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If I were not stopped short by poverty, I would travel far from here, to a country where I would go to school all week long, and play soccer on a nice grassy field, and where no one would want to mistrust me and kill me, ever again.

- Cassius Niyonsaba,Genocide survivor, Rwanda. Extract from 'Life Laid Bare' by Jean Hatzfeld.

I think that having the option to settle outside Rwanda would be one of the greatest gifts that any concerned people or country can give to Rwandan genocide survivors. Even 15 years after the genocide, many survivors today still live in fear that they will be the next victims of those people who killed their families in 1994 and now see them as the only remaining witnesses to their heinous and inhumane crimes. In addition to offering protection from the physical danger that survivors currently live in, giving genocide survivors the option to resettle outside of Rwanda would eliminate the psychological wounds that many continue to suffer living next door to the people who killed their families in 1994 and being constant targets of their harassment and taunting.

- Genocide survivor, Rwanda. (Email, August 18, 2009)

Psychologically it is very difficult to deal with this idea that we have to live with our killers. I passed a big part of my life after genocide in Kigali, far from my native city and was always afraid. I know that in the village, survivors are neighbors with the killers. It's too much for survivors and for me this is a new way to abandon survivors a second time in their solitude of genocide, in their nightmare.

-Genocide survivor, Canada (Email, August 17, 2009)

...Some of these men and women [genocide survivors] would choose, if they had an option, to live without this constant challenge, if they could be in a new place, where they could mourn privately, cry it out and start a whole new life with whole new opportunities, of course with new challenges but not necessarily connected to genocide...

-Genocide survivor, Rwanda. (Email, August 13, 2009)

Genocide survivors in Rwanda have great difficulty receiving refugee status and right of asylum to allow them to settle outside of the country. The standard reply that they receive when making queries about the possibility of immigrating to Europe, Canada, or the United States is that there is no longer persecution on the basis of ethnicity in Rwanda, and thus there is no legal merit to their request. It is true that there is no government sanctioned persecution on the basis of ethnicity in Rwanda today. However, social persecution, discrimination, marginalization, threats, and intimidation towards survivors of the 1994 genocide of the Tutsi prevail on a popular level amongst many Rwandans. Genocide survivors are targeted for physical and psychological torture and have been attacked and killed in various parts of the country.[i] Fifteen years after the genocide many lack physical and psychological security.[ii] (SURF Survivor's Fund Annual Report, 2008)

For many survivors, remaining in Rwanda post-genocide poses insurmountable obstacles to their psychological health and well being. They are subject to flashbacks and continuous retraumatization. Many find themselves trapped in the fears prompted by their experiences, the sadness and pain, and the wounds that cannot heal because justice is so incomplete and because thousands of the perpetrators of the genocide have been freed leaving survivors feeling vulnerable and despondent that justice is not and will not be done.[iii]

All the years I have passed in Rwanda after surviving were not easy in many ways. All my world before the genocide was destroyed. I felt like a foreigner in my own country. The majority of suvivors, if not all were in emptiness of life. But for all loved ones we lost during the genocide we were called to be strong, for their memory, for history, for the future and for ourselves. I did my best, but one thing persists in my mind which reduces my efforts for surviving: in Rwanda, I'm always afraid. I like my country so much, I'm so attached to its vegetation, its hills, its climate, its beauty. But it's not easy to enjoy all these when I think that among people whom I met on my way, there are some killers. When I return in my native city, I'm very frustrated while I meet those who were our neighbors, who participated in the genocide or who were just silent while my parents and friends were killed. I can't stay in that city more than a day. The flashbacks come quickly while there. And then I remember everything.[iv] (Email, August 17, 2009.)

Long after genocide has ended, genocide survivors live with its consequences on a daily basis and its legacy impedes their ability to rebuild their lives.

The United Nations General Assembly has passed several resolutions acknowledging the vulnerabilities of Rwandan genocide survivors and the responsibility of the United Nations and its member states to assist and protect them. On December 25, 2005 the UN General Assembly passed Resolution 60/225, entitled, "Assistance to Survivors of the 1994 Genocide in Rwanda, Particularly Orphans, Widows, and Victims of Sexual Violence."[v] This resolution was a reaffirmation of previous resolutions similarly calling for concrete actions to improve the quality of life of genocide survivors and ensure that their human rights are honored. Resolution 60/225 refers to resolution 59/137 of December 10, 2004 which requested that the Secretary General, "...encourage relevant agencies, funds, and programmes of the United Nations system to continue working with the Government of Rwanda to develop and implement programmes aimed at supporting vulnerable groups that continue to suffer from the effects of the 1994 genocide".[vi] It expressed solidarity with genocide survivors and urged greater efforts to enable them to access and realize their human rights. It called upon UN member states to "provide assistance to genocide survivors and other vulnerable groups in Rwanda" and recognized "the numerous difficulties faced by survivors of the 1994 genocide in Rwanda, particularly the orphans, widows, and victims of sexual violence, who are poorer and more vulnerable as a result of the genocide."[vii] The United Nations General Assembly voted again, for a third time, to endorse these previous statements on December 22, 2009.[viii]

As one way of actualizing both the content and spirit of these resolutions, member states of the UN in a position to accept genocide survivors for resettlement should enable genocide survivors to do so. In particular, the countries of the European Union, the United States and Canada should take the lead on these efforts. They are all positioned to accept refugees and all share responsibility for their failure to act to prevent the genocide, to stop the genocide once it started, and to assist genocide survivors once it ended. There are approximately 400,000 genocide survivors living in Rwanda today.[ix] Not all wish to resettle outside of Rwanda. Some have found themselves able to rebuild their lives and wish to remain in Rwanda. This is particularly true for those genocide survivors who have been able to access education and work opportunities, and who have been able to settle away from the communities in which they were persecuted and in Kigali, where they generally feel safer than in the countryside. But only a small number of genocide survivors have had these opportunities, and for most they are simply economically unfeasible. Still, for many survivors, remaining in Rwanda is too much to bear.

Many wish to settle outside of the country. The psychological scars that they carry are constantly exacerbated by being forced to live in close proximity to genocide perpetrators, tens of thousands of whom have been released from prison or received amnesties because the Rwandan government cannot afford to incarcerate them and has chosen to release them to promote 'reconciliation.'[x] As one genocide survivor explained, "When I think of going back to live in Rwanda, it simply sounds to me as a nightmare. Psychologically I can't stand living in the same villages with neighbors who killed all my family members and siblings." (Email, August 17, 2009.) International human rights law should reflect and respect the human rights of genocide survivors. As it stands, there are no legally binding instruments that enable genocide survivors to claim asylum by virtue of having survived genocide and seeking to live away from their former persecutors and away from the society that betrayed them so violently.

At the very least, such a change to international law should provide a mechanism that guarantees right of resettlement to the most vulnerable and impoverished genocide survivors and to those coming from countries in which genocide was so wide-scale and wide spread that there is no place where they can settle that will not potentially compromise their psychological health and ability to rebuild their lives. It could take the form of a United Nations treaty or convention, an amendment to the UN 1948 Convention on the Prevention and Punishment of Genocide, or a resolution of the United Nations Security Council. International law takes years to develop and any effort to codify into current laws the rights of genocide survivors to asylum would doubtlessly be subject to lengthy negotiations and delays. Because it will likely take years of deliberations to amend international law and there may be little desire to do so, an alternative for the short term ought to be created: a voluntary program of resettlement for genocide survivors organized by nations willing to accept them as immigrants for humanitarian reasons.

The most practical way of initiating the process of providing genocide survivors with immigration rights is through partnership with the organizations founded and run by genocide survivors themselves to promote the rights and well being of genocide survivors. In Rwanda three of the main organizations providing services to large numbers of genocide survivors are: AVEGA which focuses on providing care for widows and female genocide survivors, Ibuka which serves as an umbrella organization that unites and coordinates all organizations providing support and advocating for genocide survivors, and AOCM, the association for orphans who survived the genocide. Together with the Rwandan government, a program for the resettlement of those genocide survivors who choose to live outside of Rwanda for reasons of personal safety and/or psychological health and well-being can be developed and implemented. It need not necessarily involve the United Nations nor must it be coordinated by a centralized bureaucratic structure which would only slow down the process of resettlement. Rather, each country that is able and willing to accept genocide survivors as immigrants, in whatever amount, can directly communicate this with the Rwandan government and the aforementioned genocide survivor organizations who would arrange the implementation of the immigration. They would match genocide survivors with the countries in which they wish to settle and in which they are most likely to acclimate with minimal difficulty due to criteria such as knowledge of the local language, relatives already living there, and other such factors that can ease resettlement. The rights and responsibilities of resettled genocide survivors would not necessarily fall under the category of ordinary asylum seekers/refugees and would need to be negotiated between the Rwandan government, genocide survivors and the organizations representing them, and the countries accepting them for resettlement.

The total number of potential survivors wishing to immigrate stands at roughly 400,000 individuals, although a significantly smaller number will likely seek to resettle outside of Rwanda. Immigration will likely need to be staggered over the course of several years. It is likely, also, that some countries such as the United States and Canada may choose to accept a disproportionate amount of genocide survivors as immigrants because of already well established Rwandan communities and a high demonstrated ability to absorb immigrants successfully and integrate them into society. Again, these decisions will need to be made on a state level and then negotiated in relation to the overall effort so that immigration is coordinated and no country accepts more survivors than it can successfully absorb. Survivors should be settled in large enough numbers that they can create their own support networks and build strong communities. Ideally then they would be settled in two or three cities in each country. In the United States, for example, 50,000 Somalians settled in Minneapolis, and were able in this way to build a community that would empower Somalians coming to the United States with few resources, minimal language skills, and a significant cultural gap. The same should be done for Rwandan immigrants so they are not scattered in small communities across the country without the possibility of intensive mutual support.

Every effort should be made to provide the survivors who experience the greatest vulnerability by remaining in Rwanda the opportunity to immigrate. However, this criterion will need to be balanced with pragmatic concern for their ability to transition to a drastically different society and culture and to acquire the skills needed to become financially independent. In terms of differentiating amongst the survivors, I recommend setting practical criteria for who would stand to benefit the most from immigration rights and be able to become economically self-sufficient within a reasonable period of time. Most likely teenage survivors and survivors in their twenties-forties would stand to benefit the most and best be able to take advantage of the opportunities offered by immigration to a Western country, both in terms of work and education. But wherever possible, they should be allowed to immigrate with surviving relatives, including older individuals - as transitioning to a new society without the support of what remains of one's family is exceedingly difficult. Immigration of survivors should not cause families that have already suffered from loss and destabilization due to the genocide to be further fragmented.

Another survivor states,

My staying in North America has enabled me to recover from the bad memories since I live far away from where the genocide happened. On the other hand I feel very sorry for other survivors who stayed there, since they are under a serious threat of the genocide suspects and those who were released without judgment. (Email, August 17, 2009.)

For survivors the memory of the genocide is always fresh, it haunts them and living in Rwanda they have no respite from it. Because the genocide took place in almost every part of the country and on such a massive scale the presence of death and of evil, the reminder of the innocents killed is permanent, constant, and relentless. There is no place within Rwanda where a survivor can retreat to and feel him or herself far from the genocide. Wherever they may go in the country, in addition to their particular individual memories of the genocide they are confronted by the remains of the hundreds of thousands of others who were killed for being Tutsi.

Although some genocide survivors appreciate certain aspects of the communal justice system established by the Rwandan government, known as gacaca, many critique its leniency vociferously on both moral and practical grounds. The gacaca system enables genocide perpetrators to be freed with generally short prison sentences and sometimes no prison sentences at all, if confession is made and community service is done. Many survivors explain that the burden of reconciliation is placed on them, that they are asked and sometimes demanded to forgive perpetrators, and face enormous social pressures to do so and social ostracism, intimidation, and threats if they do not. They doubt the sincerity of perpetrators who claim in gacaca courts to have rejected their past actions, but who often make these statements simply as practical means to ensure a minimal prison sentence and freedom. They fear the perpetrators who are being released from prison, some of whom go on to kill genocide survivors. And they feel fundamentally alienated from their own land because of this combination of physical and psychological insecurity, and loss of faith in the willingness of the justice system to hold genocide perpetrators fully accountable for their murderous actions.

The consequences of the Genocide against Tutsis did not end when the killings stopped. Many of us still live with open wounds that are made even more painful by the indifference and non- repentance of those who carried out this genocide. While thousands marvel at the progress made in our country over the last 15 years, for so many of us, every street corner, a growing bush, every river, any given forest, brings back the memories of brutal murders and those of being hunted like an animal by your own neighbors of then and now. While for so much time, I have wanted to forgive, and for even a few moments, I am tempted to forget, the longing and hard struggle to achieve a reconciliation with those Rwandans who murdered and vanquished my loved ones; I am simply too close to the situation. I can still feel the pain they have inflicted me and they have no remorse or regret for what they have done. (Email, August 17, 2009.)

As these testimonies show, there is a strong demand and need for an alternative living arrangement for genocide survivors.

Survivors continue to insist that perpetrators of the genocide be punished for their crimes as a matter of justice, deterrence, and a break with the impunity of the past in which under a Hutu supremacist regime from 1959 - 1994 the murder of Tutsis was condoned and enabled by the government. Massacres of Tutsis took place frequently, roughly every ten years, and tens of thousands of innocent Tutsis, civilians, were murdered because of their ethnic identity. Bertrand Russell, as early as 1964, called one of these massacres which took place in 1963, "the most horrible and systematic massacre since the Holocaust."[xi] Even though Rwanda's gacaca system of communal justice has failed to provide the justice which many if not most survivors seek, as one survivor says, restorative justice for survivors can at least help them to heal some of their wounds and right the wrongs that have been done to them.

To some extent many Rwandan genocide survivors have resigned themselves to the fact that they will never see justice, that the people who killed their families and friends in 1994 will never get the punishment that they deserve. This however does not mean that survivors also have to live the rest of their lives in fear or with the psychological wounds that are inflicted whenever they step outside their houses to go to their farm, to draw water from a nearby river, to go school, to go church, to go anywhere. (Email, August 18, 2009)

The United Nations, Europe, the United States and Canada and the entire international community failed the survivors and failed their family members and friends who were murdered in the genocide.[xii] It is time that they honestly ask themselves how they can best contribute to their well being. They should continue to support Rwanda's development and accepting Rwandan genocide survivors as asylum seekers should not come at the expense of doing so. But they have a very particular obligation to each and every one who survived the genocide. They can offer them the possibility of a transformed life where they will not live under the shadow of their past experiences and subject to constant retraumatization. In enabling Rwandan genocide survivors to immigrate, the governments of each country accepting genocide survivors for resettlement should take care to provide them with adequate support. It is not enough to provide genocide survivors with immigration rights without acting with sensitivity to their unique needs and the immense challenges that they face because most have lost their family members and must confront the challenge of resettlement alone or with very few siblings and relatives. Support services that would likely be necessary include temporary housing and/or financial grants for housing, assistance with job applications, language and general educational programs, and the support of dedicated social workers. Governments accepting genocide survivors for resettlement may wish to apply a portion of their foreign aid/development budgets domestically to assist in meeting the costs associated with resettlement.

It is essential to acknowledge the efforts of the Rwandan government in supporting genocide survivors. Five percent of every annual budget is devoted to programs to support their needs.[xiii] However, its resources are intensely strained and it simply cannot afford to provide survivors with their basic needs because it does not have the budget to do so. Even with this level of support tens of thousands of genocide survivors find themselves without access to adequate shelter, nutritious meals, dependable healthcare, and a steady source of income. Many children and teenagers, numbering in the thousands, orphaned by the genocide cannot afford school fees and are thus denied an education because of their poverty and their lack of a family support network because they have lost their parents and relatives in the genocide.[xiv] In this way genocide survivors are further impoverished and marginalized and rendered unable to rebuild their lives and reconstitute their communities.

Even if the Rwandan government had the economic resources to assist survivors in meeting their needs there would still be many survivors who prefer not to remain in Rwanda because of the immense psychological stress and trauma this can entail. The Rwandan government cannot jail the thousands of Rwandans who were not directly implicated in acts of genocide but who were willing bystanders who looked aside or cheered as Tutsis were murdered and whose actions during the genocide and presence in Rwanda today haunt survivors. Even with the best of intentions there are limits to the extent to which the Rwandan government can help genocide survivors to realize their human rights to live in dignity and free of fear.

Building an extensive Rwandan diaspora ultimately will be of great benefit to all Rwandans. The remittances that survivors who establish themselves abroad will send home to those who remain in Rwanda will inject much needed capital in the Rwandan economy, and some will return to Rwanda to invest, create new businesses and employment opportunities, and to apply skills gained through education acquired abroad.[xv] Enabling genocide survivors to settle abroad then will ultimately not only empower survivors and promote their rehabilitation, it will also promote the development of Rwanda as well as foster positive relations between Rwanda and other nations. There is a Rwandan diaspora in countries like Canada, the United States, Belgium, and Britain. The local Rwandan community in these countries is well placed to welcome Rwandan genocide survivors and extend them support to enable them to integrate the society and to ease the inevitable strains that accompany immigrating to a new country and acculturating.

This article focuses on the responsibility to offer genocide survivors the choice to claim asylum. Under no circumstances should they be required or pressured to do so. Such a decision must reflect their informed consent and be an autonomous choice reflecting their individual interests as they define them. Every human being has the right to dignity and the right to security. Living beside perpetrators of such human rights abuses is a violation of these rights and for many survivors constitutes a form of torment and exposes some to tortuous psychological and social conditions. This proposal focuses on Rwandan genocide survivors primarily because the situation of Rwandan genocide survivors is unique because, as noted earlier, of the small size of Rwanda and the enormous scale and scope of the genocide in virtually every part of the country. Consequently, Rwandan genocide survivors cannot be resettled within their own country away from perpetrators of the genocide, as the perpetrators literally live everywhere throughout the country. There are relatively few countries in which the size of the country and the scale and scope of the genocide creates such a universally traumatizing environment for genocide survivors. One survivor states,

Rwanda is our country. It is our mother land. It is where our existing History starts from. However it is also a world of sorrow. These people who did that [killed and tortured] to my family were released in 2006.I meet them every day. I am having lots of difficulties to even look at their faces. I feel bad when I try. It's as if I am the one who did wrong to them. It's for me to feel ashamed. But I don't give much thought on that. I have to mind my own business. However, I imagine how deep sadness is for survivors that live in rural areas. Those who decided to keep silent and never hope that Justice be done to their loved ones, because in Gacaca courts, people are making fun of them when they say what they saw. They are treated like drunkards, or fools by the participants. Those who do that are their neighbors.The ones that will live with them forever. They do that because they want their family members to be released out from prisons. They want judges to never take into consideration the truth from these survivors. And survivors choose to become the supporters of the killers who made their families to perish. They cry in hidden places, by fear of what would be happen if they struggle for the memories of their loved ones. (Email, August 17, 2009)

Perhaps one of the most psychologically damaging aspects of being forced to live alongside perpetrators is the need to curry favor with them and to repress one's own feelings in order to minimize the chance that perpetrators will try to harm you and at the same time, to suffer their mockery, indifference, and the cruelty of their continued sympathy for the genocide and for the genocidal ideology.

Genocide survivors have waited long enough. They are not reaping many of the benefits of the extensive development programs implemented by European and North American aid agencies in Rwanda.[xvi] The wishes of genocide survivors too often go unheard and so it is important that their voices are acknowledged and given opportunity to be shared in public. Every year in Rwanda delegates from European countries, the United States, Canada, other members of the international community, and the United Nations acknowledge in ceremonies the evil of the Rwandan genocide, its gross injustice, and its brutality. And then, after placing a wreath, writing words such as 'Never Again' in a memorial book, and speaking to the media, they leave. But the genocide survivors remain in Rwanda. None of these words, sentiments, and symbolic actions amount to a real attempt to address their human rights and needs.

If the United Nations and its member states believe that the genocide was wrong, if they acknowledge that they failed to prevent and stop it, then it is incumbent upon them to care for its survivors. If they fail to do so survivors will continue to suffer, perpetuating the legacy of the genocide. As these testimonies show, right of resettlement has a central role to play in restorative justice. There is no greater moral obligation, no clearer expression of human solidarity and compassion than to enable these genocide survivors to live in freedom and safety without fear and with their dignity honored and restored.
References:
Emails between the author and Rwandan genocide survivors who wish to remain anonymous. I was assisted in this effort by a survivor who also wishes to remain anonymous who reached out to a diverse group of genocide survivors and collected their testimonies in addition to ones I collected (many of which informed the article but are not directly quoted) during field research visits to Rwanda in 2008, 2009, and 2010. Some of the quotes were collected over the course of several weeks and then emailed to me in one email, without stating the exact date on which they were received. The dates I have listed are the dates on which I received the testimonies.

Email message to the author, August 13, 2009.

Email message to the author, August 17, 2009.

Email message to the author, August 19, 2009.

GETTLEMAN, Jeffrey. Back from the Suburbs to Run a Patch of Somalia. Available at http://www.nytimes.com/2009/10/03/world/africa/03somalia.html?scp=4&sq=Somalia&st=cse )

HATZFELD, Jean. (2007.) Life Laid Bare: The Survivors in Rwanda Speak. (New York: Other Press.)

HATZFELD, Jean. (2009.) The Antelope's Strategy: Living in Rwanda After the Genocide. (New York: Farrar, Straus and Giroux.)

MCVEIGH, Karen. Spate of Killings Obstructs Rwanda's Quest for Justice. Available at http://www.guardian.co.uk/world/2006/dec/03/rwanda.karenmcveigh.

MELVERN, Linda. (2009.) The Role of the West in the Rwandan Genocide. (London: Zed Books.)

MELVERN, Linda. The Mechanics of Genocide. New Humanist. Available at www.Newhumanist.org.uk (retrieved 24 October 2009).

REDRESS and African Rights Report, 'Survivors and Post Genocide Justice in Rwanda.'

Available at,

http://www.redress.org/downloads/publications/Rwanda%20Survivors%2031%20Oct%2008.pdf

(retrieved February 15, 2010)

SURF Survivor's Fund Annual Report 2008.

Available at, http://www.survivors-fund.org.uk/resources/reports/surf-reports.php

(retrieved 26 September 2009).

United Nations Resolution Adopted by the General Assembly. Available at http://www.undemocracy.com/A-RES-60-225/page_1 (retrieved 15 September 2009).

[1] Already 165 genocide survivors have been murdered in Rwanda by fellow Rwandans, many of whom face trials and are afraid of the punishments that will be meted out against then when genocide survivors testify that they were involved in the genocide. 'Spate of Killings Obstructs Rwanda's Quest for Justice. Available at, http://www.guardian.co.uk/world/2006/dec/03/rwanda.karenmcveigh

[2] For more on the current situation of genocide survivors in Rwanda see The Antelope's Strategy: Living in Rwanda After the Genocide by Jean Hatzfeld.

[3] See the report by Redress and African Rights entitled 'Survivors and Post Genocide Justice in Rwanda.' Available at <http://www.redress.org/downloads/publications/Rwanda%20Survivors%2031%20Oct%2008.pdf

[4]United Nations Resolution Adopted by the General Assembly. Available at http://www.undemocracy.com/A-RES-60-225/page_1 (retrieved 15 September, 2009).

[8] United Nations Press Release, ( http://www.un.org/News/Press/docs/2009/ga10908.doc.htm)

[9] Surf's Annual Report 2008, p. 1. Available at http://www.survivors-fund.org.uk/assets/docs/reports/surf-ar-2008.pdf (retrieved 20 October 2009)

[10] SURF Website, 'Justice.' Available at http://www.survivors-fund.org.uk/resources/reports/ar2008/justice.php and also p. 25 http://www.survivors-fund.org.uk/assets/docs/exhibition/surf-hereos-exhibition-web.pdf (retrieved 21 October 2009).

[11]'The Mechanics of Genocide' by Linda Melvern. New Humanist.Available at www.Newhumanist.org.uk (retrieved 24 October 2009).

[12]Linda Melvern. 'The Role of the West in the Rwandan Genocide.' London: Zed Books, 2009.

[13]'Life for Survivors' SURF Survivor's Fund Report. Available at www.survivors-fund.org.uk/assets/docs/.../life-for-survivors-v01.pdf. (retrieved 22 September 2009).

[14]Surf's Annual Report 2008. Available at http://www.survivors-fund.org.uk/assets/docs/reports/surf-ar-2008.pdf (retrieved 20 October 2009).

[15]For an example of how a member of the Somalian diaspora community is contributing to Somalia's development see: 'Back from the suburbs to run a patch of Somalia.'Available at
http://www.nytimes.com/2009/10/03/world/africa/03somalia.html?scp=4&sq=Somalia&st=cse) (retrieved on 4 October 2009).

[16]See the article in Development in Practice by Noam Schimmel entitled, "Failed Aid: How Development Agencies Are Neglecting and Marginalizing Rwandan Genocide Survivors" for a detailed account of how Rwandan genocide survivors are being overlooked by United Nations, multilateral, national, and international aid agencies and non-governmental organizations. Spring, 2010.

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A Safe Place to Call Home: Securing the Right of Rwandan Genocide Survivors to Resettlement Outside Rwanda

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If I were not stopped short by poverty, I would travel far from here, to a country where I would go to school all week long, and play soccer on a nice grassy field, and where no one would want to mistrust me and kill me, ever again.

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The killers mocked us saying: “Aha, it is the girls. Let’s go and ‘liberate’ them. We must
give them something to celebrate.” They took us and another girl who was carrying a
baby, to a nearby hill. We passed a roadblock where we saw that people were being
killed. Right in front of us people were forced to squat on the floor and were then
macheted or killed with a masu. A big truck was on standby where the bodies were
piled on and taken away.
When they were tired of killing, the men came to us and ordered us to take off our
clothes. They each in turn raped us. One man pleaded with the others to leave my 14
years old sister alone, saying she was only a kid. The other men laughed and said, that
we were all going to be killed anyway. That we would have to chose between rape or a
cruel death. They raped my 14yearold sister. I stopped feeling my pain. I wanted to
protect her, but I couldn’t. After raping us they gave us food to eat by the roadside.
Many people were being captured by villagers and brought to the roadblock. Soon there
were so many women kept aside for rape. This went on two weeks. My sister and I met
many women, some were raped and killed, others were macheted and lay in agony for
days before eventually dying. Others were piled on lorries with the dead, even though
they were still breathing.

http://www.un.org/en/preventgenocide/rwanda/testimonies/pdf/59%20-%20Adeline%202009.pdf

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In Rwanda, psychologists found that in 2015, several youth in the age range of 15-35 suffered Genocide trauma, meaning that those who are 35, were only aged 14 during the Genocide, while those aged 15 were not born yet then but suffer through hereditary and environmental factors.

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It is known that people who get traumatised over the 1994 Genocide against the Tutsi are the people who experienced the horrific occurrences at the time. But recently psychologists have shifted the scope of Genocide trauma even to people who were not around at the time, especially the children who can inherit that trauma.

In Rwanda, psychologists found that in 2015, several youth in the age range of 15-35 suffered Genocide trauma, meaning that those who are 35, were only aged 14 during the Genocide, while those aged 15 were not born yet then but suffer through hereditary and environmental factors.

"Those who were not yet born, though they never saw or experienced the physical pain or mental effect of the Genocide, have grown in a traumatised society, thus fall in the same category. Someone born after the Genocide can experience or acquire the trauma from parents, relatives, neighbours and generally people that surround him because he/she is in a world where they see traumatised thereby developing their own imagination of the Genocide after observing their parents in unusual conditions," says Dr Yvonne Kaitenshonga.

She says it's not only in Rwanda where transgenerational trauma occurs in children, but also in countries that also suffered similar tragic history like in Israel, Vietnam, Cambodia and Armenia, where children's born by survivors could experience and inherit trauma through their parents' DNA.

Recent research, for instance, found that Holocaust survivors and their children both had lower cortisol levels than Jewish families who had lived outside of Europe during the war. Cortisol is a hormone that helps humans copes with stress. Low cortisol levels can cause depression, emotional hypersensitivity, and social anxiety.
Signs, symptoms of intergenerational trauma
Psychologists say victims experience the usual symptoms related to post trauma stress disorder such loss of appetite, emotional breakdown, frightening thoughts, flash back of traumatic events, numbness, feeling of hopelessness, hyper arousal, aggressive behaviour and recklessness.

A person suffering from intergenerational trauma can be helped to lead a normal life. But experts warn that though trauma can be healed by chemical medications could worsen the patients situation.

"The healing comes better through psychological and social treatment through conversation and counselling which allow the victim speak her heart out, crying or other forms of relief as one speaks about the tragic history," Kaitenshonga adds.

"Post-traumatic stress disorder is triggered by the anxiety and fear of events that happened before and could be only handled psychologically not like other kinds of mental disorders like depression and psychosis that can be healed through medicines," says Dr Jean Damascene Iyamuremye.

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Psychologists warn of transgenerational Genocide trauma

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It is known that people who get traumatised over the 1994 Genocide against the Tutsi are the people who experienced the horrific occurrences at the time. But recently psychologists have shifted the scope of Genocide trauma even to people who were not around at the time, especially the children who can inherit that trauma.

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https://www.youtube.com/watch?v=FI2S3YVWXMU

Aurea Mukakalisa talks about her experiences during the genocide. She was widowed and was raped which is how she was infected with HIV/AIDs.

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Umuhoza, 43 is infected with HIV and has not yet told her son the origins of his birth.“I have not being able to disclose to my son how he was born. My son doesn’t know. I got married in September 1994, after the genocide ended.“I was pregnant when I married and after giving birth my husband realised the child born was not his. He didn’t accept this and as a result he left home,” she told IPS.Umuhoza never remarried. Rape is a taboo subject in Rwanda’s society.

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Umuhoza, 43 is infected with HIV and has not yet told her son the origins of his birth.“I have not being able to disclose to my son how he was born. My son doesn’t know. I got married in September 1994, after the genocide ended.“I was pregnant when I married and after giving birth my husband realised the child born was not his. He didn’t accept this and as a result he left home,” she told IPS.Umuhoza never remarried. Rape is a taboo subject in Rwanda’s society.

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http://www.ipsnews.net/2014/04/trauma-still-fresh-rwandas-survivors-genocidal-rape/

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had to leave my sister behind. I was distraught.

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had to leave my sister behind. I was distraught.

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1.2. Suffering due to the genocide and its aftermath
https://www.tandfonline.com/doi/full/10.1080/23311908.2017.1333244

Although suffering is experienced by the individual, it is in this particular context based on an interplay between perpetrator and victim. It is therefore to a large extent a social experience (Kleinman, Veena, & Margaret, 1997Kleinman, A., Veena, D., & Margaret, L.(1997). Introduction: Social suffering. Berkeley, CA: University of California Press. [Google Scholar], p. ix; Wilkinson, 2005Wilkinson, I. (2005). Suffering: A sociological introduction. Cambridge: Polity Press. [Google Scholar], p. 80). Many years after the Rwandan tragedy, reconciliation among Rwandan people, both in Rwanda and abroad, is still a big challenge, since many Rwandans are burning with anger, hatred, deep frustration, and dashed hopes (Nowrojee, 2005Nowrojee, B. (2005). Your justice is too slow: Will the ICTR fail Rwanda’s rape victims (Occasional Paper 10). Geneva: United Nations Research Institute for Social Development. [Google Scholar], pp. 2−4).

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In the aftermath of 1994, genocide survivors showed high rates of mental health and psychosocial problems due to the inconceivable, dehumanized brutality that the majority of them had been exposed or witness to. Entire family systems as well as the general social fabric that formerly provided support were destroyed due to losses of family members and growing mistrust and fear following the genocide. A great majority of the survivors were female and woman-headed households proved to be especially vulnerable, suffering from the effects of economic deprivation, which included a lack of food, housing and money for the education of their children. (basic needs)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3620568/

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http://www.psychiatrictimes.com/dissociative-identity-disorder/ptsd-survivors-rwandas-1994-war

In May 1997, a young Rwandan girl came to a clinic in Kigali reporting nausea and the feeling of insects crawling on her face. She complained of the strong smell of feces and grew increasingly agitated and fearful, describing vivid images of people trying to kill her at that moment. For months she had vomited at the sight of avocados, and for three years she had been unable to tolerate the sight of rice.

During the evaluation, she related that her parents and siblings had been murdered in the spring of 1994 and that she had been severely wounded. The perpetrators, thinking she was dead, had thrown her into an open public toilet, where she lay for one week among feces and maggots-white maggots resembling bloated grains of rice-feeding on the avocados that fell on her from a tree above the toilet.

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According to the United Nations' (UN) Lessons from Rwanda, some 100,000-250,000 women were raped in the genocide. This sexual violence brought devastation to Rwanda on the large and small scales in the form of increased national HIV transmission as well as in the physical and psychological trauma suffered by the individual women and their families.

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international criminal tribunal for rwanda

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17 Years Later, Rwandan Children Feel Effects of Genocide

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The lingering effects of the 1994 Rwandan genocide continue to be felt among the country's children, particularly the one million orphans and vulnerable children living in the country, child charity reports.

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testimony of a survivor of the  Rwandan Genocide.

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This is the testimony of Adeline, a survivor of the Rwandan genocide
I am the only survivor of my family. I was only 19 years old when the genocide took
place. My parents, three sisters and two brothers were killed in Gitarama on the 14th
April.  When the killing began, my family escaped in many different directions. My two brothers
and younger sister, then aged 14, escaped to Butare. Along the way my other sister
and I separated from my brothers, managing to hide in a trench.
On 16th April we were discovered by some local villagers, who had joined with the
interahamwe. We pleaded with them to leave us alone. We were extremely lucky,
because they did just that. At around 2.00pm, still on the 16th, we naively believed that
the situation must have improved. We came out of the trenches.
The killers mocked us saying: “Aha, it is the girls. Let’s go and ‘liberate’ them. We must
give them something to celebrate.” They took us and another girl who was carrying a
baby, to a nearby hill. We passed a roadblock where we saw that people were being
killed. Right in front of us people were forced to squat on the floor and were then
macheted or killed with a masu. A big truck was on standby where the bodies were
piled on and taken away.
When they were tired of killing, the men came to us and ordered us to take off our
clothes. They each in turn raped us. One man pleaded with the others to leave my 14
years old sister alone, saying she was only a kid. The other men laughed and said, that
we were all going to be killed anyway. That we would have to chose between rape or a
cruel death. They raped my 14yearold sister. I stopped feeling my pain. I wanted to
protect her, but I couldn’t. After raping us they gave us food to eat by the roadside.
Many people were being captured by villagers and brought to the roadblock. Soon there
were so many women kept aside for rape. This went on two weeks. My sister and I met
many women, some were raped and killed, others were macheted and lay in agony for
days before eventually dying. Others were piled on lorries with the dead, even though
they were still breathing.

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"Marita Mukashema was 11 years old during the 1994 Genocide against the Tutsi. She recalls that it was a time of panic and horror and the sound of gunshots everywhere made the situation appear like the world was coming to an end. It was a time many died as they tried to flee from the marauding Interahamwe."

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Marita Mukashema was 11 years old during the 1994 Genocide against the Tutsi. She recalls that it was a time of panic and horror and the sound of gunshots everywhere made the situation appear like the world was coming to an end. It was a time many died as they tried to flee from the marauding Interahamwe.

It wasn't long before the militia came for her family amidst chanting that they had come to smash cockroaches, she recalls.

"They had guns and machetes and were ready to take our lives. We started shivering from where we were in our hiding places. They commanded us to come out and show our identity cards. As we were queuing up outside, I stealthily slipped away and escaped," she recalls.

Little did Mukashema know that in a few seconds she would be the only survivor in her family. She was barely a few metres away from the scene when she heard gunshots; the assailants had killed everyone - her parents and siblings, including her two-year-old sister.

"For a moment I thought it was just a bad dream but sadly it was all real and I could see death coming for me next. Alone and frightened, I ran not knowing where I was heading," says Mukashema.

She sought help from the neighbours and miraculously survived death. To this day she is thankful for the second chance she had at life, but the loss of her family is a pain that still bites her hard down in her heart.

The image of pulling the remains of her family members from a trench (where their bodies were thrown) for burial will forever stay in her mind and this is one challenge she grapples with in her day-to-day life.

Scores of Genocide survivors struggle with scary memories from the 1994 massacre, and though it's been years after all this happened, the victims still struggle with the trauma they were inflicted upon.
How can they cope?
Dr Wilbur Bushara explains that emotional and psychological trauma can be a result of extreme events that involve a threat to life, shattering one's sense of security and making the world a very dangerous place for them.

When one suffers a painful physical or emotional experience, they often get feelings of anger, grief and fear. For some people, a traumatic event can even lead to mental health issues such depression, anxiety or worse to post-traumatic stress disorder and drug abuse, he explains.

"Psychological trauma can leave a person struggling with distressing emotions and memories that can't fade away easily. The person ends up feeling disconnected and unable to trust other people and this can take a while to get over the pain and feel safe again," he says.

Some people will recover quite quickly whereas others might take longer to heal.

Emilienne Mukansoro, a psychotherapist, says victims of the Genocide went through a lot and that the pain they experienced remains fresh in some people's minds.

She says most of the survivors lost children and spouses, while others experienced sexual violence, all of which caused overwhelming trauma in their lives.

"Today most of the survivors are aging and they neither have anyone to care for them nor one to call mother or father. Being a survivor is painful beyond measure, and some of these victims are still incomplete because they didn't manage to bury their loved ones," she says.

Mukansoro says being close to the survivors and being there for them in time of need can be of great help in terms of their healing.

"Helping them get what they need since some are living under extreme poverty can also be of great help. Providing a platform for them to share their experiences is another way of letting their pain out which also aids in healing.

"Helping them to have a vigil for those who didn't manage to bury their loved ones can put the hearts of survivors at peace," the psychotherapist adds.

Damien Mouzoun, a counselor, says it is difficult to heal the heart and the mind of someone who went through the Genocide. He, however, says survivors need to take heart and find strength to look at a bright future.

"I would like to quote a conversation between a camel driver and Santiago, the boy in Paulo Coelho's bestselling book "The Alchemist": "I'm alive," he said to the boy as they ate a bunch of dates one night, with no fires and no moon. "When I'm eating, that's all I think about. If I'm on the march, I just concentrate on marching. If I have to fight, it will be just as good a day to die as any other. Because I don't live in either my past or my future. I'm interested only in the present.

"If you can concentrate always on the present, you'll be a happy man. You'll see that there is life in the desert, that there are stars in the heavens, and that tribesmen fight because they are part of the human race. Life will be a party for you, a grand festival, because life is the moment we're living right now," the quote reads.

Mouzoun says that our general psychological well-being some time after a tragedy is influenced by two things; the event and everything else.

"While sympathising with Rwanda and Africa in general with hope that genocide and war tragedy may never again come our way, I invite our affected brothers and sisters to lift their eyes beyond the pain of our past to the hope of tomorrow, and one day we shall all be free and have a truly peaceful coexistence," says Mouzoun.

He calls upon survivors to seek the speed and power of their psychological immune system, which includes their strategies for rationalising, discounting, forgiving and limiting trauma.

"Being unaware of this emotional recovery system, we accommodate disabilities, romantic break-ups, exam failures, tenure denials and personal and team defeats more readily than we would expect."

*****
EXPERT TIPS Emmanuel Semwanga, gynecologist/obstetrician at La Croix Du Sud, Kisementi, Kigali
Depression and trauma may occur due to different reasons. For instance, people with psychosomatic disorders tend to develop stress. This can even be more dangerous for pregnant women. The best way to handle this is to consult obstetricians for guidance and counseling. Patients should be informed about the repercussions of being in that state. Jean d'Amour Mutambazi, general practitioner at Centre Medical Orkide, Kigali
In cases of acute depression, physiotherapy medication is recommended. In cases where someone is traumatised they really need emotional and social support, counselling or professional treatment.
Charles Gatsinzi, a physiotherapist
For those with such problems, the first thing is that they should be made to understand why they are going through a particular situation by an expert. After that it becomes easier to handle what they are experiencing with the right support from specialists. Claudine Uwajeneza, a final year medical student at University of Rwanda
The family and community should be in a position to find time and give support to their loved ones who might be depressed or traumatised. With support from the family, it becomes easier to adhere to the treatment or counselling being offered by experts. Follow @DonahMbabazi

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Marita Mukashema was 11 years old during the 1994 Genocide against the Tutsi. She recalls that it was a time of panic and horror and the sound of gunshots everywhere made the situation appear like the world was coming to an end. It was a time many died as they tried to flee from the marauding Interahamwe.

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https://www.google.co.nz/search?rlz=1CAHPZQ_enNZ786NZ788&biw=1366&bih=629&tbm=isch&sa=1&ei=2P6uWoT3BoHd8QX3qI_gCw&q=traumatised+rwanda+genocide+raped+girls&oq=traumatised+rwanda+genocide+raped+girls&gs_l=psy-ab.3...177939.181520.0.181858.12.11.0.0.0.0.429.1539.2-3j0j2.5.0....0...1c.1.64.psy-ab..7.0.0....0.C6XMgfopopQ&safe=active&ssui=on#imgrc=hcbs8okiS6qqvM:

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During the 1994 conflict in Rwanda, rape occurred on a massive scale to annihilate the ethnic Tutsi; an estimated between 250,000 and 500,000 women were raped. According to the United Nations Special Reporters of the Commission on Human Rights in Rwanda, women and girls were systematically subjected to rape; some were killed or seriously injured by having arrows, spears or other objects pushed into their vaginas, or by being shot in the genitals. In addition, many Tutsi women were given as rewards to Hutu men who had excelled at killing Tutsi, and many were forced to submit to sex in exchange for temporary security, particularly at roadblocks. Many of them were subjected to the worst public humiliation, mutilated, and raped several times, often in public, in the Bureau Communal premises or in other public places, and often by more than one assailant.

https://www.tandfonline.com/doi/full/10.1080/23311908.2017.1333244

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http://www.dw.com/en/rwandan-genocide-survivor-tells-of-three-months-in-mortal-fear/a-17549630

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With some friends I managed to hide in a building that housed a herd of cows. I didn't know whether my parents were dead or alive, but there was no time to look for them and no time to think about it. We had to concentrate on hiding. We stayed hidden while the militia stole the cows. When they were gone, we decided to swim across Lake Kivu.There were 12 of us - the other 11 drowned. I couldn't think about it, I had to keep swimming. After two nights I reached the other side. A fisherman gave me food and I went to find my uncle who lived there.A year later, I went back to Rwanda. I was traumatised. I didn't want to go back to school, but a priest convinced me to. After school, I got a job but I wanted to leave. I had two cousins who survived, but everyone else was gone. I couldn't take the loneliness any longer, so in 1999 I came to the UK.I met my wife, another survivor, through friends. We got married in 2005 and now have a daughter. It's hard for survivors to speak about what happened, and my wife doesn't like to talk about it to strangers. But it helps me, because I am doing something to continue the memory of what happened. I speak to groups about it through the charity Survivors Fund. People are shocked that it happened, that they didn't know. It is exhausting, but that is what we have left, the story of our loved ones.

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With some friends I managed to hide in a building that housed a herd of cows. I didn't know whether my parents were dead or alive, but there was no time to look for them and no time to think about it. We had to concentrate on hiding. We stayed hidden while the militia stole the cows. When they were gone, we decided to swim across Lake Kivu.There were 12 of us - the other 11 drowned. I couldn't think about it, I had to keep swimming. After two nights I reached the other side. A fisherman gave me food and I went to find my uncle who lived there.A year later, I went back to Rwanda. I was traumatised. I didn't want to go back to school, but a priest convinced me to. After school, I got a job but I wanted to leave. I had two cousins who survived, but everyone else was gone. I couldn't take the loneliness any longer, so in 1999 I came to the UK.I met my wife, another survivor, through friends. We got married in 2005 and now have a daughter. It's hard for survivors to speak about what happened, and my wife doesn't like to talk about it to strangers. But it helps me, because I am doing something to continue the memory of what happened. I speak to groups about it through the charity Survivors Fund. People are shocked that it happened, that they didn't know. It is exhausting, but that is what we have left, the story of our loved ones.

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https://www.theguardian.com/lifeandstyle/2009/jul/18/survived-rwanda-genocide

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Whole swathes of the population are unable to find peace. Constantly on their guard, survivors react to the slightest sound that might recall the genocide. The mere sound of children whistling can sometimes be enough to bring back the terrible memory of the extremist Hutu militias.

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Ndera is Rwanda's only psychiatric hospital
(swissinfo.ch)

Left in ruins at the end of the 1994 genocide, Rwanda's only psychiatric hospital is now seen as a model for the entire African continent. Specialists from Geneva helped to train the staff, who now care for some very disturbed patients.

The Ndera hospital, perched on a hill not far from Kigali's international airport, seems like a haven of peace. It is surrounded by green spaces and boasts a well-maintained basketball court. A pleasant, relaxing place, it would seem, only a few kilometres from the hustle and bustle of the Rwandan capital.

But as the visit continues, the silence weighs ever more heavily. The patients, with their drawn looks and eyes glazed by the medicines they take, gather in little huddles and stare at the visitor.

"I've been working here for 14 years, and have never been the target of aggression," Jean-Michel Lyamuremye, the hospital's medical director, assured swissinfo.ch. "What these patients need most is someone who listens to them and understands them, who feels their suffering."

Region in focus

The area comprising Rwanda, the Democratic Republic of Congo and Burundi is a high priority for Switzerland when it comes to international cooperation and development.

In 2012, the Swiss government supported projects worth CHF38 million in the region, mostly having to do with health and government leadership.

In 2013, the region became one of the core areas for Swiss development policy, with focuses on promoting economic development, vocational training, agriculture and the ecological production of building materials.

The foreign ministry has recognised Rwanda's "remarkable results" in the areas of health, education and agriculture since its 1994 war and genocide.

However, economic and social progress cannot come at the price of democracy, warned the foreign ministry. In Rwanda, freedom of speech remains under threat and the media cannot operate without restrictions.

end of infobox

The most complex cases

"We deal with some very complicated cases. These people are often suffering from a psychiatric illness, like schizophrenia, combined with serious mental trauma as a result of the 1994 genocide," Lyamuremye explained.

The World Health Organization (WHO) estimates that nearly a third of the country's population is still suffering from severe psychological trauma arising from the massacres of Tutsis and moderate Hutus carried out nearly 20 years ago.

"In one way or another everyone was affected by the genocide," says Lyamuremye. "But people who are well integrated into society, who have work and social contacts, find it easier to overcome this tragedy."

Ndera also houses drifters expelled from the city by the police as well as disruptive prisoners.

But beyond the hospital compound, how many poor souls are still wandering around, still tormented by the demons of the past? People apparently living normal lives often find it difficult to talk about, failing to find words to express the unspeakable.

(swissinfo.ch)

Traumatised children

But every April, during the official commemorations, the collective trauma returns. The Ndera hospital calls up a large team of carers who travel to the memorial sites to look after the patients on the spot.

"Some people seem to be numbed by the flash-backs. You have to touch them gently to bring them back to reality," says Alphonse Nkurunziza, who works as a psychotherapist with the AMI association, a local group that looks after people suffering from psychological traumas.

The fact that the scars of the past are not fully healed is sometimes manifested in a less spectacular way.

"A lot of Rwandans don't want to take part in the commemorations. They go into avoidance mode and refuse to go through the grieving process. This is often an indirect sign of serious trauma," said Nkurunziza.

Whole swathes of the population are unable to find peace. Constantly on their guard, survivors react to the slightest sound that might recall the genocide. The mere sound of children whistling can sometimes be enough to bring back the terrible memory of the extremist Hutu militias.

Lyamuremye is worried by a new phenomenon. "Some of the children born after the genocide present symptoms of post-traumatic stress. They cannot bear to hear the stories told by older people."

Domestic violence

The privatisation of violence is another important aspect of this collective injury.

"The traumas suffered are having an impact within families and are a source of conflict," Nkurunziza said. "It's reflected in domestic violence and the use of drugs and alcohol."

Rwanda, a developing country, has only one child psychiatrist and fewer than ten psychiatrists for adults. Given the size of the task, this might seem very meagre. But huge efforts have been made to re-establish a mental health system after the devastation of the genocide, even if the government has sometimes been accused of going too fast in trying to overcome the evils of the past.

Lyamuremye believes that the awareness-raising work conducted by the authorities - it is now a criminal offence to discriminate against the physically and mentally ill - and the establishment of a mutual insurance system for all has made it much easier for people to have access to mental health services.

Swiss aid

Lyamuremye proudly enumerated the services that have been launched in the past few years: clinical psychology, addiction, mental illnesses and HIV, psychotherapy, and a neurological service for epilepsy sufferers.

"Specialists from neighbouring countries come here to gain experience. We also regularly host African and European students."

But without the support of international funding agencies the Ndera hospital would not be able to function to the same standards. From 1996 to 2008 the Geneva University Hospitals (HUG) and the Swiss Agency for Development and Cooperation (SDC) helped set up a psychiatric care network in Rwanda, of which Ndera is the linchpin.

The project has been handed over to the Rwandan authorities - a good indication of the confidence placed in the local partners. But the HUG is still

cooperating with training on an ad hoc basis, as André Laubscher of the HUG told swissinfo.ch.

There are 250 in-patients, and another 100 are treated every day at Ndera. Lyamuremye is not resting on his laurels. He would like to see just two patients per room, as opposed to eight at present. That all depends on funding.

He has faith in the future, given the healthy competition he says is typical of Rwandans. "Everyone wants to prove he is capable of achieving the highest standards. Mental health is no exception."

Collaborative treatment

International organisations working on mental health issues in Rwanda must often adjust their practices to local realities. For example, placing the individual at the centre of care isn't always possible.

Therefore, a collaborative effort must be made to treat traumatised people, including biological, social and spiritual aspects. In Rwandan culture, people generally don't speak about their feelings, so relaxation techniques like breathing exercises are used instead.

To maintain traditional village structures, the government adheres to the concept of Ubudehe, which addresses small problems on a community level.

This method allows conflicts to be addressed before they escalate into something larger.

end of infobox

Horizontal Line

WEF Teaser 2018

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Scars of the Rwandan genocide remain open

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Left in ruins at the end of the 1994 genocide, Rwanda's only psychiatric hospital is now seen as a model for the entire African continent. Specialists from Geneva helped to train the staff, who now care for some very disturbed patients.

# data[].attributes.body
With some friends I managed to hide in a building that housed a herd of cows. I didn't know whether my parents were dead or alive, but there was no time to look for them and no time to think about it. We had to concentrate on hiding. We stayed hidden while the militia stole the cows. When they were gone, we decided to swim across Lake Kivu.

There were 12 of us - the other 11 drowned. I couldn't think about it, I had to keep swimming. After two nights I reached the other side. A fisherman gave me food and I went to find my uncle who lived there.

A year later, I went back to Rwanda. I was traumatised. I didn't want to go back to school, but a priest convinced me to. After school, I got a job but I wanted to leave. I had two cousins who survived, but everyone else was gone. I couldn't take the loneliness any longer, so in 1999 I came to the UK.

I met my wife, another survivor, through friends. We got married in 2005 and now have a daughter. It's hard for survivors to speak about what happened, and my wife doesn't like to talk about it to strangers. But it helps me, because I am doing something to continue the memory of what happened. I speak to groups about it through the charity Survivors Fund. People are shocked that it happened, that they didn't know. It is exhausting, but that is what we have left, the story of our loved ones.

# data[].attributes.body
With some friends I managed to hide in a building that housed a herd of cows. I didn't know whether my parents were dead or alive, but there was no time to look for them and no time to think about it. We had to concentrate on hiding. We stayed hidden while the militia stole the cows. When they were gone, we decided to swim across Lake Kivu.

There were 12 of us - the other 11 drowned. I couldn't think about it, I had to keep swimming. After two nights I reached the other side. A fisherman gave me food and I went to find my uncle who lived there.

A year later, I went back to Rwanda. I was traumatised. I didn't want to go back to school, but a priest convinced me to. After school, I got a job but I wanted to leave. I had two cousins who survived, but everyone else was gone. I couldn't take the loneliness any longer, so in 1999 I came to the UK.

I met my wife, another survivor, through friends. We got married in 2005 and now have a daughter. It's hard for survivors to speak about what happened, and my wife doesn't like to talk about it to strangers. But it helps me, because I am doing something to continue the memory of what happened. I speak to groups about it through the charity Survivors Fund. People are shocked that it happened, that they didn't know. It is exhausting, but that is what we have left, the story of our loved ones.

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Hundreds of thousands of women were raped, including nearly every survivor over the age of 12. For the first time, rape was listed as an official act of genocide by the International Criminal Tribunal for Rwanda (ICTR).
- https://borgenproject.org/5-rwandan-genocide-facts/

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Rwandan Genocide survivor recalls horror 

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Rwandan Genocide survivor recalls horror 

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https://www.cbsnews.com/news/rwandan-genocide-survivor-recalls-horror
She says she was terrified the entire time she was cooped up in the tiny space. They all expected to be killed, eventually. One said she just hoped she'd be shot and not tortured; another made the pastor promise to put dirt on her corpse so dogs wouldn't eat her.

And what did the women have to eat? Not much.

"I remember sometimes we used to eat just like, beans. And there was this little insect that came out of the beans. And he brought it. It was 'Jesus, well how am I going to eat it.'"

But after a while, she managed to eat, by closing her eyes. Still, Immaculee said she lost 40 pounds - one third of herself disappeared during her three months hidden in the bathroom.

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https://www.tandfonline.com/doi/full/10.1080/23311908.2017.1333244

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A great majority of the survivors were female and woman-headed households proved to be especially vulnerable, suffering from the effects of economic deprivation, which included a lack of food, housing and money for the education of their children. Apart from general population samples, studies analyzing the mental health situation in Rwanda following the genocide have mainly focused on groups of widows and orphans or children living in child-headed households. An elevated level of depressive and anxious symptoms as well as PTSD was found in each of these groups

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In May 1997, a young Rwandan girl came to a clinic in Kigali reporting nausea and the feeling of insects crawling on her face. She complained of the strong smell of feces and grew increasingly agitated and fearful, describing vivid images of people trying to kill her at that moment. For months she had vomited at the sight of avocados, and for three years she had been unable to tolerate the sight of rice.

During the evaluation, she related that her parents and siblings had been murdered in the spring of 1994 and that she had been severely wounded. The perpetrators, thinking she was dead, had thrown her into an open public toilet, where she lay for one week among feces and maggots-white maggots resembling bloated grains of rice-feeding on the avocados that fell on her from a tree above the toilet.

In February 1997, outside Rwanda's capital of Kigali, a roadblock stopped a public bus on the Kigali-Gisenyi road. Armed men ordered the passengers to separate according to ethnic allegiance. The armed men then gunned down those suspected of ties with the current regime and let the other passengers go. In January 1998, Rwandan genocide perpetrators entered a working brewery and murdered 30 workers.

Is the War Over?

Rwanda's 1994 civil war officially ended in July of that year, but as massacres and episodes of genocide continue to erupt sporadically within and around Rwanda's borders, the many faces of posttraumatic stress disorder (PTSD) continue to surface in dramatic ways. Each April through July, the anniversary of the genocide, the Trauma Clinic in Butare sees a parade of people with severe PTSD.

In April 1997, more than 30 teenagers from Nyanza Secondary School attended a reburial ceremony of the remains of their relatives who died in 1994. They developed acute emotional reactions such as agitation, seeing vivid images of genocide and weeping for over two days after the ceremony ended. The children fled the scene; the government ordered the school to close.

The same phenomenon happened in Nyamata in a similar memorial service. Closer investigation by the school faculty and a consulting psychiatrist suggested mass hysteria as the most likely explanation.

The horrors of the civil war in Rwanda have no match in recent history. Never before have so many civilians (at least 500,000) been killed so rapidly (within 3 months) by hand-to-hand combat, primarily with machetes and short-range firearms.

The most active perpetrators were young men from rural villages. The majority of them had no prior combat experience and were trained in the militia of the ruling party. The majority of the victims were innocent civilians, often neighbors of the perpetrators, and sometimes friends or extended family members.

In April 1994, high government authorities initially sanctioned genocide by explicit commands transmitted by word-of-mouth and over the radio. Bishops of the Anglican and Catholic churches did nothing to discourage the killing. In a culture that traditionally accords its leaders high respect, such betrayal defied the public trust.

Following the genocide, the exodus of refugees was rapid and enormous: Over 2 million refugees fled into Zaire and Tanzania by the end of August 1994, and most remained exiled for over two years. The pervasive effects of the genocide, massacres and refugee exodus have spared no one. Every family has experienced maiming, torture or death; each family has witnessed atrocities, lost a home or a family member to refugee status. Many citizens remain missing. And in the three-and-a-half year wake of these events, no satisfactory explanation has emerged for why such unprecedented genocide and massacres should have happened in Rwanda at this time.

PTSD Epidemic

No one knows how prevalent PTSD is in Rwanda, but according to our recent survey its prevalence may approach 20% in the adult population-much higher than in other war-torn countries.

The sudden, overwhelming trauma afflicting most civilians and the persistence of unpredictable threats four years after the "end" of the war (a period now commonly known as "the insecurity" in Rwanda) have caused an epidemic of PTSD and related psychiatric disorders. And yet only one study of the recent prevalence of psychiatric disorders in Rwanda has been published (Hagengimana, 1997).

To assess the exposure to trauma and the prevalence of psychiatric disorders, Hagengimana completed a door-to-door community survey in 1996. By interviewing the household members in various neighborhoods in Kigali and several outlying towns, he collected data on a sample of 157 citizens between the ages of 8 and 60. Each subject completed the Kinyarwanda translations of the Harvard Trauma Questionnaire and the Standardized Psychiatric Interview, administered by the investigator as an interview.

Fifty percent (79 out of 157) met DSM-IV criteria for a psychiatric disorder. The most common diagnosis was acute grief reaction (25%), but depression (22%) and PTSD (20%) were also common. The average number of traumatic events during the 1994 war reported by each subject was 15. Four of these events were significantly related to the diagnosis of PTSD: forced isolation, the helpless witnessing of atrocities, rape and loss of parents. Treatment for any of these disorders was rare.

Anecdotal support for the findings of this small pilot study comes from the observations of physicians and nurses working in primary care clinics around the country. Emmanuel Gasakure, M.D., a cardiologist and secretary of the faculty of medicine at the National University of Rwanda in Butare, reports that he continues to see many patients with minor physical complaints who are unable to function due to unnamed psychological distress.

Treatment Obstacles

The growing burden of mental illness in Rwanda remains largely unknown and untreated. The culture and its language, Kinyarwanda, still lack words for common depressive and anxiety syndromes. Only since the 1994 civil war has a word emerged for PTSD: ihahamuka, which means "breathless with frequent fear."

Substance abuse, particularly alcohol dependence, and smoking has risen dramatically since the war, according to Hagengimana's study.

Two psychiatrists serve a population of 8 million, so specialty mental health treatment is rare. Mental health treatment is usually delivered in outlying clinics or at Rwanda's only psychiatric hospital (outside Kigali) by a few nurses untrained in psychiatry. Other treatment is delivered through the primary care system and by traditional healers. Psychotropic medications have been ample at the hospital but scarce in the rural clinics, so the incentive to diagnose mental illness remains low where pharmacologic treatments are scarce.

Public health experts in Rwanda generally agree that the highest risk groups for psychiatric disorders currently are widows, orphans and soldiers. Over 60 cases of PTSD among soldiers have presented to the clinic in Butare, mainly in the form of conversion and dissociative reactions.

One soldier, referred from the front line, presented with aphonia, pseudoparalysis of the right side of the body and contractions of the right hand, particularly the index finger (his trigger finger).

Another man, an escort for a top officer in the army, lost his siblings and parents in the 1994 genocide. Although he wants to leave the army, his sense of duty prevents him. In January 1998 he lost his auditory acuity and developed la belle indifference. Audiometry done in the Ear, Nose and Throat (ENT) service was normal.

Signs of a PTSD epidemic abound in Rwanda, but no one knows the size and severity of the trauma-related psychiatric disorders. The barriers to further study of the prevalence and severity of mental disorders are the same barriers that limit access to care; namely, insufficient medical resources, competing political agendas and inadequate public awareness, both within Rwanda and around the world, of the toll of mental disorders related to the 1994 war.

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In May 1997, a young Rwandan girl came to a clinic in Kigali reporting nausea and the feeling of insects crawling on her face. She complained of the strong smell of feces and grew increasingly agitated and fearful, describing vivid images of people trying to kill her at that moment.

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Jean-Louis Mazimpaka
survivor of the Rwandan genocide, photographed at his home in West Drayton, London. Photograph: Ivor Prickett . https://www.theguardian.com/lifeandstyle/2009/jul/18/survived-rwanda-genocide

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https://www.tandfonline.com/doi/full/10.1080/23311908.2017.1333244

It was found that 57.5% of the respondents had lost one or more family member during the 1994 genocide against the Tutsi. In this sample, 72.5% reported being traumatized, and of these, 37.5% extremely traumatized. Fifty percent reported having sleeping problems often, and of these, 22.5% very often. Seventy-five percent reported having bad dreams at least sometimes, 30% of these often, and 20% very often. Thirty percent of women and 5% of men reported having been raped. Of these, 15% of the women became pregnant due to the rape, and 10% were contaminated with HIV/AIDS. Ten percent of the respondents were born as a result of rape. Although 50% reported living peacefully with other Rwandans, 35% considered reconciliation difficult or extremely difficult.

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The people were terrorised and traumatised. They were inheriting a wasteland

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The streets of Kigali were almost empty. From a previous population of 300,000, there were 50,000 people left and half of these were displaced. Their condition was disastrous, and they lacked adequate food and clean water. Outside the capital, whole families and communities had been destroyed.

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In the aftermath of 1994, genocide survivors showed high rates of mental health and psychosocial problems due to the inconceivable, dehumanized brutality that the majority of them had been exposed or witness to. Entire family systems as well as the general social fabric that formerly provided support were destroyed due to losses of family members and growing mistrust and fear following the genocide.

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Abstract

Background

The 1994 genocide of the Tutsi in Rwanda left about one million people dead in a period of only three months. The present study aimed to examine the level of trauma exposure, psychopathology, and risk factors for posttraumatic stress disorder (PTSD) in survivors and former prisoners accused of participation in the genocide as well as in their respective descendants.

Methods

A community-based survey was conducted in four sectors of the Muhanga district in the Southern Province of Rwanda from May to July 2010. Genocide survivors ( n = 90), former prisoners ( n  = 83) and their respective descendants were interviewed by trained local psychologists. The PTSD Symptom Scale Interview (PSS-I) was used to assess PTSD, the Hopkins Symptom Checklist (HSCL-25) to assess symptoms of depression and anxiety and the relevant section of the M.I.N.I. to assess the risk for suicidality.

Results

Survivors reported that they had experienced on average twelve different traumatic event types in comparison to ten different types of traumatic stressors in the group of former prisoners. According to the PSS-I, the worst events reported by survivors were mainly linked to witnessing violence throughout the period of the genocide, whereas former prisoners emphasized being physically attacked, referring to their time spent in refugee camps or to their imprisonment. In the parent generation, when compared to former prisoners, survivors indicated being more affected by depressive symptoms ( M = 20.7 (SD = 7.8) versus M = 19.0 (SD = 6.4), U = 2993, p < .05) and anxiety symptoms ( M = 17.2 (SD = 7.6) versus M = 15.4 (SD = 7.8), U = 2951, p < .05) but not with regard to the PTSD diagnosis (25% versus 22%, χ(1,171) = .182, p  = .669).

A regression analysis of the data of the parent generation revealed that the exposure to traumatic stressors, the level of physical illness and the level of social integration were predictors for the symptom severity of PTSD, whereas economic status, age and gender were not. Descendants of genocide survivors presented with more symptoms than descendants of former prisoners with regard to all assessed mental disorders.

Conclusions

Our study demonstrated particular long-term consequences of massive organized violence, such as war and genocide, on mental health and psychosocial conditions. Differences between families of survivors and families of former prisoners accused for participation in the Rwandan genocide are reflected in the mental health of the next generation.

Keywords: Rwanda, PTSD, Anxiety, Depression, Risk factors, Genocide survivors, Former prisoners, Descendants

Introduction

In April 1994, Rwanda was immersed in a brutal wave of organized violence that left an estimated one million people dead in a period of only three months. Civil war, genocide against the Tutsi minority group and violent reprisal attacks until 1998 horrified its inhabitants. The thoroughly planned and state-monitored genocidal violence was specifically marked by the extensive participation of the local population: neighbors went after neighbors by means of guns, machetes or sticks during house to house searches, at roadblocks or at central congregation points. Looting, destroying property and genocidal acts including murder and sexual violence were common [ 1]. Overall, more than 10% of the country's 7.8 million population and approximately 75% of the Tutsi ethnic minority were killed and a huge number of people ended up widowed or orphaned. In the direct aftermath of genocide, two million people took refuge in the neighboring countries. Many of them did not reenter Rwanda prior to 1996, when the refugee camps began breaking down and people felt encouraged and/or coerced to return. In many cases, a return to Rwanda was followed by immediate incarceration. The release of these prisoners did not begin before 2002 when Gacaca, a judicial initiative based on a traditional Rwandan mechanism of local conflict resolution, was implemented to confront the estimated 1.2 million cases [ 2]. Until the present day, genocide survivors and those who participated in the genocide continue to live next door to each other.

In the aftermath of 1994, genocide survivors showed high rates of mental health and psychosocial problems due to the inconceivable, dehumanized brutality that the majority of them had been exposed or witness to. Entire family systems as well as the general social fabric that formerly provided support were destroyed due to losses of family members and growing mistrust and fear following the genocide. A great majority of the survivors were female and woman-headed households proved to be especially vulnerable, suffering from the effects of economic deprivation, which included a lack of food, housing and money for the education of their children [ 3]. Apart from general population samples, studies analyzing the mental health situation in Rwanda following the genocide have mainly focused on groups of widows and orphans or children living in child-headed households. An elevated level of depressive and anxious symptoms as well as PTSD was found in each of these groups [ 4- 7]. On the other hand, little to nothing is known about the mental health situation of former prisoners in Rwanda, many of which spent several years in refugee camps after 1994. It is assumed that former prisoners - that is, accused perpetrators and their respective families - also present with mental health problems, whether due to their participation in [ 8, 9] or exposure to violence, genocide and their refugee status. Concrete data on this is, however, currently lacking.

To our knowledge, no existing study has used data from a local population sample investigating both survivors and former prisoners as well as their respective descendants living together in the same communities. We opted for a comparison of these two, as they constitute important stakeholders within the post-conflict Rwandan society and assumingly present with different mental health and socioeconomic profiles. This also assumed that a neutral, unaffected group would be near impossible to find owing to the pervasive effects of violence on the Rwandan population as a whole. As the primary targets of genocidal acts were men and boys, genocide survivors proved to be mainly women, whereas genocide-related crimes were mainly committed by men [ 10]. A gender imbalance was therefore assumed in the examined sample of parents. We furthermore hypothesized that families of genocide survivors had been exposed to more traumatic events and that they were more affected in terms of mental and physical health. With regard to social and economic factors, we assumed that they live under worse conditions than the group of former prisoners and their descendants.

Methods

Sampling and procedure

The inclusion criterion for all participants born prior to 1994 was that they must have resided in Rwanda in the same year, while parents of children born prior to 1994 had to be at least 18 years old at the time of genocide. In the present study, survivors were defined as targets of the 1994 genocide and therefore represent today's rescapés. They were mainly categorized as Tutsi but were in some cases Hutu as well (e.g., Hutu women who were persecuted for being married to a Tutsi). Both groups were thus included in the survey. Former prisoners were defined as released prisoners who in the aftermath of genocide were incarcerated because of being suspected of participation in genocide. Therefore, all former génocidaires were included, even if they claimed to be innocent, declaring that they had not killed or harmed anyone. Following this definition, we were interested in the local perception of the family as a "perpetrator family" rather than in the legal status of the individuals.

The survivor sample consisted of 64 women (71.1%) and 26 men (28.9%) and the former prisoner sample consisted of eight women (9.8%) and 74 men (90.2%). In the group of descendants, eligible participants had to be between 19 and 31 for those born prior to the genocide and between 13 and 15 for those born after 1994. The sample of descendants of survivors consisted of 55 women (56.7%) and 42 men (43.3%) and the sample of descendants of former prisoners consisted of 45 women (49.5%) and 46 men (50.5%). Eight participants of the 368 refused to participate in the study for reasons of mistrust, lack of further financial support and owing to the fear of being sent back to prison.

The present study was designed as a cross-sectional survey of a local population sample in the Muhanga district of the Southern province of Rwanda. Muhanga and its main provincial town Gitarama are located in the geographic center of the country, one hour away from the capital of Kigali. Before 1994, the province's population was characterized by cohabitation and a high incidence of intermarriage between Hutu and Tutsi [ 11, 12]. By choosing this research site, we intended to investigate communities where both former ethnic groups (and to a small amount Twa, the third population group) live alongside one another until today and that have an elevated number of Tutsi in contrast, for instance, to districts in the North. Four sectors were selected within the Muhanga district (Nyamabuye, Muhanga, Shyogwe, Cyeza) using a simple random sampling approach. Approval for the implementation of the survey was obtained from the National Institute of Statistics of Rwanda, Kigali (NISR), and from the Ethical Review Board of the University of Konstanz. Furthermore, district and sector representatives were informed of the survey and provided a research permit in the local language of Kinyarwanda. All participants provided their written informed consent and parents signed for their children after having received extensive information on the aim of the study. Interviews were conducted by seven local Bachelor-level psychologists (four men and three women) who had participated in former epidemiological studies and had thus already received extensive training and experience in conducting structured interviews. An additional week of training was provided to all interviewers in order to review, and afterwards practice unfamiliar parts of the interview by means of role-playing and group discussions. Interviewers were closely supervised throughout the entire procedure by a female clinical psychologist (H.R.). Whenever needed, follow-up care of the interviewees was provided. If necessary, participants- especially victims of sexual violence - were referred to self-help groups or trauma counselors for further care.

The study was conceived as a community-based study with a house-to-house survey. In all four selected sectors, two quarters were randomly chosen (one quarter per interviewer) and interviewers went door-to-door, starting at a convenient location within the assigned sector. Each subsequent house was approached until the required number of interviews was achieved. The first adult person encountered in the household was asked whether genocide survivors or former prisoners resided in the house. As soon as it was determined that one eligible person and his or her child met the conclusion criteria, the interviewer started the interview with the person already spoken with. When two or more eligible adult persons were present, one of these was randomly selected for participation. If no one was at home at the time of the first visit, interviewers returned afterwards to ask for eligible participants. If eligible parents had children that met criteria for both age ranges (born before or after the genocide), both children were interviewed. If more than one child within one age group was available and willing to participate, one of these was randomly chosen. Each interviewee received 1,000 Rwandan Francs (about 1.30 Euro) as compensation for the time spent in the interview. The interviews lasted between one and two hours, were carried out individually in the respondent's home and took place between May and July 2010.

Measures

The socio-demographic part of the interview contained questions about gender, age, marital status, educational background as well as some economic and social variables. A social integration index was built by integrating the number of current close friends, the participation in any community activity and the integration in cooperatives or associations. The economic index contained the following variables: possessions (house, agricultural fields), any monthly monetary income, the capacity to satisfy the family's needs and facts on typical nutrition (number of meals, with protein or not). Both the social integration and economic indices were calculated by the addition of their z-transformed variables divided by the square root of their number. These indices were only calculated for the parent generation, as these variables were not assessed for descendants born after 1994 and could therefore not be calculated for the whole group of descendants. Furthermore, six questions on physical health within the previous six months were included, referring to common symptoms or syndromes in Rwanda (e.g., chronic pain or diarrhea, tuberculosis, HIV or any kind of disability). Answers were compiled on an index of physical illness with a possible range of 0 to 6. Finally, questions concerning the experience of displacement and loss due to war and genocide and with regard to the group of former prisoners, their time spent in prison, were added.

To assess trauma confrontation, the Rwandan adjusted Event Scale was used [ 5]. This contained 25 potentially traumatic events, for example, to witness a massacre, to be physically attacked or to hide under cadavers. Each type of event was assessed referring to a specific period of time, namely before, during and after the genocide, as well as lifetime exposure. In all four categories, events were summed up to a total number of event types to which participants had been exposed.

Diagnostic status and symptom severity of PTSD were determined using the PTSD Symptom Scale Interview (PSS-I) [ 13], which assesses the 17 symptom criteria in the previous month according to the DSM-IV. Each item was evaluated on a four-point Likert scale ranging from 0 (not at all/only one time) to 3 (five or more times a week/almost always) and a PTSD severity score with a possible score range of 0 to 51 was established for every subject by adding all symptom scores. The Kinyarwandan version of this was first produced by colleagues conducting research in the Ugandan refugee camp Nakivale and was later also applied in different settings in Rwanda [ 9, 14]. Its translated version demonstrated satisfactory psychometric properties [ 15, 16].

Depressive and anxiety symptoms in the week prior to the interview were administered by the use of the Hopkins Symptom Checklist (HSCL-25) [ 17]. For further analysis, a severity score for anxiety (scores range from 10 to 40) was established and syndromal anxiety was estimated by using a critical cut-off value for clinical relevance at a mean score of 1.75 [ 18, 19]. A symptom score for depression (scores range from 15-60) was established and again, syndromal depression was estimated using a critical cut-off value of 1.75. For further analysis of the validity of this procedure, a cross-check was made by also establishing syndromal depression according to the DSM-IV criteria using an algorithm suggested by Bolton and colleagues [ 20]. At least five out of nine depressive symptoms including at least one of the depressed mood items (e.g., crying easily, feeling hopeless) had to be present to fulfill the diagnosis, whereas functional impairment was not further assessed. The risk of suicidality was estimated by means of the corresponding section of the Mini International Neuropsychiatric Interview (M.I.N.I.) [ 21] and two items about alcohol and other drug abuse in the previous week were added.

All instruments were applied in Kinyarwanda language versions, produced by colleagues and applied before in Rwanda. All diagnostic scales (including the self-rating scales) were applied in the form of a clinical interview.

Statistical analyses

Descriptive data are presented as frequencies (%), mean scores and standard deviations. Chi square analysis and Mann-Whitney tests are used to analyze between-group differences. To explore the impact of different predictor variables on the severity of the posttraumatic stress symptom score in the group of adult survivors, a regression analysis was calculated. As the PTSD symptom score is a count variable and as our data did not fulfill the assumptions to run a linear regression, we applied an extended generalized linear model for count data based on the assumption of a negative binomial distribution of the data. The Lagrange multiplier test statistic revealed that overdispersion of the data was not a problem ( χ(1,176) = 3.8, p  = .052); a Poisson regression was thereby performed. The predictor variables included in the model were age, gender, exposure to traumatic stressors (number of traumatic events), physical illness, the social integration index and the economic index. Spearman's Rho correlations are used to further investigate links between different socio-demographic variables. Data analysis was conducted using SPSS software version 20.

Results

For further discussion, it must first be considered that socio-demographic profiles between groups differed significantly in that survivors were mainly female (71%), more educated and half of them were widowed (53%), whereas former prisoners were mainly male (90%), presented fewer years of schooling and were significantly more often married (83%). A detailed description of the characteristics of the sample can be drawn from Table .

Table 1

Exposure to war and genocide-related events

Respondents reported having been exposed to about eight different types of traumatic stressors. The average number of events experienced by each group with regard to different periods of time is illustrated in Figure . No gender difference was found in the parent generation with regard to the number of events ever experienced, but women reported a higher trauma load with regard to the period of the genocide ( U = 2446.0, p = .0001) and men reported a higher trauma load with regard to the aftermath of the genocide ( U = 1880.0, p = .0001). In the group of descendants, no gender difference was found at all. Potentially traumatic events such as being captured or kidnapped, witnessing a massacre, serious injury or attack with a weapon as well as sexual abuse or rape were mainly reported by the survivor group and their descendants and linked to genocidal violence. Confrontation with other war or combat situations linked to political events in 1959 or 1973 as well as to the war against infiltrators from 1996 to 1998 were reported by the parent generation of the survivor group (43% and 20%) and to a lesser extent by former prisoners (18% and 9%). On the other hand, 65% of the latter group reported having experienced physical attack especially after the genocide and thereby mainly in relation to their imprisonment as well as their time spent in camps for Internally Displaced Persons (IDP) in Kibuye in the Western region of Rwanda or in refugee camps in the Democratic Republic of Congo (DRC).

Witnessing the killing of someone, seeing dead and mutilated bodies, being attacked with a weapon and physical attack proved to be the most upsetting experiences reported by the entire group. However, survivors and former prisoners as well as their descendants reported different types of events to be the worst (see Figures and ). Whereas former prisoners reported being mostly affected by their own experience of being physically attacked and incarcerated, the three other groups mentioned mainly witnessing the killing of someone to be worst.

Level of distress

The analysis of the PDS data revealed that 81% of the whole sample fulfilled the A1 criterion for a traumatic event according to the DSM-IV. The prevalence rate for current PTSD was 25% in the survivor group, 16% in all their descendants and 22.4% in their descendants born before 1994. 24.6% of all widows and widowers fulfilled this diagnosis. 22% of the group of former prisoners, 1% of all their respective descendants and 1.6% of their descendants born before 1994 suffered from PTSD. The severity score of the PDS ranged from 8 to 48 ( M = 23.9, SD = 10.3) for those who fulfilled the diagnosis. In the parent generation, intrusions associated with the B cluster of the PTSD diagnosis turned out to be as frequent in survivors as in former prisoners. The HSCL severity score for anxiety ranged from 10 to 40 ( M = 14.6, SD = 6.7). 37% of the survivor group and 23% of their descendants were above the cut-off value for clinical relevance. In families of former prisoners, 22% of the parent generation and 8% of their descendants were thus likely to suffer from an anxiety disorder. The HSCL severity score for depression ranged from 15 to 55 ( M = 18.2, SD = 5.9). Considering a cut-off score, 21% of the survivors and 3% of their descendants as well as 14% of the former prisoners and 5% of their respective descendants were likely to suffer from depression. Following the Bolton algorithm as earlier described, 30% of the survivor group and 16% of their descendants might have been ill with symptoms of an affective disorder and 15% of the former prisoners as well as 5% of their respective descendants likewise. Prevalence rates resulting on the one hand from a cut-off mean score of 1.75 and on the other hand from symptom criteria of the DSM-IV diagnosis for major depression thereby proved not to be in accordance with each other. The analysis of the M.I.N.I. data revealed that 11% of the sample reported suicidal tendencies. One quarter of the survivor group and 7% of the former prisoners turned out to be at risk. 15% of all former prisoners reported alcohol abuse in the week prior to the interview, whereas only 7% of victims reported this. In the parent generation, women showed a higher level of suicidality than men ( U = 2826.0, p = .000) and a lower level of alcohol abuse ( U = 3120.0, p  = .005). All group differences in psychopathology are presented in Table .

Table 2

Association between PTSD symptom severity and related disorders

Positive correlations were found between the PDS symptom severity score and other related disorders in the total sample (N = 360). The symptom severity score of PTSD was associated with the severity of depressive symptoms (Spearman, r = .62, p = .000) and symptoms of anxiety ( r = .59, p = .000). Depression and anxiety symptom scores were associated as well ( r = .69, p = .000). PTSD symptom severity occurred to be linked to suicidal tendencies ( r = .35, p  = .000), but neither alcohol nor other drug abuse.

Physical health

In the parent generation, general complaints such as headaches, coughing and malaria (51.2%) were most frequently reported, followed by chronic pain (32.0%) and HIV (7.0%) especially amongst survivors as well as disability due to genocide-related violence (5.8%). Survivors were more affected and differed significantly from the group of former prisoners in the physical illness index ( U = 2896.0, p = .009). Again, a gender difference was found as women reported more physical symptoms ( U = 2640.0, p = .001). Descendants of survivors seemed as well to be more affected than descendants of former prisoners, while this difference did not reach significance ( U = 3742.0, p  = .058). Among those, general complaints (44.2%) especially about stomachaches as well as chronic pain (5%) were again reported most frequently.

Prediction of traumatic stress in the parent generation

Predictors of traumatic stress were analyzed by calculating a negative binomial regression on the PDS symptom severity score of the parent generation (see Table ). Poor physical health, a low level of social integration as well as a high exposure to war and genocide were the strongest predictors for PTSD symptom severity, whereas age, gender and economic status were not.

Table 3

Socio-economic conditions in the parent generation

Regarding the two indices, the social integration and the economic index, the parent generation did not differ significantly in the first, but rather in the latter one ( U = 2699, p = .006) identifying the group of former prisoners as the wealthier one. While further analyzing gender differences, men presented a higher level in both the economic ( U = .2723.0, p = .006) and the social indices ( U = 2805.0, p = .029). And, with regard to marital status, widows and widowers showed a lower economic status ( U = 2054.0, p = .000), but no difference in the social integration index compared to non-widowed. A negative correlation between physical illness and both indices, the social integration ( r = −.20, p = .000) and economic status ( r = −.33, p  = .000) was found.

Discussion

The present study examined mental health problems and psychosocial conditions in Rwandan families 16 years following the 1994 genocide. Its main aim was to investigate the impact of war, genocide and other potentially traumatic experiences on genocide survivors on the one hand and former prisoners on the other hand, as well as the respective descendants of both groups. The study also examined correlates of PTSD and the prediction of the PTSD symptom severity. In general, survivors and their descendants reported more traumatic events and proved to be more affected than families of former prisoners. Posttraumatic stress reactions were especially elevated in adult survivors who had experienced a high number of traumatic events, had poor physical health and were lacking in social integration.

Not surprisingly, survivors and their descendants, as the primary targets of the 1994 atrocities, showed the highest exposure to traumatic stressors with twelve and ten different event types, thus reflecting their exposure to genocide-related violence. These findings are in line with other studies conducted in Rwanda [ 4, 5, 9]. The average number of event types reported by former prisoners and their descendants ranged from six to nine events and was also mainly linked to the period of genocide, although both generations in this group emphasized its aftermath more frequently than the families of survivors. Former prisoners especially pointed to physical attacks experienced in refugee camps in the eastern Congo or related to the imprisonment upon their return. Their descendants often became witnesses of these imprisonments and the circumstances under which they took place. In this way, the past and recent political situations in Rwanda, which were marked by various episodes of persecution, attack, massacre, and forced displacement, were also directly reflected in the number of events reported before and after 1994. This furthermore highlighted the repetitive and cumulative nature of trauma in Rwanda and the Great Lakes Region, which is not only limited to genocide.

In the present study, 25% of the genocide survivors and 22% of the former prisoners were diagnosed with PTSD. In Rwanda, studies reported 25%-29% of PTSD in non-specified adult populations [ 6, 22, 23], 41%-51% in widows and genocide survivors [ 6, 7] and 37% within the Southern province of Rwanda [ 24]. Our sample therefore showed a lower level of distress than previously reported data on Rwanda, while also presenting a high trauma load. In addition, it is in discordance with data collected in the Southern province. These differences might be due to recovery over time [ 25] but might also be linked to differences in exposure to genocide within the same province. As stated by Straus [ 26], Gitarama manifested less "anti-Tutsi violence" in comparison to other Southern cities such as Butare or Gikongoro, and, according to des Forges [ 27], the nearby Kabgayi church offered special protection to a great number of Tutsi in the area. While in the present study genocide survivors and former prisoners significantly differed in their PTSD severity scores, this was not the case with syndromal PTSD. This was due to the fact that both groups manifested the same level of intrusions - the B criterion of the DSM-IV diagnosis. While this elevated level of intrusions seems unsurprising in genocide survivors, it needs further explanation with regard to former prisoners. The prisoners examined in the present study had spent about eight years in prison: some of them were incarcerated in the direct aftermath of the genocide and others upon their return from refugee camps, as only a few did not leave their home district in 1994. For those prisoners, to be put in prison might have felt like the point of no return as the accused did not necessarily expect to ever leave prison or at least not until the implementation of Gacaca jurisdiction in 2002. Adverse experiences throughout their prison time such as malnutrition, lack of appropriate health care, overcrowded detention conditions or physical harassment and attacks might have added new traumatic events to the already existing fear network [ 28], and feelings of hopelessness and helplessness over the years might have fostered and maintained intrusive symptomatology. Acute fear, one might argue, characterized their time in prison as well as the arrival in their respective communities as they did not know what to expect and how they would be perceived by others in this changed political environment.

Comparing rates of symptoms of anxiety and depression between survivors and former prisoners, the former showed a significantly higher level of distress. With regard to the HSCL score, 37% of survivors and 22% of former prisoners fulfilled the criteria for anxiety disorder, and according to the Bolton algorithm 30% versus 15% for depression. When relying on these results, our findings are consistent with earlier reported studies on survivors and widows or on the general Rwandan population [ 6, 7, 20, 23, 29], even though no comparable data are available for former prisoners. A high level of disagreement was nonetheless found when comparing prevalence rates gained either by using a cut-off score or following DSM-IV symptom criteria, as suggested by Bolton and others [ 20], to screen for depression. In a recently published study, Ertl et al. [ 16] critically discussed the unevaluated adjustment of a cut-off score developed in a different context - that is, for example, not appropriate to the given East African situation. Therefore, in future research, the HSCL might be better applied to investigate symptom severity instead of prevalence rates based on a specific cut-off value.

Suicidal tendencies were found in 25% of all survivors and in 7% of the group of former prisoners, occurring more often among women. Rates showed to be lower compared with an earlier reported study [ 7], but still displayed a considerable level of distress in a society where suicidal tendencies had not previously been commonly reported and were rejected by the majority of our sample as, to quote a participant, "an inappropriate way to solve problems for any Rwandan believing in God". Alcohol consumption occurred twice as much in the group of former prisoners (15%) than in the survivors and was especially linked to males. This had not received much attention in earlier reported studies on Rwanda and is not easily admitted to by Rwandans, whose sense of disclosure prohibits openly talking about sensitive topics, even while the consumption of locally produced alcohol is a common phenomenon in rural areas and symbolic for good neighborhood relationships [ 30]. To further differentiate between general alcohol consumption and clinically relevant problems associated to alcohol and other substances, a recent representative study by the Rwandan Ministry of Health [ 23] examined a general population sample and found rates of drug and alcohol abuse ranging from 3%-6% and alcohol addiction of 5%-7%. Even while our data do not allow for any causal attribution, one might argue that these two specific features, suicidality and alcohol abuse, point to possible reactions and mechanisms for dealing with loss and trauma. Family dynamics might therefore be affected by these issues, especially if the broader family and community support is broken. Furthermore, it is possible that the experience of war and violence can lead to an elevated level of family violence, which often turns out to be moderated by alcohol abuse in a parent. Catani et al. [ 31] demonstrated an association between the father's alcohol intake and maltreatment reported by his children in a Sri Lankan sample of children affected by long-lasting conflict. Although systematically collected data on domestic violence in Rwanda are scarce, another recent study reported that alcoholism ranges under the first three causes of aggressive and violent behavior towards intimate partners or children in this country [ 32]. Therefore, psychological disorders within the local population following experiences such as war and genocide, including alcohol and drug abuse, need to be considered in community-based interventions, which tend to diminish the risk of further violence on following generations.

Overall, the present study demonstrated a high degree of co-morbidity between diverse disorders, as postulated earlier [ 33- 35]. Altogether, one quarter of all adult survivors suffered from PTSD, clinically relevant depression and/or anxiety, reflecting the serious mental health situation as well as the long-term consequences of massive violence even 16 years following the genocide [ 36- 38].

With regard to the group of descendants, our study revealed that 16% of the descendants of survivors compared to only 1% of the descendants of former prisoners (and none of those born after 1994) fulfilled the DSM-IV criteria for the diagnosis of PTSD. In a study on a general sample of Rwandan youth interviewed during the direct aftermath of the genocide, Neugebauer et al. [ 39] reported a PTSD rate of 62%. Recent research on vulnerable groups such as orphans showed lower PTSD rates, between 24% and 34% [ 5, 7, 40]. With regard to those born before 1994, our sample of descendants of survivors manifested a similar level of PTSD to those reported by these last studies. Among these descendants, a particularly high trauma load was found and 50% showed to be half-orphaned. Their specifically vulnerable and life-threatening situation in 1994 and afterwards was strongly shaped by their families' experiences. Due to persecution and death, parental protection throughout the period of violence was often missing. In the aftermath of the genocide, their families had to cope with severe circumstances and descendants often took over great responsibilities, which often continue today and might explain the ongoing sequelae of distress as depressive and anxiety symptoms [ 7]. The group of descendants of former prisoners within the present sample, however, differed even more from the youth described in Neugebauer's study, though concrete comparable data is missing. Throughout the genocide, descendants of former prisoners did not necessarily flee with their families, but rather stayed at home or were individually sent to other remaining family members. When they had to take refuge with their families who were moving to the western parts of Rwanda, they often went in groups and the mainly Hutu background of their mothers offered them special protection in comparison to the descendants of survivors. Even if they had witnessed war and genocidal violence, they had never been specifically targeted, as the primary aim of the genocide perpetrators was to eliminate the group of Tutsi and their families [ 24]. Finally, information on what was going on in Rwanda in 1994 was scarce. A lack of cognitive understanding of the dimension of the events might therefore also have modulated the affect regulation and in turn have added a protective factor for those children [ 41]. Our data furthermore suggest that younger children born after 1994 did not specifically suffer from PTSD or other mental disorders. Further research is needed to better understand potential transgenerational effects of genocide on those children who did not live through the genocide in comparison to their older siblings [ 42]. Apart from these family issues, when referring to previous studies the broader social climate is in question as well, thereby demonstrating a clear association between mental health problems such as PTSD and feelings of hatred and revenge in the aftermath of conflict [ 22, 43]. These possible adverse implications also need to be considered while developing initiatives to foster reconciliation and mutual understanding.

Another key finding of the present study was that the number of event types as well as physical health and social integration explained the biggest part of the variance of posttraumatic stress symptoms in the parent generation. The presently observed dose-effect of the number of traumatic event types on the PTSD symptom severity score - highlighting the impact of cumulative stress on mental health - has already been widely discussed [ 44, 45]. The relationship between PTSD and lower self-reported physical health and other health problems has also been reported in previous studies [ 46, 47]. In a recently published study by Schaal et al. [ 7], both physical illness and trauma exposure were the two main predictors for PTSD symptom severity in Rwandan widows and orphans, while social factors were not further differentiated. The authors discussed this association as a possible difficulty of survivors with PTSD for developing effective coping mechanisms to deal with somatic and chronic health problems or, conversely, that the latter might affect them in such a way that they are no longer able to take care of themselves. Our findings demonstrated chronic pain to be the main physical complaint. With regard to the hypothesis that both syndromes mutually maintain each other as, for instance, acute pain proves to be mediated by symptoms of arousal and vice versa [ 48, 49], this offers an alternative explanation of why PTSD continues to occur at this level, even 16 years after the genocide. Recovery without any treatment or only basic medical-oriented services seem to be reserved to only a fraction of the population. While no evidence for direct prediction of PTSD symptom severity using economic factors was found, physical illness seems to function as a mediator between both, as its correlates with social as well as economic factors demonstrate. The direct consequences of genocidal violence such as HIV infection, chronic pain or disability, which were especially present in the group of survivors, have an immediate impact on the economic growth of a family in an already poor environment [ 50]. The respondents mainly worked as peasants, as is common for the rural Rwandan population. Therefore, as reported by an interviewed female survivor, when a widow was a victim of sexual violence during the genocide and, due to continued bleeding and other associated physical ailments, was no longer able to perform hard farm labor, her family's economic status was subsequently and negatively impacted. Even if this kind of survivor were willing to receive psychological support, the challenges of the distance from home to center, money for travel and privacy from neighbors highlight the delicate interconnectedness of economic and social issues in this region.

The present study revealed that lower levels of social integration and activity were associated with elevated levels of PTSD symptoms, indicating a mutual maintenance effect. Interestingly, women in our sample had a lower social status than men, whereas no difference was found either between survivors and former prisoners or between widowed and non-widowed persons. One possible explanation for these results might be that especially vulnerable groups such as widows or genocide survivors infected with HIV tend to stick together and support each other, which is not necessarily the case with people currently suffering from PTSD [ 51]. According to our findings, genocide survivors had lost an average of 14 family members. In Rwanda, family and community support is crucial for the well-being as well as for the reputation and prosperity of individuals. Depressive moods and feelings of hopelessness in survivors, therefore, were often linked to this missing support, as reported by respondents. As remarriage is socially not necessarily tolerated, widows have difficulties taking care of their family in an appropriate way, especially when they are not further integrated in the community [ 52].

In comparison to this, former prisoners showed a better economic profile, but surprisingly no higher level of social activity and integration. In our study, while released prisoners rarely mentioned problems of reintegration following their release, their other family members such as their wives and children did. As Richters et al. [ 50] demonstrated, sources for ongoing conflicts might be found within families in which the father is extensively absent due to imprisonment. In such circumstances, the man returning home from prison may find that his wife has brought another man home or has even had children with other men. Additionally, there has been sharp economic decline and property loss - all factors leading to the father's realization that he has limited authority in the new family system facing him following imprisonment [ 53]. Alcohol abuse and the aggressive behavior of released prisoners toward family members or, on the contrary, social withdrawal might also affect family dynamics. As several researchers have demonstrated, mistrust in the communities started to grow again after the first massive release of prisoners in 2003 in Rwanda, many of whom have since been presumed innocent or assigned to minor offenses. Alliances that had previously been made between, for example, genocide widows and wives of prisoners, were thereby once again put into question [ 54, 55]. A large portion of our sample of former prisoners was released within about the same period of time and therefore took part "in the government confession program" that provided a reduced sentence for perpetrators who admitted guilt and remorse [ 56, 57]. Released prisoners expressed being especially grateful to the government as well as for the introduction of the Gacaca tribunals, as most of them were released due to this new judicial initiative. At the same time, the majority felt that their own suffering due to imprisonment did not receive any recognition. Therefore, one can argue that social reintegration as a so-called aim of governmental-driven directions on how to behave when going back to their families and communities [ 56, 58] might not necessarily be experienced by the individual former prisoner. This also includes the notion of being innocent and a victim of "someone else's war" [ 59], as, in the present study, released prisoners frequently reported physical attack or incarceration as their worst experiences according to the PSS-I. These results are in line with data from a recently published study on incarcerated, accused perpetrators in Rwandan prisons [ 9]. Only 13% reported their participation in murder as their most stressful event; Schaal et al. thus argue whether high rates of mental health problems in this population are in fact due to the causes or the consequences of imprisonment.

These results highlight the ambiguous and complex nature of victimhood in post-conflict societies as well as the need for further empirical evidence and lead to a first limitation of the study: comparing survivors with former prisoners seems critical with regard to its restriction in conceptualization. As emphasized by numerous authors, dichotomous categories are inappropriate when describing and reflecting complex circumstances of life in and after wartimes [ 12]. A dynamic view on participation is required whenever a better understanding of the role and participation in periods of violence is in question. People do not often fit to one category alone, such as victim, perpetrator or bystander, and can change throughout time in their concrete behavior. This change and assumption of different positions within the same period of time could, therefore, influence the impact on their mental health situation. Following Bar-On [ 60] there might be an association between the use of interchangeable roles and reduced moral responsibility in a person, which together could have a disburdening effect. Therefore, one individual who protected and rescued a nearby Tutsi neighbor (who in turn survived the genocide) while having also participated in roadblocks and manhunts for the Tutsi might be a conceivable example of how one person could incorporate many roles at the same time. Our findings might not necessarily hold for the whole Rwandan population. As already demonstrated, results from different regions might vary and our data can therefore only be seen as representative for central Gitarama. Still, they offer initial insight into a local population consisting of families of survivors and former prisoners living next door to each other who had never before been examined together and compared with each other. Another limitation lies in our definition of family. In Rwandan families, older children in particular do not necessarily grow up near their parents or siblings, but often refer to the broader family context including uncles, aunts, or even grandparents as their parents or to cousins as their siblings as well. The present study does not provide further information about the previous childhood circumstances of descendants in order to draw further conclusions on potential protective factors in the aftermath of violence. Finally, conducting research in a post-conflict setting demanded a critical reflection upon data validity. Due to political restriction and oppression, speaking out loudly is not common in Rwanda. The effect of introducing local interviewers also needs to be taken into consideration. While local researchers normally benefit from their close relationships to the cultural background in question, the specific historically shaped relationships between Rwandans might sometimes foster an even stronger mistrust between Rwandans than toward foreigners.

Conclusion

16 years following the Rwandan genocide, survivors and their families continue to present with considerable rates of PTSD and substantial depressive and anxiety symptoms. The data revealed a strong association between health problems and psychosocial factors such as social integration. A high level of PTSD in the group of former prisoners - and thus the likely genocide perpetrators - demonstrated that psychological suffering affected the population at large, although the nature of traumatic stressors may have varied. By challenging the question of who "owns" trauma discourses in a post-conflict society such as Rwanda, mental health services should take the needs of the entire population into consideration when offering care - an idea that is still not mainstream in Rwanda. Finally, descendants of genocide survivors showed a higher risk for mental health problems than descendants of former prisoners. A high trauma load as well as missing family integration and support characterizes their specific vulnerable situation. Interventions and initiatives that stimulate reconciliation processes between future generations should take these particularities into consideration.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

HR conceived and designed the study and coordinated and supervised data acquisition. She was responsible for statistical analysis and drafted the manuscript. TE participated in the study design, the analysis of the data and manuscript preparation. All authors read and approved the final manuscript.

Acknowledgements

First and foremost, we would like to thank all interviewees who participated in the study for their openness and trust while speaking with us. Seven highly motivated Rwandan colleagues worked as interviewers and interpreters of the Rwandan language and cultural background: warm thanks to Agnès Nyirabizimana, Ernest Hakizimana, Albertine Muhimpundu, Primitive Mukantwari, Pierre Bisengimana, Felix Harindintwari and Charles Ingabire. HR received a scholarship from the Ev. Studienwerk e.V. Villigst and is grateful to the foundation for its ongoing support and inspiration. We would like to thank Dr. Susanne Schaal, Kathrin Groninger and Ernest Hakizimana for valuable comments given on an earlier draft of this manuscript and Danie Meyer for editing. The study was supported by the DFG (Deutsche Forschungsgemeinschaft).

References

Schaal S, Duzingizemungu JP, Jacob N, Elbert T. Rates of trauma spectrum disorders and risks of posttraumatic stress disorder in a sample of orphaned and widowed genocide survivors. European Journal of Psychotraumatology. 2011;2:6343. doi: 10.3402/ejpt.v2i0.6343. [[PMC free article] [PubMed] [CrossRef] Google Scholar]

Jacob N. Consequences of traumatic stress in Rwandan genocide survivors: Epidemiology, psychotherapy, and dissemination.Doctoral thesis. University of Konstanz, Department of Psychology; 2009. Available at: [http://kops.ub.uni-konstanz.de/handle/urn:nbn:de:bsz:352-opus-106870. Google Scholar]

Munyandamutsa N, Mahoro Nkubamugisha P, Gex-Fabry M, Eytan A. Mental and physical health in Rwanda 14 after the genocide. Social Psychiatry and Psychiatric Epidemiology. 2012. doi:10.1007/s00127-012-0494-9. [PubMed]

Hagengimana A, Hinton D, Bird B, Pollack M, Pitman RK. Somatic panic-attack equivalents in a community sample of Rwandan widows who survived the 1994 genocide. Psychiatry Research. 2003;117:1-9. doi: 10.1016/S0165-1781(02)00301-3. [[PMC free article] [PubMed] [CrossRef] Google Scholar]

Catani C, Jacob N, Schauer E, Kohila M, Neuner F. Family violence, war, and natural disasters: a study of the effect of extreme stress on childrens's mental health in Sri Lanka. BMC Psychiatry. 2008;8:33. doi: 10.1186/1471-244X-8-33. [[PMC free article] [PubMed] [CrossRef] Google Scholar]

Wielenga C, Harris G. Building peace and security after genocide: the contribution of the [gacaca courts of Rwanda. African Security Review. 2011;20(1):15-25. doi: 10.1080/10246029.2011.561008. [CrossRef] Google Scholar]

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Rwanda - lasting imprints of a genocide: trauma, mental health and psychosocial conditions in survivors, former prisoners and their children

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The 1994 genocide of the Tutsi in Rwanda left about one million people dead in a period of only three months. The present study aimed to examine the level of trauma exposure, psychopathology, and risk factors for posttraumatic stress disorder (PTSD) in ...

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Africa, Aid, Armed Conflicts, Development & Aid, Editors' Choice, Featured, Gender, Gender Violence, Global Governance, Headlines, Human Rights, Humanitarian Emergencies, Peace, Population, Poverty & SDGs, Regional Categories, TerraViva United Nations

- Claudine Umuhoza's son turned 19 this Apr. 1. And while he may be one of at least thousands of children who were conceived during the Rwandan genocide, he's not officially classified as a survivor of it. But his mother is.

Two decades after the massacre - during which almost one million minority Tutsis and moderate Hutus lost their lives - most Rwandans are still coping with the trauma of the violence. Most affected are the women who have children born of genocidal rape. It is estimated that between 100,000 and 250,000 women were raped in Rwanda during the genocide.

"The future of Rwanda will be better, people will be united. That doesn't mean that people will have forgotten they are Tutsi or Hutu." -- Claudine Umuhoza, genocide survivor

Umuhoza, who lives in Gasabo district, near the Rwandan capital, Kigali, was only 23 when a plane carrying Rwandan President Juvenal Habyarimana and his Burundian counterpart, Cyprien Ntaryamira, was shot down over Rwanda's capital Kigali on Apr. 6, 1994.

During the conflict that ensued she was raped by seven men - one of whom stabbed her in the stomach with a machete. She was left to die, lying on the floor.

Umuhoza survived only because a Hutu neighbour helped her escape to safety and gave her a fake Hutu identity card.

"The neighbour who saved my life is no longer in Rwanda, his family went to Mozambique. I'd like to say thank you for saving me. I would have died if it was not for him," she remembered.

She lost four brothers and other family members in the massacre.

Now 43, Umuhoza is infected with HIV and has not yet told her son the origins of his birth.

"I have not being able to disclose to my son how he was born. My son doesn't know. I got married in September 1994, after the genocide ended.

"I was pregnant when I married and after giving birth my husband realised the child born was not his. He didn't accept this and as a result he left home," she told IPS.

Umuhoza never remarried. Rape is a taboo subject in Rwanda's society.

According to Jules Shell, the executive director and co-founder from Foundation Rwanda, even though this Central African nation has made great strides in rebuilding the country, women who were infected with HIV as a consequence of rape still face severe stigmatisation.

The U.S.-based NGO was established in 2008 and began supporting an initial cohort of 150 children born of rape with their schooling in 2009.

"A disproportionate number of the women who were raped were also infected by HIV," Shell told IPS, explaining that the exact infection rate was not known but it is estimated that 25 percent of the country's women are living with HIV.

According to the government, women comprise the majority, 51.8 percent of this country's population of 11.5 million. However, antiretroviral treatment only became widely available here 10 years ago and is accessible through the national healthcare system.

"We will never know the true number of children born of rapes committed during the genocide.

"As many women are afraid, unable, or understandably unwilling, to acknowledge the circumstance of their children's birth ... we will never know the true number," Shell said.

The consequences of the genocide still affect the youth who were born after it.

"Many of the young people are experiencing a phenomena common to the children of Holocaust survivors, known as the 'intergenerational inheritance of trauma'.

"This has resulted from the inability of mothers to speak openly to their children about their experiences and own trauma, which in turn affects them," explained Shell.

Like Umuhoza, many other women still have not publicly acknowledged that their children were born of rape, though their children are aware that they have fathers who are unknown to their mothers.

This also creates problems for these children when they try to register for national identity cards, which requires the identification of both names of father and mother.

But thanks to Foundation Rwanda, Umuhoza's son is about to finish high school - something she did not have the opportunity to do. Umuhoza is one of 600 mothers currently supported by Foundation Rwanda, which also provides fees and school material for their children.

"I am very happy that my son is in secondary school. One thing that I pray to god for is to see my son in school ... and I have a hope that he will be able to go to university.

Preventing another genocide
There are over 3,000 volunteers in the country using various strategies to bring about reconciliation such as community dialogue, community works, poverty-reduction activities and counselling.

Richard Kananga, director of Peacebuilding and Conflict Management department at the National Unity and Reconciliation Commission, said that another genocide could occur if national authorities do not promote inclusive and reconciliation to bring people together.

"Through community dialogues people are being able to talk to one another. Talks have helped to reduce the suspicion promoting trust and healing," he said.

"It is very important for me. I know it is expensive, but I didn't even think that he would attend secondary school. So doors may open suddenly. I have hope," she trusted.

Her dream is that her son becomes a lawyer to advocate for poor and marginalised people. However, he has dreams of his own and wants to become a doctor.

"He always sees me going for treatment and feeling a lot of pain and he dreams about being able to treat me," she explained.

Because of her ill health and the severe stomach pains caused by the machete wound, Umuhoza is only able to perform light housework.

As a survivor she receives medical treatment from the Government Assistance Fund for Genocide Survivors (FARG) - to which the government allocates two percent of its national budget.

And on Apr. 15 she will undergo an operation to repair her wounds in the military hospital in Kigali.

Twenty years after the genocide, the country has not been able to forget its past, remarked Shell. She explained there is still stigma and discrimination against Tutsis, particularly in rural and isolated areas where they are very much a minority.

According to the National Unity and Reconciliation Commission ( NURC) survey, at least 40 percent of Rwandans across the country say they still fear a new wave of genocide.

"Suspicion is still there. Trauma is still an issue. We still have recently-released prisoners who are now in society but not integrated yet," Richard Kananga, director of the Peacebuilding and Conflict Management department at the NURC, told IPS.

The NURC was created in 1999 to deal with aspects of discrimination among local communities and lead reconciliation in Rwanda.

According to Kananga, reconciliation is a continuous process.

"We can't tell how long it will take, it's a long-term process. We have researchers to measure how people perceive this process of human security in the country. We cannot say that in 20 more years we're going to reach 100 percent [of people who feel secure]," he said.

The children born after the genocide may represent a dark period of Rwanda's history, but, according to Shell, they also represent the "light and the hope for a brighter future."

Umuhoza believes it too.

"I have hopes that the future for Rwanda will be good. Comparing how the country was 20 years ago and how it is today. I wish for unity and reconciliation.

"The future of Rwanda will be better, people will be united. That doesn't mean that people will have forgotten they are Tutsi or Hutu. Rwandans will still know who they are," said the mother.

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Trauma Still Fresh for Rwanda's Survivors of Genocidal Rape

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Claudine Umuhoza's son turned 19 this Apr. 1. And while he may be one of at least thousands of children who were conceived during the Rwandan genocide, he's not officially classified as a survivor of it. But his mother is.

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3620568/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3620568/

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"They were not killed during the genocide, but they are now dying of AIDS, so in essence it was a suspended death sentence." — Ms. Binaifer Nowrojee, researcher with Human Rights Watch, at a press conference on women living with HIV/AIDS from sexual violence during the Rwandan genocide

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"They were not killed during the genocide, but they are now dying of AIDS, so in essence it was a suspended death sentence." — Ms. Binaifer Nowrojee, researcher with Human Rights Watch, at a press conference on women living with HIV/AIDS from sexual violence during the Rwandan genocide