COVID-19 pandemic against mental health services for genocide survivors during commemoration week in Rwanda.

Psychology; COVID-19 mental health confinement; Rwanda; Lock down; Commemoration.

Rwanda has recorded 105 patients since March15 Coronavirus breakout. During the last three weeks the number of patients that caught Coronavirus has been increasing. But, so far, only 7 patients have recovered from this dreadful disease. Thus, the lockdown days have been extended to a month in the whole country. As a matter of fact, April 7–13, 2020 is a challenging week for Rwanda and its friends to commemorate Genocide against Tutsi because of Coronavirus spread. Indeed, over one million Tutsi were decimated during the 1994 genocide that took 100 days of hostilities.

In view of this COVID19 global crisis, therefore; the Government of Rwanda had set rules and regulations to safeguard its population. Given that gathering is forbidden, Rwanda officials have used the social media to comfort survivors and families of genocide victims in general [1]. Every genocide survivor lived a very dark period with evil consequences. For example, during this time, 250, 000 women aged between 13-35 years were raped during genocide, and 67% of them developed HIV/AIDS while 20, 000 children were born from rape [2, 3].

Previous findings from the Rwanda Mental health survey (RMHS) of 2018 reveal that survivors of the 1994 genocide against Tutsis aged between 25 and 65 years are the most affected by mental health problems including trauma and depression compared to other Rwandans. The existing major depressive episode of the overall population averages stood at 12% and 35% for genocide survivors. The current post-traumatic stress disorder (PTSD) of the population averages stood at 3.6% and 27.9% in genocide survivors. The number of cases that shows higher symptoms of trauma amounts to 27 % [4, 5].

Rwandan mental health care system consists of two agencies that provide specialized mental health care, CARAES Ndera Neuropsychiatric Hospital, the national referral hospital for neuropsychiatric disorders, and therefore the outpatient psychosocial consultation services [6]. CARAES Ndera Hospital has created a branch in Kigali, the Hope Center that is located in Kigali. This center has the mission to serve patients with PSTD [7]. Both inpatients and outpatients, individual, group, and family therapy benefit treatment from the center. The districts hospitals have trained mental health nurses, psychologists in diagnosing and treating mental disorders. However, the major mental health care still operates at national hospital level, and few patients seek mental health services in health centers [7, 8]. Furthermore, life after genocide has proven difficult. Convincingly, orphans who survived genocide have been affected by killing atrocities. Obviously, those children that survived genocide have experienced anxiety because of loss of parents. Anxiety averages 67.21 % wile, depression stands at 59. 01 % among participants in this study. More than half of participants have experienced post-traumatic stress disorders (PTSD) [9]. The comparison of mental health disorders burden of genocide perpetrators with genocide survivors reveals that, genocide survivors experience high PTSD 46% vis-à-vis genocide perpetrators that averages 14%. More so, anxiety among genocide survivors increased up to 59%, while; the same issue stands at 36% among genocide perpetrators. Depression of genocide survivors rise compared to genocide perpetrators with 46% and 41% respectively [10]. Moreover, intergeneration mental health problems are not being neglected since they cause adverse mental health disorders among children born to genocide survivors’ mothers. Thus, Shrira et al demonstrate that, where descendants from mothers who faced PTSD reveal secondary traumatization symptoms compared to children whose mothers were free from PTSD [11].

Mental health disorders have worsened during commemoration week and shortly before commemoration because genocide survivors remember tragedies that they have experienced, and sometimes think they live the same situation during genocide commemoration. That is why, the study on PTSD acute exacerbations during commemoration week reports that all participants have experienced PTSD acute exacerbations in previous commemoration periods. More than 50% of participants have faced PTSD acute exacerbations more than twice, while 33.2% of participants have faced PTSD acute exacerbations for 30 min in previous years’ commemoration weeks [12]. Thus, commemoration week in Rwanda is a mean of offering solidarity and support to genocide survivors, but also, it is a lesson to learn from previous tragedies so that genocide should not happen ever again.

Since 1995, every commemoration week has started on April7. It has been called a National Mourning Week. During this period, patients that require admission to hospital are catered for this purpose. For others, the Ministry of Health provides ambulances, drugs and mental health professionals through district hospitals. It equally provides ambulances with medical psycho-social interventions on commemoration sites across the country. This is to accommodate trauma and other mental health problems caused by this appalling souvenir.

Lockdown period in Rwanda has been implemented to minimize the risk of COVID-19 quick transmission to a vast number of populations. However, it could also worsen the limited mental health services, and online ones are required to serve genocide survivors at risk. Although this system of online mental health services may be available, the elderly in villages may not access these services because of limitations to full internet connection. Besides, in Rwanda rural areas, genocide survivors with psychiatric disorders are required. This particularly concerns both parents and children whose mental health has especially deteriorated during this period of April 7 up to July 4, 2020. Thus, the current strict COVID-19 prevention measures in Rwanda have inevitably become a major barrier to access psychosocial support and treatment for this group.

Mental health and behavior patterns of genocide survivors may worsen because of restriction imposed on the population to observe social distance. Indeed, this distancing has disfavored support to moral, spiritual and psychological health services to genocide survivors during this COVID19 consignment. Consequently, there seems to be insufficient and inadequate attention paid to this vulnerable population in this period. Nevertheless, it remains hard to adequately communicate and interact with survivors. Still, there are service limitations such as; psychological and social support for survivors and trained health professionals with relatively demanding preparation to provide mental health services in this critical period to genocide survivors.

Overall, Rwanda has invested effort to improve genocide survivors’ mental health to date. This includes but; not limited to offering mental health support and trained health professionals in districts to provide these services. Additionally, health professionals are continuously trained and this improves the quality of services delivered by health centers. However, experiences and behavior patterns of genocide survivors, especially their mental health problems during this period of commemoration may worsen the situation because of COVID great challenges to mental health services for this population that this paper has addressed.

Significantly, there were no national guidelines covering interventions in major public health crisis affecting genocide survivors during this pandemic period. Thus, the establishment of mental health hotlines across the country and provision for genocide survivors with counseling and psychological services should be suitable strategy in the future. Various services are usually performed to support genocide survivors during the National Genocide Commemoration period. These include mental health services, but, special services in a difficult situation like COVID 19 lockdown should be provided. As radios, televisions, and the internet have been used to prevent COVID 19 in Rwanda, the same strategies could have been employed for management of mental distress among genocide survivors. Equally, social media platforms have been used to share strategies, guidelines, and education programs for managing the spread of COVID-19 in Rwanda. The same strategies should be used for managing potential mental stress that often increases during commemoration days, especially commemoration 2020 during Coronavirus pandemic.

Therefore, policymakers in collaboration with the Ministry of health, Universities, and medical institutions should publish various books on the theme of genocide mental distress. The government need to formulate public health policy and instruct professionals to design details of programs, hospitals at district level to treat serious cases to reach those who cannot read and have difficulty in getting access to internet. Community Health Workers (CHWs) should be trained in trauma management, and families should bear with less seriously affected cases. Government policies should be developed to encourage more medical students’ involvement in psycho-health care to build a highly-qualified professional in trauma management.

The scarcity of psychiatrists and clinical psychologists in the country that have experienced genocide is an urgent problem that must be addressed. During this pandemic, stakeholders and health policymakers should collaborate with all parties involved to resolve these barriers that make it difficult, if not impossible, for education sector to provide highly-qualified professionals in mental health services specifically for this COVID19 period. What the Government is supposed to strategically plan in a long-term management of mental health issues during unprecedented situations like the COVID-19 pandemic have been discussed in this paper. Lock-down calls for the following recommendations that should be addressed with immediate effects: To provide access to phone-call counseling for genocide survivors support for trauma, to emphasize cash-transfer through local leaders for financial support to genocide survivors, to emphasize social mental health support through sending solidarity messages to genocide survivors, to create a WhatsApp group or any other mean of group communication between villages and cells to share information about the life of genocide survivors during commemoration week.

Declarations

Author contribution statement

All authors listed have significantly contributed to the investigation, development and writing of this article.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Competing interest statement

The authors declare no conflict of interest.

Additional information

No additional information is available for this paper.