase the likelihood of peacetime lawlessness. Disgruntled veterans are a potential source of disruption, especially in the hands of unscrupulous politicians. But those communities ravaged by soldiers may resent resources and money being given to them to aid their demobilisation.

Reconstruction of pre-war economic, social and cultural life is central to successful demobilisation of soldiers. It is vital in areas of the world that remain politically very volatile. Reintegration involves adjustment to new realities – not a return to ‘normality’. Ex-soldiers, returning refugees, the internally displaced and residents of areas most severely affected during the crisis are part of a complex, expensive and problematic endeavour for a stagnant war-ravaged economy. Funding is the key to success and a coordinated approach is essential. No start should be made until a reintegration programme has been prepared, funded and is ready to go (UN Department for Economic and Social Information and Policy Analysis, 1996). Box 4 lists the principal requirements of a demobilisation programme.

Disability

Research has shown that 80% of people with disabilities live in rural areas and 98% get no treatment (Reference HelanderHelander, 1993). People disabled during conflict have immense difficulties in reintegrating into war-ravaged countries. The poor living in rural communities are much less likely to get help for their physical needs or to live in an environment that can adapt to accommodate them. The estimated cost of one adequate rehabilitation of one person disabled by war in Cambodia is US$5000 (Reference Somasundaram and RenolSomasundaram & Renol, 1998). Some ex-combatants may wear their disabilities (war wounds) with pride, others with shame. It is important to understand the cultural views of disability in the communities one is helping. Even after conflict has ended, land-mines continue to disable, destroying livestock and livelihoods and terrorising communities. Although 50% of the land-mines in Rwanda have been cleared, 20 000 remain in the fields and woods.

Veterans with head injuries have special handicaps, and facilities for dealing with subsequent personality and behavioural problems are unlikely to be available. Most will go unrecognised and untreated. In a study of lower-leg amputees in Sri Lanka, Manoharan (1998) found that 40% were severely depressed, 30% moderately depressed and 15% happy to have escaped death. Individuals suffer both personally and socially (Box 5).

Interventions with those disabled by war require respect, empathy, listening, trust-building, in addition to befriending and comfort-giving. Cultural understanding and diplomacy are essential, and community helpers and traditional healers should be involved wherever possible. Individuals also need practical help in terms of: financial support for themselves and their families; counsel and advocacy; low-cost technical aids such as prostheses and wheelchairs; accommodation; community-based rehabilitation, to facilitate independence and improve self-esteem; and respect for human rights.

Disease and illness

Disease is the malfunction or maladaption of biological systems, whereas illness is a personal reaction to discomfort, distress or disease and it is shaped by sociocultural factors such as valuation of distress. Illness is culturally constructed, embedded within a complex nexus involving family, community and culture. Psychiatrists must be able (and willing) both to treat illness and to diagnose disease (Reference KleinmanKleinman, 1987). In doing so, they must take into account both psychosocial and cultural aspects: ignoring these may lead to frustration for all concerned. Psychiatrists should also be prepared to use their medical, non-psychiatric training at times.

Traumatic experiences

Psychiatric hospitals

This is an area in which psychiatrists can become usefully involved. All of Rwanda's psychiatrists left the country during the war. Before 1994 there were two psychiatric hospitals, in Butare and Kigali, but both were the scenes of subsequent massacres, some perpetrated by inmates on each other during psychotic episodes.

There are many problems in working with such a facility in the aftermath of mass killings. It is important to address the physical needs of the inmates and staff (food, shelter, safety, clean water and sanitation, medication, mine-clearing, structural repairs, disposal of dead and, if possible, physical examination and treatment of patients). It is also important to act as their advocates with NGOs, the UN and the military. A psychiatric hopsital can act as a focus for the education and recruitment of mental health workers. Resourcefulness, enthusiasm, determination and mental robustness are required for such work, as psychiatry is afforded low priority.

How can the international psychiatric community help?

Doctors are powerful both medically and politically and they can use that power to help war-torn nations both at the site of conflict and from their own countries.

Does the College have a role?

The Royal College of Psychiatrists may lobby governments on behalf of its members, but to offer practical assistance to countries in need it could take a less parochial view of psychiatric training, which I believe is too narrowly focused. By training within and for NHS psychiatry, specialist registrars (SpRs) (and indeed registrars) may be missing much of both professional and personal value that they might gain on placement in developing or war-torn countries. Unfortunately, however, such a placement may not fulfil the College's requirements for SpR training.

Have psychiatrists forgotten the importance of society and culture in healing (rather than curing)? Let us learn from other cultures how to use our strengths and power for their benefit.

Conclusion

Wars differ in their effects on the societies and individuals involved. Intervention is not for amateurs (Anonymous, 1996b ). Any intervention is complex to organise and run. Lessons learnt in one conflict may not easily transfer to others, but all require social intervention and investment in the fabric of the nation (Reference SummerfieldSummerfield, 2000). Intervention should respect and be guided by the desires and priorities expressed by the communities in receipt of help. Psychological interventions must recognise the dignity of these communities and be synergistic with local customs and practice. Psychiatrists and their professional bodies clearly have a role to play, a role that should be encouraged.

Multiple choice questions

1. 1. Psychiatric disorders:

   1. a are the malfunction or maladaption of biological systems

   2. b are the same as illnesses

   3. c are not seen in developing countries

   4. d may be found in ex-combatants

   5. e do not require sociocultural assessment.

2. 2. Failure of economic and social reconstruction:

   1. a diminishes social tensions

   2. b increases insecurity

   3. c increases infant mortality

   4. d destabilises a country

   5. e is inevitable.

3. 3. The 1994 UNICEF survey of children revealed that:

   1. a <20% had witnessed massacres

   2. b >16% had hidden under dead bodies

   3. c 10% had been threatened with death

   4. d 1800 were in prison

   5. e 10 000 were orphaned.

4. 4. Soldiers demobilised without adequate planning:

   1. a may become social outcasts

   2. b return seamlessly to their previous communities

   3. c are at risk of criminality, lawlessness and substance misuse

   4. d are always glad to stop fighting

   5. e may disrupt social stability and reconstruction.

5. 5. As regards people with disabilities:

   1. a 80% live in cities

   2. b >98% get no psychiatric assessment or treatment

   3. c the estimated cost of an adequate rehabilitation is US$5000

   4. d depression is a common in amputees

   5. e shame is not associated with disability.