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Essay: Genocide – public health impact

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Introduction

Genocide is a global phenomenon and has been present in every historical period. (Krain 2005: 363f) It affects all sectors of society: this includes agriculture, education, government as well as civil society. This causes a profound damage to social institutions that have long-term effects on the health and quality of life.

In the light of this, the field of Public health has recently been expanding its scope to start researching issues such as war, humanitarian crisis, violence, and genocide. This is of importance as public health policies and interventions can potentially be used to prevent genocide. (Levy & Willis 2000: 612; Krain 2005: 364)

While genocide may often be seen as a human rights issue exclusively and not a public health issue, in recognizing the relationship between the two: the role of physicians and other healthcare professionals in genocide, but also in preventing and mitigating genocide becomes clear. Physicians and other healthcare professionals have a long history of protecting those affected by war and conflict. This becomes visible in their engagement in war times while continuing their duties and treating non-war as well as war-related injuries, as well as investigating and documenting human rights violations. There are several reports stating that earlier military intervention could have significantly altered the outcomes of the conflict, underlining the importance a health care professional can play.

In addition to this, we must consider the Public health impact a genocide has on the affected populations: the impact goes way further than just the number of people killed. The long-term effects are immense as in the destruction of medical facilities as well as the flight and killing of affected healthcare personnel leaves a deep mark in the psyche of the survivors and perpetrators and long-term public health initiatives, such as immunization programs and prenatal care are interrupted. Leaving the health sequelae of genocide to often be chronic, lifelong, and difficult to treat, increasing the burden of disease in affected communities for decades after the killing has ended. Hence the resultant impact of genocide on the global health economy has been and continues to be, substantial. (Reva et al. 2004: 2028f)

Medical professionals though don’t only play a role in genocide prevention but can also contribute to genocides by furthering them i.e. by doing experimental testing on the victim group or contributing to the spread of negative connotation towards the victim population. (Bloche 2001: 275)

Definitions

Public Health

Public health is “the science and art of preventing disease, prolonging life and promoting human health through organized efforts and informed choices of society, organizations, public and private, communities and individuals”. (Winslow 1920: 183) The field of public health is concerned with protecting the health of entire populations and does this by analyzing the health of these and threats posing to harm it. (Winslow 1920: 183ff)
Burkle (2007) defines public health emergencies as those

“that adversely impact the public health system and/or its protective infrastructure (ie, water, sanitation, shelter, food, fuel, and health), resulting in both direct and indirect consequences to the health of a population, and occur when this protective threshold is absent, destroyed, overwhelmed, not recovered or maintained, or denied to populations.” (Burkle 2007: 291)

These events all have the potential of being injury-creating and/or potential illness creating. There can be several major factors that promote, accelerate, or move a disaster event toward becoming a public health emergency. This can be related to the existing public health infrastructure, pre-existing geographical disaster, population size, and environmental conditions. (Burkel, Greenough 2008: 193)
Also, Internal wars, are one type of these complex emergencies. They are politically motivated disasters that can result in high levels of violence, civilian deaths, ethnic cleansing and genocide, and public health catastrophes. In the 20th century, more people were killed by forces from within their own country than from the outside. Deaths resulting from genocide and ethnic cleansing came primarily from direct violent acts in such as in Rwanda, Cambodia, Sudan, Bosnia, and Kosovo. However, in prolonged lower level conflicts, denial of public health protection as in food, water, health, and shelter, have resulted in an increasing pattern of indirect mortality and morbidity. Additionally, indirect deaths from war-exacerbated malnutrition and disease exceeded battle deaths by a huge margin among the civilian population, especially internally displaced people and refugees. (Burkel, Greenough 2008: 196) All leading to public health emergencies.

Genocide

In the field of public health research, the definition mainly used is the one by the United Nations General Assembly in 1948. Here Genocide is defined as any of the following acts

“committed with intent to destroy, in whole or in part, a national ethnical, racial or religious group as such:

(a) Killing members of the group;

(b) Causing serious bodily or mental harm to members of the group;

(c) Deliberately inflicting on the group conditions of life calculated to bring about its physical destruction in whole or in part;

(d) Imposing measures intended to prevent births within the group;

(e) Forcibly transferring children of the group to another group.” (United Nations 1948)

The definition goes on arguing that intent is the most difficult element to determine and

“To constitute genocide, there must be a proven intent on the part of perpetrators to physically destroy a national, ethnical, racial or religious group. Cultural destruction does not suffice, nor does an intention to simply disperse a group. It is this special intent, or dolus specialis, that makes the crime of genocide so unique. In addition, case law has associated intent with the existence of a State or organizational plan or policy, even if the definition of genocide in international law does not include that element.

Importantly, the victims of genocide are deliberately targeted – not randomly – because of their real or perceived membership of one of the four groups protected under the Convention (which excludes political groups, for example). This means that the target of destruction must be the group, as such, and not its members as individuals. Genocide can also be committed against only a part of the group, as long as that part is identifiable (including within a geographically limited area) and “substantial.” (United Nations 1948)

The Convention on the Prevention and Punishment of the Crime of Genocide was adopted by the United Nations General Assembly on 9 December 1948 and entered into force on 12 January 1951 in accordance with article XIII. (United Nations 1951) As in the Public health discourse when spoken of Genocide it is often referred to by this definition I will also use this definition within my paper. Though there is criticism surrounding this definition. Due to space constraints of this paper, I will not begin a longer discourse on this. Even though it would make sense and is important to note, as a general acceptance about a definite definition is still not yet available by scholars. Some even call this definition too broad or too narrow. (Totten and Parsons, 2004:3f)

In the public discourse, many papers focus on the aspect that violent acts occur in genocide. Violence is also reflected in the above-mentioned definition by the United Nations (1948). Hence a lot of work that comes out of the academic realm in focus on the public health impacts of genocide especially in regards to the physical effects does often do not mention genocide in particular or in a side note, but rather violence and torture. The terms torture and violence have to be looked at in a differentiated manner, as they can occur on a small scale but in genocide, they occur in a widespread manner affecting whole populations. Torture just like genocide is hard to define. The United Nations (1984) convention against torture defines it as:

“an act by which severe pain or suffering (physical or psychological) is intentionally inflicted on a person for such purposes as (a) obtaining information; (b) obtaining a confession; (c) punishment; (d) intimidation or coercion; (e) any reason based on discrimination.” (United Nations 1984).

Of importance when relating this definition to the one of genocide is that the torturer does these things against the will of the victim. Additionally, the Convention states that torture is carried out by or in agreement with public officials. According to Turner and Gorst-Unworth, this definition boils down to torture being an act of the state against either individuals or groups in order to achieve specific psychological changes in their victims and often their communities. (Turner, Gorst-Unsworth 1990: 475) While there is also a clear distinction between the two, we see that torture and violence are essential elements in the general strategy of ethnic cleansing or genocide.
The ‘official’ definitions of torture and genocide set up by the United Nations both have similar elements. Yet we must also differentiate the two as genocide has other punishable elements that differ from other acts of violence. Since, genocide is a special type of mass violence that distinguishes itself from terms that describe other events that have other explanations, although some of these terms are sometimes considered equal or related. (Shaw 2007:7) According to Hintjes (1999), the context of war and violence is necessary for and contributes to the likelihood of genocide. (Hintjes 1999: 244f) Based off of this I chose not to disregard Literature that didn’t particularly mention genocide but violence instead in order to evaluate the impact genocide has on public health. I did make sure though, that if only violence or torture were mentioned it was in countries and the time frame in which genocides took place.

Impact of genocide on Public health

Some of the impacts of genocide on public health may seem more obvious than others. In genocides indispensable requirements for public health: such as the right to life, food, and adequate shelter are violated. (Fein 1997:12)
The direct impact of genocide on the death rate and morbidity may seem apparent, while the aftermath of genocide may not be: survivors are often chronically disabled from injuries sustained in genocide and in addition to this are mentally scarred for life and maybe even pass this on over generations. This is not only an issue for the victims but also for the perpetrators as they may have been involved, possibly against their will, and carry a mental scarring which also impairs their lives.
In order to portray the scope of the impact of genocide on public health, I will split this paper into two parts: the health impact of the victims and the perpetrators. Beginning with the victims.
Additionally, I will illustrate the different dimensions of the genocide on public health giving examples of how it was in previous genocides. Mainly along the lines of the Rwandan Genocide. However, due to the formal restrictions of this paper, I will not further elaborate on the academic discussions surrounding these two instances, as well as that I will not contextualize the two by giving an in-depth historic outline of the event.

Rwanda

As I am working mainly off of the Rwandan genocide it does seem appropriate to give a short outline of the public health situation before the genocide.

“Rwanda had one of the densest health networks in Africa. There were 34 hospitals and 188 health centers (center de sante) offering up to 80% of the population access to some form of health facility within 5 km of their homes. […] By the time the conflict ended few if any health centers were open, most having been looted by the Interahamwe or taken over by displaced people. Most hospitals were functioning at sharply reduced capacity and were dependent on the services of expatriate medical staff but the Rwandese population had been almost halved with up to one million dead and two million living in refugee camps in neighboring countries.” (Hall & Carney 1994: 30)

Furthermore, to display a short outline of the human rights violations occurring during the genocide which had effects on the nation’s public health.

“[M]assive assaults on non-combatants; the torture and murder of men, women, and children; the widespread and systematic use of rxxe to terrorize whole communities; the destruction, by explosives and arson, of homes, farms, industries, and basic infrastructures that provided water, electrical power, food, fuel, sanitation, and other necessities; denial of medical care and other violations of medical neutrality; and siege, blockade, and interference with humanitarian relief. Soldiers and non-combatants alike were starved, tortured, or killed in prison camps, to many of which the International Committee of the Red Cross was denied access. Thousands were victims of arbitrary and extrajudicial execution and were buried in mass graves. Refugees and internally displaced persons were denied protection and deliberately attacked; subjected to beatings, rxxe, and extortion; forced to walk through minefields; and slaughtered in churches, hospitals, and other sanctuaries.” (Levy , Sidel 2008:5)

Victims

In order to illustrate the effects that genocide has on the public health of a nation, I have split this chapter into 3 subchapters: mental health, physical health, and social health. This provides to be helpful as it gives an in-depth look into different fields that all constitute to a nations public health.

Impact on Mental Health

WHO defines mental health as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community”. Mental disorders, on the other hand, are a quite broad term and characterized by some combination of disturbed thoughts, emotions, behavior and relationships with others. This includes anxiety, depression, schizophrenia, and substance abuse. (Kessler et. al 2009: 23ff)

There have been several studies that have been conducted on the impact of genocide on mental health. Since 1980 there has been a continues to increase in research one on the mental health of those affected by genocide resulting in exposing that people affected by political violence are more likely to meet the criteria for psychopathology meaning: depression, anxiety, and PTSD. (Lindert 2012: 168) This can be contributed to the traumatic events the population undergoes in genocide. They face, for example, the following: family members being killed, family members dying from disease, friends being killed, relatives or friends disappearing, being separated from their families, forced evacuation, destruction of homes, farms, neighbourhoods, schools and churches, injuries, physical assault, necessity to hide for long periods, starvation, betrayal by neighbours or friends. (Steward 2015: 7) Entire family systems, as well as social support systems which formerly provided support, were destroyed not only due to the loss of family members but also because of the growing mistrust amongst the populations (Rieder, Elbert 2013: 2) meaning cohabitation was profoundly affected. (Buckley-Zistel 2006: 131) Hence not only affecting the mental health but also the social health of the people, as I will further elaborate on later.

In Rieder and Elbert’s (2013) study about the mental health of the survivors of the Rwandan genocide there are testimonials that state that: “witnessing the killing of someone, seeing dead and mutilated bodies, being attacked with a weapon and physical attack proved to be the most upsetting experiences reported by the entire group.” (Rieder, Elbert 2013: 4) This is also uniform with eyewitness and survivor reports that during the genocide family members were forced to witness the death and murder of their own. Parents murdered children and husbands in mixed marriages murdered wives.

“Hundreds of thousands experienced unimaginable horrors, either directly or indirectly. Writes one woman, ‘I will never forget the sight of my son pleading with me not to bury him alive […] he kept trying to come out and was beaten back. And we had to keep covering the pit with earth until […]there was no movement left” (Kolini 2008: 8)

Several studies were conducted regarding mental health being connected to Genocide. In the Rwandan example: In refugee camps, for instance, it was estimated that the rate of people affected by mental health problems lays at 50% for people who had fled the genocide. (de Jong et. Al 2000: 171) Other studies revealed that most children who have survived the genocide had witnessed some sort of traumatic experience. According to the study by Dyregov et. Al (2000) 90% stated that they had witnessed a killing with 54-74% of them meeting the criteria for having PTSD. (Dyregov et. Al 2000: 5ff)

Rieder and Elbert (2013) had also evaluated that women experienced a higher trauma load in regard to the period of genocide, while men experienced a higher trauma load in regards to the aftermath of genocide. This could be attributed to the fact that Tutsi women were particularly targeted by the military, during the genocide, in order to wipe out the entire group. They were seen as procreators and in order to destroy also the future life of the Tutsis, women and children had to be killed. Women were forced to murder their own children in order to save themselves (Khan 2000: 17) and demonstrate their commitment to Hutu power. How this must have affected a person’s mental state is beyond imagining, (Rwanda: The Preventable Genocide 2000) yet must have defiantly been traumatizing. And displays the intent of the perpetrator group “to physically destroy a national, ethnical, racial or religious group”. As the United Nations Convention (1948) puts it.

Rxxe was another form of assault Rwandan women were severely subjected to during the genocide, as it was a popular tool for the perpetrators of genocide. This carried a heavy mental and physical toll on the rxxe victims. The hate propaganda put out by the Hutu extremists had portrayed the seductive nature of Tutsi women, leading to the killers often raping and mutilating their female victims beforehand. Women were subjected to violent sexual abuse by the genocide militias. This also left mental scarring in the victims caring on beyond the genocide into the rest of their lives. (Kolini 2008: 9f)

Long-term studies reveal estimates that the level of PTSD in 2012 was still prevailing at 26% hence still posing a public health problem in Rwanda. (Munyandamutsa et al 2012: 1754)

In the aftermath of genocide, there is a major gap in medical professionals who can diagnose and treat mental health conditions within Rwanda. There are about 0.05 psychiatrists per 100.000 inhabitants in Rwanda. (World Health Organization 2011)

Regarding Mental Health infrastructure: before the Genocide had begun the country had one psychiatric hospital: the Caraes psychiatric hospital in Ndera in Greater Kigali. After short fire against the Interhamwes from within the hospital, they returned the attack with grenades, automatic rifles, and cannons. Leaving only 22 of the initially documented patients and no medical staff to perform their duties and the patients suffering from a recrudescence of psychotic symptoms. (Hall & Carney 1994: 27) Hence leaving not local psychiatric hospital remaining at the end of the Genocide.
Mental health is often linked to a person’s physical health as patients in Rwanda for instance which had shown signs of PTSD also turned out to have a higher prevalence of somatic symptoms as well as other mental disorders. Many physicians who worked in the psychiatric hospital described this somatization. Children had come to the clinic with loss of senses, convulsions, body pain or a headache without any physical cause why a psychological or psychiatric is used as an explanation. (Munyandamutsa et al 2012: 1755) Sleeping disturbances are another symptom, sometimes causing the child to use drugs to find sleep. Rieder et al (2013) showed similar figures and are especially pointing out physical illness in relation to the PTSD symptoms.
Impact on physical health
The infrastructure that supports social well-being and health—including medical care facilities, electricity-generating plants, food supply systems, water treatment and sanitation facilities, as well as transportation and communication systems are often destroyed in genocides. (Levy & Sidel 2008: 10) This leads to people not having access to food, to higher rates of malnutrition, not having access to clean water to the spread of water-borne diseases, and the shortage of medical supplies and treatment possibilities to populations not being able to maintain or recuperate their health.
To illustrate the impact Genocide has on the physical health of a nation, I again chose to use the example of Rwanda, because more than 10% of the country’s 7.8 million population and approximately 75% of the Tutsi ethnic minority were killed and a huge number of people ended up widowed or orphaned. In the direct aftermath of genocide, two million people took refuge in the neighboring countries. Many of them did not re-enter Rwanda prior to 1996 when the refugee camps began breaking down and people felt encouraged and/or coerced to return. (Rwanda: The Preventable Genocide 2000)
The thoroughly planned and state-monitored genocidal violence was specifically marked by the extensive participation of the local population: neighbors went after neighbors by means of guns, machetes or sticks during house to house searches, at roadblocks or at central congregation points. Looting, destroying property and genocidal acts including torture, murder, maiming, rxxe and other forms of sexual violence were common. (Straus 2004: 85ff) This resulted in the seemingly obvious death of millions and survivors sustaining physical injuries, some suffering permanent disabilities after i.e. losing limbs, eyesight or hearing. In addition to these traumatic injuries, there is often an abundance of sexually transmitted diseases and other infectious diseases, low rates of infant birth weights, perinatal mortality and malnutrition as well as an increased rate of acute and chronic disease. Many of these had not only immediate but long-term consequences. (Reva et al 2004: 2035f)
In Rwanda, there was the deliberate murder of healthcare professionals within the victimized group leading to the death or flight of 60 to 80% of trained healthcare personnel in some regions in the country. This limited the population accessibility to obtain medical care and left resulted in a shortage of medical facilities within the country. (Reva et al 2004: 2036f)
Those that remained open were then often tremendously overwhelmed: In a field hospital set up by the ICRC International Committee of the Red Cross, which was at one stage the only running hospital accepting all patients during the genocide, a very high number of casualties were admitted. Up to 100 patients coming in daily. Admissions consisted mainly of bullet, shrapnel and machete wounds, and landmine injuries. Additionally, more than 50 babies of injured women were delivered there. All whilst being regularly attacked by the Interhamwe. (Hall & Carney 1994: 31) Other hospitals that remained open throughout the genocide reported similar conditions.
Though we do have to differentiate between local hospitals and medical facilities set up by humanitarian aid organizations such as the ICRC, as in public hospitals there is often segregated treatment of perpetrators and the victim population, in times of genocide. We see that access to doctors during genocide for the victim group is often limited, if not restricted by law. This is also reflected in the Rwandan genocide as Testimony’s from Rwanda state that by June no more civilians were being treated for their injuries in hospitals anymore only military personnel. (Hall & Carney 1994: 29)
While more men than women were killed in the genocide, the women received particularly harsh treatments at the hand of their genocidaires:

“Women were subject to all sorts of torture; they were rxxxd, burned alive, or buried alive. Women were also rxxxd by large groups of soldiers and militia. The soldiers and militia did the most they could to humiliate the woman, raping her in front of her husband and children, then killing her children and husband in front of her before taking her life.” (Berry & Pott Berry 1999:21)

Injuries and infections obtained through rxxe, where then often not promptly and effectively treated: According to a UN study, a quarter of a million women were rxxxd during the Genocide in Rwanda resulting in 67% of them being infected by HIV, which some the unknowingly passed on to their partners and children. Hence there is an increase in the HIV rate which can be ascribed to the Rwandan genocide. Creating an HIV/AIDS epidemic within the country and revealing a whole new challenge to the nation’s public health. (United Nations n.d.)
In addition to these more obvious physical injuries, Rieder and Elbert (2013) evaluated other physical complaints in their sample group of Rwandan genocide survivors these being: headaches, coughing, malaria, chronic pain, and stomach-aches. Women also tend to suffer from chronic pelvic infections as a result of the sexually transmitted diseases they have acquired when rxxxd. Additionally, carcinoma of the cervix is a problem that women survivors face due to those chronic pelvic infections obtained amongst other through the raping mentioned above. (Rieder &Elbert 2013: 4f)

Also, Children are especially vulnerable in and after the Genocide. According to a UNICEF study, many Children suffer under amputated limbs, scars and from machete wounds, especially across the face, head, and neck. (UNICEF 1996:6) Others are severely malnourished or even die of malnutrition and other diseases and military attacks. Additionally, many are forced to become soldiers themselves and are exposed to battle-related wounds or are recruited as sex slaves, again increasing the risk for sexually transmitted diseases. Their health suffers through this but also in the increased infant and young child mortality rates and decrease of immunization coverage. (Sidel & Levy 2005: 289f) About 1% of Rwandan youths are still infected with HIV. Betancourt et al have shown that many HIV-positive children in rural Rwanda present themselves with typical affective symptoms as well as the changes in behavior such as isolation and interaction difficulties. (Betancourt et al 2011: 402ff) This again, ties in how mental health and physical health are often tied in with one another and underlines the long-term public health impact resulting out of the Rwandan genocide.

Lastly, studies suggesting an impact of genocide in a war on physical health years after the genocide are not conclusive. Though they suggest an association with increased mortality late in life and others suggesting no differences between genocide survivors and those who did not experience genocide. (Sagi-Schwartz et al 2013:e69179)

Genocide and Social Health

Genocide also has an impact on social health. Social health can be split into several subcategories: family, communities and social institutions.

Beginning with families the impact of Genocide on social health has effects on the structure and function of the nuclear and extended family. The economic and social problems of genocide are immense. In regard to health, the medical costs that a family has to bring up due to an injured family member during and after the genocide can be profound. As an example in the Rwandan Genocide more than 10% of the country’s population, of which 75% were of Tutsi ethnicity. (Rieder, Elbert 2013: 2) Men were disproportionately targeted during the Rwandan genocide leaving a majority of female and women-led households. These turned out to be especially vulnerable to the economic problems the genocide brought with it. This means that they were not able to feed their families anymore, often didn’t have proper housing and could not continue to send their children to schools. If family members were injured in the genocide it is also difficult for the families to cover those costs making the economic burden even higher. Additionally, families had to be restructured and women took on positions formerly covered by men. (Rieder, Elbert 2013: 2ff, Kumar 2001: 27f) Furthermore, as mentioned before the rxxe and other forms of torture were a popular method in the Rwandan Genocide. Survivors often also faced social stigma which may lead to them being ejected from their families and isolated from their communities. (Levy & Sidel 2008:5 ff) A UNICEF study (2004) with 3000 children revealed that 80% of them had experienced death in their family, 70% had witnessed killing or injury. (UNICEF 2004) Children who are born out of ethnic hatred and rxxe brings on a whole different scope of problems for the family on a personal level but also communal level.

Lastly, Individuals and groups targeted on the basis of their communal characteristics are forced to undergo a profound disorientation in their sense of social stability, trust, and personal identity. (Levy & Sidel 2008: 6) This can also be passed on in transgenerational trauma, affecting the young Rwandan generation of today.

If we carry on with the example of Rwanda we can see also see how social health and psychological health are tied to each other, as genocide survivors showed high rates of mental health and psychosocial problems. As the victims have been exposed to brutality and dehumanization in which entire family systems and general communal/social support systems broke down with the killing of family members and a general mistrust and fear arose (Rieder, Elbert 2013: 2) as victims often suffered at the hands of family members or neighbors during the genocide. (Palmer, Firmin 2011: 86) This also ties in with distrust at a community level. As this may occur shattering networks and social relations having repercussions even towards social intuitions, especially among the victim group as they were victimized amongst others also by family members or their neighbors. This has led to them isolation themselves from their collective past and current social and political realities. (Palmer, Firmer 2011: 86)

Physicians for Human Rights released a report in 1994 written by Hall and Carney documenting the atrocities committed in the Rwandan Genocide with a special focal point on medical professionals and their field of work. Herein it is described whom hospitals were used to seek out injured Tutsis, and their relatives who were visiting them. (Hall & Carney 1994: 27) Hence a mistrust towards former ‘safe spaces’ such as hospitals and the trust one lays in a medical professional is broken, resulting in the question of where does one go when one is sick. After the genocide, the medical infrastructure was completely destroyed there are severely reports stating for instance that less than ten trained pediatricians had remained within the country after the genocide. This can also be contributing to the fact that there was deliberate targeted controlled fire onto sites where the population could seek medical attention, also those provided by international aid organizations such as Doctors without Borders. (Hall & Carney 1994: 28)

Lastly, survivors of genocide have been found to adopt violent solutions to conflict within partnerships, the community, and the society, hence an increase in domestic violence. Long term having witnessed genocide and other forms of violence contributes to the mindset that violence is the only way to resolve conflicts resulting in an increase of domestic violence, which also has an impact on the current public health. (Levy & Sidel 2008: 2)

Perpetrators

Role of Public health professionals in genocides

Medical complicity has played a key role in the uprising of genocides in the 20th Century. The General Government including Public Health Officials down to doctors also play a role in genocides as public health policies can intensify the perpetrator’s measures of mass murder. (Bloche 2001: 274)

This may seem contradictory at first, as it goes against the professions ethical commitment to serve the sick as taken in their Hippocratic oath. Yet history has shown that medical techniques have been used by governments and religious institutions for their own purposes. Yet as Bloche (2001) states medicine is used in several different situations beyond to improve the well-being of patients. This he groups into three categories: “(1) pursuit of public health objectives, (2) advancement of nonmedical ends, and (3) ascription of rights, responsibility, and opportunity based on health status.” (Bloche 2001: 276) displaying the professions susceptibility to negative state purposes.

It is routine for doctors and other health professionals to include population-wide health concerns in their daily work in order to i.e. pursue public health goals. This practice includes, for example, the reporting of contagious diseases to state authorities (Bloche 2001: 276). Hence doctors that are not politically active but identify with the perpetrator groups ideologies but also doctors who don’t, can contribute to the spreading of propaganda regarding the victim group by i.e. proclaiming that members of the victim group are more prone to carry certain diseases or ascribe them to have other physiological disadvantages over the perpetrator groups. (Browning 1998: 22) Physicians which do intentionally report certain diseases to be associated more with the victim group then often justify their doings by ascribing them to their public health thinking and thereby proclaiming it as ethical – for the greater good. (Bloche 2001: 276f)

To give an example doctors in Nazi Germany were convinced that the Jewish population was more prone to carry diseases such as spotted fever and typhus. They believed and propagated that, if these were to spread amongst the German population this would result in a far higher mortality rate than it does amongst the Jewish population, as they have already built up a resistance to it. (Browning 1998: 22f)

By spreading facts such as this one, the general population also developed a sense of fear towards the victim group, in this case, the Jewish population. Which makes it easier for the Government to induce policy change to the disadvantage of the victim’s population. Additionally, we see that reasoning behind this may have been contributed to the belief that in order to protect the German population’s health, hence the nation’s public health interests, German physicians saw it as their duty to contain the spreading of such a disease. Thus justifying their participation in the mass killing of the Jewish population.

In the example mentioned before several countermeasures were suggested in order to prohibit the “spread of spotted fever or typhus” amongst others, there was an increase of sanitation regulation measurements including delousing initiatives, which imply a dehumanization of the Jewish population as well as ascribing them to be dirty. Furthermore, it was suggested to restrict the of movement of the Jewish population, sealing them off into ghettos and insisting that food and medical services be withheld in order to control the epidemic and increase their goal of increasing death rates through starvation. (Browning 1993: 23f, Bloche 2001: 280)

To name an example from the Rwandan genocide notable physicians played key roles in the planning and execution of the genocide. High-level government officials such as the President Theodore Sindikubwabo, who was a pediatrician and Dr. Casimir Bizimungu are just two mentionable personalities that actively participated alongside with many other medical professionals in the act of genocide but also the identification, torture, and murder of individuals in particular patients in hospitals. (Hall & Carney 1994: 33) A surviving doctor gives a testimony in the mentioned report stating:

“When the patients’ wounds had healed some of the doctors, the “bad doctors,” (named) expelled the Tutsis even though everyone knew they would be killed outside. At night the Interahamwe and RGF came in but these doctors were colluding willingly. If people refused to go they were taken out at night. They could be seen being killed by the Interahamwe waiting at the gates. “(Hall & Carney 1994: 24)

Patients who were not knowingly released to their death by doctors, where often dragged out of the hospital by militia and soldiers. Eventually, doctors allegedly even refused to treat Tutsi patients.

This is just two examples of “medicine’s vulnerability to becoming an adjunct to illicit state purposes.” (Bloche 2001: 275)

The question arises why doctors participated in the genocide. Hall & Carney set up three idea constructs: One is that they too had been influenced by the broadcasted propaganda and popular sentiment. The other laid in the risks the doctors were exposed to when opposing the extremism: being singled out and killed by. And the third being contributed to the absence of a regulatory which guides supports and sets standards for doctors in Rwanda. (Hall & Carney 1994:33)

The perpetrators of these atrocities and wars are also consumed by rage, fear, and humiliation. The perpetrators suffer in their own mix of silence, rejection, and denial, blocked from the processes of explanation and expiation that might lead to their reintegration into society. (Levy & Sidel: 2008: 6)

Conclusion

“[G]enocide is one of the most pressing threats to the health of populations in the twenty-first century. […] mortality rates due to genocide violence are far in excess of other public health emergencies including malaria and HIV/AIDS”. (Reva et al 2004: 2028) We have seen the consequences on populations affected by genocide and created a public health crisis within the respective nations. People living in these countries, lives have been threatened, permanently altered and their ability to procreate was limited. Their right to life was violated. In the aftermath of genocide communal, family and friendly structures were altered leaving a toll on mental and social health. New trust must be built in order to recreate safe spaces in which people are also willing to recuperate their mental health but also their physical health. To gain the confidence of survivors of the genocide in Rwanda, the Rwandan medical society must help rebuild the compromised medical system, define ethical codes of conduct, and regulate the profession. The international medical community should support these efforts and call for the establishment of a permanent international tribunal, whose mandate will include investigation and punishment of physician complicity in human rights abuses. (Geltman 1997: 64) Furthermore, Healthcare professionals local as well as international should be educated on the processes and consequences of genocide in order to be able to recognize early warning signs and report them in order to prevent future genocides.

Moreover, countries such as Rwanda that is low-income countries tend to struggle with the efforts to rebuild the former healthcare structures, in order to supply the respective nation with the medical system needed to cope with the consequences of the genocide.

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