Cambodians unsure tribunals will heal wounds of mass killings, JAMA study suggests

These skulls, from victims of the Khmer Rouge, are on display in a Buddhist stupa at Choeung Ek, a mass burial site commonly known as one of "the killing fields."

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Aug. 21, 2009 -- Lessons learned from research into the societal effects of post-Apartheid "truth and reconciliation" hearings in South Africa are now being applied to a U.S. National Institute of Peace-sponsored study of the long-term mental health impact on Cambodians from human rights tribunals targeting the killing of millions by the nation's former Khmer Rouge regime, says James L. Gibson, Ph.D., a professor of political science at Washington University in St. Louis and co-author of a study published Aug. 6 in the Journal of the American Medical Association (JAMA).

"This study is a collaboration between medical people, who are interested in problems like PTSD (posttraumatic stress disorder), and political scientists, such as me, who are interested in transitional justice," Gibson explains. "This initial paper focuses on PTSD, but the larger project (funded by a grant from the National Institutes of Health) addresses as well the question of whether the tribunal will create a collective memory in Cambodia and whether that memory will lead to some degree of reconciliation, both with each other and with the past."

Gibson, the Sidney W. Souers Professor of Government in Arts & Sciences at Washington University and a Fellow of the Centre for Comparative and International Politics and Professor Extraordinary in Political Science at Stellenbosch University in South Africa, is the author of "Overcoming Apartheid: Can Truth Reconcile a Divided Nation?" (2004, Russell Sage Foundation). He's been in South Africa this summer conducting further research on issues related to the truth and reconciliation process.

James Gibson

The JAMA study, which Gibson describes as "preliminary to our large, NIH-funded panel survey on the tribunal," explores a central medical question: As leaders of the former Khmer Rouge regime testify in a human rights tribunal, in harrowing detail, for the killing of more than a million Cambodians from 1975 to 1979, will the trials help a society heal or exacerbate the lingering affects of widespread trauma?

The study offers insight, but sustains the paradox: more than 75 percent of Cambodians believe the Khmer Rouge trials, formally called the Extraordinary Chambers in the Courts of Cambodia, will provide justice and promote reconciliation, but more than 87 percent of people old enough to remember the torture and murder during the Khmer Rouge era say the trials will rekindle "painful memories."

"Cambodians have high hopes that the Khmer Rouge trials will deliver justice. However, they also have great fears of revisiting the past," says Jeffrey Sonis, M.D., M.P.H., an assistant professor in the departments of Social Medicine and Family Medicine at the University of North Carolina at Chapel Hill School of Medicine, lead author of the JAMA study. "We just don't know how tribunals affect a society, whether they increase mental and physical disabilities or relieve them," Sonis says.

Sonis, Gibson and their colleagues are now conducting a longitudinal study, funded by the National Institute of Mental Health, to measure the effects of the trials on Cambodians over time.

Preparation for the trials, cosponsored by the Cambodian government and the United Nations, began in 2006, 26 years after the collapse of the Khmer Rouge under its leader, Pol Pot. The first public trial, of Kaing Guek Eav, leader of the notorious Tuol Sleng prison, where thousands were tortured and killed, began earlier this year. Accounts of the genocide estimate between one million and two million people were killed to create an "agrarian collectivism," a communist concept for an ideal society.

Between December 2006 and August 2007, Sonis, Gibson, and an international team of colleagues, including researchers from the Center for Advanced Study in Phnom Penh, conducted a national survey of more than 1,000 Cambodians age 18 and older; 813 were 35 and older and would have been at least 3 years old when the killings began.

Other co-authors on the JAMA study include Joop T. V. M. de Jong, M.D., Ph.D., a professor of cultural and international psychiatry at Vrije Universiteit Medical Center, Amsterdam; Nigel P. Field, Ph.D., professor at the Pacific Graduate School of Psychology; Sokhom Hean, Ph.D., president of Center for Advanced Study, Phnom Penh, Cambodia; Ivan Komproe, Ph.D., of HealthNet TPO, Amsterdam.

More than 14 percent of respondents over age 35, and 7.9 percent of people 18 to 35, suffered from "probable PTSD" (respondents met the criteria for PTSD on a common questionnaire, but did not receive an official clinical diagnosis), which resulted in significant rates of mental and physical disabilities. Previous studies have reported higher rates of PTSD in Cambodians, but were mostly conducted among Cambodia refugees, an atypical population. The rate (11 percent) of probable PTSD among all Cambodians over the age of 18 was more than 5 times the rate among U.S. adults, based on the National Comorbidity Survey.

Among the older group, half said they were close to death during the Khmer Rouge era and 31 percent reported physical or mental torture.

Respondents who did not believe justice had been served, up to the time of the survey, and those who felt the need for revenge were more likely to have PTSD. Also, people who had more knowledge of the trial had higher rates of PTSD. Yet most Cambodians had highly positive attitudes about the trials.

Another paradox emerged from the respondents: Almost half of the respondents in this overwhelmingly Buddhist country thought the trials "go against the teachings of Buddha." However, when asked about attitudes toward the Khmer Rouge, 63 percent of respondents strongly agreed, and 21 percent agreed with the statement, "I would like to make them suffer."

Tribunals to assess crimes of war and crimes against humanity are becoming more common. In June, Charles Taylor, former president of Liberia, answered questions in an international courtroom in Paris about his alleged role in genocide in Sierra Leone in the 1990s. The International Criminal Tribunal for the Former Yugoslavia, a UN-sponsored trial, has been underway since 1993 and the International Criminal Tribunal for Rwanda since 1995. The Nuremberg Trials is perhaps the most well known.

The Khmer Rouge trials offer the opportunity to better gauge the efficacy of these trials, and those lessons hold relevance across a spectrum of injustice. Sonis, Gibson, and their colleagues interviewed 1800 people earlier this year and will re-interview them this fall and again next year. They are currently at work analyzing the first-wave data.

"The larger question raised by our study is whether attempts to promote justice for survivors of violence — whether en masse or inflicted by one individual to another — can help lessen its psychological toll," Sonis says. "We simply don't know the answers yet."

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Editor's Note: This release includes material provided by the news office of the University of North Carolina. For media assistance there, contact Media contact: Clinton Colmenares, (919) 966-8757, ccolmena@unch.unc.edu.