In the spring of 1994, ethnic tensions in Rwanda erupted into some of the most harrowing scenes of the 20th century. The next one hundred days saw more than 800,000 Tutsi and moderate Hutu dead at the hands of Hutu extremists.1 Neighbors killed each other, often with machetes. The violence was merciless. Although villages were destroyed, the identity of a people remained intact through community, tradition, and morality. It is these core tenets that create meaning and serve as an integral part of responses to atrocities as well as the healing process in general.
Before this healing process could begin in Rwanda, however, there was to be a divisive split as the global community faced an impossible choice. As civilians fled the country in droves into neighboring Zaire (modern-day Democratic Republic of Congo), Tanzania, and Uganda, refugee camps cropped up along these borders. Along with the refugees came Hutu génocidaires hoping to regroup and take advantage of the humanitarian resources offered in the camps.1 Governmental organizations and NGOs such as the Red Cross were aware of the alarming situation but continued to provide aid without discretion or distinction, adhering to a strict practice of neutrality (refusing to take political or military sides while providing aid). For these organizations, neutrality is a guiding principle to preserve access to care, safety of staff, and operational capacity. Neutrality can serve these purposes during crises when aid reaches the intended populations and armed perpetrators cannot exploit camp resources. Rwanda demonstrates what happens when these conditions fail. Médecins Sans Frontières (MSF), also known as Doctors Without Borders, acted differently. Calling for an armed intervention and removing aid from the camps in November of 1994, MSF demonstrated their view of ethical intervention: not unwavering neutrality or an imposing force, but rather an organization conscious of its ethical boundaries.2 The decision showed that withdrawing services (stopping the provision of medical care) and publicly advocating for external protection (calling for outside military interventions) can sometimes be not only ethical but more effective than overbearing aid. This marked yet another instance of MSF’s commitment to moral aid, which started during the Biafran crisis in the late 1960s.3 MSF’s intervention during the genocide showcased the limitations of humanitarian aid and the moral clarity needed to prevent involvement with those causing harm. Handed a situation that was devoid of a clear answer, MSF acted decisively to withdraw complicity and create space for Rwandan healing.
It is this adherence to moral principle that has allowed for not only apparently impossible decisions to be made but also for healing to occur in the face of great suffering. Meaning-making permeates every level of humanitarian aid and is especially visible when it comes to the psychiatric needs of societies in crisis. Meaning-making is how trauma is processed in both a cognitive and somatic sense: creating a narrative from which the pain emerged while also sitting with the physical weight of loss and suffering. It is these two concepts that must be integrated into a society in the form of institutions and policies that allow for healing to take place. Although values across societies are often not constant, humanitarian psychiatry provides a fascinating intersection for the mutual diffusion of learning and healing to take place. While humanitarianism has roots deeply entrenched in colonialism, we have the power to shift the framework moving forward. There is growing recognition of limitations in applying standardized, Western-oriented treatment models without integrating cultural elements. As the playbook is rewritten, there is an opportunity to look to the voices that have contemplated suffering on its deepest, most existential level. This allows for a look beyond the physical condition and a move towards the mental ramifications of suffering. Western medicine has historically emphasized a body-mind separation in many clinical contexts. Research suggests that, in some contexts, this approach might not only be inefficient but can also perpetuate the injustice and invalidation felt by those suffering.4 Those who have stared into the jaws of suffering and despair often come not from the clinic but instead from the typewriter. It was Albert Camus who insisted that the fundamental meaninglessness and absurdity of the world was not a cause for despair but instead a canvas from which one could sketch their own meaning.5 This radical free will also implies that meaning cannot be handed down or prefabricated but instead distilled from one’s own experiences and culture. From every instance of suffering must come an organic resolution. The only meaning that aid should create is the one that the culture presents, resulting in a collaboration between foreign actors and communities that respects both parties’ morals while remaining efficient. The act of creating meaning has been reflected in international doctrine, including the UN’s Resolution 1514 (XV, 1960), “All peoples have the right to self-determination; by virtue of that right they freely determine their political status and freely pursue their economic, social and cultural development.”6 Humanitarian aid must provide the resources necessary to heal while allowing the space for communities to construct meaning where it was previously destroyed.
When humanitarian aid is provided in camps, there is a core set of metrics that can be used to assess its efficacy. Health outcome indicators include mortality rates and disease incidence rates due to overcrowding and lack of sanitation, consistent with the established framework for humanitarian response.7 Protection and rights indicators, including exposure to violence, obstruction of safe return for civilians, and deprivation of autonomy/rights, are primarily observed through monitoring and operational reports and serve as protection and rights indicators. Together, these numbers allow for an evaluation of whether harm is being continued in the camps. In the Goma refugee camps in Zaire during 1994, the crude mortality rate reported by the Office of the United Nations High Commissioner for Refugees was 20-35 deaths/10,000/day, far exceeding the 0.5 deaths/10,000/day emergency threshold outlined by Sphere, meaning minimum standards were not met.8 Reports from MSF personnel documented the presence of inequitable distribution of resources through intimidation and coercion by armed actors inside the camps, many of whom were alleged génocidaires. The continual failure of NGOs to create safe conditions in refugee camps, largely due to violent actors, meant that pulling out of the camps was a necessary political move until safe conditions could be obtained. For future disasters, Rwanda serves as an important case study: when camp resources are diverted to armed actors instead of reaching vulnerable populations, withdrawal of services becomes not only morally sound but operationally necessary. NGOs must rely on the aforementioned metrics to decide if the aid provided is genuinely helping those in need or if it perpetuates harm.
With the right to self-determination in mind, the Rwandan Patriotic Front entered Kigali on July 4th, 1994, led by Paul Kagame, who would later become the president of Rwanda.1 This effectively ended the genocide but was only the beginning of an ongoing healing process. With the installation of the new government, two major policy developments would reflect the cultural values of Rwanda: the Gacaca courts and National Unification. Established in 2002, the Gacaca courts included community-appointed elders as judges for lower-level cases that pertained to the genocide.9 Although it received international criticism for its perceived lack of due process, it allowed communities the ability to reconcile and obtain justice in a local and personal way. In addition to these courts, the Kagame administration formed the National Unification and Reconciliation Commission (NURC), which abolished ethnic identity cards that had been in existence since colonial times. It also included the support of Abunzi mediators, community members who functioned to resolve disputes on a small scale to solve issues as they cropped up, complementing the Gacaca courts. These policies were implemented against the backdrop of humanitarian aid, which created a stable springboard from which these culturally informed, Rwandan-led policies could be put in place. It allowed for meaning-making to occur on individual, community, and national levels. From a reality devoid of meaning or order sprouted a new national identity created largely by the people. This collaboration is a model for what might define modern humanitarianism, as the dependency structures of past aid are replaced by frameworks in which cultures lead the way to their own destiny.
Meaning-making is not merely a matter of respect or cultural humility but also serves to restore agency and faith in systems. As a result of armed violence dictating resource distribution, inequalities can emerge in refugee camps. These both create as well as exacerbate existing problems: malnutrition, disease, and violence. Until these factors are corrected, societies are unable to restore their own agency and humanitarian work cannot function. Rwanda’s Gacaca courts and Abunzi mediators showcase that locally led options can serve to help process collective trauma while external systems only provide resources.
Although the reforms pushed by Kagame’s administration generally served to foster the rebuilding of Rwandan society following the genocide, they are not without consequence. These come primarily in the form of human rights abuses, with limited freedom of speech landing dissenting journalists, activists, and candidates in jail.10 These tradeoffs are real and contested. Despite this, Rwanda’s Human Development Index has increased from 0.294 in 1994 to 0.578 in 2023, indicating significant progress alongside limited freedoms.11
The failure of humanitarian aid usually lies in an assumption of shared meaning between the Western cultures providing aid and those receiving it. A forced adherence to a predetermined set of values only serves to further colonial structures and acts as a band-aid. Examples of ignorance here are also part of the story of Rwanda: those same camps that MSF pulled back from were still staffed by the UN and other NGOs. They believed that the Western humanitarian ideal of neutrality would carry into the camps seamlessly; however, they provided aid to those perpetrating the genocide and allowed the horrors to continue. This situation demonstrated that any notions of right and wrong that are brought alongside the aid can serve to counteract good faith efforts; meaning can only be conceived through understanding the entire picture. What is required is a listening ear in addition to resources. Governmental organizations and NGOs often reduce aid to a ubiquitous checklist to make the process “efficient” and remove the cognitive labor of those coordinating the efforts.
Rwanda demonstrates how humanitarian aid can be most effective when it is approached with morality and restraint. MSF showed that space could be left for Rwandans to create their own avenues for justice and meaning while remaining effective. The Gacaca courts and NURC initiatives allowed for the creation of societal purpose from devastation. With the international community providing resources, the reconstruction efforts were led by Rwandans. Meaning-making occurred at every level: foreign actors knew their limitations while Rwandans created community-led justice efforts. Modern humanitarian aid now has the ability to look towards a locally led approach to providing aid. The question now lies in whether governments and NGOs will learn from what happened in Rwanda and give space and care to those trying to create meaning in the wake of unimaginable tragedy.
Acknowledgements
This commentary was inspired by Dan Bartolotti’s Hope in Hell, which shaped the author’s understanding of ethics in global health and the nuances of providing humanitarian aid.
Disclosure Statement
The author has no relevant financial disclosures or conflicts of interest.
Author Positionality Statement
The author is an undergraduate student at Northwestern University studying global health and psychology. He acknowledges that his education at a Western institution, as well as his interest in humanitarian psychiatry, influences his worldview. This, in turn, shaped the analysis, which was made through field reports, historical accounts, and data collected during the Rwandan genocide.
Author Biography
Alexander Myers is a junior at Northwestern University pursuing a degree in Jazz Performance with a minor in Global Health on the pre-med track. He conducts research in Northwestern’s ADAPT Lab examining psychiatric risk factors in adolescents and has founded the university’s psychedelics research club. Myers is interested in integrating trauma-informed care and humanitarian psychiatry.