Download Post traumatic torture disorders - A 3 year retrospective study

Statistique, Développement et Droits de l‘Homme
Session C-Pa 7a
Post Traumatic Torture Disorders: A 3 Year
Retrospective Study of Patients’ Records at a
Specialised Treatment Centre in Kampala,
Uganda
Samuel NSAMBA
E. KINYANDA
H. LIEBLING
R. MAYENGO-KIZIRI
Seggane MUSISI
R. SENVEWO
Montreux, 4. – 8. 9. 2000
Statistique, Développement et Droits de l‘Homme
Post Traumatic Torture Disorders: A 3 Year Retrospective
Study of Patients’ Records at a Specialised Treatment Centre
in Kampala, Uganda
Samuel NSAMBA
Medical Director, African Centre for Treatment and Rehabilitation of Torture Victims - ACTV
Makerere, Kavule, Bombo Road
PO Box 1483
Kampala, Uganda
T. + 256 41 567 183 F. + + 256 41 533 189
[email protected]
E. KINYANDA, Psychiatrist
H. LIEBLING, Senior Lecturer
R. MAYENGO-KIZIRI, Senior Lecturer
Seggane MUSISI, Consultant Psychiatrist and Lecturer
R. SENVEWO
African Centre for Treatment and Rehabilitation of Torture Victims - ACTV
ABSTRACT
Post Traumatic Torture Disorders: A 3 Year Retrospective Study of Patients’ Records at a
Specialised Treatment Centre in Kampala, Uganda
This is a 3 year retrospective study of the effects of torture on patients attending a specialised
torture treatment centre (ACTV) in Kampala, Uganda.
A total of 310 patients’ records were reviewed and information on socio-demographics,
torture events, sequalae of torture and treatment interventions offered was collected by a pre-tested
questionnaire.
The most common methods of torture included: Kickings and beatings (79.7%), rape (26%)
and witnessing family members, relatives and other victims tortured (48%). Amongst the
perpetrators of torture, the army accounted for 85.8% of the torture and armed rebels were
responsible for 7.6% of torture. The surviving victims were mostly women (60%) and of a peasant,
low income and low education social class (67.8%)
Most of the torture survivors developed various psychological disorders including chronic
(and complex) post traumatic stress disorder (75.4%), depression (28%), anxiety disorders (17%),
somatoform disorders (32%) and chronic pain disorders/syndromes (82%).
A number of patients also had physical sequalae of torture including fractures (43.5%),
hernias (7.7%) and sexually transmitted diseases (60%) contracted through rape.
The treatments offered included psychotherapy (98.5%), physiotherapy (82.9%) and
psychopharmacotherapy (61%).
In 54.8% of the cases, there was significant symptom reduction with treatment. However in
40.3%, there was only minimal improvement with many of these still getting on-going treatments.
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Torture is often accompanied by development of chronic Post Traumatic Stress Disorder
(PTSD) as well as physical and social sequalae. Our findings reflected this fact in keeping with the
established literature. This emphasizes the need for early treatment interventions and also for
prevention through universal respect of human rights and early conflict resolution through good
governance and democracy.
RESUME
Désordres post-traumatiques liés à la torture : une étude rétrospective sur 3 ans des
dossiers de patients du Centre de traitement spécialisé de Kampala, Ouganda
Il s’agit d’une étude rétrospective sur trois années portant sur les conséquences de la torture
chez des patients dans un centre spécialisé dans le traitement de la torture (ACTV) à Kampala,
Ouganda.
Au total, 310 dossiers de patients ont été suivis parallèlement à la collecte d’informations
sociodémographiques, sur les séquelles des actes de torture et sur les interventions de traitement au
moyen d’un questionnaire pré-testé.
Les méthodes de torture les plus couramment appliquées comprenaient : coups et coups de
pied (79%), viols (26%), assister à des actes de torture sur des membres de sa famille, des parents
et d’autres victimes (48,1%).
Parmi les responsables, l’armée est à l’origine de 85% des actes de torture et les rebelles
armés de 7,6% des tortures. Les victimes ayant survécu sont le plus souvent des femmes (60%)
issues d’une classe sociale paysanne de faible éducation et à faibles revenus (67,8%).
La plupart des survivants d’actes de torture développent différents troubles psychologiques
(critères de diagnostic ICD – 10DSM IV), incluant des névroses post-traumatiques chroniques (et
complexes) (75,4%), de la dépression (28%), de l’anxiété (17%), des troubles somatoformes (32%)
et des douleurs/syndromes chroniques (82%).
De nombreux patients présentaient également des séquelles physiques des actes de torture et
notamment des fractures (4,5%), des hernies (7,7%) ainsi que des maladies sexuellement
transmissibles (6%) contractées lors de viols.
Les traitements offerts comprenaient des psychothérapies (98,5%), des physiothérapies
(82,9%) et des psychopharmacothérapies (61%).
Dans 54,8% des cas, le traitement a permis une réduction significative des symptômes. Dans
40,3% des cas, on n’a malheureusement observé que des améliorations minimes et nombre de ces
patients sont toujours sous traitement.
La torture s’accompagne souvent de névroses post-traumatiques chroniques ainsi que de
séquelles physiques et sociales. Nos recherches corroborent ce fait et confirment ainsi la littérature.
Cela souligne la nécessité d’intervenir rapidement au moyen de traitements adaptés et d’une
prévention par le biais du respect universel des droits de l’homme et de la résolution rapide des
conflits grâce à un exercice rationnel du pouvoir et au respect de la démocratie.
1. Introduction
For more than 30 years, Uganda has experienced significant social strife due to cyclic mass
violence consequent to warfare, armed insurgencies, political instability, population displacements
and family disruptions (1, 2). Armed insurgencies and forced abductions continue to plague the
North and Western parts of this country, with the specter of wanton city bombings having come on
to the scene over the last two years (3).
The above scenario has characterized Uganda's institutionalized torture; a term which has
been defined as the deliberate, systematic or wanton infliction of physical or mental suffering by
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one or other persons acting alone or on orders of any authority to force another person to yield
information, to make a confession or for any other reason (4). Indeed in its 1998 annual report,
Amnesty International sighted cases of torture and ill-treatment of people at the hands of the
Uganda Police, Prisons and Military (5).
Institutionalized torture not only has the immediate dehumanizing effect on the victim, it also
has long term psychological, physical and social consequences on the victims (6,7,8,9). This study
sought to investigate the physical, psychological and social sequelae of torture on the torture
survivors treated at torture treatment centre in Kampala, Uganda. It also investigated the torture
perpetrators and their methods as well as the treatments given to the torture survivors.
2. Method
This was a 3 year retrospective study of patients records who attended a specialized torture
treatment centre in Kampala, the African Centre for Treatment and Rehabilitation of Torture
Victims (ACTV), between January 1st 1996 and January, 1st 1999.
ACTV was created in June 1993 as a non political organization dedicated to the identification,
treatment and rehabilitation of victims of institutionalized torture (10) by a group of indigenous
professionals with guidance from the IRCT, Copenhagen.
Treatment at the ACTV centre is offered through 3 modalities namely: in-patient care, outpatient care and outreach community programmes.
Psychotherapy, psychophamacotherapy, physiotherapy and referrals to the relevant specialists
are some of the treatments offered to the patients through a multidisplinary team including social
workers, nurses and a pastoral therapist.
The nature and consequences of institutionalized torture on its victims in this country is not
known nor adequately researched. This study was therefore undertaken to investigate the method of
torture used against the torture survivors attending the ACTV treatment centre, their sociodemographic characteristics, the psychological, physical and social sequelae and the various
treatments offered to them including prevention.
A total of 403 patient records were reviewed. Of these, 93 (33%) were exclude from the study
because they did not meet the eligibility criteria which included: being at least 15 years of age at the
time of torture, being victims of institutionalized torture as defined by the ACTV mission statement,
and having been reviewed by a psychologist or psychiatrist during treatment (4). The records were
reviewed over a 4 month period beginning 1st October 1998 to 1st January 1999. This is the period
when psychological services were introduced at the centre.
The patients records were treated with utmost confidentiality with personal identifiers
removed from the data collection instruments, and informed consent was obtained. The data was
collected from the patients records using a pretested standardized questionnaire which was
completed by a psychiatrist for each studied patient. Diagnostic criteria for psychological disorder
were based on ICD-10/DSM IV criteria.
The statistical programme SPSS was used in analysis to generate frequencies and frequency
tables, with the help of a statistician.
3. Results
The socio-demographic characteristics of the 310 patients are shown in Table 1. For purposes
of this study, the cut off age at the time of torture was set at 15 years of age because children
survivors of torture present differently from adults and their recall of events is less reliable (15).
Table 1. Age. Sex, Family Education and Employment Characteristics of the Torture Survivors
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Variable
Age (years):
15-19
20- 44
45- 64
Not recorded
Sex:
Male
Female
Not recorded
Male: Female ratio
Marital Status:
Never married
Maried/cohabiting
Separated/divorced
Widow/widower
Not recorded
No. of children:
0
1-3
4-7
8-10
>=11
Not recorded
Educational Status:
No formal education
Primary school
Secondary school
Post secondary institution
Not recorded
Employment status:
Unemployment
Self employed
Formal employment
Peasant farmer
Full time housewife
Student (full-time)
Retired
Not recorded
Number (N=310)
%
10
132
129
31
3.2
42.6
41.7
10.5
117
183
10
2:3
37.9
59
3.1
-
18
163
49
72
5.7
52.7
15.8
23.3
38
69
118
44
19
12.3
22.4
38.2
14.2
6.0
74
136
47
12
41
24
43.8
15.1
3.8
13.3
37
47
27
165
10
12
2
10
12
15.1
8.8
53.3
3.2
3.8
0.7
3.1
The vast majority 261 (84%) of the subjects were between the ages of 20-65 years with the
age ranges 20 44 years and 45-64 years being evenly split at 42% and 42% respectively.
The male to female ratio was 2:3 indicating that there were more female torture survivors
seeking treatment. Among the survivors, 163 were married while 121 were either separated,
divorced or widowed with 23 now living as single parents.
The majority of torture survivors had either no formal education -74- or only a primary school
education –136. Most were employed as peasant farmers (53%) or as self employed (15%); those
who were unemployed were 12%.
The patients records did not indicate income levels although it seems from these results that
the majority of survivors were of very low income and education and lived rural peasant lives.
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Table 2 shows that at the time of torture most of the victims were living in the central (Mpigi
and Kampala) (219, that is 70.6%) and Northern (Gulu and Kumi) (48, that is 15.5%) parts of this
country. These were the sites of major armed insurgency respectively in the early 1980's and
recently in the 1990's.
However, 94% of the torture survivors are currently living in the central region (Mpigi and
Kampala) indicating that some of the torture survivors did not return to their former districts of
residence where they were tortured.
Table 2. Ethnicity, Religion and Geographical Residences of the Torture Survivors
Variable
Current District of residence:
Mpigi
Kampala
Mukono
Mubende
Others
Not recorded
District at time of Torture:
Mpigi
Kampala
Gulu
Luwero
Kumi
Others
Not recorded
Ethnic Tribe:
Ganda (Central)
Rwanda/Rundi (South Western)
Acholi/Langi (North)
Etesot (Eastern)
Kiga/Nyankore (Western)
Others
Not recorded
Religion:
Catholic
Protestant
Muslim
Traditional
Others
Not recorded
Number (N=310)
%
220
70
3
3
3
11
71
22.5
1
1
1
3.6
177
15
28
27
20
14
21
57
4.6
9
8.8
6.6
4.5
7
186
40
24
24
13
18
5
59.9
13
7.8
7.8
4.1
5.8
1.6
157
94
11
5
1
47
50.5
30.5
3.5
1.6
0.3
13.8
Ethnically 60% of torture survivors belonged to the Ganda tribe in the central and southern
parts of this country, the site of major armed insurgency in the early 1980's.
4. Methods of Torture
By far the most common form of torture was physical beatings and kickings which accounted
for 247 (80%) of the cases. Rape was the second commonest method of torture accounting for 81
(26%) of the victims, all of whom were women (44%) except for one man who was forced to have
anal sex. Women were raped or abducted and forced to marry their abductees. Men were forced to
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do hard labour or forcefully recruited to fight e.g. for the rebels. Lastly a severe form of tying of the
upper limbs at the back, locally called “kandoya” was meted out to 26 (8%) of the cases. This often
resulted in vascular occlusion of the tied limbs with consequent neuromuscular damage. Table 3
summaries the methods of torture.
Table 3. Methods and Places of Torture
Variable
Physical Torture:
Beatings & Kickings
Rape
Bayonet injuries
Forced hard labour
Tying (Kandoya) **
Deprivation of food/water
Gunshot wounds
Psychological Torture:
Verbal threats
Interrogations
Military detention
Moved or fled to live in bush - (months to years)
False accusations
Abduction
Forced to witness:
- Killing of family members
- Torture of family members
- Torture of others
Destruction (or stealing) of family property
Places where tortured:
Home
Work place
Prison
Refugee camp
In transit (road blocks)
Military detention
Not recorded
Number (N=310)
%
247
81
47
35
26
37
24
79.7
26
15.2
11.3
8.4
11.9
7.7
31
30
28
62
22
10
9.7
9
20
7.1
80
32
37
106
25.8
10.3
12
34
174
11
24
10
91
43
9
56.1
3.5
7.8
3.2
29.3
13.8
2.8
*Some of the variables are overlapping and thus not mutually exclusive
Direct psychological methods of torture were less often used. Of these the most common was
witnessing the rape, torture and killing of family members, relatives or others 149 (48%).
Destruction of the torture survivors property including homes, household items and livestock
(cows, goats, chicken, pets etc.) occurred to 106 (34%) of the survivors. Verbal threats, threatening
interrogation and false accusations were experienced by 83 (26.8%) of the torture survivors.
Most of the torture took place in peoples homes or while in transit at military check points.
Torture in military detention and prisons was experienced by 22% survivors. All these factors show
that victims were often attacked in their homes, beaten, killed, tortured, raped and their property and
livestock destroyed.
Many fled their homes to live either in the bush or to go to other areas with less conflict
(62%) but often they fell victim to military check points where they were again tortured 91 (29%).
5. Perpetrators
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The period of torture most frequently reported by torture survivors was the period 1979-1985
accounting for 43% cases. This was the period of the most intensified military and political conflicts
in Uganda and hence the most sighted reasons for torture was political and the perpetrators were the
army.
Table 4 summaries the characteristics of the perpetrators, the reasons for torture and the
period of torture broken down into 6 year blocks.
Table 4. Perpetrators of, Period of and Reasons for Torture
Variable
Period of torture:
1965-1971
1972-1978
1979-1985
1986-1998 (2 periods)
Unrecorded
Reasons for torture:
Political
Criminal investigations
Mistaken identity
Refused to give information
Refusal to give sex
Extortion of money
Unrecorded
Perpetrators of torture:
Police
Prison officers
Army
Local Administration
Rebels
Others
Number (N=310)
%
2
4
135
165
4
0.7
1.3
43.4
53.3
1.3
248
11
19
6
10
7
9
80.4
3.5
6
1.8
3.2
2.2
3
16
5
266
11
24
1
5
1.6
85.8
3.4
7.6
0.3
*Some victims were tortured in more than one period or for multiple reasons or by multiple perpetrators.
The twelve year period of 1986-1998 has seen continued fighting between the Uganda
National Army and armed insurgencies which fighting is still on going. Again this points to
political conflict as the reasons for perpetrated torture. This has been more so in Northern and
Western parts of Uganda (3).
Police and prison officers both accounted for 7% of the perpetrators. In this case the reasons
for the torture were for criminal investigation or refusal to give information. This torture in
custody/detention places has been reported frequently in the media and it has been at the hands of
the police and/or prison officers against ordinary civilian prisoners e.g. suspected thieves(3).
Local administrative officials and their defense units often held impromptu courts and meted
out torture during arrest.
6. Consequences of Torture
Table 5 summaries the psychological sequelae of torture suffered by the survivors.
Table 5. Psychological Disorders of the Torture Survivors
Condition
Number (N=310)
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Post traumatic stress disorder:
- Acute
- Chronic
- Complex
- Total
Organic Brain Syndrome (from head trauma)
Depression
Anxiety disorders
Somatoform Disorders
A typical psychosis
Mixed features/psychological disorders
Chronic pain disorder/syndrome
Chronic fatigue
1
206
27
234
10
88
52
99
2
7
255
15
0.3
66.6
8.8
75.7
3.2
28
17
32
0.6
2.2
82
4.8
*Often patients had more than one disorder
The majority of torture survivors attending ACTV suffered from some form of post traumatic
stress disorder (PTSD), as defined by J. Herman (16).
This was especially true of the rebel-abducted torture survivors who, if women were often
forced to marry their abductees. If men they were forcibly recruited in rebel ranks and ordered to
fight for their abductees causes until they would escape. Ten of the victims who were seriously
beaten on the head sustained brain injury resulting in permanent brain damage with signs of chronic
organic brain syndrome often with associated epilepsy.
One hundred and forty (45%) of the torture survivors had depression or anxiety as common
presenting psychological disorders either by themselves or in association with PTSD. These often
presented with significant somatization. Indeed 99 (32%) of the torture survivors had various
somatoform disorders as their main presenting symptoms.
Table 6 summaries the physical complaints and disorders amongst the ACTV treated
survivors. It should be noted that many of these would meet criteria for psychological somatization.
Table 6. Physical Disorders Amongst the Torture Survivors*
Complaints
Number (N=310)
%
Painful scars
Dermatological complaints
Eye problems
E.N.T. problems
Pelvic pains
Chronic headache
Musculoskeletal aches, pains & Fatigue
Fractures
Hernia
Physical deformities
Recurrent coughs
Recurrent "fever" complaints
Excessive sweating
Malaria (Laboratory confirmed)
Anemia (Laboratory confirmed)
STD (Laboratory confirmed)
Hypertension
54
26
45
17
53
120
270
14
24
16
33
69
14
16
16
19
18
17.4
8.3
14.5
5.5
17.1
38.7
86.8
4.5
7.7
5.2
10.6
22.2
4.5
5.2
5.2
6
5.8
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Dyspepsia/ulcers
Intestinal Helminthiasis
Others
87
16
31
28
5.2
10
*Some survivors had more than one complaint.
Many of these physical complaints would meet psychiatric diagnostic criteria for somatization
with many features associated with PTSD and many patients had combinations of these complaints.
A number of victims, however, sustained organic physical injuries including fractures, hernia,
motor paralysis, hemiplegia, contractures and other physical deformities.
Many torture survivors reported torture-related disruptions of their lives including loss of
family members (132) economic difficulties (74) loss of property (106) and displacements (37).
Table 7 summaries the social sequelae as a result of the torture unleashed on the torture
survivors.
Table 7. Social Sequelae of Torture Survivors
Sequelae
Family disruptions:
Lost extended relatives
Spouse killed
Children killed
Spouse and children killed
Spouse, children and relatives killed
Single parenthood
Marital problems
Severe financial problems
Employment problems
Social isolation/destitute
Disabled/handicapped status
Lost property (home belongings, livestock)
Permanently displaced
Number (N=310)
%
132
32
28
15
12
23
18
66
8
22
145
106
37
42.5
10.5
9.0
4.8
3.9
7.4
5.8
21.3
2.6
7.2
46.8
34
12
*Some victims had more than one sequelae
One hundred and forty torture survivors were found to be living a disabled/handicapped status
either due to chronic mental or physical disorders as a result of torture. These were healthy
individuals prior to being tortured. In 27 of the cases, almost the entire family was wiped out
including spouse, children and relatives akin to ethnic cleansing or genocide.
One hundred and six (34%) of the torture survivors had their homes, livestock or household
belongings destroyed and 37 (12%) went into permanent displacement. It should be recalled that all
this happened in a mainly peasant lowly educated country population.
7. Treatment Methods Used
Table 8 summaries the modalities of treatment given at ACTV in Kampala.
Table 8. Treatment Given to the Torture Survivors at ACTV*
Treatement
Mode of treatment:
Community outreach
Outpatients at ACTV
Number (N=310)
%
114
126
36.8
40.6
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Inpatients at ACTV
Referrals to outside consultants:
Surgeon
Gynaecologist
Otolaryngologist
Dermatologist
Dentist
Ophthalmologist
Physician Internist
Modality of treatment:
Psychotherapy
Physiotherapy:
- Exercise
- Massage
- Physical rehabilitation
Pharmacotherapy:
Anxiolytics
Antidepressants
Antipsychotics
Anticonvulsants
Analgesics
Anti-inflamatories
Antibiotics
Antimalarials
Antihelminthics
Antacids
Antihistamines
Others
67
22
110
44
12
10
4
9
16
35.5
13.9
3.9
3.2
1.3
2.9
5.2
305
98.2
257
264
8
82.9
85.2
2.6
138
48
3
6
185
157
179
89
73
56
45
42
44.5
15.5
1.0
1.9
59.4
50.6
57.7
28.7
23.5
18
14.5
14
*Some patients had combinations of these treatments
Table 9 summaries the treatment outcome of the ACTV torture survivors.
Table 9. Duration and Outcome of the Treatment of the ACTV Torture Survivors
Variable
Duration of treatment (months):
<6
6-12
13-24
> 24
Treatment still on going:
Discharged with no symptoms
Discharged with minimal symptoms
Minimal improvement & still on treatment
Absconded from treatment
No improvement & still on treatment
Discharged on request (unimproved)
Referred for treatment elsewhere
Number (N=310)
%
119
42
18
6
125
5
170
125
3
2
3
2
38
13.5
5.3
1.8
40.3
1.6
54.8
40.3
1.0
0.6
1.0
0.7
8. Treatment Outcome
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One hundred and sixty one torture survivors were successfully treated in a period of less than
12 months and discharged. However quite a number of victims needed longer treatment times and
indeed 125 of the victims were still under-going treatment indicating the tendency to chronicity of
PTSD and its associated complications. The thrust of the longer treatment was usually of a
psychotherapeutic nature and occasionally there was need for psychopharmacologic agents
particularly when there was decompensation e.g. when re-experiencing flashbacks and trauma cues
e.g. at the outbreak of war in Congo or when experiencing stressful life events such as bereavement.
There were no behavioural therapy programmes.
9. Prevention
ACTV undertook a number of preventive activities. These included education awareness
workshops directed towards management as well as creating awareness of the torture problem in
Uganda and Human Rights education to the public.
Table 10 Summaries these activities for the 3 year research period of Jan 1st 1996 to Jan 1st
1999.
Table 10. Awareness, Management and Prevention f Torture Education: Seminars and
Workshops
Target group:
Local Administrators
Civic Leader
Police & prisons officers
Military personnel
Schools/institutions
Health workers
Public rallies
Others
Total
Topic:
Community Policing
Good Governance & Democracy
Human Rights
Consequences of Torture
Treatment of Torture
Others
Total
No. of Seminars Held
No.
%
11
15.7
11
15.7
15
21.4
5
7.1
4
5.7
11
15.7
10
14.3
3
4.3
70
100
Total No. of Participants
No.
%
1116
24.7
202
4.5
506
11.2
71
1.6
56
1.2
689
15.2
1704
37.7
176
3.4
4520
100
3
25
30
28
9
3
98
80
1862
1550
2405
569
207
6673
3
25.5
29.4
28.6
9
3
100
1.2
27.9
23.2
36.0
8.5
3.1
100
Some participants attended more than one session or topic
Of the law enforcement officers, police and prison officers were given 15 seminars with 506
participants in all. Military personnel only contributed with 71 of the participants and were given 5
seminars only. This is in contrast to the fact that 85.8% of the survivors reported having been
tortured by armed forces. The most popular and well attended 3 topics were good governance and
democracy, human rights education and torture consequences and their management.
Seminars on good governance and democracy accounted for 25 of the seminars or 1862
participants. Human rights education received 30 seminars with 1550 participants. Seminars on the
consequences of torture were 28 with 2404 participants.
Finally various health providers were also given workshops on the phenomena of torture, its
consequences and treatment. These accounted for 15% of the participants.
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10. Discussion
Most Western studies report on torture survivors who are usually educated professional
refugees and asylum seekers fleeing their home totalitarian regimes e.g. in Latin America (6,7,8).
Our study dealt with torture survivors living in their local home countries. The overwhelming
majority of our torture survivors were low income peasants of low education living in their villages
in the countryside.
The torture perpetrators in this study were armed forces i.e. the army, armed rebels and law
enforcement agents. The survivors were mostly women and children and many reported loss of
relatives especially male spouses who were killed. These findings are similar to those recently
sighted in the Yugoslav Republics (9). Indeed it has often been stated that women and children
make up the majority of the World's refugees, poor and victims of war (17). The most sighted
reasons for torture was political and the torture usually took place in peoples homes or at mounted
military check points.
Most of the affected areas of the country were places where militarized political conflict was
being waged. All these factors go to show that mass political coercion was the reason for fighting
and subsequent torture and points to lack of good governance and democracy in conflict-resolution.
Indeed the period of torture reported by most survivors was the protracted civil war period of 19801985 in the central region followed by the 12 year period of rebel insurgency (1986-1998)
especially in the northern and recently western parts of Uganda (3). These insurgencies have been
increasing with desperate rebel-instigated torture and probably the worst kind of human rights
abuses and torture in all three aspects i.e. physical, psychological and social. Again this emphasizes
the need to find culturally acceptable and democratic means for political conflict-resolution in
Uganda.
The studied ACTV torture survivors were home grown and many are still living in the same
rural communities (10). Thus of the four ACTV treatment models, the outreach service was the
most unique and effective as it took services direct to the people in their rural communities where
the torture took place. The out-patient care, in-patient care and referrals to specialists i.e. the
"Centre" based approach to treatment helped the ambulant and also the referred victims from the far
outlying countryside or from areas where active conflict and war was still raging.
The treatment form mostly used was supportive psychotherapy given that the clientele was
usually rural peasantry with low education. Rehabilitation therapy including legal and financial
redress has only recently been started through initiatives in the Uganda Human Rights court (3).
Often survivors also presented with illness acquired after the torture event e.g. malaria and
helminithiasis and these were treated too at ACTV. Finally most of the studied subjects had longstanding torture related sequelae e.g. chronic or complex PTSD with associated depression anxiety
or somatoform disorders including chronic pains and headaches. Psychopharmacological agents
including minor tranquilizers and antidepressants and analgesics and antinflammatories were used.
These findings are similar to those observed elsewhere in European and most American studies
(8,12). The use of culturally accepted traditional healers has not yet been attempted at ACTV
despite reports of their usefulness (12). Behavioral cognitive therapy and other more intensive
psychotherapy interventions were not attempted although they have been reported to be effective in
the treatment of PTSD (13,14). Group therapy and home visitations were also not used. The reasons
for not using these techniques were mostly logistical, lack of trained personnel or the
unsophistication of peasantry clientelle.
Torture prevention efforts was part of the management strategies employed at ACTV by
initiating non- confrontational education awareness and Human Rights education to the police and
prison officers. There were, however, no seminars on "good-military conduct among civilian
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populations". Nonetheless, the idea of non confrontational but educational targeting of the potential
military perpetrators in prevention work was unique to ACTV and very commendable.
11. Conclusions, Limitations and Recommendations
This was a retrospective study. A good deal of information was not available in the patients'
records or they were inadequately filled out. Secondly the ACTV torture survivors we studied
mostly had chronic disorders having undergone their torture ten or more years ago. Thus the
generalizations and conclusions reached may not pertain to fresh victims of recent torture e.g. the
girl students abducted by rebels in Northern Uganda (3) or the burn victims of the Kichwamba
Technical Institute rebel attack (3).
As this study has shown, the long term sequalae of torture are severely disabling and
incapacitating and frequently run a chronic waxing and warning course. Thus the question of the
role of torture in impeding development efforts in a community therefore begs to be researched and
addressed. It also points to the need to institute early treatment intervention in all areas affected by
armed conflict.
There were more female than male torture survivors attending the ACTV services in a ratio of
2:3 respectively. There is therefore a need to institute gender sensitive treatment programmes and to
address the issue of poverty and low education in this population.
Lastly efforts at primary prevention of armed conflict in Uganda and the world at large
through promotion of good governance and democracy needs to be emphasized as well as the
universal respect for human Rights and democratic principles of conflict-resolution and prevention.
Acknowledgement
We thank DANIDA for funding this research through the African Center for Treatment and
Rehabilitation of Torture Victims (ACTV) and the African Psycare Research Organisation (APRO)
for availing their facilities to this research team.
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