The genocide in Rwanda occurred 15 years ago, but people in the African
country are still coming to grips with its psychological and social aftermath
in a process that is likely to continue for years, said speakers at APA's 2009
annual meeting in San Francisco in May.
During three months in 1994, between 800,000 and 1 million ethnic minority
Tutsis and their moderate Hutu allies were killed by Hutus, who made up 84
percent of the population. The dead included men and women, adults and
children, often cut down by neighbors with whom they had been living
peacefully for many years, said Lisa Rone, M.D., an assistant professor of
clinical psychiatry and behavioral sciences at Northwestern University's
Feinberg School of Medicine.
Following the genocide, more than 250,000 women were raped, leaving 70
percent of the victims infected with HIV and thousands of their"
children of hate" left to grow up with those facts as part of
their legacy. More than 90 percent of Tutsi children lost at least one family
member, and 56 percent saw relatives killed.
Kristin Welch, M.D. (left), a psychiatrist in private practice who is
affiliated with the Heartland Alliance in Chicago, and Lisa Rone, M.D., an
assistant professor of clinical psychiatry and behavioral sciences at
Northwestern University's Feinberg School of Medicine, reported on their
psychiatric work at a clinic for survivors of Rwanda's 1994 genocide.
Credit: Aaron Levin
In 2008, Rone and colleague Kristin Welch, M.D., a psychiatrist in private
practice who is affiliated with the Heartland Alliance in Chicago, established
a psychiatric clinic as part of the existing Women's Equity in Access to Care
and Treatment (WE-ACTx) in Kigali, the capital. The clinic provides HIV
testing, antiretroviral therapy, and trauma
Besides trying to help the survivors, the two Americans hoped to minimize
the intergenerational transmission of trauma by people who found it"
impossible to forgive and impossible to judge," said Rone.
"Traumatized parents can be a source of traumatic stress for their
children," said Rone. In Rwanda, parents weren't able to protect
themselves or their children during the genocide and now fear "emotional
contamination" if they talk about it, she said.
The affective and cognitive consequences of parental trauma on children are
ameliorated to some degree by creating safety, continuity, and predictability
to their lives. Several measures have been adopted to further those
Rwandans are beginning to recreate social bonds, often adopting orphaned
children and creating new families to replace ones lost in the genocide, said
A sense of political and social safety is slowly developing through the
gacaca system—village tribunals in which victims tell their
stories, and perpetrators recount their deeds and accept some punishment.
"Hearing perpetrators' and survivors' stories in these tribunals
brings some sense of justice," said Rone.
While this process sounds hopeful in theory, the reality is more complex.
Some fear retraumatizing survivors. One boy, for example, wanted to testify
about his mother's rape at a gacaca trial "to give my shame to
the killers," but his mother said she would commit suicide if he did
Welch quoted Rwandan President Paul Kagama as saying, "It's the best
we have, but nobody likes it."
At the WE-ACTx clinic Rone and Welch initiated interventions to provide
simple, inexpensive ways to treat psychiatric symptoms as part of broader
recovery efforts. Many patients had not slept without nightmares for 14 years
but were helped by a mix of social engagement, peer support, and medications.
A simple group-therapy room, consisting of a roof surrounded by curtains,
allows women to tell their stories, assisted by trauma counselors.
However, nothing will be simple in helping Rwandans live with their
tragedy, said Welch.
"I thought I'd heard it all after working with torture survivors, but
Rwanda haunts me," she said. Victims and perpetrators still live next
door to each other in a small, densely populated country.
While she believes that a psychologically healthy society is necesssary to
bring about needed postconflict development in the country, Welch has found no
consensus on the best practices to accomplish that.
There is general agreement that mental health care ought to be integrated
into primary care in Rwanda, but that, too, is not easy. Many doctors were
killed in the genocide. Psychiatry is not included in the curriculum of the
nation's only medical school. Doctors and nurses are already very busy, and
few resources exist for training and supervising them in psychiatric ideas and
methods, said Welch. Routine psychopharmacological therapy is little used
because local doctors are unfamiliar with psychotropic medications.
To help overcome stigma, the WE-ACTx Clinic hired a Rwandan psychiatric
nurse who could reassure patients that it was all right to take medications or
But the steps are small, and the work is vast.
"It is not possible to forget or to get too far from the past,"
said Naason Munyandamutsa, M.D., a Rwandan psychiatrist, in a video presented
by Rone and Welch. "We have to live together, but how do we deal with
our past?" he asked. "We need justice, but we must also find a way
to reconciliation. It is not easy to find that compromise." ▪