title: Exposure to genocide and risk of suicide in Rwanda: a population-based case-control study.
abstract: BACKGROUND
  In Rwanda, an estimated one million people were killed during the 1994 genocide, leaving the country shattered and social fabric destroyed. Large-scale traumatic events such as wars and genocides have been linked to endemic post-traumatic stress disorder, depression and suicidality. The study objective was to investigate whether the 1994 genocide exposure is associated with suicide in Rwanda.
  
  
  METHODS
  We conducted a population-based case-control study. Suicide victims were matched to three living controls for sex, age and residential location. Exposure was defined as being a genocide survivor, having suffered physical/sexual abuse in the genocide, losing a first-degree relative in the genocide, having been convicted for genocide crimes or having a first-degree relative convicted for genocide. From May 2011 to May 2013, 162 cases and 486 controls were enrolled countrywide. Information was collected from the police, local village administrators and family members.
  
  
  RESULTS
  After adjusting for potential confounders, having been convicted for genocide crimes was a significant predictor for suicide (OR=17.3, 95% CI 3.4 to 88.1). Being a survivor, having been physically or sexually abused during the genocide, and having lost a first-degree family member to genocide were not significantly associated with suicide.
  
  
  CONCLUSIONS
  These findings demonstrate that individuals convicted for genocide crimes are experiencing continued psychological disturbances that affect their social reintegration into the community even 20 years after the event. Given the large number of genocide perpetrators reintegrated after criminal courts and Gacaca traditional reconciling trials, suicide could become a serious public health burden if preventive remedial action is not identified.
authors.affiliation: Department of Epidemiology and Biostatistics, University of Rwanda College of Medicine and Health Sciences, School of Public Health, Kigali, Rwanda Rwanda National Police, Directorate of Medical Service, Kigali, Rwanda.
authors.forename: Wilson
authors.initials: W
authors.lastname: Rubanzana
authors.affiliation: Department of Epidemiology and Biostatistics, University of Rwanda College of Medicine and Health Sciences, School of Public Health, Kigali, Rwanda Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.
authors.forename: Bethany L
authors.initials: BL
authors.lastname: Hedt-Gauthier
authors.affiliation: Department of Epidemiology and Biostatistics, University of Rwanda College of Medicine and Health Sciences, School of Public Health, Kigali, Rwanda.
authors.forename: Joseph
authors.initials: J
authors.lastname: Ntaganira
authors.affiliation: Oregon Health & Science University, School of Medicine, Portland, Oregon, USA Faculty of Medicine, Section of Forensic Medicine, Umeå University, Umeå, Sweden Faculty of Health Sciences, Department of Forensic Medicine, Aarhus University, Aarhus, Denmark.
authors.forename: Michael D
authors.initials: MD
authors.lastname: Freeman
mesh_terms: D000328:Adult; D016022:Case-Control Studies; D005260:Female; D063365:Genocide / Q000208:ethnology / Q000523:psychology*; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011329:Prisoners / Q000523:psychology; D065840:Protective Factors; D012111:Residence Characteristics; D012307:Risk Factors; D012432:Rwanda / Q000453:epidemiology; D012742:Sex Offenses / Q000523:psychology; D012944:Social Support; D013313:Stress Disorders, Post-Traumatic / Q000453:epidemiology / Q000209:etiology / Q000523:psychology*; D013405:Suicide / Q000523:psychology* / Q000706:statistics & numerical data; D017741:Survivors / Q000523:psychology*; D014104:Torture / Q000523:psychology; D055815:Young Adult
keywords: EPIDEMIOLOGY; HEALTH STATUS; SUICIDE