HHr Health and Human Rights Journal

Societal Healing in : Toward a MultisystemicHHR_final_logo_alone.indd 1 10/19/15 10:53 AM Framework for Mental Health, Social Cohesion, and Sustainable Livelihoods among Survivors and Perpetrators of the Genocide against the Tutsi alexandros lordos, myria Ioannou, eugène rutembesa, stefani christoforou, eleni anastasiou, and thröstur björgvinsson

Abstract

The genocide against the Tutsi in Rwanda left the country almost completely devastated, with tremendous

consequences for mental health, social cohesion, and livelihoods. In the aftermath of such extreme

circumstances and human rights violations, societal healing should be conceptualized and approached

based on a multisystemic framework that considers these three sectors—mental health, social cohesion,

and livelihoods—as well as their interactions. The aims of the present study are twofold: (1) to review

evidence on multisystemic healing initiatives already applied in Rwanda using fieldwork notes from

interviews and focus groups, alongside relevant scholarly and gray literature, and (2) to propose a

Alexandros Lordos, PhD, is a Lecturer in Clinical Psychology at the Department of Psychology of the University of Cyprus and the Special Advisor on Mental Health and Peacebuilding at Interpeace, Geneva, Switzerland. Myria Ioannou, PhD, is a Postdoctoral Researcher in Clinical Psychology at the Department of Psychology of the University of Cyprus, Nicosia, Cyprus. Eugène Rutembesa, PhD, is a Professor of Clinical Psychology at the , , Rwanda. Stefani Christoforou, MSc, is a postgraduate student in the Clinical Psychology Doctoral Program at the Department of Psychology of the University of Cyprus, Nicosia, Cyprus. Eleni Anastasiou, MSc, is a postgraduate student in the Clinical Psychology Doctoral Program at the Department of Psychology of the University of Cyprus, Nicosia, Cyprus. Thröstur Björgvinsson, PhD, is the Director of the Behavioral Health Partial Program at the McLean Hospital in Belmont, USA, and an Associate Professor of Psychology at the Department of Psychiatry of Harvard Medical School, Boston, USA. Please address correspondence to Alexandros Lordos. Email: [email protected]. Competing interests: None declared. Copyright © 2021 Lordos, Ioannouis, Rutembesa, Christoforou, Anastasiou, and Björgvinsson. This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted noncommercial use, distribution, and reproduction.

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scalable multisystemic framework for societal healing in Rwanda that builds on existing innovations.

Within a participatory action research methodology, we used a grounded theory approach to synthesize

fieldwork findings and compare them with literature to generate a set of principles for multisystemic

recovery in Rwanda. Recognizing the strengths and limitations of the current mental health system and

other initiatives, including sociotherapy and collaborative livelihood projects, we propose a scalable and

rights-based multisystemic approach for recovery and resilience that would target mental health, social

cohesion, and sustainable livelihoods within an integrative cross-sectoral framework, thus reducing the

risk of post-genocide conflict.

Introduction the genocide after defeating the Hutu militia in late July 1994. Rwanda’s political and socioeconomic Starting in the late 1950s, Rwanda intermittently infrastructure had been destroyed, while the coun- experienced periods characterized by community try was left devastated, especially in the areas of level conflict between the ethnic divisions of Hutu social cohesion, mental health, and livelihood sus- and Tutsi. Social tensions and discrimination tainability. Fearing reprisals or seeking to escape policies continued after Rwanda gained formal in- accountability, more than 2.5 million Rwandans dependence from Belgium in 1962 and gradually led fled to neighboring countries in the aftermath of to a mass exodus of the Tutsi minority population to the genocide. 1 neighboring countries. Extensive effort was made According to the Rwanda Ministry of Health, to ease tensions, including international mediation, a large segment of the Rwandan population expe- culminating in an August 1993 peace agreement rienced severe mental illness after the genocide. 2 signed in Tanzania. However, starting in April Numerous studies were conducted in the years 1994, for over 100 days Rwanda was immersed in following the genocide to establish prevalence a brutal state-sponsored genocide instigated by ex- rates for posttraumatic stress disorder (PTSD) tremist factions within Hutu leadership. According and other clinical disorders among the survivor to the Rwandan National Commission for the Fight population, with estimates of PTSD prevalence against Genocide, the genocide resulted in the in early post-genocide years ranging from 45% to death of 1,070,014 Tutsis and moderate Hutus, while 54%.6 More than two decades after the genocide, almost two million persons were accused of having mental health challenges appear to persist for a participated actively in the genocide (population 6 large proportion of survivors. The 2018 Rwanda million at that time).3 The genocide included highly Mental Health Survey conducted by the Rwanda local violence, as victims often lived in the same Biomedical Centre revealed a high prevalence of villages as perpetrators.4 Extremist propaganda several disorders both in the population of survi- fueled sexual violence during the genocide against vors and in the general population. Most commonly the Tutsi. As a result, 350,000 women and young reported were major depressive disorder (found in girls, as a lower-bound estimate, were subjected to 35% of genocide survivors and 12% of the general rape, torture, sexual slavery, and mutilation.5 The population) and PTSD (found in 27% of genocide Tutsi-led Rwanda Patriotic Front brought an end to survivors and 3.6% of the general population).7 In

106 JUNE 2021 VOLUME 23 NUMBER 1 Health and Human Rights Journal a. lordos, m. Ioannou, e. rutembesa, s. christoforou, e.anastasiou, and t. björgvinsson / public and mental health, human rights, and atrocity prevention, 105-118 line with these findings, a recent meta-analysis of cure such disorders at the individual level—even 19 original studies conducted in the country found though the factors that have led to such adverse that the proportion of genocide survivors who had psychological experiences are primarily social and PTSD was 37%.8 When considering that perpe- political in nature. The case of Rwanda, where a sig- trators and survivors were often people from the nificant burden of ongoing mental distress has been same village, the damage extended beyond mental detected among survivors of the genocide against health, human capital, infrastructure, and available the Tutsi, provides strong evidence in support of community resources, to severe societal wounds. the Special Rapporteur’s position: more than two The impact on society and economy and the severe decades after the genocide, the severe human rights magnitude of trauma in Rwanda resulted in what violations it entailed constitute social determinants might be termed as “collective trauma” or “trau- of a significant mental illness burden that is still matized nation.”9 Collective and historical trauma felt by a substantial proportion of the Rwandan are prevalent in populations that have experienced population. war, displacement, genocide, and poverty, causing considerable distress across whole communities Conceptualizing multisystemic recovery and interference with functioning in multiple areas and resilience as a rights-based approach of educational, work-related, and social activities. for mental health in post-genocide Rwanda Historical genocidal trauma, combined with socioeconomic adversities, represents severe threats To the extent that the mental health burden expe- to development and mental health. Social cohesion, rienced in Rwanda today can be attributed to the or its absence, has been implicated in the etiology experience of the genocide and its consequences and recovery from both physical and psychological across multiple social and economic systems, it is illnesses.10 Additionally, a significant correlation reasonable to assume that efforts to restore mental has been reported between income deprivation and health in affected communities through a purely low social cohesion with poor mental health.11 The biomedical approach would likely fall short of the United Nations Special Rapporteur on the right to objective due to not addressing the social deter- health advocates that good mental health cannot minants of psychological distress, such as extreme exist without human rights, peace, and security. poverty, social isolation, and ongoing community While the currently prevalent biomedical model of polarization. A general principle in resilience mental health focuses predominantly on individual science is that multisystemic adversities need to determinants of mental distress, by emphasizing, be met with multisystemic solutions.13 Address- for instance, the role of neurochemical imbalances ing mental health issues that accompany societal and maladaptive personality traits, advocates of wounds while developing community livelihoods rights-based approaches, such as the Special Rap- and strengthening local social cohesion could pro- porteur, argue that a greater emphasis should be mote resilience and contribute to a more complete placed on the social determinants of mental illness. recovery. From a systems perspective, individuals, Notably, the Special Rapporteur argues that mental households, communities, and higher-level institu- distress is caused primarily by contextual factors tions are considered to be mutually evolving and that include human rights violations, such as viola- adjusting to meet oncoming challenges. All these tions of the rights to life, food, housing, education, diverse layers of society are required to achieve sys- work, development, nondiscrimination, and equal- tem-wide resilience.14 ity.12 Denial of such rights leads to experiences of There are several plausible mechanisms trauma, fear, isolation, and despair which, from a through which multisystemic interventions might biomedical perspective, can meet the diagnostic influence mental health. These include psychosocial criteria for mental illness and trigger an attempt to processes (for example, enhancement of self-es-

JUNE 2021 VOLUME 23 NUMBER 1 Health and Human Rights Journal 107 a. lordos, m. Ioannou, e. rutembesa, s. christoforou, e.anastasiou, and t. björgvinsson / public and mental health, human rights, and atrocity prevention, 105-118 teem, community support, and respect), adoption or genocide-affected countries. The study’s sec- of health-promoting activities and norms in the ond aim is to propose an integrative and scalable community, and increased social organization and public health framework for multisystemic recov- trust levels that encourage the utilization of existing ery and societal healing in Rwanda, building on mental health services while directly contributing local innovations while strengthening them with to psychological well-being.15 In addition, diversity evidence-based practices that have already been and sustainability of livelihoods have been shown validated in other contexts. While the immediate to be essential for social sustainability, as measured objective is to propose scalable solutions to be im- through key indicators of social cohesion, inclusion, plemented across the various districts of Rwanda, it and gender equality.16 Finally, UNICEF studies have is our hope that the proposed framework can have shown that providing humanitarian assistance and broader utility within the field of post-conflict and basic livelihoods to displaced or vulnerable pop- post-genocide recovery and resilience. ulations predicts better health, including mental 17 health and higher levels of well-being. Methods Approaching mental health from a multi- systemic perspective is not just empirically sound Participatory action research framework but also consistent with a rights-based perspective. This study adopts an action research approach.19 According to the Special Rapporteur on the right Action research begins with an effort to understand to health, mental health interventions should the facts of a situation within the context in ques- acknowledge social and economic determinants tion, leading to planning and action to address the of mental illness and address these through mul- problem (that is, implementing a targeted interven- tisectoral policies and programs. In contrast, an tion) and then reflecting on the result of the action. excessive medicalization of mental health, com- All research activities within this Rwanda-specific bined with a singular emphasis on the individual study were designed to pursue tangible solutions to level, can serve as an excuse to violate social and real-world problems and were outlined in the fol- economic rights while labeling the resulting psy- lowing action agenda: (1) determine how Rwanda chological distress as mental illness.18 Therefore, can be assisted in transitioning beyond the legacy only a multisystemic approach to recovery and of the genocide in ways that simultaneously address resilience—where rights in one domain (for exam- genocide-associated mental health challenges and ple, the right to development or the right to peace disrupted social cohesion while contributing to and security) are understood to beget rights in livelihoods development and poverty mitigation, other domains (for example, the right to mental and (2) determine how these solutions build on the health)—can be considered to be consistent with a progress already made in order to provide a scalable rights-based approach. framework that can reach and benefit the majority Adopting a rights-based lens of multisystemic of Rwandans. recovery and resilience, as outlined above, the pres- Participatory action research is a variant of ent study has a twofold aim. First, we seek to review action research that brings in community stake- existing initiatives in Rwanda for multisystemic holders as co-directors of the research process.20 In recovery and societal healing. In its efforts to over- this study, the stakeholders involved included the come the extreme challenges posed by the genocide formal mental health sector, government-appoint- against the Tutsi, Rwanda has become a breeding ed commissions that focus on societal healing and ground for innovation and leadership within the reconciliation, municipal authorities in districts field of multisystemic recovery. Understanding that were severely impacted by the genocide, and such efforts can provide essential insights into mul- international partners with a strong interest in tisystemic recovery and resilience processes, with supporting Rwanda’s transformation. Numerous potential applications in other conflict-affected consultations with such stakeholders took place

108 JUNE 2021 VOLUME 23 NUMBER 1 Health and Human Rights Journal a. lordos, m. Ioannou, e. rutembesa, s. christoforou, e.anastasiou, and t. björgvinsson / public and mental health, human rights, and atrocity prevention, 105-118 over five field missions to Rwanda between May sense of respondents’ experiences and perspectives. 2019 and October 2020. To explore current gaps in service provision, we made sure to ask participants about service gaps, Field-based service mapping beneficiary needs, potential areas of improvement, In support of the participatory process described and recommendations for practice and policy. above, we conducted interviews and focus groups to map out the field of services currently provided Interview procedure in Rwanda within the domains of mental health, All interviews and focus groups took place at a social cohesion, and sustainable livelihoods. We mutually agreed-on and convenient place and then discussed our findings with participating time. Individual interviews lasted 30 to 90 minutes, stakeholders, further informing the direction of while the duration of focus groups was 120 to 180 the action research process. minutes. Field notes were taken by three authors. To mitigate unforeseen risks, we have protected Participants and recruitment participants’ identities in the reporting of results. We recruited 31 participating service providers from various organizations based in Kigali (Rwan- Ethical considerations da’s capital) and Bugesera (a district south of the The study design was reviewed and received eth- capital). Bugesera was chosen as the area of focus ical clearance from the Rwanda National Ethics for the fieldwork based on guidance from partic- Committee, which is registered under the US fed- ipating senior stakeholders. Bugesera was among eral-wide assurance for the protection of human the hardest hit during the period of the genocide; subjects for international institutions. therefore, any future intervention program for mul- tisystemic recovery and resilience would be more Review of relevant scholarly and gray credible and promising for countrywide scaling if literature it were first shown to be effective in the particularly challenging context of Bugesera. Senior project We also reviewed scholarly and gray literature stakeholders recommended which service provid- about policy frameworks and available services ers should be interviewed, suggesting organizations for mental health, social cohesion, and sustainable (governmental, nongovernmental, or private) that livelihoods, sharing our insights with community were actively providing services in the domains stakeholders within the action research process. of mental health, social cohesion, or sustainable The literature under review was based on electronic livelihoods. Executives and other staff from these database searches in PubMed, PsychArticles, and organizations had the choice to participate through Google Scholar. Our review aimed to scope the individual interviews or focus groups. Participants body of literature and identify gaps in services included, among others, clinical psychologists, while mapping the available evidence. We accessed trauma counselors, public health professionals, the following reports through the above websites: development specialists, dialogue facilitators, and the 2019 report on healing practices by the National community workers. Unity and Reconciliation Commission; the report on future drivers of growth in Rwanda, which was Materials prepared by the government of Rwanda and the We used unstructured interviews due to the flexi- World Bank Group; and the mental health strate- bility they offer and to allow for the generation of gy report published by the Rwandan Ministry of qualitative data through the use of open questions. Health.21 We also reviewed relevant international Moreover, this approach offered time and space for scholarly and gray literature on global emerging participants to talk in depth and express themselves practices to identify advances and innovations that in their own words, which helped us obtain a better could be applied in the Rwandan context.

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Developing a grounded theory for and other mental health disorders, with almost no multisystemic recovery and resilience in services to meet this unprecedented mental health Rwanda emergency. Thus, the development of a fully func- tioning mental health sector soon became a priority Data from the participatory action research pro- of the Rwandan government. After an initial stage cess was analyzed and interpreted to propose a of building up core capacities at the national lev- grounded-theory framework for multisystemic el, the focus rapidly shifted to decentralizing the recovery and resilience in Rwanda, to be validated mental health system to the district level, to more by community stakeholders. Grounded theory is effectively reach beneficiaries.24 By 2012, Rwanda described by its founders as “a theory derived from had established a functioning referral hospital data, systematically gathered and analyzed through in its 30 districts, each coordinating a network of the research process, which is structured but still up to 20 primary health centers at the sector lev- flexible.”22 It is considered a method for “creating el. These infrastructure development efforts have conceptual frameworks through building inductive been complemented by a mentoring and enhanced analysis from the data.”23 Purposive acquisition of supervision framework, which has strengthened relevant data through all methods described earlier monitoring and evaluation practices while enabling was followed by open coding to assign meaning to the implementation of clinical protocols.25 Prelimi- the data, followed by theoretical sampling to collect nary results from these evaluations have identified additional data that would enrich the emerging the need for a better diagnostic assessment for de- framework. The outcome of this process was twofold: first, a conceptual taxonomy of existing pression, posttraumatic stress, and alcohol-related 26 innovations in post-genocide Rwanda and, second, disorders. Concerning genocide perpetrators, a set of principles to enrich, systematize, and scale targeted psychotherapeutic interventions were gen- up existing efforts for multisystemic recovery and erally missing or applied in small-scale studies only resilience across all Rwanda districts. for research purposes, while local mental health professionals’ training and education systems were still insufficient.27 In 2019, the Ministry of Health Results: Toward a conceptual taxonomy upgraded the Rwanda Health System Package to of existing innovations for multisystemic include guidelines on psychological interventions recovery and resilience in post-genocide conducted in health centers.28 However, the absence Rwanda of an integrated mental health strategy that would One of the most remarkable insights from the re- operate across the public sector and nongovern- search process as a whole is the breadth and scope mental organizations limited the potential of such of innovation for multisystemic recovery and resil- interventions to achieve mental health outcomes ience in Rwanda—but also specifically in Bugesera at scale. Cognizant of these challenges, the gov- district. This innovation appears to cut across the ernment formulated an updated national mental formal and informal sectors at the national and health strategy for 2020–2024, which is compatible district levels, while frequently combining meth- with a rights-based multisystemic approach. It ods and approaches from the mental health, social highlights the need to integrate recovery with social cohesion, and livelihoods domains. Various aspects inclusion and recommends organizing campaigns of this multidimensional effort are outlined below. to reduce mental health stigma in communities while encouraging the private sector’s engagement in efforts to reintegrate individuals with mental The post-genocide emergence of a sophisticated health disorders, following their treatment at mental health sector in Rwanda district-level mental health units. Currently, the The genocide left a significant proportion of the private sector utilizes mainly individual integrative population suffering from posttraumatic stress psychotherapeutic approaches that include narra-

110 JUNE 2021 VOLUME 23 NUMBER 1 Health and Human Rights Journal a. lordos, m. Ioannou, e. rutembesa, s. christoforou, e.anastasiou, and t. björgvinsson / public and mental health, human rights, and atrocity prevention, 105-118 tive exposure therapy, trauma-informed therapy, as a mentally ill person or being expected to dis- cognitive behavioral therapy, humanistic therapy, cuss sensitive personal issues with an unknown functional analysis of behavior, psychoeducation, professional as would a traditional Western-style and art-based therapy. Within the state sector, one-to-one clinical intervention. In this regard, implementing the mentoring and enhanced super- emerging evidence-based approaches in group- vision framework at health centers has resulted in based therapy programs that focus on skills and the development of care packages for individuals resilience could also inform practices in Rwanda. struggling with schizophrenia, bipolar disorder, For example, the McLean Hospital in Boston, United major depressive disorder, and epilepsy. These States, implements a Behavioral Health Partial Hos- assist mental health providers in delivering more pital Program, which is focused primarily on group targeted interventions at the individual level.29 therapy for individuals with various co-occurring While the mental health care system has mental disorders. The treatment program builds made tremendous efforts to support recovery in participants’ psychological skills and resilience, post-genocide Rwanda, there are still challenges simultaneously focusing on ameliorating cognitive, ahead.30 A medicalized mental health care model emotional, and social processes implicated in devel- still prevails, with patients seeking mental health oping and maintaining mental health symptoms. care typically being referred for individual treat- This flexible treatment approach is set up in an out- ment at district-level hospitals. Western approaches patient, partial hospital setting, which is cost- and in conceptualizing mental health provision in time-effective, while the diversity of skills taught in Rwanda have limited the scaling up of the services the program reinforces community reintegration provided and resulted in a “treatment gap” between after discharge.32 the people who need care and those who receive care. Compounding this challenge is the severe Sociotherapy as a hybrid intervention that shortage of fully trained mental health personnel. cuts across psychological trauma healing and For instance, by 2019, only 12 psychiatrists were rebuilding of community trust registered in Rwanda, and no child psychiatrists In Rwanda, community-based sociotherapy has were reported as practicing. Another factor that been used as a hybrid intervention that integrates contributes to the treatment gap is the possible psychological trauma healing with rebuilding unwillingness of sufferers to utilize individual community trust and resilience.33 Within a group one-on-one treatment services, which appear to setting that actively encourages the participation of be a poor fit for collectivist sub-Saharan African both perpetrators and survivors in the same heal- cultures, where most issues and challenges of daily ing space, participants are given the opportunity to life are addressed in the context of group-based go through various phases of transition. Distinct processes at the community level.31 sequential stages of the healing process include One possibility for addressing Rwanda’s “safety,” “trust,” “care,” “respect,” “new life orienta- mental health treatment gap might be to emphasize tion,” and “memory”. The approach has often been group-based, resilience-oriented psychological in- described as promoting psychological and com- terventions. Such approaches could simultaneously munity resilience through shared storytelling.34 address scalability challenges (since the limited Participants in sociotherapy are groups of 10–15 number of mental health professionals would be in people who meet weekly for three hours, covering a position to serve a greater number of beneficia- 15 sessions in total, with the support of two facilita- ries) and issues related to the cultural acceptability tors selected from the same community. Evidence of interventions. To take one example, an invita- shows that sociotherapy leads to improvements in tion to participate in a group-based intervention interpersonal and community tolerance and trust to strengthen psychological resilience might not while contributing to the mitigation of mental raise the same concerns about being stigmatized health symptoms. More than 20,000 Rwandans are

JUNE 2021 VOLUME 23 NUMBER 1 Health and Human Rights Journal 111 a. lordos, m. Ioannou, e. rutembesa, s. christoforou, e.anastasiou, and t. björgvinsson / public and mental health, human rights, and atrocity prevention, 105-118 estimated to have participated in different variants an effective pathway to strengthen social cohesion of sociotherapy since the approach became popular after the genocide, especially between survivors in the early 2000s.35 and perpetrators.39 In this regard, the formation of However, because the focus of sociotherapy “reconciliation villages” has been a notable initia- groups is not directly mental health, social recon- tive for integrated socioeconomic development and nection objectives might be hampered for those peacebuilding. In these communities, survivors presenting with more severe mental health prob- and perpetrators are invited to coexist while being lems or those with limited cognitive, emotional, given resources, skills, and opportunities for coop- and interpersonal skills. At the same time, the erative economic enterprises.40 Through engaging National Unity and Reconciliation Commission together in livelihood projects of all kinds, the pre- has recognized a need to assess sociotherapy more vious, trauma-associated identities of survivor and systematically and has noted that healing should be perpetrator gradually become less salient, while provided as an intervention with greater regulari- citizens have an opportunity to rediscover each ty, not only during the genocide commemoration other through their present- and future-oriented period.36 socioeconomic roles and identities.41 The promising concept of utilizing col- Practical reconciliation in Rwanda through laborative livelihood initiatives as a pathway to collaborative livelihood initiatives simultaneously achieve social cohesion and local One additional critique that has been levied against economic growth is not unique to Rwanda. Having sociotherapy is that it might not adequately address reviewed numerous such initiatives around the practical livelihood challenges. In regions where globe, Ana Maria Peredo and James Chrisman have the socioeconomic fabric and human capital have proposed a comprehensive theoretical framework been devastated due to the genocide, often resulting for community-based enterprises (CBEs) as an al- in extreme poverty, a singular focus on meeting ternative form of social and economic organization survivors and perpetrators’ social and psychologi- for communities experiencing social and economic cal needs runs the risk of putting participants into stress.42 CBEs build on preexisting social capital, a situation where relapse is likely. Thus, in recent skills, and natural assets in the community. Once years, greater emphasis has been placed on ensuring initiated, such enterprises further strengthen social that psychosocial processes related to sociotherapy and human capital while serving as incubators for are complemented with hands-on, collaborative downstream independent entrepreneurship. How- livelihood initiatives, which lead to income gen- ever, CBEs are not without their challenges. In one eration for the whole community. In this way, review of community enterprises in the Songkhla graduates of sociotherapy groups have an oppor- Lake Basin of Thailand, several management tunity to capitalize on the skills and relationships problems were identified, particularly in market- that they have developed through sociotherapy. The ing, finance, accounting, production, information livelihood initiative, therefore, has positive effects systems, product design, and cost control.43 While on both the social cohesion and mental health of its understandable, given the informal context in participants.37 which such enterprises emerge, these are real chal- Such an integrated understanding of liveli- lenges that must be addressed if CBEs are to become hoods development and social cohesion has been a mainstream solution to promote social cohesion formally acknowledged in Rwanda’s “Vision 2020,” and socioeconomic development in Rwanda. which prioritizes poverty reduction through rural development, increased productivity, and youth em- Multidimensional approaches for the ployment.38 Inspired by contact theory, the strategy reintegration of convicted genocide perpetrators assumes that collaborative contact in the context of into their home communities a community-based livelihoods initiative could be Genocide perpetrators are a large subgroup of the

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Rwandan population, and their reintegration is reintegration in Rwanda are inspiring and effec- considered crucial for social cohesion. An ethno- tive, they are not yet the mainstream standardized graphic study demonstrated that ex-prisoners who approach by which prisoner reintegration occurs return home feel lost, carry the label of genocidaire, in Rwanda, nor have they been fully incorporated and are in an awkward position since they cannot into relevant policy frameworks of the formal sec- become a part of the social world.44 Other studies tor, even though efforts are currently being made have also reported high levels of posttraumatic toward that end. stress, emphasizing the need to facilitate the perpe- trators’ family relationships while providing mental Ongoing efforts to prevent the intergenerational health interventions to assist reconciliation.45 Yet transmission of trauma another critical dimension of the reintegration While most healing efforts in the 25 years since process is the need to prevent recidivism and en- the genocide focused on supporting direct survi- sure that the return of former perpetrators to their vors of the genocide, challenges related to the next home communities does not lead to the retraumati- generation, particularly children born to survivors zation of survivors or to the reemergence of societal or perpetrators of the genocide, have received in- dynamics that had enabled the genocide. creasing attention in recent years. Recent studies While several organizations and government have shown that the offspring of survivors have entities contribute to different aspects of prisoner a nearly threefold higher risk of PTSD compared care and community reintegration, some notable to the general population (16.5% prevalence versus approaches deserve special mention. Prison Fel- 6.2%), suggesting the presence of mechanisms that lowship Rwanda (PFR), a local nongovernmental contribute to the intergenerational transmission organization that is affiliated with Prison Fellow- of trauma.48 Such findings are contributing to ship International, is implementing a broad-based deliberations on how to mitigate the risk for in- multidimensional approach to the reintegration of tergenerational transmission of trauma and other former genocide perpetrators. The PFR approach mental health problems, but also on ensuring that includes, among others, psychosocial support and intergroup tensions and pre-genocide conflict dy- behavioral activation while perpetrators are still namics do not reemerge in the next generation.49 incarcerated; motivational interviewing to assess The developmental challenges experienced readiness to engage in a reconciliation process; by descendants of survivors and of perpetrators coaching through the process of experiencing are distinct but equally significant. Children born remorse for the genocide and seeking forgiveness to survivors are likely to have been raised in an from survivors; civic education to orient perpe- environment where the extended family network trators into the new post-genocide sociopolitical had been devastated by the genocide, with few realities of Rwanda; the acquisition of vocational or no mentally healthy adults to support their skills; family reintegration; and the socioeconomic development, regular exposure to memories or integration of released prisoners through participa- commemorations of the genocide, and fears of tion in collaborative livelihood initiatives.46 Dignity renewed persecution. In contrast, children born in Detention Rwanda (DIDE), also a local nongov- to perpetrators were often raised under conditions ernmental organization, has a similar approach to where one or both parents were incarcerated. On PFR but with a more specific emphasis on the needs many occasions, children grow up with the false of detained women and youth. DIDE programs belief that their parent’s case was one of unjust include the distribution of food, access to health imprisonment, contributing to sentiments of anger services and education, skills development, human and bitterness against society.50 rights advocacy, and cooperatives aimed to help Interventions to support children of survivors families of detainees become economically active.47 and children of perpetrators are multifaceted, While the initiatives of PFR and DIDE for prisoner though not yet commensurate to the challenge at

JUNE 2021 VOLUME 23 NUMBER 1 Health and Human Rights Journal 113 a. lordos, m. Ioannou, e. rutembesa, s. christoforou, e.anastasiou, and t. björgvinsson / public and mental health, human rights, and atrocity prevention, 105-118 hand. Some approaches include the establishment main challenges to a cohesive public health frame- of youth clubs, where principles for peaceful living work for multisystemic recovery and resilience are taught while youth from all backgrounds can revolve around standardization and coordination, develop bonds of friendship and solidarity; individ- both of which are essential prerequisites for scaled- ual and group psychotherapy, where young people up and sustainable service delivery. Ultimately, can process traumatic memories while developing the unspoken objective of such scaling efforts is more secure identities; vocational counseling and genocide prevention. Just like the 1994 genocide guidance, to support genocide-affected youth in struck at the heart of every community of Rwanda, making responsible life choices; intergenerational destroying lives, livelihoods, and the social fabric, dialogue, to heal the rift that is often experienced so must the recovery effort achieve equivalent scale, between post-genocide youth and their survivor or so that every community and household in the perpetrator parents; entrepreneurship programs, country can have the opportunity to heal from the to encourage youth from all backgrounds to form multidimensional impact of the genocide. Achiev- enduring friendships and partnerships; and parent ing impact at scale is an essential prerequisite for training programs, focused on vulnerable popu- an intervention to be considered rights based: in lations affected by the genocide.51 While this is an the absence of scalability and access by all, thera- impressive array of tools to support youth adaptation peutic interventions can inadvertently reinforce in post-genocide Rwanda, the greatest challenge is preexisting patterns of inequity by leaving the most that most have not yet been systematized or tested vulnerable behind.52 Furthermore, a multisystemic for effectiveness, nor are they provided at a scale approach to societal healing that simultaneously that is adequate to address population needs. targets the protection of the rights to mental health, development through economic collaboration, and Toward a scalable public health framework security through reconciliation is more likely to for mental health, social cohesion, and achieve sustainable social change for all segments sustainable livelihoods in Rwanda of the population. After contrasting the current state of affairs in The review of existing initiatives for multisystemic Rwanda against its aspirations for societal healing recovery and resilience in post-genocide Rwanda, and socioeconomic growth, we propose the follow- outlined above, reveals a rich and dynamically ing theoretical principles for a rights-based public evolving tapestry of initiatives, which display a high health approach to societal healing: degree of complementarity and potential when it comes to developing a multisystemic, rights-based Principle 1: Standardize protocols and approach to mental health and societal healing. approaches across sectors and initiatives While recent and emerging developments within Currently, there appears to be a dearth of stan- the formal mental health sector can play an im- dardized protocols or approaches accepted as a portant role in addressing biomedical and other “gold standard” within the various subdomains of individual determinants of mental distress, the societal healing (for example, in sociotherapy or social determinants of mental distress can more prisoner reintegration). Without such agreed-on effectively be mitigated through community-based and standardized protocols, it is difficult to test the approaches, such as sociotherapy and collabora- effectiveness of interventions and therefore deter- tive livelihoods initiatives. At the moment, the mine what, precisely, should be scaled up within challenge for Rwanda is not a shortage of societal the context of a rights-based public health approach healing efforts but rather an unregulated plethora to societal healing. The standardization of proto- of highly diverse and multidimensional initiatives cols and approaches would require coordination by different actors at varying levels of sustainability between existing service providers and a willing- and scale. From a public health perspective, the ness to empirically validate current approaches,

114 JUNE 2021 VOLUME 23 NUMBER 1 Health and Human Rights Journal a. lordos, m. Ioannou, e. rutembesa, s. christoforou, e.anastasiou, and t. björgvinsson / public and mental health, human rights, and atrocity prevention, 105-118 such as through randomized trials with wait-list initiatives across different sectors and levels—from control groups. A key benefit of having standard- psychosocial support, sociotherapy, and livelihood ized approaches is that it would greatly simplify initiatives at the village level to clinical interventions professional training in ways that would eventually for mental health at the sector or district level. It is enable scaled-up service delivery. Sociotherapy essential to ensure effective coordination to max- could be an early target for standardization, given imize service complementarity while minimizing the extensive literature that has been developed overlap. A potentially effective formal mechanism around this approach over the past 20 years. This for coordination could be provided through the would require close collaboration between the existing decentralized health sector system. This several nongovernmental organizations that are includes health centers at the sector level (typically implementing different variants of sociotherapy, staffed by psychologists and nurses), health posts at so that they can agree on a consensus approach or, the cell level, and community-based psychosocial at the very least, make explicit the divergences and workers at the village level. While this network is similarities between alternative approaches. part of the formal health sector, it can also serve as a coordination hub for additional societal healing Principle 2: Blend local innovations with efforts provided by the nongovernmental or private emerging international practices sector. The scope and intensity of local innovation for soci- etal healing in Rwanda over the past two decades is Principle 4: Develop standardized screening, remarkable. Much of this innovation, for instance assessment, and referral systems to prescriptively in the mental health sector, has occurred through allocate beneficiaries to matching interventions the filtering of international practices through the Given the multisystemic nature of recovery and lens of Rwanda’s social and cultural context. In resilience efforts in Rwanda, appropriately allocat- other efforts, such as the development of sociother- ing beneficiaries to the interventions they can most apy and of collaborative livelihood initiatives for benefit from (for example, sociotherapy, a clinical social cohesion, innovation was inspired by Rwan- mental health group that focuses on skills and dan community-based culture, with international resilience, a family-based intervention, or a collab- tools brought in to provide more cogent expression orative livelihood initiative) is a challenge that must to Rwandan home-grown solutions. This confident be carefully considered and addressed. The estab- blending of what is most valuable from Rwanda’s lishment of appropriate assessment-to-allocation culture with what is most beneficial from relevant systems would help ensure that scarce human and international practices can and should continue. financial resources are optimally allocated in ways Specific directions for future blending include that maximize overall impact. Through appropri- learning from international group-based mental ate community mapping and screening methods, it health treatment approaches to strengthen the may be possible to determine what mix of services Rwandan mental health sector in culturally appro- should be made available in any specific commu- priate ways, as well as learning from international nity and which community members should be practices in community-based entrepreneurship to invited to participate in each program. strengthen the effectiveness and strategic relevance of collaborative livelihood initiatives in Rwanda. Principle 5: Establish a sustainable funding system to enable decentralized multisectoral Principle 3: Strengthen the coordination of service delivery for societal healing service delivery, particularly at the level of Financial resources for societal healing in Rwanda sectors and local communities are currently provided through a patchwork of As has been noted throughout this study, societal funding streams, from government funds that are healing in Rwanda’s case requires services and disbursed through the annual government budget

JUNE 2021 VOLUME 23 NUMBER 1 Health and Human Rights Journal 115 a. lordos, m. Ioannou, e. rutembesa, s. christoforou, e.anastasiou, and t. björgvinsson / public and mental health, human rights, and atrocity prevention, 105-118 to international grants provided directly to non- serious consideration in any country emerging governmental organizations, to services that are from violent conflict or genocide. self-funded by individual and institutional benefi- ciaries. While this is not necessarily problematic, it Acknowledgments can be an obstacle to sustainability and scaled-up delivery. As protocols, assessment systems, and co- This study would not have been possible without ordination systems become standardized, it might the engagement and participation of numerous become feasible to offer a more comprehensive colleagues, with whom we have been collaborating range of societal healing services under a national to advance the cause of societal healing in Rwanda. insurance framework. Within such a framework, Most notably, we would like to thank Interpeace, funding could be available so that beneficiaries and the International Organization for Peacebuild- providers can engage with one another regardless of ing, for its contributions in establishing the space whether providers originate in the public, private, where investigation of societal healing approaches or nongovernmental sectors. This would further in Rwanda could occur. Furthermore, thanks are ensure the provision of rights-based mental health due to several national stakeholders—policymak- care, an integral aspect of health care for all. ers and practitioners—whose passion and insights about Rwanda have inspired us and added depth to this manuscript. Conclusion This paper outlines several notable innovations Disclaimer that have emerged in Rwanda through its efforts for recovery and resilience in the aftermath of the All views, thoughts, and opinions expressed in this genocide against the Tutsi. At the current juncture, article belong solely to the authors and cannot be moving toward a public health framework for ad- ascribed to our academic institutions, Interpeace, dressing mental health and societal healing could or any of the stakeholders who were consulted in be the soundest approach to systematize, consoli- Rwanda. date, and scale existing gains. Such a public health approach would require extensive collaboration Funding between formal government and nongovernmental service providers, as well as a creative synthesis We gratefully acknowledge the support of Inter- between local innovations and emerging interna- peace, which covered the costs of our field missions tional practices. The effort should be scholarly and to Rwanda in the context of a broader effort to evidence driven, diligently reflecting on theories establish the Bugesera Societal Healing Initiative. and mechanisms of change, but at the same time pragmatic. References While Rwanda’s challenges have been extreme 1. M. Denov, L. Woolner, J. P. Bahati, et al., “The intergenera- in their intensity, the multidimensional impact of tional legacy of genocidal rape: The realities and perspectives violent conflict and genocide on mental health, of children born of the ,” Journal of Inter- social cohesion, and sustainable livelihoods is, personal Violence 35/18 (2020), pp. 3286–3307. unfortunately, a widespread global phenomenon. 2. C. Umulisa, “We are also mothers: Rwandan women with From this perspective, several countries can learn children born of genocide,” in A. Sgoutas and T. Takseva (eds), Mothers under fire: Mothering in conflict areas (Brad- from Rwanda’s decades-long effort toward mul- ford: Demeter Press, 2015), pp. 137–154. tisystemic recovery and resilience. Adopting a 3. Republic of Rwanda, National Commission for the Fight multisectoral rights-based public health approach against Genocide. Available at https://cnlg.gov.rw/index. for societal healing is a prospect that should merit php?id=127.

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