Pham PN, Weinstein HM, Longman T. Trauma and PTSD Symptoms in RwandaImplications for Attitudes Toward Justice and Reconciliation. JAMA. 2004;292(5):602-612. doi:10.1001/jama.292.5.602
Author Affiliations: Payson Center for International Development and Technology Transfer, Tulane University, New Orleans, La (Dr Pham); Human Rights Center (Drs Pham, Weinstein, and Longman) and School of Public Health (Dr Weinstein), University of California, Berkeley; and Political Science and Africana Studies, Vassar College, Poughkeepsie, NY (Dr Longman).
Context The 1994 genocide in Rwanda led to the loss of at least 10% of the country's
7.7 million inhabitants, the destruction of much of the country's infrastructure,
and the displacement of nearly 4 million people. In seeking to rebuild societies
such as Rwanda, it is important to understand how traumatic experience may
shape the ability of individuals and groups to respond to judicial and other
Objectives To assess the level of trauma exposure and the prevalence of posttraumatic
stress disorder (PTSD) symptoms and their predictors among Rwandans and to
determine how trauma exposure and PTSD symptoms are associated with Rwandans'
attitudes toward justice and reconciliation.
Design, Setting, and Participants Multistage, stratified cluster random survey of 2091 eligible adults
in selected households in 4 communes in Rwanda in February 2002.
Main Outcome Measures Rates of exposure to trauma and symptom criteria for PTSD using the
PTSD Checklist–Civilian Version; attitudes toward judicial responses
(Rwandan national and gacaca local trials and International Criminal Tribunal
for Rwanda [ICTR]) and reconciliation (belief in community, nonviolence, social
justice, and interdependence with other ethnic groups).
Results Of 2074 respondents with data on exposure to trauma, 1563 (75.4%) were
forced to flee their homes, 1526 (73.0%) had a close member of their family
killed, and 1472 (70.9%) had property destroyed or lost. Among the 2091 total
participants, 518 (24.8%) met symptom criteria for PTSD. The adjusted odds
ratio (OR) of meeting PTSD symptom criteria for each additional traumatic
event was 1.43 (95% CI, 1.33-1.55). More respondents supported the local judicial
responses (90.8% supported gacaca trials and 67.8% the Rwanda national trials)
than the ICTR (42.1% in support). Respondents who met PTSD symptom criteria
were less likely to have positive attitudes toward the Rwandan national trials
(OR, 0.77; 95% CI, 0.61-0.98), belief in community (OR, 0.76; 95% CI, 0.60-0.97),
and interdependence with other ethnic groups (OR, 0.71; 95% CI, 0.56-0.90).
Respondents with exposure to multiple trauma events were more likely to have
positive attitudes toward the ICTR (OR, 1.10; 95% CI, 1.04-1.17) and less
likely to support the Rwandan national trials (OR, 0.90; 95% CI, 0.84-0.96),
the local gacaca trials (OR, 0.80; 95% CI, 0.72-0.89), and 3 factors of openness
to reconciliation: belief in nonviolence (OR, 0.92; 95% CI, 0.87-0.97), belief
in community (OR, 0.92; 95% CI, 0.87-0.98), and interdependence with other
ethnic groups (OR, 0.86; 95% CI, 0.81-0.92). Other variables that were associated
with attitudes toward judicial processes and openness to reconciliation were
educational level, ethnicity, perception of change in poverty level and access
to security compared with 1994, and ethnic distance.
Conclusions This study demonstrates that traumatic exposure, PTSD symptoms, and
other factors are associated with attitudes toward justice and reconciliation.
Societal interventions following mass violence should consider the effects
of trauma if reconciliation is to be realized.
From April to mid July 1994, an unprecedented wave of organized violence
swept across the small East African state of Rwanda. By the time the violence
ended in mid July, estimates indicated as many as a million people were dead,
victims of genocide, war, and reprisal attacks.1- 3 The
impact of these horrific events included not only the loss of at least 10%
of the country's 7.7 million inhabitants but the destruction of much of the
country's infrastructure and the displacement of nearly 4 million people,
including 2 million who fled into exile in neighboring countries. Survivors
were exposed to scenes of unmitigated violence, masses of dead bodies, and
the breakdown of any semblance of civility.1,2
The principal response by diplomats and the human rights community to
prevent future violence and promote reconciliation in postconflict societies
has been to hold perpetrators accountable by establishing legal mechanisms
to try those accused of human rights violations.4 In
November 1994, the International Criminal Tribunal for Rwanda (ICTR) was charged
with trying the organizers of the 1994 genocide. The majority of those accused
of participation in the Rwandan genocide, however, will be tried by national
courts. Yet the classical judicial system is incapable of handling the more
than 100 000 alleged perpetrators of genocidal crimes who have been imprisoned
in Rwanda. As a result, Rwanda has implemented a new judicial program, gacaca, that builds on a traditional local dispute mechanism.
Gacaca trials, conducted by popularly elected committees of lay judges, have
been organized throughout the country to try those accused of less serious
crimes in open community trials, reserving more serious crimes for classical
courts. Organizers have claimed that all 3 of these judicial responses contribute
to reconciliation in Rwanda. However, whether any forms of justice contribute
to the process of reconciliation is not known, and if they do, for whom and
under what circumstances. Reconciliation is a complex process that entails
difficult tasks such as the reforging of societal linkages and the rebuilding
of communities. Whether judicial responses are capable of contributing substantially
to this process has not been empirically tested.
The purpose of this study was to examine attitudes toward the contribution
of judicial processes and reconciliation and to explore how exposure to traumatic
events, symptoms consistent with posttraumatic stress disorder (PTSD), and
other factors may affect these attitudes in 4 communes of Rwanda.
During February 2002, almost 8 years after the genocide, a team of 26
trained members carried out interviews with a standardized questionnaire in
4 communes, the local political unit at the time of the genocide. In 1994,
Rwanda was divided into 11 prefectures, and each prefecture was divided into
communes, for a total of 154 communes in the country. The communes were themselves
divided into sectors and the sectors into cells. The 4 communes, Ngoma (known
as Butare town), Mabanza, Buyoga, and Mutura, were selected to represent Rwanda's
diversity in terms of region, level of urbanization, experience with the genocide,
and relationship to the ICTR, as illustrated in Figure 1. These communities were all exposed to genocidal activity
and/or retaliation in the war with varying degrees of exposure to and/or protection
from the resulting violence and trauma. Ethnicity was a significant issue
in Rwanda and, before the genocide, all individuals were required to carry
an ethnic identity card. We randomly selected participants without knowing
their ethnicity and asked them to provide us with their ethnic identity at
the very end of the interview. The interviewer did not read the list of possible
responses. We first asked the respondent, "Are you comfortable discussing
your ethnic identity?" then, "If yes, what is your ethnicity?"
Study participants within each of the 4 communes were selected through
a multistage cluster sampling method (Figure
2). Using proportionate probability sampling, 5 sectors from each
of the 4 communes and half of the cells (the lowest administrative unit level
in Rwanda equivalent to a neighborhood) were selected. From these cells, at
least 500 households per commune were randomly selected. In each selected
household, we interviewed 1 adult (≥18 years old) chosen by the name closest
to the beginning of the alphabet.
Because of the high population illiteracy rate, we obtained consent
orally with a standardized format. The Committee for the Protection of Human
Subjects at the University of California, Berkeley, the National University
of Rwanda, and Rwandan local government officials approved the research protocol.
No incentive was provided to survey participants.
Sample size was determined using the difference in proportion formula
and was adjusted for stratification and design effect due to cluster sampling.
The assumed level of precision was 10%, with 80% power.
The questionnaire consisted of 9 sections that included scales measuring
current symptoms of PTSD; attitudes toward reconciliation, the ICTR, Rwandan
national trials, and gacaca; and questions on demographic factors and exposure
to traumatic events. Given the centrality of ethnicity to the conflict in
Rwanda, we also included 7 questions about situations in which individuals
were comfortable with members of another ethnic group. The summed responses
formed an "ethnic distance" scale (α = .94).
Given the nationwide nature of the genocide and war and the density
of the population, we made the assumption that all who were in Rwanda in 1994
had some exposure to horrific events and were at risk of developing symptoms
of PTSD. To assess exposure to specific traumatic events, we asked respondents
to answer the question, "Did you experience the following during the events
of 1994 or their aftermath?" We assessed 7 traumatic events: property destroyed
or lost, being forced to flee, serious illness, a close family member killed,
a close family member died from illness, sexual violence, and physical injury.
These were summed for each individual and were used as an indicator of cumulative
traumatic exposure. The list of traumatic events emerged from about 100 individual
interviews and focus groups conducted among an additional 104 genocide survivors,
women, youth, and older adults in Rwanda. These traumatic events do not represent
all the possible traumatic events but those that were reported frequently.
They were included on the survey instrument that was pilot-tested among individuals
residing in one of the nonselected cells prior to carrying out the survey.
Illnesses were described that respondents related to the events of the genocide,
as well as loss of family members due to illness that could not be treated
during the genocide.
To assess symptoms of PTSD, we used the PTSD Checklist–Civilian
Version (PCL-C), a self-reported 17-item instrument corresponding to the symptoms
associated with the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition diagnostic criteria for PTSD. The
PCL-C has been correlated with the Clinician-Administered PTSD Scale (CAPS)
and uses simple language that eases the process of translation and administration
by nonclinicians to a population with low education. We used an overall cutoff
score of 44 for meeting symptom criteria of PTSD and an item score of 3 for
each symptom criterion, based on recommendations from tests of psychometric
properties.5,6 The checklist specifically
asked about current symptoms of stress during the past month.
We defined reconciliation as the processes whereby individuals, social
groups, and institutions (1) develop a shared vision and sense of collective
future ("community"); (2) establish mutual ties and obligations across lines
of social demarcation and ethnic groups ("interdependence"); (3) come to accept
and actively promote individual rights, rule of law, tolerance of social diversity,
and equality of opportunity ("social justice"); and (4) adopt nonviolent alternatives
to conflict management ("nonviolence"). We developed a 29-question scale about
these components of the reconciliation process and entered the responses into
a principal component analysis, which confirmed the 4 factors. The 4 factors
comprised 14 of 29 items that accounted for 58% of the total variance. The
estimated Cronbach α (a measure of internal reliability) for the 4 factors
was: community, α = .69; interdependence, α = .46; social justice, α
= .75; and violence, α = .88. For each of the 4 factors, we obtained
a total score and dichotomized each sample into 2 categories using the median
score. Dichotomizing the factors allowed us to obtain odds ratios (ORs), making
interpretation and communication of a complex concept easier without losing
Similarly, we developed a scale for attitudes toward the 3 judicial
processes, the ICTR, Rwandan national trials, and gacaca trials. The survey
included 10 statements about the ICTR, its policies, and its functioning;
attitudes toward the Rwandan national courts (4 statements); and gacaca (4
statements), to which respondents were asked to express whether they strongly
agreed, agreed, were uncertain, disagreed, strongly disagreed, or were not
informed. Through principal component analysis, we confirmed that there were
3 factors comprising 9 items that accounted for 63% of the total variance:
attitudes toward the ICTR (α = .82), attitudes toward the Rwandan national
trials (α = .61), and attitudes toward gacaca (α = .51). We then
dichotomized the scales on the 3 factors into categorical variables (positive
and negative attitudes) by using the median score.
Prior to the launch of the survey, the survey instrument was piloted
first among local experts, then among randomly selected individuals, and finally
among a random sample of approximately 100 participants from a nonstudy site.
Means and proportional 95% confidence intervals (CIs) were calculated
by Epi Info C-Sample Analysis, version 6.0 (Centers for Disease Control and
Prevention, Atlanta, Ga), which adjusts for design effect. Sampling was conducted
proportionate to population size; hence, no weighting was performed. We imputed
the middle score of all missing data for the questions on the 2 scales measuring
attitudes toward reconciliation and judicial responses. Overall, a range of
15 to 28 responses was missing on each of the items on the 2 scales. We explored
the relationship between symptoms of PTSD and their potential predictors and
confounding variables in 2 stages. At the univariate stage, we analyzed the
following possible predictor variables of PTSD symptoms: sex, marital status,
religion, education, age, ethnicity, physical presence in Rwanda during 1994,
frequency of traumatic experience, and ethnic distance. We then performed
stepwise multivariate logistic regression to obtain ORs, 95% CIs, and P values for each significant risk factor.
To examine the relationship between exposure to specific traumatic events,
symptoms of PTSD, and attitudes toward the judicial responses and openness
to reconciliation, we ran 7 separate multivariate stepwise logistic regression
analyses with the 3 factors of the judicial response scale (ICTR, Rwandan
trials, and gacaca) and the 4 factors of openness to reconciliation scale
(interdependence, community, social justice, and violence) as dependent variables.
For all 7 models, the independent variables were sex, age, education, physical
presence in Rwanda during 1994, cumulative traumatic exposure, ethnicity,
ethnic distance, economic frustration, defined as the perception of current
poverty level compared with 1994 (ie, improved, same, or worse) and belief
that poverty was the root problem of the 1994 genocide (based on a 5-point
Likert scale; 1 = strongly agree and 5 = strongly disagree), perception of
current access to security compared with before 1994 (improved, same, or worse),
and symptoms of PTSD. We also added attitudes toward the 3 judicial responses
as the independent variables for the 4 models using the openness to reconciliation
scales as the dependent variables. The 2 predictors of most interest were
PTSD symptoms, as measured by the PCL-C, and the number of traumatic events
to which respondents were exposed. We used a Bonferroni-adjusted level of
significance of .007 to adjust for the multiple analyses.
We interviewed a minimum of 500 individuals in each commune for a total
of 2091 interviews (544 in Ngoma; 508 in Mabanza; 534 in Buyoga; and 505 in
Mutura). We replaced 23 (1%) selected households with the next qualifying
household after 2 failed attempts to reach an eligible participant. We were
unable to interview 14 selected individuals (<1%) because of unavailability
or refusal to participate and, hence, selected the next eligible household
member (Figure 2).
There were statistically significant differences among the 4 stratified
communes in all sociodemographic variables as well as in attitudinal, traumatic
exposure, and PTSD symptom variables (P<.001 for
all). For this reason, we present the results as stratified during our first
stage of sampling (Table 1). Approximately
half (51.5%) of participants were female. The age distribution ranged from
18 to 94 years, with an overall mean of 36.4 years. A high percentage (89.2%)
of respondents were willing to provide their ethnic identity. Ngoma had the
highest percentage of respondents who refused to reveal their ethnicity, and
it was the only commune where there was a higher percentage of Tutsi than
Hutu. Of those who specified their ethnicity, 70.3% were Hutu, 26.0% were
Tutsi, and 3.4% identified themselves as being of another ethnicity (generally
Twa or immigrants).
More than one quarter (26.7%) of respondents had never attended school,
56.2% had at least some primary education, 15.4% had at least some secondary
education, and fewer than 2% had any university education. Ngoma, where the
National University of Rwanda is located, had a higher percentage of respondents
with some level of university education and was the only commune selected
where there were respondents who had completed university education.
Prior to the events of 1994, 10.7% of respondents lived outside Rwanda,
primarily as refugees, while 72.8% of respondents reported to have been displaced
during 1994 (Table 1). In Ngoma,
6.8% and 10.1% of the respondents previously resided in the 2 closest neighboring
countries, Burundi and the Democratic Republic of Congo (then called Zaire).
In Mutura, 21.6% of the respondents were in the Democratic Republic of Congo
before 1994. Mabanza, which was under French control immediately after the
Rwandan Patriotic Front rise to power, had the lowest percentage of respondents
who were displaced during 1994 (37.6% compared with 80%-90% in the other 3
Of 2074 respondents with data on exposure to trauma, 1563 (75.4%) were
forced to flee their homes, 1526 (73.0%) had a close member of their family
killed, and 1473 (70.9%) had property destroyed or lost (Table 2). The level of traumatic exposure was significantly different
across the 4 communes (P<.001). In Ngoma and Mutura,
more than 80% of the respondents had at least 1 close family member killed
during the events of 1994 and their aftermath. Ngoma had the highest percentage
of respondents (23.9%) who reported that they or a close family member had
experienced sexual violence. The highest percentage of family members killed
was among siblings, ranging from 49.6% to 77.0%, followed by cousins, ranging
from 42.1% to 62.5% (Table 2).
Within the 4 communes sampled, 2091 participants responded to all items
on the PCL-C. Of these, 518 (24.8%) met symptom criteria for PTSD (Table 2). The prevalence of PTSD symptoms
varied from 12.2% in Buyoga to 33.8% in Ngoma and was statistically different
across the communes (P<.001). In addition, the
prevalence of PTSD symptoms was higher in women than men. More than half of
the sample (56.8%) had 1 or more of the 5 reexperiencing symptoms, 43.2% had
3 or more of the avoidance/numbing symptoms, and 25.7% had 2 or more of the
Of the 518 respondents who met PTSD symptom criteria, complete data
on all trauma items were available for 475. Of these, 11 reported no exposure
to the 7 listed trauma events; however, all were in Rwanda during the genocide
in 1994 (Table 3). Thus, they
may have had other exposures that were not assessed in this survey, such as
witnessing an atrocity committed against nonfamily members. Among those in
the sample who met PTSD symptom criteria and had complete data, 92.8% were
in Rwanda at the time of the genocide; 34 (7.2%) were outside of Rwanda in
1994. Of those with PTSD symptoms who were outside of the country, all reported
at least 1 exposure to 1 or more of the listed traumatic events (Table 3). Those with PTSD symptoms who
were outside of Rwanda at the time of the genocide were primarily refugees
living in the Democratic Republic of Congo (n = 20; 58.5%) or Burundi (n =
10; 29.3%), where extensive ethnic violence also occurred in the early 1990s.
At the univariate level, we found several factors to be statistically
associated with symptoms of PTSD (sex, age, marital status, religion, ethnicity,
presence in Rwanda in 1994, commune of residence, ethnic distance, and cumulative
traumatic exposure). At the multivariate level, the statistically significant
predictors of PTSD symptoms can be grouped into 4 major categories: sociodemographic
characteristics (age and sex), cumulative traumatic exposure, proximity to
conflict (in Rwanda in 1994 and commune of residence), and ethnicity and ethnic
distance. Table 4 lists the adjusted
ORs for all significant variables, adjusted for the effects of the other significant
predictors in the model. The adjusted OR of having PTSD symptoms for a 1-event
difference comparison was 1.43 (95% CI, 1.33-1.55), with similar increments
for each additional event. The more the individual was exposed to these traumatic
events, the greater the likelihood of reporting PTSD symptoms. Women were
more likely to have symptoms of PTSD than men (OR, 1.43; 95% CI, 1.19-1.90).
The OR for a 10-year increase in age was 1.19 (95% CI, 1.10-1.29). Those who
were in Rwanda before 1994 were more likely to have PTSD symptoms than those
who were not (OR, 3.10; 95% CI, 1.95-4.94). Also, those who described themselves
as Tutsi were more likely to meet symptom criteria for PTSD than those self-identified
as Hutu (OR, 2.02; 95% CI, 1.49-2.75). The OR for each increment of the ethnic
distance scale was 1.17 (95% CI, 1.05-1.29).
Table 2 shows the attitudes
of the respondents toward the 3 judicial responses. More respondents were
positive toward the 2 Rwandan-based judicial systems (90.8% supported the
gacaca trials and 67.8% supported the Rwanda national trials) than the ICTR
(which had support from 42.1%). With respect to openness to reconciliation,
64.7% reported their ability to be interdependent with the other ethnic group,
63.6% of the respondents supported the process of achieving social justice,
48.2% supported the idea of community, and 44.6% opposed the use of violence
for conflict management. About 1.9% of respondents were not open to reconciliation
on any of the 4 factors, 15.3% supported 1 factor, 38.4% supported 2 factors,
34.0% supported 3 factors, and 10.3% supported all 4 factors of reconciliation.
As illustrated in Table 5 and Table 6, after controlling for other significant
variables, respondents who met the symptom criteria for PTSD were less likely
to have positive attitudes toward the Rwandan national trials (OR, 0.77; 95%
CI, 0.61-0.98) and were less likely to believe in community (OR, 0.76; 95%
CI, 0.60-0.97) and less likely to support interdependence (OR, 0.71; 95% CI,
0.56-0.90) than those who did not meet the PTSD symptom criteria.
As Table 5 illustrates,
after controlling for other significant variables, cumulative traumatic exposure
was associated with positive attitudes toward the ICTR (OR, 1.10; 95% CI,
1.04-1.17) and negative attitudes toward Rwandan national trials (OR, 0.90;
95% CI, 0.84-0.96) and gacaca (OR, 0.80; 95% CI, 0.72-0.89). Cumulative trauma
exposure was also associated with negative attitudes toward nonviolence (OR,
0.92; 95% CI, 0.87-0.98), community (OR, 0.92; 95% CI, 0.87-0.97), and interdependence
(OR, 0.86; 95% CI, 0.81-0.92) (Table 6).
Other variables that were associated with attitudes toward judicial
processes and openness to reconciliation were education level, ethnicity,
perception of change in poverty level and access to security compared with
1994, and ethnic distance (Table 5 and Table 6). As shown in Table 5 and Table 6,
a higher level of education was associated with less support for all 3 judicial
responses (ICTR [OR, 0.91; 95% CI, 0.84-0.98], Rwandan national trials [OR,
0.72; 95% CI, 0.66-0.79], and gacaca [OR, 0.82; 95% CI, 0.72-0.93]) and less
openness to reconciliation (interdependence [OR, 0.73; 95% CI, 0.68-0.80],
community [OR, 0.85; 95% CI, 0.78-0.92], and social justice [OR, 0.91; 95%
CI, 0.84-0.98]). Those with more education were less likely to have positive
attitudes toward any of the 3 judicial responses and less likely to support
community and interdependence. In addition, those who perceived that the economic
situation had improved since 1994 were more likely to support the Rwandan
national trials (OR, 2.21; 95% CI, 1.76-2.79) and the gacaca trials (OR, 1.95;
95% CI, 1.29-2.91) than those who perceived their economic situation to have
Among this sample of 2091 Rwandans surveyed 8 years after the 1994 genocide,
rates of cumulative traumatic exposure (94.1% reported having at least 1 traumatic
event) and prevalence of those meeting PTSD symptom criteria (24.8%) are consonant
with what we would expect to see for the country and representative of the
areas sampled. Furthermore, the number of traumatic events and the prevalence
of those meeting the PTSD symptom criteria were high, with some geographic
differences that reflect the level and type of exposure in various areas.
Symptom clusters raise questions as to how culture may play into the
experience or reporting of traumatic effects. According to Breslau,7 avoidance/numbing is the criterion that is critical
for the diagnosis of PTSD and is least frequently met. In our sample, 43.2%
of those meeting PTSD symptom criteria experienced at least 3 avoidance/numbing
symptoms. Rwandan culture discourages open displays of emotion, suggesting
that some of these symptoms may be mediated by cultural expectations. In addition,
our study suggests that mass violence likely has long-term psychological effects,
given that the genocide had occurred more than 8 years before.
Risk factors associated with symptoms of PTSD found in the study are
consistent with the literature. We found that all those with symptoms of PTSD
either were in the country during the genocide and/or had been exposed to
1 or more of the specific traumatic events assessed. Those who were in Rwanda
in 1994 were more likely to meet the PTSD symptom criteria. Not surprisingly,
a significant predictor of symptoms of PTSD was exposure to trauma. Several
studies have shown that the level and type of traumatic events are associated
with more symptoms of PTSD.8- 10 Also,
we found that after controlling for all other effects, the only significant
difference in PTSD among the communes sampled was in Buyoga, where the prevalence
was significantly less. Buyoga was the only commune where the genocide directly
occurred in only part of the commune.
Moreover, we found that personal factors (sex, age, ethnicity) were
also associated with PTSD symptom criteria. The relationship between female
sex and PTSD symptoms and older age and PTSD symptoms are consistent with
findings in Western populations.7,11 In
Rwanda, women were particularly targeted for violence, and there may be greater
vulnerability or less resilience in older populations.1(p215) With regard to ethnicity, the Tutsi, who were the targeted ethnic
group during the 1994 events, were more likely to report PTSD symptoms than
other ethnicities. In addition, ethnic distance was associated with symptoms
of PTSD, suggesting that the effects of traumatic exposure are perhaps associated
with fear of "the other."
An important finding was the significantly greater support for gacaca
trials compared with other judicial responses. There are 2 possible interrelated
explanations for this finding. People may have a more positive attitude toward
gacaca because they may feel more informed and involved with the process.
Social learning theorists such as Bandura12 have
proposed that self-efficacy is a critical dimension of well-being and behavior
change. When people feel as though they have more control of the outcome,
they are more likely to support the process. Since gacaca is community-based
and trials are held publicly within the community, people may be more involved
and committed. In another article, we note that a substantial portion of Rwandans
(87.2%) do not have enough information about the ICTR. We concluded that a
lack of reliable information is the key factor undermining the capacity of
the tribunal to contribute to reconciliation in Rwanda (T.L., P.N.P., and
H.M.W., unpublished data, February 2002).
There was more support for interdependence and social justice (Table 2). However, there was less support
for community and nonviolence. Interdependence was measured by such questions
as whether respondents had shared a drink with a member of another group or
attended a funeral. It may be that respondents are willing to develop relationships
at an individual level but that these relationships do not yet constitute
a shared sense of community.
As shown in Table 5 and Table 6, higher level of education was
associated with less support for trials and less openness to reconciliation.
This challenges the commonly held belief that education contributes to greater
understanding while ignorance contributes to conflict and division.13 A perception of improved economic conditions was
associated with positive attitudes toward Rwandan trials and gacaca and toward
support for community and opposition to violence. Also ethnicity was associated
with PTSD symptom criteria and attitudes toward the ICTR and social justice.
This suggests that ethnicity remains important in Rwanda and continues to
shape people's perceptions.
To our knowledge, this is the first study to examine associations between
exposure to trauma and symptoms of PTSD and attitudes toward justice and reconciliation.
Increased exposure to traumatic events was associated with less support for
gacaca, or desire to reconcile, as evidenced by a decreased support for interdependence.
After controlling for the effects of other significant variables such as exposure
to violence, we found that those with PTSD symptoms as measured by the PCL-C
were less likely to support the Rwandan trials and 2 critical components of
reconciliation, community and interdependence. However, some of the associations
observed among PTSD symptoms, trauma exposure, and attitudes toward judicial
responses and reconciliation had ORs with 95% CI close to or including 1.
Further explanation of these associations with more refined measures is needed.
There are several limitations to this study. Our data may not be nationally
representative since we selected only 4 communes in Rwanda. We chose 4 communes
because we knew that they had unique experiences with genocide exposure and
experience with the ICTR. As well, they differed in their level of urbanization
and geographic location. Furthermore, given the geography and demography of
Rwanda and the history of the genocide and war, we have made the assumption
that exposure to the genocide and its aftermath was inevitable and that this
basic exposure produced PTSD symptoms in a significant proportion of the population.
We do not know the prevalence of PTSD symptoms prior to 1994. Another possible
limitation to this study is the assessment of exposure to specific traumatic
events. We had asked respondents to state "yes" or "no" as to whether they
experienced any of the listed traumatic events of 1994 and their aftermath.
The survey took place almost 8 years after the 1994 genocide. Inaccurate recall
may have affected the validity of the responses. Also, they may have experienced
other kinds of traumatic events. Furthermore, we used a self-reporting measure
for PTSD symptoms that could affect the validity of the assessment. However,
several studies have shown that the PTSD Checklist is highly correlated with
the CAPS.5,6 Also, we assessed
only 1 of several possible psychological effects of exposure to trauma, PTSD
symptoms. Another potential limitation to the study is the political climate
in which the survey was conducted. Rwanda's violent recent history, the fact
that the national government was not democratically elected, and that genocide
trials were currently under way in Rwanda might have constrained people in
their ability to respond openly, particularly to highly sensitive questions.
Nevertheless, we have a high degree of confidence in the responses because
they show wide variation and because people demonstrated a willingness to
express opinions divergent with the positions articulated by the government
(T.L., P.N.P., and H.M.W., unpublished data, February 2002). Although performing
7 logistic regression analyses increased type I error, our sample size was
large and the significance level was high enough that, even with Bonferroni
adjustment, the P values obtained were still significant.
The lack of association found in some of the analyses could have resulted
from the dilution effect of imputing the middle score for missing item data
in the 2 scales. However, this is unlikely, as this was performed for only
1% of the data. Finally, our 2 scales—openness to reconciliation and
attitude toward judicial responses—are newly developed. Several subscales
in these scales have a Cronbach reliability α less than the desired
.80. More work needs to be done to improve the scales and validate them for
Our study provides a first glimpse at how traumatic exposure, symptoms
of PTSD, and other factors—such as education, perceptions of economic
stability and security, ethnicity, and ethnic distance—are associated
with a person's attitude toward justice and reconciliation. We encourage further
work to explore how other psychological effects of trauma may influence individual
and national reconciliation and how interventions can assist those with PTSD
symptoms and the process of reconciliation. We urge that this method be tested
in other cultures and conflicts so as to enhance our understanding of ways
to promote reconciliation. Other than in our Balkan study,14 we
have found no empirical research that links personal traumatic exposure to
openness to reconciliation. In that study, there was no direct link unless
there was a negative prior relationship with members of the opposing side.
In summary, we developed measures to assess the prevalence of traumatic
exposure, PTSD symptoms, attitudes toward judicial responses, and openness
to reconciliation. We found that symptoms of PTSD affect about one quarter
of respondents and that these symptoms were associated with traumatic exposure,
proximity to trauma, and some sociodemographic factors. We also found associations
between symptoms of PTSD, judicial attitudes, and 2 factors of openness to
reconciliation. Those who met the PTSD symptom criteria were less likely to
support the Rwandan national trials, to believe in community, and to demonstrate
interdependence with other ethnic groups. These findings suggest that the
relationship of judicial trials to reconciliation cannot be assumed, nor can
we assume that all trauma survivors necessarily see justice in the same way.
Furthermore, the data from Rwanda indicate that openness to reconciliation
is related to multiple other personal and environmental factors that must
be considered in developing policies for peace-building in societies that
are emerging from mass violence. We recommend that further exploration and
research be undertaken to improve the measures to further investigate the
impact of conflict on trauma and to examine how trauma may affect the road
to reconciliation. If countries are to rebuild after genocide or ethnic cleansing,
it is important to understand the factors that may facilitate or inhibit that