PTSD & Genocide

April 7^th of this year marked 32 years since the 100-day genocide in Rwanda that killed approximately one million people, where two hundred fifty thousand women were brutally raped (often with family members being forced to witness this atrocity) and where millions of Rwandese were displaced. Researchers estimate that 94% of the population experienced at least one genocide event (Binagwaho et al., 2014). Rwandese families, children and soldiers witnessed a wide range of horrors that cannot be understated. This horrific historic event had a multitude of devastating consequences for Rwandese people, including an increased prevalence of Post Traumatic Stress Disorder, or PTSD. 

PTSD is defined as a mental illness that people develop after experiencing a life-threatening event, like combat, a natural disaster, a car accident, or sexual assault (Musanabaganwa, et al., 2020). PTSD is characterized by acute flashbacks, avoidance, dissociation, hypervigilance, and intense feelings of guilt. (Department of Veterans Affairs D, Health Administration V, Health Strategic Healthcare Group M, Center for Posttraumatic Stress Disorder N. Understanding PTSD and PTSD Treatment. 2017;(September):1–16.)

80% of people with PTSD also develop at least one additional mental health disorder. PTSD and a history of trauma are closely linked to physical health disorders. Following is a list of conditions that are more common among those diagnosed with PTSD:

• Cardiovascular disease
• Diabetes
• Chronic pain
• Cancer
• GI disorders
• Auto-immune disorders
• Increased risk of suicide
• Sleep disorders
• Substance abuse
• Memory disturbances
• Anger/violence

PTSD-linked conditions most often seen in Rwanda are major depressive disorder, panic disorder, chronic pain, substance use disorders, and intergenerational trauma. Globally, the lifetime prevalence of PTSD is between 3% – 14% (Atwoli L, et al., 2015). Among Rwandan genocide survivors, estimates are 25% – 46%.

Before the genocide, PTSD was not well known in Rwanda. Cultural views regarding mental health as well as a lack of psychiatric professionals contributed to this. No formal diagnostic criteria existed. Treatment of the symptoms now associated with PTSD consisted of culturally specific healing practices which varied by region. Families quietly managed their loved ones’ symptoms and were unlikely to share their challenges with outsiders, which increased feelings of shame associated with seeking help and further isolating an already strained population.

After the genocide, every health facility in Rwanda was flooded with people experiencing symptoms of PTSD. The presentation of these specific symptoms was a new phenomenon, and it is widely reported that there was only one psychiatrist in Rwanda at that time. Additionally, there were no formalized criteria for diagnosing and treating mental health disorders (Hagengimana et al., 2003). This created a devastating health crisis that the country could not adequately address. For almost a decade, this traumatized and vulnerable population suffered severe symptoms that were not well understood or treated.

In 2012, the Government of Rwanda launched the Human Resources for Health (HRH) Program to strengthen the country’s healthcare education system and develop the workforce needed to sustain a high-quality healthcare system. At the time, Rwanda’s population of approximately 10 million people was served by only 633 physicians and 6,970 nurses, 90% of whom possessed the lowest level of nursing qualification.

Through the HRH Program, 13 institutions from the United States committed to sending approximately 100 faculty members to Rwanda each year to mentor healthcare professionals and educate students in medicine, nursing, and public health. During the program’s first year, funding was provided by the United States government, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and ELMA Philanthropies.

Participating medical schools included Harvard, Brown, Yale, Dartmouth, Duke, the University of Virginia, and Columbia, while participating nursing schools included Duke, New York University, the University of Illinois at Chicago, the University of Maryland, and Howard University. The Yale School of Public Health also participated in the initiative.

By the conclusion of the seven-year program, the initiative aimed to train more than 500 medical specialists, enhance the qualifications of nearly 2,000 nurses and midwives, and establish a sustainable, high-quality healthcare and health education system capable of operating independently of foreign assistance.