The referral system in action Once a victim has been identified, a needs assessment is conducted, typically by a medical doctor and a psychologist. The project developed standard forms that centres used to conduct this assessment, which had the dual role of assessing the victim and strengthening the quality of the centres’ client files. This simple form allowed all the partner centres to collect comparable data, which could be used to identify trends within the region the types of perpetrators, types of care provided and their effectiveness. Based on the needs assessment, the centre staff decided whether a referral was necessary. If so, the institution that could provide the most appropriate care was identified. This approach was secured by embedding it in a network of referral hospitals. Between 2011 and 2015, the centres identified and signed co-operation agreements with 18 different referral hospitals. These agreements ensured that victims were treated immediately and had an increased range of options when seeking services. By enabling centres to connect with hospitals, the project forged new relationships between institutions that were previously disconnected; and in the case of the hospitals, often did not have an understanding of the role they could play in providing holistic care to victims of torture. The referral hospitals provide an array of physical rehabilitation services, including standard clinical examinations and consultations, in addition to medicine and other treatment prescriptions, surgery and hospital admittance. Through a series of trainings on the medicolegal documentation of torture (using the Istanbul Protocol), high-quality documentation of torture cases was produced, assisting centres in their advocacy and legal activities. These trainings targeted both hospital and centre staff and increased the capacity of individual participants to document torture, as well as facilitating better co-operation between centres and referral institutions to produce quality documentation. The centres not only identify and refer victims to trusted medical institutions to receive appropriate and specialised medical care, but also provide follow-up visits to the referral hospitals. During these visits, victims are provided with direct psychological support and in some cases even food. The medical referral system also focused on secondary victims, such as children, spouses, parents and members of the community close to the victim. Secondary victims were provided with psychological, 14 IRCT Great Lakes Project 1,403 89 539 90 794 415 TOTAL BURUNDI 141 0 TOTAL MEN 769 TOTAL WOMEN 1,328 In addition to the co-ordination and provision of services to primary and secondary victims, rehabilitation centres offer the protection and confidentiality that torture victims seek and need, something state-controlled medical facilities often cannot provide. Through their neutrality and independence vis-à-vis state-controlled institutions, rehabilitation centres can gain the trust of the victims, their family and communities. An essential element in the rehabilitation process. 520 TOTAL DRC 1,044 victims when they return to their communities, and ensure there is follow-up at community level through community-based rehabilitation services. TOTAL RWANDA 534 393 Once a victim has gone through the initial referral process they then move to the post-referral stage. Victims are generally counter-referred to the rehabilitation centre after treatment. They receive whatever further medical assistance they need, as well as legal and psychological support. Before returning to their community, a series of follow-up visits are planned. In many cases, rehabilitation centres continue this follow-up in the form of home visits for months and sometimes even years. Victims are also encouraged to get involved in social counselling groups and income generating activities in the community. TOTAL CHILDREN 884 Victims referred to specialised health institutions for medical treatment psychosocial and sometimes socio-economic support. For example, in 2014 one of the centres in Rwanda received a patient with a serious psychiatric disorder. He was an orphan who had become the head of the household after the Genocide, and was taking care of his two younger sisters. During the Genocide he suffered a serious head injury and his health dramatically deteriorated more than a decade later when he started to suffer from chronic psychiatric problems. His condition had a profound psychological and economic impact on his sisters, who were still dependent on him. The centre referred him to a neuropsychiatric hospital, where he received care for long periods of time. In parallel, the centre supported his sisters by getting them involved in income generating activities and social counselling and ensuring they were kept up to date on the status of their brother’s condition. Finally, the centre provided economic support so they could make the long trip to visit him, and they were often accompanied by a nurse or psychologist from the centre. For me and my brothers, Uyisenga Ni Imanzi got us out of the darkness and gave us hope for the future. They helped me to chase the sadness and the hatred away. Sometimes, I lose my strength and then everything turns bad. But Uyisenga Ni Imanzi is as a parent for me, and when these bad feelings come up, they are always there to give me hope again. E.R., Rwamagana, Rwanda This means that the medical referral system is embedded in a larger rehabilitation approach of a holistic nature; where centres play a pivotal role in co-ordinating, providing and following up on different rehabilitation services. Centre staff support the The support provided by the Great Lakes Project demonstrated that a well-functioning medical referral system is a basic requirement for torture victims to regain the physical and psychological strength required to rebuild their lives and participate actively in society. “I was eight years old when the genocide happened. When my entire family was killed, a neighbour took care of me. I was wounded on my leg, and the scars did not heal. wound Throughout my school years, the ered suff and time would open all the walk ly bare from infections. I could and although I am schooled in carI mechanics, I could not find a job. ne, anyo to ing talk did not feel like unity. and I was an outsider in my comm ly. I I had no friends and felt so lone started to suffer from depression. A “A few years ago, I met ARAMA. ARAM the to me send decided to help me and e my military hospital of Kanombe wher d to leg was operated on. They continue cine be there for me and gave me medi t can’ I s. and therapeutic shoe out describe how it felt to walk with gical pain. They also gave me psycholo and psychosocial support. sleep. “Before I met ARAMA, I couldn’t that ries memo I was afraid of the bad p. always come at night when I slee p Since last week, I started to slee ! gone are es tmar again and the nigh e Thanks to ARAMA, I don’t feel alon talk to anymore, and I have started much to other people again. I feel so better now.” B. M., Rwanda