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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. 2 Montreux, 4. – 8. 9. 2000 Statistique, Développement et Droits de l‘Homme 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 3 Montreux, 4. – 8. 9. 2000 Statistique, Développement et Droits de l‘Homme 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 4 Montreux, 4. – 8. 9. 2000 Statistique, Développement et Droits de l‘Homme 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. 5 Montreux, 4. – 8. 9. 2000 Statistique, Développement et Droits de l‘Homme 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 6 Montreux, 4. – 8. 9. 2000 Statistique, Développement et Droits de l‘Homme 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 7 Montreux, 4. – 8. 9. 2000 Statistique, Développement et Droits de l‘Homme 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) 8 Montreux, 4. – 8. 9. 2000 % Statistique, Développement et Droits de l‘Homme 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 9 Montreux, 4. – 8. 9. 2000 Statistique, Développement et Droits de l‘Homme 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 10 Montreux, 4. – 8. 9. 2000 Statistique, Développement et Droits de l‘Homme 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 11 Montreux, 4. – 8. 9. 2000 Statistique, Développement et Droits de l‘Homme 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. 12 Montreux, 4. – 8. 9. 2000 Statistique, Développement et Droits de l‘Homme 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 13 Montreux, 4. – 8. 9. 2000 Statistique, Développement et Droits de l‘Homme 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. REFERENCES 1. Kasozi A.B.K.: The social origins of violence in Uganda 1964 - 1985: McGill - Queen's University Press, 1994 2. African Guerillas: Foundation Publishers, Kampala, Uganda. Edited by Christopher Clapham, 1998 3. New Vision and The Monitor Newspapers, Kampala, Uganda. Various articles and news throughout 1997 and 1998 4. 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New York. 1997 17. The Canadian Centre for Victim of Torture (CCVT) News letter. Toronto. March 1999 18. Arcel L.T. (Ed). War Violence, Trauma and the coping Process. IRCT Publication, Copenhagen, Denmark 1998 15 Montreux, 4. – 8. 9. 2000