- Email: [email protected]
The Village of Aro
513
sity of Ibadan, it has had full charge of teaching, clinical work, and research in the villages. Clinics have been built in two of the villages, at which treatment and of fascinating to see these pictures endoreduplication pathological investigations can be carried out. A small in leukxmia cells. But the real problem is to learn why mobile clinic serves more distant villages. In a venture of this sort the practical details of managea process so regularly seen in caterpillar kidneys and spinach roots, and in so many other normal tissues, ment can be decisive in determining success or failure. should be so rare in the normal precursors of the Family-care systems in European countries have foundered on this rock. At Aro shrewd precautions leukxmia cells. reflect the foresight and local knowledge of the psychiatrists. The ratio of villagers to patients is fixed at 3 to 2. The Village of Aro Substantial benefits have been extended to the particiIT is a long way from Antwerp to Abeokuta, but the pating villages: they have piped water, a mosquito cultural distance is not great between the shrine of eradication squad, and pit latrines; the villagers’ St. Dymphna near the one and the Aro village com- economic level has been raised through their employmunity near the other. When the legendary Irish ment as gardeners and porters in the clinics and the princess fled from her incestuous father, to be martyred hospital; they are paid lOs. a month for acting as the at Gheel, she gave the impetus for a religio-social hosts, or landlords, of the patients; and loans are available development which now, after thirteen centuries, can be to them to build new houses to accommodate the called by the same modern names as the Nigerian centre patients and their escorts. Patients of every sort are admitted to the villages and -therapeutic community, village day hospital, mental health unit. The story of how Gheel grew into its treated within the village community and services. present shape and functions has been often told, but the Even violent and otherwise grossly disturbed patients short history of Aro is less well known. are accepted and effectively dealt with, outside the In 1954 a Yoruba physician, Dr. ADEOYE LAMBO, who hospital. An advantage of the organisation (though received his medical education in this country, founded necessitated by the limited medical resources for a large a day hospital as part of the mental health services for population) is that physical illnesses such as asthma and the Western Region of Nigeria. He soon perceived that malnutrition are also treated as they arise. LAMBO by taking account of the sense of social security which believes that in the traditional environment to which the African patient derives from his closely knit rural patients are exposed in the villages there are forces that society, with its well-defined groups and traditional protect the mentally ill against social pressures. " Conroles, the benefits of the day hospital could be greatly fession, dancing, rituals, suggestions inherent in tradiextended. LAMBO grafted on to four villages at Aro tional cults, flexibility and tolerance of the environment, (which is a suburb of Abeokuta) a therapeutic unit to mention a few, could be mobilised and utilised as accommodating between 200 and 300 patients who powerful psychotherapeutic armament, especially in came from a wide area. They did not come alone: it was psychoneurosis." required that they should be in the care of at least one Nothing could more tellingly illustrate LAMBO’s use many lines in cancer research, one finds oneself asking not so much why the tumour cell acts as it does but why the normal cell does not. It is As in
so
relative, who would look after their material needs and escort them to hospital and back each day for their It appeared that those who were boarded out in one of the villages in this way more quickly adapted themselves to their situation than those who were taken into hospital, and that this was largely the result of their contact with a settled, tolerant, and healthy environment, in which, as LAMBO put it, " the ego of the patient should be able to gain sufficient strength to function without overwhelming anxiety. Reality testing could go on without any fear of the ego being further traumatized ". The relatives who accompanied the patient discovered how the doctors and other professional workers regarded mental illness, and so acquired -a desirable attitude towards the patient’s disorder, which would be of special importance when they all returned from the village centre at Aro to their homes. After a couple of years the village services were further organised and consolidated. The physicians took full responsibility for the administration and public health of the villages; the villagers had a voice in these matters through monthly meetings between the hospital staff and the village elders. Since the professorial department of psychiatry has been set up at the Univertreatment.
of the traditional elements in Yoruba culture than his collaboration with native healers-more commonly known as witch-doctors. Like Dr. TiGANi EL-MAHI, his erudite colleague in the Sudan, LAMBO has chosen to bring the " medicine men " within the scope of his programme of treatment, though he is well aware of the reasons why Western psychiatrists would refrain from giving countenance to the magical practices and the supernatural beliefs upon which the native healers base their activities. African patients, whether educated or illiterate, tend to regard their dreams as actual happenings and their illnesses as possibly due to witchcraft or possession. " The Yoruba native doctor," wrote Dr. R. PRINCE, a psychiatrist who has studied the matter in the Western Region, sees a good deal of his work as protecting his patients from witchcraft, against malevolently-used words (i.e., curse, incantation and invocation) and against various other types of homeopathic and contagious magics ... It is true that many native doctors have some conception of the physical causation of disease ... still the elements of witchcraft and sorcery are much emphasised."1 That incisive observer, MARY KINGSLEY, said of the medicine men that they do more "
1.
J.
ment.
Sci. 1961, 107, 799.
514
than harm, and that their practices bespeak an " elaborated common sense ". This was how they seemed before they had come much in contact with Western civilisation. In the face of that contact they have not wilted or dwindled : EvANS PRITCHARD and other anthropologists have recognised their adaptability, their readiness to take over new methods and medicines, their consequent increase in influence, and the spread of their magical practices which the people believe in. Animistic notions about disease have their repellent aspects, as the history of witchcraft sadly records; but it seems that in Ghana, Nigeria, the Sudan, and other parts of Africa the cruelty and injustice which such notions induced have been cut to a minimum, and their therapeutic power in psychological disturbances has been retained or strengthened. It by no means follows that the present conjunction of native healers and psychiatrists will continue happily when the cultural system has become more stable, but in the contemporary transitional phase there is much efficacy in the methods of suggestion and abreaction, seasoned with shrewd appraisal of motives, which the native healers employ. LAMBO noted that around Abeokuta in 1955 eight times as many patients were dealt with at native treatment centres as at the psychiatric centres in the villages. By 1958, however, there were three times as many patients under village care as at the native treatment centres.
good
Annotations PREVENTIVE MEDICINE IN UNDERGRADUATE TEACHING
A REPORT1 by a W.H.O. expert committee discusses the teaching of preventive medicine to the undergraduate in terms of who should teach it, as well as when, how, and where it should be taught. None will question the recommendation that each undergraduate medical school should have a professorial department. The report might have further emphasised that for the developing countries the department of preventive medicine should, in staff, budget, teaching, and research facilities, perhaps be the strongest in the school. About the qualifications of teachers, the report is rather idealistic: it might have been more helpful for the committee to suggest what the minimum requirements should be-for example, a good foundation of clinical training and experience as well as a training in public health. There are, alas, too few people with these basic qualifications teaching preventive medicine, especially in the tropics. There is little doubt that preventive medicine should be taught in both preclinical and clinical years, and the guiding principles suggested by the expert committee are admirable. In fact, at least two schools in the tropics, Ibadan in Nigeria2 and Cali in Colombia3 are already successfully teaching preventive medicine as a continuous process from the beginning of medical studies. The contents of the teaching programme will vary according to the medical needs of the countries, and a frequent reappraisal of the situation is vital, especially in 1. Promotion of Medical Practitioners’ Interest in Preventive Medicine. Wld Hlth Org. tech. Rep. Ser., no. 269, 1964. Obtainable from H.M. Stationery Office, P.O. Box 569, London, S.E.1. 2. Gilles, H. M. Proceedings of Seventh International Congresses on Tropical Medicine and Malaria; p. 379. 1963. 3. Velazquez, P. ibid. p. 379.
at Aro, the disposal of patients who did and whose relatives could not continue to improve, with them in the villages indefinitely, became a stay serious problem. Partial solutions are being worked out by trial and error. Some such patients are now living on selected farms; others live in Aro villages near the hospital and earn their keep, but need regular supervision. The similarity to the problems of Gheel is patent, and the methods of rehabilitation or support are common to the two centres. Among the advantages of the Aro system are the means it affords for epidemiological study of mental illness. The most notable fruits of this are provided by the monograph, Psychiatric Disorder among the Yoruba,2 which sets out the findings of the rapid but careful investigation made by ALEXANDER and DOROTHEA LEIGHTON, of Cornell University, with the cooperation of LAMBO and a number of American and African workers. It is a prelude and an invitation to more detailed studies of the determinants, the course, and the possible prevention of the various mental disorders in Western Nigeria, which have much the same general characters as in other peoples and other continents.
After
a
time,
not
Leighton, A. H., Lambo, T. A., Hughes, C. C., Leighton, D. C., Murphy, J. M., Macklin, D. B. Psychiatric Disorder among the Yoruba. New York and London, 1963. See Lancet, 1964, i, 477.
2.
developing countries. At present, the main preoccupations of these countries are the mass diseases, hygiene, environmental control, and nutritional problems; some years from now this will alter. The teaching should the
include reviews of health services, assessment of their merits, and discussion of improvements. It is the duty of the staffs of the departments of preventive and social medicine to acquaint themselves with the problems that arise in planning a health service for a particular community. They should reveal shortcomings, after careful inquiry, and suggest how to remedy defects. Finally, the W.H.O. committee discusses how and where preventive medicine should be taught. Their emphasis on active as opposed to passive work in the teaching and learning of preventive medicine is unquestionable. The old concept of hygiene exclusively taught in the lecture-room is obsolete, and guaranteed to antagonise any student. Ideally, the teaching of preventive medicine takes place in the community, with the fewest possible hours in the lecture-theatre. In Puerto Rico, for example, students were given opportunities to participate in the work of health centres which were being set up as part of a programme of regionalisation of medical care.4 In Ibadan the Ibarapa project5 was launched in February, 1963. There will be six batches of students attached to the project every year, each batch consisting of 12-16 fourth-year medical students, who will spend two months in the district. During teach posting, students will one month about spend working in the community health the and the laboratory, and the other centre, clinics, month will be devoted to current research programmes in health statistics, epidemiology, the social aspects of obstetrics and pxdiatrics, and environmental health, as well as in the supervision of the primary health units in 4. 5.
Seipp, C. Lancet, 1963, i, 1364. Ogunlesi, T. O. Ibarapa Project. University of Ibadan, 1964. See Lancet, 1964, i, 813.
sity of Ibadan, it has had full charge of teaching, clinical work, and research in the villages. Clinics have been built in two of the villages, at which treatment and of fascinating to see these pictures endoreduplication pathological investigations can be carried out. A small in leukxmia cells. But the real problem is to learn why mobile clinic serves more distant villages. In a venture of this sort the practical details of managea process so regularly seen in caterpillar kidneys and spinach roots, and in so many other normal tissues, ment can be decisive in determining success or failure. should be so rare in the normal precursors of the Family-care systems in European countries have foundered on this rock. At Aro shrewd precautions leukxmia cells. reflect the foresight and local knowledge of the psychiatrists. The ratio of villagers to patients is fixed at 3 to 2. The Village of Aro Substantial benefits have been extended to the particiIT is a long way from Antwerp to Abeokuta, but the pating villages: they have piped water, a mosquito cultural distance is not great between the shrine of eradication squad, and pit latrines; the villagers’ St. Dymphna near the one and the Aro village com- economic level has been raised through their employmunity near the other. When the legendary Irish ment as gardeners and porters in the clinics and the princess fled from her incestuous father, to be martyred hospital; they are paid lOs. a month for acting as the at Gheel, she gave the impetus for a religio-social hosts, or landlords, of the patients; and loans are available development which now, after thirteen centuries, can be to them to build new houses to accommodate the called by the same modern names as the Nigerian centre patients and their escorts. Patients of every sort are admitted to the villages and -therapeutic community, village day hospital, mental health unit. The story of how Gheel grew into its treated within the village community and services. present shape and functions has been often told, but the Even violent and otherwise grossly disturbed patients short history of Aro is less well known. are accepted and effectively dealt with, outside the In 1954 a Yoruba physician, Dr. ADEOYE LAMBO, who hospital. An advantage of the organisation (though received his medical education in this country, founded necessitated by the limited medical resources for a large a day hospital as part of the mental health services for population) is that physical illnesses such as asthma and the Western Region of Nigeria. He soon perceived that malnutrition are also treated as they arise. LAMBO by taking account of the sense of social security which believes that in the traditional environment to which the African patient derives from his closely knit rural patients are exposed in the villages there are forces that society, with its well-defined groups and traditional protect the mentally ill against social pressures. " Conroles, the benefits of the day hospital could be greatly fession, dancing, rituals, suggestions inherent in tradiextended. LAMBO grafted on to four villages at Aro tional cults, flexibility and tolerance of the environment, (which is a suburb of Abeokuta) a therapeutic unit to mention a few, could be mobilised and utilised as accommodating between 200 and 300 patients who powerful psychotherapeutic armament, especially in came from a wide area. They did not come alone: it was psychoneurosis." required that they should be in the care of at least one Nothing could more tellingly illustrate LAMBO’s use many lines in cancer research, one finds oneself asking not so much why the tumour cell acts as it does but why the normal cell does not. It is As in
so
relative, who would look after their material needs and escort them to hospital and back each day for their It appeared that those who were boarded out in one of the villages in this way more quickly adapted themselves to their situation than those who were taken into hospital, and that this was largely the result of their contact with a settled, tolerant, and healthy environment, in which, as LAMBO put it, " the ego of the patient should be able to gain sufficient strength to function without overwhelming anxiety. Reality testing could go on without any fear of the ego being further traumatized ". The relatives who accompanied the patient discovered how the doctors and other professional workers regarded mental illness, and so acquired -a desirable attitude towards the patient’s disorder, which would be of special importance when they all returned from the village centre at Aro to their homes. After a couple of years the village services were further organised and consolidated. The physicians took full responsibility for the administration and public health of the villages; the villagers had a voice in these matters through monthly meetings between the hospital staff and the village elders. Since the professorial department of psychiatry has been set up at the Univertreatment.
of the traditional elements in Yoruba culture than his collaboration with native healers-more commonly known as witch-doctors. Like Dr. TiGANi EL-MAHI, his erudite colleague in the Sudan, LAMBO has chosen to bring the " medicine men " within the scope of his programme of treatment, though he is well aware of the reasons why Western psychiatrists would refrain from giving countenance to the magical practices and the supernatural beliefs upon which the native healers base their activities. African patients, whether educated or illiterate, tend to regard their dreams as actual happenings and their illnesses as possibly due to witchcraft or possession. " The Yoruba native doctor," wrote Dr. R. PRINCE, a psychiatrist who has studied the matter in the Western Region, sees a good deal of his work as protecting his patients from witchcraft, against malevolently-used words (i.e., curse, incantation and invocation) and against various other types of homeopathic and contagious magics ... It is true that many native doctors have some conception of the physical causation of disease ... still the elements of witchcraft and sorcery are much emphasised."1 That incisive observer, MARY KINGSLEY, said of the medicine men that they do more "
1.
J.
ment.
Sci. 1961, 107, 799.
514
than harm, and that their practices bespeak an " elaborated common sense ". This was how they seemed before they had come much in contact with Western civilisation. In the face of that contact they have not wilted or dwindled : EvANS PRITCHARD and other anthropologists have recognised their adaptability, their readiness to take over new methods and medicines, their consequent increase in influence, and the spread of their magical practices which the people believe in. Animistic notions about disease have their repellent aspects, as the history of witchcraft sadly records; but it seems that in Ghana, Nigeria, the Sudan, and other parts of Africa the cruelty and injustice which such notions induced have been cut to a minimum, and their therapeutic power in psychological disturbances has been retained or strengthened. It by no means follows that the present conjunction of native healers and psychiatrists will continue happily when the cultural system has become more stable, but in the contemporary transitional phase there is much efficacy in the methods of suggestion and abreaction, seasoned with shrewd appraisal of motives, which the native healers employ. LAMBO noted that around Abeokuta in 1955 eight times as many patients were dealt with at native treatment centres as at the psychiatric centres in the villages. By 1958, however, there were three times as many patients under village care as at the native treatment centres.
good
Annotations PREVENTIVE MEDICINE IN UNDERGRADUATE TEACHING
A REPORT1 by a W.H.O. expert committee discusses the teaching of preventive medicine to the undergraduate in terms of who should teach it, as well as when, how, and where it should be taught. None will question the recommendation that each undergraduate medical school should have a professorial department. The report might have further emphasised that for the developing countries the department of preventive medicine should, in staff, budget, teaching, and research facilities, perhaps be the strongest in the school. About the qualifications of teachers, the report is rather idealistic: it might have been more helpful for the committee to suggest what the minimum requirements should be-for example, a good foundation of clinical training and experience as well as a training in public health. There are, alas, too few people with these basic qualifications teaching preventive medicine, especially in the tropics. There is little doubt that preventive medicine should be taught in both preclinical and clinical years, and the guiding principles suggested by the expert committee are admirable. In fact, at least two schools in the tropics, Ibadan in Nigeria2 and Cali in Colombia3 are already successfully teaching preventive medicine as a continuous process from the beginning of medical studies. The contents of the teaching programme will vary according to the medical needs of the countries, and a frequent reappraisal of the situation is vital, especially in 1. Promotion of Medical Practitioners’ Interest in Preventive Medicine. Wld Hlth Org. tech. Rep. Ser., no. 269, 1964. Obtainable from H.M. Stationery Office, P.O. Box 569, London, S.E.1. 2. Gilles, H. M. Proceedings of Seventh International Congresses on Tropical Medicine and Malaria; p. 379. 1963. 3. Velazquez, P. ibid. p. 379.
at Aro, the disposal of patients who did and whose relatives could not continue to improve, with them in the villages indefinitely, became a stay serious problem. Partial solutions are being worked out by trial and error. Some such patients are now living on selected farms; others live in Aro villages near the hospital and earn their keep, but need regular supervision. The similarity to the problems of Gheel is patent, and the methods of rehabilitation or support are common to the two centres. Among the advantages of the Aro system are the means it affords for epidemiological study of mental illness. The most notable fruits of this are provided by the monograph, Psychiatric Disorder among the Yoruba,2 which sets out the findings of the rapid but careful investigation made by ALEXANDER and DOROTHEA LEIGHTON, of Cornell University, with the cooperation of LAMBO and a number of American and African workers. It is a prelude and an invitation to more detailed studies of the determinants, the course, and the possible prevention of the various mental disorders in Western Nigeria, which have much the same general characters as in other peoples and other continents.
After
a
time,
not
Leighton, A. H., Lambo, T. A., Hughes, C. C., Leighton, D. C., Murphy, J. M., Macklin, D. B. Psychiatric Disorder among the Yoruba. New York and London, 1963. See Lancet, 1964, i, 477.
2.
developing countries. At present, the main preoccupations of these countries are the mass diseases, hygiene, environmental control, and nutritional problems; some years from now this will alter. The teaching should the
include reviews of health services, assessment of their merits, and discussion of improvements. It is the duty of the staffs of the departments of preventive and social medicine to acquaint themselves with the problems that arise in planning a health service for a particular community. They should reveal shortcomings, after careful inquiry, and suggest how to remedy defects. Finally, the W.H.O. committee discusses how and where preventive medicine should be taught. Their emphasis on active as opposed to passive work in the teaching and learning of preventive medicine is unquestionable. The old concept of hygiene exclusively taught in the lecture-room is obsolete, and guaranteed to antagonise any student. Ideally, the teaching of preventive medicine takes place in the community, with the fewest possible hours in the lecture-theatre. In Puerto Rico, for example, students were given opportunities to participate in the work of health centres which were being set up as part of a programme of regionalisation of medical care.4 In Ibadan the Ibarapa project5 was launched in February, 1963. There will be six batches of students attached to the project every year, each batch consisting of 12-16 fourth-year medical students, who will spend two months in the district. During teach posting, students will one month about spend working in the community health the and the laboratory, and the other centre, clinics, month will be devoted to current research programmes in health statistics, epidemiology, the social aspects of obstetrics and pxdiatrics, and environmental health, as well as in the supervision of the primary health units in 4. 5.
Seipp, C. Lancet, 1963, i, 1364. Ogunlesi, T. O. Ibarapa Project. University of Ibadan, 1964. See Lancet, 1964, i, 813.