Rwanda, how are you with pain?

Over the past few years, I’ve seen a rising number of reports praising the great rebirth of Rwanda – its technological progress, empowerment of women, fight against corruption, improved hygiene, not to mention its management of the coronavirus pandemic. I left the country in 1994 and visit only sporadically, so for me it is the satisfying image of a land that has effectively, courageously and efficiently rebuilt itself.

As both a writer and survivor of the genocide against the Tutsis, what interests me, however, is not so much the reconstruction of the country, but the heart of its inhabitants. That is not to say that I am not pleased by one, but rather that the other compels me more.

How can a society recover from a catastrophe of this magnitude? What traces are left in the minds of its inhabitants, remnants of the inconceivable violence that one group of Rwandans enacted on another?

In Rwanda there were 300,000 survivors, 700,000 killers and just one psychiatrist

It is estimated that one million people were killed. Yet they weren’t killed from a distance – with a rifle, or some kind of chemical or industrial weapon. The vast majority were slashed, decapitated, stabbed with blades, machetes or knives, or bludgeoned. It wasn’t carried out quickly, so that the victim would find peace. The attackers weren’t strangers. No. The murderers were almost always neighbours, friends, sometimes even relatives by marriage. They demonstrated a macabre skill for torture, humiliation and dehumanisation.

Then there were gang rapes, deliberate contaminations of living victims with HIV and Aids, and the insertion of stakes, bottle shards and other objects into women’s vaginas. It is estimated that there were 250,000 victims of these rapes.

That’s it. That’s how it happened. In the space of just three months, in broad daylight, practically live on televisions around the world, in such close proximity that the term “neighbourhood genocide” becomes terribly accurate.

You could tell me that this all took place 30 years ago, that the country has rebuilt itself since then. It’s all in the past. But the genocide also created mental health problems that affect thousands of people to this day.

In the aftermath of the genocide, it was estimated that there were around 300,000 Tutsi survivors, and more than twice as many Hutu génocidaires.

They needed to rebuild a nation, find a way for all these people to live side by side, build a country on the rubble of a depraved kind of humanity.

There were 300,000 survivors, 700,000 killers and one psychiatrist for the whole country. You read that correctly. One psychiatrist.

Each time I think of these figures, of this impossible equation that my little country had to solve, I am astounded. How, just how were they able to rebuild the country, revive it from the ashes under the watchful eyes of the world, which had condemned it to remain in tatters?

It remains a mystery to me. Of course, there was guilt-filled support from the famous “international community” which had allowed the unimaginable to happen, and there was the judicial invention of the gacaca tribunals in Rwanda, a resurrection of a pre-colonial practice, adapted to the monstrous challenges of the new world. There was undoubtedly something that I don’t quite know how to explain, which stems from Rwandan culture and its inherent great restraint, both in terms of joy and pain, a phenomenon that would no doubt benefit from being explored by sociologists. Above all, there was the incredible dedication of Naasson Munyandamutsa, the sole psychiatrist, who returned to Rwanda from Switzerland, where he had been training at the time of the genocide. Right up until his death in 2016, he put all his energy into offering care in the country, training general practitioners and nurses, as well as a dozen psychotherapists. It wasn’t until 2014 that a second psychiatrist joined him. Now, there are 13 of them, treating a population of almost 13 million. That equates to 0.17 psychiatrists per 100,000 inhabitants. In comparison, France has 23 psychiatrists for every 100,000 inhabitants. The World Health Organisation estimates that globally there is an average of nine mental health professionals for every 100,000 inhabitants. This figure falls to 1.4 in the African continent.

To paraphrase the title of a Raymond Depardon film, when I’m asked to speak about the genocide, I will often reformulate the question in this way: Rwanda, How Are You With Pain? Two studies were carried out, around 10 years apart, which allow us to answer as honestly as possible: not very well.

In 2009, a national inquiry led by the minister of health revealed that almost 99 per cent of survivors had witnessed scenes of violence, and that 31 per cent of women were raped or sexually assaulted.

From this inquiry, we also learnt that almost 7.5 per cent of young people between the ages of 14 and 35 suffered from alcohol dependency.

More recently, the 2018 Rwanda Mental Health Survey revealed the flagrant discrepancy in mental illness between the general population and those who survived the genocide against the Tutsi. If the prevalence of depressive episodes concerns almost 12 per cent of Rwandans in general, this figure is almost three times higher in survivors of the genocide who continue to suffer. Some 28 per cent of these same survivors will suffer from PTSD, compared to just 3 per cent of the general population. More than a quarter of survivors are also likely to suffer from panic attacks and, in many cases, there is a likelihood of co-morbidity. The study also showed that only 14 per cent of those showing signs of mental illness have been offered care.

That’s the picture. The country may well have been rebuilt but, as one of the characters says in my novel All Your Children, Scattered, “hearts cannot be repaired the way a roof can, or a road, or a city razed to the ground”.

It is a long and torturous journey. Evil is so ingrained, that it will outlive all other kinds of destruction. It is likely to pass from generation to generation.

Last year, researchers in epigenetics also published the first ever study highlighting that the trauma of the genocide has chemically modified the DNA of female Tutsi survivors, and of the children that they carried during the genocide. A genocide doesn’t end when the murders stop. As the ancient Rwandan proverb says: “agahinda ntikica kagira mubi” – grief doesn’t kill, it destroys.

To rebuild the heart of the country, “gusana intima”, there needs to be a large investment in mental health services. During colonial times, people suffering from psychological problems were cared for by traditional healers, as was the case in many societies. But the widespread Christianisation of the country banned this, leaving a decades-long void of care and sense, before the first psychiatric hospital was built in the country: the Caraes Ndera Hospital near to Kigali which is, itself, managed by Catholic clergymen.

In the aftermath of the genocide, it was the sole existing structure in the territory that specialised in mental health. Then in 1999, a service offering psychosocial consultation was created to provide outpatient care. The first ten years of operation saw the number of consultations multiply sixfold. At the same time, decentralised services were put in place across the whole country.

One of the main challenges was the lack of staff trained and qualified in handling problems associated with mental health. Efforts were made to train psychologists, nurses and community therapists. The National University of Rwanda created a psychology department, and a mental health department was established at the Kigali Health Institute. Many NGOs proposed short courses specialising in mental health. Today, each district hospital must offer a mental health service with an assigned nurse.

But so much remains to be done.

There is not a single centre specifically dedicated to addiction in the country. Nor is there a service offering child or youth psychiatric care.

I say this with full knowledge of the facts. I am a survivor, who had an enormous amount of luck. In the aftermath of the genocide, at just 15 years old, I was welcomed into France by a foster family who immediately took me to see a psychiatrist. And for the last 30 years, I have been able to benefit from the formidable system of care that is offered in France, which has allowed me to rebuild myself, and reflect on what happened in my past.

Without this, I never would have become a fiction writer, I never would have dedicated myself to poetry, nor would I have been able to overcome my own personal history in order to find the words of solace that are capable of making Rwandan fates universal.

Today I am a mental health first aid trainer in Bordeaux, and more than ever I can see the importance of fixing the broken heart of humanity. For our children, and for the future.

All Your Children, Scattered by Beata Umubyeyi Mairesse is published by Europa

Photo: skulls at a genocide memorial church in Rwanda, commemorating the genocide in 1994 (Shutterstock)