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Aro Village System of Community Psychiatry

in Perspective*

The Aro Village system ofcommunity psychiatry was tal. The program was based in four villages which could
started in Nigeria in 1954 by Dr. T.A. Lambo with the accommodate 200 to 300 patients. The villages were tra-
aim ofmaking use o.ftraditional sociocultural resources ditional villages in Aro on the outskirts of Abeokuta,
of the community in the treatment of mentally sick per- about 100 kilometres from the federal capital of Lagos.
sons. The history ofthe program ispresented, and advan- Aro Hospital, a modern 200-bed psychiatric hospital,
tages and disadvantages are discussed. In addition, the was surrounded by the four villages. Each patient was
future role of the program in the health care delivery admitted to the villages on condition that a well relation
system of Nigeria is discussed with emphasis on how to came to live with him there for the purpose of looking
guarantee the continuing relevance of the vii/age scheme after his basic needs (cooking, washing of clothes, and so
to the socioeconomic realities ofa changing society. forth), taking him to the hospital for treatment in the
morning and bringing him back to the village in the
afternoon. Patients, their relatives and the ordinary vil-

T he village system at Aro was established by Lambo in

1954 as part of an effort to study neuropsychiatric
conditions present in Nigeria and to find out the most
lagers regularly attended social activities, such as films,
traditional plays and dances, in the hospital.
It was discovered that the experience of family
effective approach to treatment (I). One overriding con- members staying with the patients in this way helped to
sideration in starting the experiment was Lambo's strong foster favourable attitudes in the family and the commun-
conviction that community-based treatment of the men- ity (of origin of patient and his relatives) toward the
tally ill was particularly important in Africa owing to the patient, thereby facilitating his rehabilitation (2). The
existence of a closely knit society in which a clearly first phase lasted two years.
defined kinship system prescribed "definite roles and
mutual obligations." The Second Phase:
Another consideration in the setting up of the village Comprehensive Vii/age-Based Services
system was the need to have the simplest treatment The first phase gradually merged into the second one.
method which takes local customs into consideration, an The emphasis was on treating patients in the village
outlook that in fact confirms Lambo's practical orienta- community without the patient going to the hospital at
tion. It was Lambo's belief that a psychiatrist in Africa all. In other words, the villages no longer served merely as
should be able to assume the role of a general practitioner a dwelling place for the patient and his relative. All
because the population from which his patients are treatment facilities were based in the villages, two of
drawn expect a physician to be able to take care of all which had clinics established in them while mobile clinics
sorts and conditions of illness. It is clear from the above visited the others. Dr. Lambo and his team, along with
that Lambo's approach to treatment was deeply rooted in village elders, formed a health council which became
the belief that effective treatment must be based on prac- responsible for planning, administration and execution
tical application of the knowledge of the society's cus- of health projects (including public health) for the vil-
toms and beliefs. lages. Regular meetings of the council occurred at least
once a month. When Dr. Lambo moved to the University
The History of the Aro Village System of Ibadan to take the Chair of Psychiatry, the staff of the
department of psychiatry replaced the Aro Hospital staff
The First Phase: The Day-Hospital Scheme in assisting him to run the treatment centres in the vil-
The day hospital project was started in October 1954as lages. As a result, there are currently no formal links
part of the community psychiatry program of Aro Hospi- between Aro Village and Aro Hospital which is less than
one kilometre away. However, there is a rather close but
*Manuscript received July 1980; revised October 1980.
informal relationship between the personnel in the two
'Senior Lecturer and Consultant Psychiatrist, Department of Psychia- institutions. This facilitates referrals from one facility to
try. University of lbadan, lbadan, Nigeria. the other.
Can. J. Psychiatry Vol. 26, April 1981 Treatment in the clinics in the villages covered a broad

range including electroconvulsive therapy, modified provided at cost to the more sophisticated patients who
insulin therapy, psychopharmacotherapy, group psycho- may not be used to the less attractive conditions in the
therapy and abreactive techniques. The clinics had labor- typical village houses.
atories for routine investigations and also served as Patients with serious medical problems are not admit-
administrative centres for the doctors and nurses. ted to the village but are referred to Aro Hospital or to the
Lambo (3) reports that he employed traditional healers University College Hospital, Ibadan, depending on the
with wide experience in the management of psychiatric nature of the physical illness.
patients. Under the supervision of Dr. Lambo and his There are four psychiatric nurses with many years'
staff the traditional healers ran the social and group experience who run a 24-hour service for admission and
activities of the village patients. Lambo found the tradi- treatment of patients in the village. The nurses live in or
tional healers invaluable in furthering understanding of near the village. They admit patients and start them on
the psychopathology and psychodynamics of psychiatric treatment pending the arrival of consultant psychiatrists
conditions in the patients. from the Department of Psychiatry, University of Iba-
The villagers benefited in several ways from their dan, who visit the village weekly. Treatment is essentially
involvement in the community psychiatry program. as described above, although traditional healers are no
First,they received treatment in the villages when they longer involved.
were physically sick so that only the more serious cases One important feature of treatment in the village is the
were referred to the hospital. Second, the villagers were relaxed pace at which it occurs. There is no pressure for
encouraged to build additional houses, and their incomes beds, a perennial problem at the University College Hos-
increased through renting rooms to patients and in other pital, Ibadan. Consequently, patients are usually kept in
ways. Third, the general living standards were improved the village until both staff and relatives are satisfied that
considerably owing to provision of pipe-borne water, a the patients are well enough to go home. A few weeks'
better sewage disposal system and provision of jobs. notice are usually given before discharge, and this period
The Third Phase is often extended at the request of relatives. Many dis-
It was planned that in the third phase in the develop- charged patients are seen for follow-up care in the psy-
ment of the Aro Village community psychiatry program chiatric clinics at the University College Hospital. Others
an expansion would be carried out to enable the facility are referred to the nearest psychiatrists. Several patients
to treat up to 1,000 patients. Second, hostels were to be prefer outpatient treatment in the village even though it
built in and around the villages to facilitate increased involves considerable time and expense. Thus, some
teaching and training of medical students and mental patients prefer to travel from Lagos, where there are
health workers. It was also intended that a few beds psychiatrists, to be seen in the village by the visiting
would be provided for treatment of patients with acute psychiatrist.
physical illnesses (2). Unfortunately, these changes had The Department of Psychiatry, University of Ibadan,
not occurred before Dr. Lambo moved from Ibadan to located in University College Hospital, at Ibadan, a dis-
Geneva. tance of90 kilometres from Aro Village, continues to run
the treatment facility located in the village. The nurses
and other staff(nurses' assistants, clerk, and so on) are all
The Functioning of the Village System Today employed by the university. One of the nurses is respon-
Organization of the Village System sible for the day-to-day administration but he is respon-
Currently only one village, Aro Village itself, is func- sible to the head of the Department of Psychiatry.
tional. The others have ceased functioning because of Table I shows admissions and discharges of psychiatric
shortage of staff and funds. The admission procedure patients at Aro Village and the University College Hospi-
remains informal, and patients and their relatives con- tal, Ibadan in the years 1975 to 1977. It is clear from the
tinue to come from near and far to seek treatment. Most table that more patients are admitted to the village than
patients are referred by relatives, friends or neighbours, to the hospital, this being due to the previously menti-
who have been treated in the village. At any given time oned fact that there are only nine psychiatric beds in the
there are up to 40 patients (plus their relatives) living hospital, while up to 40 patients can be admitted to the
there. There is a residential block with modern amenities village. The number of Aro Village patients is much
Table I
Psychiatric Admissions and Discharges at Aro
Villageand University College Hospital, Ibadan

1975 1976 1977

Male Female Male Female Male Female
Aro Village 57 52 84 73 80 64
University College
Hospital 5 88 17 66 13 73

smaller than it would have been if duration of admission cribed by Lambo (2) there were three sets of advantages
in the village was as short as in the hospital. It will be - social, medical and economic.
recalled that there is minimal pressure for early discharge Social advantages included active involvement of the
of patients from the village unlike the hospital where such community, with all its sociocultural peculiarities, in psy-
pressure is great indeed. This is reflected in the period of chiatric treatment; promotion of relaxation of negative
time spent by patients in the two institutions, and this community attitudes; provision of a more natural envir-
ranges from several days to a few months for hospital onment for measuring the degree of social competence or
patients and a few weeks to one year for village patients. impairment, this being a striking contrast to the artifi-
Table I also shows a marked disproportion by sex in cially structured environment of a psychiatric hospital;
the use of the two facilities: most patients admitted to and promotion of social adaptation and integration of
University College Hospital were female while, for Aro the patients as well as lessening of the social stigma
Village patients, the females were relatively close in associated with mental illness.
number to males. The' main reason for this finding is that The medical advantages, according to Lambo (2),
there is a 6-bed female ward in the hospital whereas included relatively quick recovery, lessening of the risk of
males, for whom there are only 3 beds, are admitted to the social disability and reduction of problems associated
male medical ward. Two implications of this arrange- with after-care. The opportunity for interdisciplinary
ment are: (a) all things being equal, more females than cooperation and research and for teaching were among
males will be admitted to the hospital; (b) while seriously the advantages of Aro Village system. It should be menti-
disturbed and disruptivefemale patients can be admitted oned that no formal comparative study of the recovery
to the female psychiatric ward, which has a high staff- rate in the village has been done.
patient .ratio, such patients, if they are male, are referred The economic advantages included relatively low cost
to Aro Hospital because the male medical ward is under- of running the program and effective utilization of mea-
staffed and the available nursing staff usually have little gre human and material resources. Collomb (4) also
psychiatric training. claims that his therapeutic villages in Senegal, based on
It may be concluded from the above that Aro Village the Aro Village model, are also cheaper than hospitaliza-
constitutes an important part of the treatment facility tion by as much as 10-20 times.
offered by the Department of Psychiatry, University of The major disadvantage has been described by Lambo
Ibadan. (2); the program can only be carried out in agrarian
economies as found in developing countries. Difficulties
The Role ofAro Village in Undergraduate Teaching and in the program might follow in the wake of social change.
Residency Training Currently, the advantages and disadvantages of the
Right from its inception Aro Village has been an inte- Aro Village system are essentially as described by
gral part of the teaching program of the Department of Lambo. The only additional comment is that difficulties
Psychiatry of the University of Ibadan. Medical students have indeed arisen in the operation of the system. Rapid
regularly go to Aro Village and the adjacent Aro Neuro- socioeconomic change is affecting treatment in the village
psychiatric Hospital for clinical clerkship. Currently, the in important respects. For a few patients on treatment in
students spend two out of their six-week psychiatry post- the village, it becomes necessary for the relatives to travel
ing outside Ibadan. During this time they live in a hostel to their homes for brief periods in order to take care of
in the hospital but not uncommonly some of them stay in one personal problem or another. Second, it is increas-
Aro Village if they are too many for the hostel. Psychia- ingly difficult for patients, especially those from the
trists from the Department of Psychiatry supervise the urban centres, to find relatives able and willing to stay
students' clerkship in Aro village while psychiatrists from with them indefinitely. As a result, many times in the past
both Aro Hospital and the Department of Psychiatry, few years patients seen at the University College Hospital
Ibadan, supervise clerkship done at Aro Hospital. In the who were asked to go to Aro Village for admission
village the students have an opportunity to see a wider because of bed shortage at the hospital have had to be
range of patients, especially actively psychotic patients, treated as outpatients because none of their relatives
than are available at the University College Hospital. could go to the village with them.
In regard to residency training the village plays an In the village itself, it is not uncommon for several
equally important role. Residents have always provided relatives to take turns staying with a patient or for a
much of the service in the village under supervision of patient's relative, who has to go away for one ortwo days,
consultant psychiatrists. Currently one or two residents to ask another person in the village to take care of his
go to the village with a consultant psychiatrist every patient while he is away. In spite of this most patients at
Tuesday and Thursday. Both of them see patients and the Aro Village have very dedicated and concerned relatives
psychiatrist also use's the opportunity to teach the who enthusiastically stay with them throughout their
resident. treatment.
Advantages and Disadvantages of Aro Village System
The Future of Aro Village System of Treatment
Advantages and. disadvantages of the village system as
operated by Lambo up to 1971 (when he left Nigeria) will Although its mode of functioning has changed to some
be considered first, then the current situation. As des- extent, the Aro Village system of community psychiatry

continues to play an important role in the treatment of period of time. If this suggestion is adopted, it becomes
psychiatric patients in Nigeria. Eloquent testimony to easier for several employed relatives to share staying with
this is provided by the fact that most patients are referred a patient, each person staying for a month or so. It should
by those who have benefited from treatment in the village be obvious that it will not be economical for highly paid
in the past and by patients' willingness to travel several workers, unless they are on annual leave, to participate in
hundred kilometres to come to the village, often passing the village treatment under the suggested scheme. Never-
by other psychiatric institutions in the process. The fact theless, most people earn relatively low incomes, which
that the village system has been replicated in other parts from the economic point of view, makes the guaranteed
of Nigeria and in other African countries is further wage scheme workable.
testimony to the significant role of the system (2,4). In spite of incentives to relatives to stay with patients in
What will become of the Aro Village system as Nigeria the village, there will be some persons who have no
changes from its present agrarian orientation and available relatives to accompany them to the village.
becomes an industrialized country? Will the village sys- Such a situation is bound to occur with increasing fre-
tem die slowly because oflack of relatives to stay with the quency partly because of the geographical mobility and
patients? In answering these questions we will pay atten- other recent developments, such as industrialization,
tion to certain issues. First, in spite ofthe general belief- which result in people living and working far away from
and there is some evidence for it - that family ties are their relations. The possibility of employing special
weakening, many persons still have the traditionally assistants to stay with such patients in the village should
strong sense ofloyalty and obligation to their relatives, as be explored. Again, this approach, which should be part
a result of which they will not hesitate to sacrifice time of a comprehensive national health program, has the
and money for taking care of sick relatives. As long as this advantage of lower costs in that village-based treatment
sense of duty exists, there will be a reservoir of relatives is facilitated, thereby minimizing the need for expensive
willing to accompany patients to Aro Village and similar hospital treatment. For emphasis it should be mentioned
facilities. that the three approaches suggested for ensuring con-
However, current experience shows that given willing tinued use of the village system - namely, rotation of
relations, there may still be other difficulties militating two or more relatives instead of one relative staying with
against their going to the village. The increasing complex- a patient throughout his treatment, guaranteed wages for
ity of urban life, especially the trend towards a wage employed relatives who stay with patients in the village,
economy, limits the number of people who can afford the and employment of assistants to stay with patients with-
time to stay indefinitely with a sick relation. Thus, while out available relatives - are not mutually exclusive.
the woman who is a housewife or a petty trader may be Indeed they complement each other, and the first two are
able to leave home or business without serious economic interrelated as has been pointed out earlier.
repercussions, a person who works in an office or a
factory will lose his job if he stays away without authori- Conclusion
zation, or if he is absent for too long even if due permis- The Aro Village system of community-based psychiat-
sion has been given. It is clear then that as more people ric treatment, while not an entirely new idea in that it was
participate in the wage economy, the number of those based on the practice at Gheel (5), has been a major
available to engage in such activities as accompanying a contribution to psychiatric treatment in Nigeria and
relation to Aro Village will dwindle. This development other agrarian economies of developing countries, espe-
will also affect the practice of traditional healers as they cially those of Africa in general, hence its replication in
usually have psychotic patients along with the well rela- Senegal by Collomb (4,6). The resounding success of the
tives of the latter living with them during treatment. scheme derives from the practical application of the tra-
The Aro Village system will remain relevant to the ditional sense of obligation of the African to his kinfolk
needs of the Nigerian society for a long time, given the in time of need.
social and economic advantages mentioned previously. The preference of Nigerians, especially those in the
What is needed then is to make it easier for interested rural areas for traditional healers when seeking treatment
persons to accompany their sick relatives to Aro Village for mental illness, which has been shown in Harding's
in spite of the changing nature of the economy. One study in Nigeria (7), along with the widespread use of
possibility, which has already being tried, is for a few traditional healers in primary health care facilities (8),
relatives to stay with the patient in rotation, one at a time. suggests a large-scale replication of a modified form of
This arrangement ensures that no single person stays with the Aro Village system in other parts of Nigeria. What is
the patient for months on end. being recommended here is the use ofa traditional healer
Another possibility - and it is not unrelated to the last as an assistant to the nurse in charge of each village, as is
one - is to guarantee relatives' wages while they stay done in the villages started by Collomb in Senegal (4).
with patients in the village. This could be part of a nation- As has been discussed in greater detail elsewhere (9), I
wide health insurance program. It will be more economi- support incorporation of traditional healers into the
cal for a person with a relatively low income to take a few health care delivery system so as to facilitate total popula-
months'leave with pay than for the patient to stay in the tion coverage for treatment of physical and mental
hospital (with its high maintenance cost) for the same illness. However, such integration will among other

things necessitate trying to change definitely harmful chiatry. New York: International Universities Press
treatment practices (such as flogging and chaining of 1961 :215-231.
patients) of traditional healers through appropriate re- 2. Lambo T A. Patterns of psychiatric care in developing Afri-
orientation educational measures. Traditional healers can countries. In: Kiev A, ed. Magic, faith and healing.
can and should play an important role in treatment of London: MacMillan, 1964:443-453.
mental illness not only in Aro Village-type treatment 3. Lambo TA. The village of Aro. In: King M, ed. Medical
care in developing countries. Chapter 20, London: Oxford
centres, but also in general hospitals and elsewhere. University Press, 1966.
In regard to Lambo's intention to extend treatment
4. Collomb H. L'economie des villages psychiatriques. Soc
coverage at Aro Village to a thousand patients, it appears Sci Med 1978; 120:113-115.
that this proposal may not yield desired benefits as prob- 5. Lambo TA. The village of Aro. 1964; Lancet ii: 513-514.
lems due to overcrowding and personnel shortage may 6. Collomb H. Recontre de deux systemes de soins. A propos
then arise. Location of similar villages, which can cater de therapeutiques des maladies mentales en Afrique. Soc
for up to a few hundred patients, in everyone of the 19 Sci Med 1973; 7:623-633.
states of the country would appear to be more desirable. 7. Harding T. Psychosis in a rural West African community.
Several states at present have no psychiatric facilities Soc Psychiatry 1973; 8:198-203.
except those provided by traditional and/ or religious 8. Maclean U. Magical medicine. London: Penguin Press,
healers: Initially some of the proposed villages may have 1971.
no access at all to psychiatrists because they are in short 9. Jegede RO. A study of the role of socio-cultural factors in
supply (10), in which case they will depend on nurses as the treatment of mental illness in Nigeria. Soc Sci Med (In
the sole treatment personnel. press).
The relatively meagre financial and human resources 10. Jegede RO. Nigerian psychiatry in perspective. Acta Psy-
of Nigeria and other developing countries demand the chiatr Scand (In Press).
use of cheap and effective methods of treatment. The Aro
Village experiment is thus a bold and imaginative Resume
attempt at achieving this goal. Because it is based on, and Le Dr. T.A. Lambo a instaure en 1954 un systeme de
derives its success from, the sociocultural peculiarities of psychiatrie communautaire de villages Aro dans Iebut de
the society, it must, if it is to maintain its relevance, be
tirer avantage des ressources socio-culturelles tradition-
evaluated constantly in view of the rapidly changing nelles de la communaute dans Ie traitement d'individus
nature of the society, hence the importance of the three
souffrant de maladie mentale. On retrace I'histoire de ce
suggestions aimed at adapting the present organization programme, tout en discutant de ses avantages et de ses
of the village to meet the needs of a society in transition. inconvenients. De plus, on examine Ie role quejouera ce
programme dans Ie systeme nigerien de sante mentale et
References surtout lafacon de garantir lapertinence de la continuite
I. Lambo T A. A plan for the treatment of mentally ill in de cette structure de villages en regard des realites socio-
Nigeria. In: Linn L. ed. Frontiers in general hospital psy- economiques d'une societe en evolution.