Epi.1985.Jackson.socsciMed.malaria in Liberian Children and Mothers Bio Cultural Perceptions of...

8/14/2019 Epi.1985.Jackson.socsciMed.malaria in Liberian Children and Mothers Bio Cultural Perceptions of Illness vs Clinical

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Sm. Sci. Med. Vol. 20, No. 12, pp. 1281-1287, 1985Printed in Great Britain. All rights reserved

0277-9536/853.00+ 0.00Copyright 0 1985Pergamon PressLtd

MALARIA IN LIBERIAN CHILDREN AND MOT HERS:

BIO CULTURAL PERCEPTIONS OF ILLNESS VS CLINICAL

EVIDENCE OF DIS EASE

LINDA COLLIER ACKSONDepartment of Anthropology, University of California, Berkeley, CA 94720, U.S.A.

Abstract-1046 non-hospitalized children and mothers from various regions of Liberia were studied todetermine the relationships between their indigenous perceptions of malaria illness with on-goingPlusmodium parasitemia and annual incidence of clinical malaria. Eleven pediatric and 14 maternal signsand symptoms of malaria were described, ranked by cultural severity, and evaluated biomedically.Between cultural perceptions of the severity of illness and biomedical evidence of the severity of disease,significant rank order correlations are observed for children @ = 0.713, P < 0.01) and mothers (p = 0.875,P -C 0.001). Clinical, parasitological and cultural concordance were observed for anorexia, joint pain,abdominal tenderness, nausea, chills, severe headache, stomach pain, and dizziness: Five othersymptoms however either over or underpredicted observed levels of biomedically confirmed malaria:

fever, convulsions, vomiting, body weakness and psychological distress.Biomedical studies revealed a parasite rate among children of 68.6x, a mean annual incidence ofpediatric clinical malaria of 3.12; and a mean annual incidence of maternal clinical malaria of 2.42. Clinicalmalaria demonstrated a very early onset among newborns and a shift in acute parasitemia to a chronicstatus around 2.3 years of age. A significant positive linear correlation (r = 0.75, P < 0.01) was observedbetween parasitological and clinical measures of malaria in children.

The indigenous perspectives on malaria and the biomedically predictive powers of various bioculturalsymptoms are discussed and evaluated as an integrative and valuable means of assessing the impact ofmalaria in an endemic region.

1NTRODUCIlON

One of the most perplexing problems facing cliniciansand health planners working in areas of endemic

malaria is that of accurately assessing the impact ofmalaria morbidity in non-Western societies. Thisdifficulty is to a great extent a by-product of thenarrow parameters of most biomedical inquirieswhich emphasize the quantification of parasite loadsand hospitalized cases, yet devalue or ignore indigen-3~s perceptions of illness and knowledge of disease.The literature on malaria in Liberia consists ofsurveys of the high parasite prevalence [l-7] andreports on the pronounced incidence of clinical illness:8-lo], yet offers no insights into indigenous evalu-ltions of malaria. Ironically, it is a biocultural per-option of illness based upon subjective assessmentswhich motivates individuals to seek biomedical evalu-

ation and treatment in the first place. Thus, under-standing the cultural and biological parameters ofsymptomatology and their connection with actual

sources of research support: National Fellowships Fund,Sigma Xi, Huber Foundation.

Natural (illness): malaria exists ethnomedically in Liberia,it is viewed indigenously as a non-magical disease cate-gory, and it is treated as a regular component of theenvironment. The illness is readily identifiable and is notseen as an expression of any particular supernaturalphenomena. Malaria is usually not one of the maladiesa sorcerer would inflict upon his or her victim. Thenaturalness of malaria, particularly among adults, isprobably a reflection of its longstanding and dominantpresence, its high level of endemicity, the populationsearly exposure, and their rapid acquisition of a semi-immune status.

clinical disease incidence and parasite prevalence iscrucial. This paper represents a first attempt toidentify and integrate in a natural, non-hospitalized

population of Liberians information on the indigen-ous malaria-associated symptomatology with para-sitological and clinical data. The data reported arethe result of a series of studies carried out in theRepublic of Liberia between 1978 and 1982 among1046 autochthonous Liberians and other West Afri-cans. The research was designed to test the hypothesisthat the indigenous perception of malaria illness andranking of symptom severity is significantly associ-ated with clinical evidence of disease.

The Republic of Liberia was selected for studysince it is an area in which Plasmodium protozoa,particularly P. falciparum and P. malariae, continueto maintain a high level of endemicity [ll, 121. Al-though not all indigenous groups subscribe to identi-cal notions of malarias etiology [13], they considermalaria to be a natural* illness, and its signs andsymptoms are broadly recognized interethnically. Yetwith meso- to holoendemicity, many infected individ-uals remain clinically and culturally asymptomatic.The inconsistent clinical picture of falciparum ma-laria among such semi-immunes [14-161 has been amajor obstacle in assesssing the impact of this patho-gen. Under these conditions an acknowledgement ofthe patient perceptions of malaria is particularlyimportant.

METHODS AND MATERL4I.S

Description of the sample523 pairs of low income Liberian and other selected

West African children and their biological mothers

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1282 LINDA COLLIER JACKSON

(1046 individuals) who were attending pediatric orwell-baby outpatient clinics within rural and urbanLiberia were studied over the course of 20 months.With the informed consent of mothers, participantswere sampled in both the wet and dry seasonsopportunistically (as they were available) at five

different sites within the country. Clinics were locatedat the Kennedy Maternity and Mamba Point HealthCenters in Monrovia, at the Firestone Medical Cen-ter and Harbel Health Clinic in Harbel, and at theClinic of the Liberian Institute for Biomedical Re-search in Robertsfield. Three of these clinics werepublic, government-run centers, while two clinicswere owned by the Firestone Plantations Companyfor the use of resident agricultural workers and theirfamilies. Children studied ranged from newborn to 9years 11 months with 97.7% of all children (511children) under 5 years of age and 76.6% (400children) under 1 year of age. The mean age ofchildren was 10 months; the mean age of mothers was

24 years with an age range of 14-47 years. Mothersand children of Liberian ethnic groups comprised91.9% of the total sample (961 individuals) with theremaining 85 mothers and children from other neigh-boring West African communites. All major Liberianethnic groups were represented in the sample and atproportions significantly similar to their proportionsin the larger population (p = 0.75, P = 0.01). Thelargest ethnic groups represented included 169 Kpelle(16.2%) 129 Bassa (12.3x), 94 Grebo (9.0x), 88Gissi (8.4%) 73 Kru (7.0x), 71 Loma (6.8x), 61 Vai(5.8%) and 56 Gio (5.4%). Other Liberian groupsincluded 40 Gbandi, 39 Mano, 34 Krahn, 28Mandingo, 26 Gola, 23 Mende, 19 Congo, 7 Belle

and 4 Dei.

Definition of terms

Without a cultural context, distinguishing betweendisease and illness is frequently problematic. In tiiisstudy, the term malaria illness is used to identify theindigenous ethnomedical perceptions of malaria-caused ill health. These perceptions are expressed byspecific symptomatologies which have both biologicaland sociocultural dimensions. Among Liberians, abroadly recognized constellation of signs and symp-toms form the basis for the biocultural identificationof malaria. These include a high fever of regularperiodicity and the simultaneous occurrence of jointpain, general body weakness, headache and otherevents. The term malaria disease, on the other hand,is restricted in use to the parasitological confirmationof Plasmodium protozoa in the red blood cells ofaffected individuals. In this usage disease equals thepresence of pathogens whether or not illness is ex-pressed. Given the high endemicity of malaria inLiberia, many individuals infected with low levels ofthese pathogens may remain relatively asymptomatic.When malaria is diagnosed by cliniciaps using largelynon-indigenous parameters of infection and illness,the term clinical malaria is applied. This designationis evidenced by the presence of selected signs andsymptoms, usually quantitative, which are expressedin conjunction with microscopic evidence of Plas-medium parasitemia. Thus, clinical malaria equals thepresence of pathogens plus selected symptoms.

Sources of cultural, clinical and parasitological data

Data on malaria symptomatology were obtainedfrom all mothers, many of the older children, andapproximately 40 Liberian health personnel by meansof interviews and participant and non-participantobservations. Ethnographic data were collected atclinics, villages, markets, homes and local pharma-cies. The discussions with health personnel wereusually conducted in English, the national language,while the exchanges with most rural mothers wereconducted in a local language familiar to the mother.Translating the expressed malaria symptomatologieswas not difficult since the majority of the mothersstudied were fluent in several local languages. Indig-enous assessments of the severity of specific signs andsymptoms were elicited prior to biomedical assess-ment. These cultural evaluations were based upon theperceived power of particular symptoms to causedeath or profound illness in children or adult women.Individual severity rankings were then grouped and

the consensus rankings used in further statisticaltests.

Past malaria histories were reconstructed for chil-dren and mothers based upon mothers recall andclinic or health center documentation of clinicalevidence of disease. Clinical examinations of studyparticipants were conducted by medically trainedpersonnel at each of the research sites. Deter-minations of clinical severity were based upon thenumber of times malaria was experienced (andtreated biomedically) within the preceeding 12months.

With the informed consent of mothers and Liber-ian health authorities, peripheral blood samples were

collected from all children to provide a cross-sectional measure of on-going parasitemia. Thick andthin blood films were made from two microscopeslides, allowed to air dry and stained with a goodquality Giemsa solution. Triton X-100 was added tothe stain to eliminate parasite transfer (during stain-ing) and to enhance the Giemsa stain. After exam-ining at least 100 oil immersion fields per slide,parasite density, developmental stage and speciesidentification were noted for positive films. A 94%diagnostic reproducibility was obtained when indis-tinguishable duplicate control films were examined.Assessments of parasitological severity were basedupon parasite infection rates, i.e. the density of

Plasmodium asexual forms per microliter blood.Statistical treatment

All data were analyzed using the Statistical Analy-sis System (SAS) computer program on an IBM370/168 computer. Chi-square, one-way ANOVA,rank order correlation and linear regression are theprimary statistical tests presented in this report.Values of P < 0.05 are considered significant.

RESULTS

The Biocultural Evidence

Indigenous views of malaria

Among adults malaria is a nuisance illness whichfrequently incapacitates and causes a loss of vigor butvery rarely produces death. Malarias presence is


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Malaria in Liberia 1283

Table 1. Symotomatoloav of malaria illness for children and mothersBiocultural signs and symptoms Frequency distribution

Children Mothers

Clinical Number % Number %Indigenous expression equivalent reporting Affected Severity* reporting Affected Severity*

Body cold all overHead hurting too badBody hot all overBody can be weakAll (my) bones can be hurting(I) can sweat plentyBelly can hurtBelly can be sore (to the touch)(I) can be sick(I) can throw-upBody can jerk and shakeCan lose (my) appetiteEyes can be turning

Other svmotoms

ChillsSevere headacheFever

Body weaknessJoint pain

Excessive sweatingStomach pain

Abdominal tendernessNausea

VomitingConvulsions

AnorexiaDizziness

Psychological distressOther svmotoms

129-250

9170

157

90 17.2117 22.4109 20.8

26 5.011 2.1

35 6.7

24.7 2

47.8 2-317.4 213.4 l-230.0 3

343 65.6339 64.8332 63.5293 56.0270 51.6258 49.3216 41.3146 21.9-1112116152

25

21.24.03.12.91.04.8

222-3

2l-23

2

3

*Severity designations: 1 = high; 2 = moderate; 3 = low.

linked to the environment and is felt to display adistinct seasonality in prevalence and severity. Mostcases of malaria-caused illness, irrespective of theirprecise etiology, were thought to occur during andjust following the rainy season. Informants felt thatexposure to the causative agents were inevitable, thatcontracting malaria was determined largely by fate,and that the chances of exhibiting illness were unpre-dictable. No subgroups of the adult population werefelt to be particularly susceptible but a number ofinformants expressed the view that the wealthy intheir country did not suffer as much from malariabecause they lived in screened houses and had accessto Western and traditional medicines*. When malariacaused a protracted or severe illness it was felt to beoperating in conjunction with other factors. In thesecases a country doctor would be consulted to deter-mine the spiritual basis of the situation and to obtainmore powerful herbal preparations and ritualisticdirectives.

For children malaria is viewed as a more seriousillness and was cited as the 5th leading cause of death.Although malaria shares the cultural and clinicalspotlight with other infectious diseases, it was felt tobe an ever present threat to the health of children andmost mothers reported routinely giving their childrenteas and baths containing special plant extracts asboth a prophylaxis and curative regime for malariaand fever in general. In spite of malarias acknowl-edged role in producing severe illness and even deathin children however, no special charms or amulets areworn exclusively for this illness.

Symptomatology of malaria illness

A total of 11 malaria-associated signs and symp-toms were reported for children and 14 malaria-related symptoms were cited for mothers. Amongchildren, the most frequently reported sign or symp-

*Medicines: in Liberian usage medicine is a very broadterm encompassing pharmaceuticals, psychic knowl-edge, and technological innovations. In this contextmedicine is secret. Access to it is limited and it is usuallyobtained by its users after some sacrifice.

tom experienced in connection with malaria illnesswas fever (47.8%). Among mothers, the most fre-quently cited symptoms were chills (65.6x), severeheadache (64.8%) and fever (63.5% percent). Othersymptoms reported by more than 40% of the mothersincluded general body weakness (56%) and joint pain(41.3%). Table 1 summarizes the numbers and per-centages of children and mothers encountering eachsign and symptom, and the relative severity of eachbased upon the consensus of indigenous perspectives.

No significant ethnic variability was found in themalaria symptomatology profiles for children ormothers. Interethnically, there was a high degree ofuniformity, particularly among children. Amongmothers, these similarities in symptoms persistedalthough a non-significant but ostensible differencewas observed in the frequency of stomach pain.Mothers from the related Kru, Grebo, and Bassaethnic groups reported the highest prevalance of thissymptom.

Influence of age on symptomatology

Among children, the probable appearance of vari-ous malaria-related symptoms was perceived cul-turally to be influenced by the childs age. Althoughthe age ranges for each sign or symptom were fairlybroad, as shown in Fig. 1, each displayed a peak ageof intensity. The mothers studied suggested thatyounger children around the mean age of 11 months,were most likely to exhibit convulsions in response tomalaria illness. Vomiting appeared with greatest fre-quency among slightly older children of mean age 1year 2 months. Around this same age, malaria illchildren could be expected to demonstrate excessivesweating, nausea, and fever as well. At 1 year 6months of age mothers reported an increased like-lihood of joint pain and abdominal tenderness intheir sick children. Chills were expressed maximallyone month later and body weakness perceived mostfrequently at mean age 1 year 9 months. Anorexiabased feeding problems were clearly associated witholder children, of mean age 2 years 7 months.

The distribution of symptoms among mothers didnot display important variation by age.


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1284 LINDA COLLIER ACKSON

Mon?h YOOr AgeFig. 1. Age associations with specific malaria-related symptoms and incidence of clinical malaria in

children.

Biocultural hierarchies of sign and symptom severity

Certain signs or symptoms associated with theillness were considered by the majority of informantsto be more severe and life-threatening than wereother signs and symptoms. Anorexia was perceived asthe most serious consequence of malaria amongmothers and children. It was viewed as a signal ofprofound morbidity. Vomiting followed anorexia inseriousness. This symptom in adults was viewed asparticularly repulsive and indicated an extreme con-dition. Convulsions were also indicators of severemalaria illness. Gradations of joint pain were ex-pressed which spanned a continuum of high to mod-erate severity. The most severe cases were said tomake walking impossible; joint pain of moderatedistribution and intensity was largely tolerable andtreated with common herbal preparations such asbitter leaf juice (Veronia amygdalina) and mango treebark tea (Mangifera indica). Joint pain was usuallyexperienced in association with chills and body weak-ness, although these latter symptoms were thought toindicate less severe malaria. Another symptom inmothers associated with moderate illness was severeheadache, usually expressed in conjuction withdizziness. Mothers of very young infants appearedparticularly susceptible to this combination. Fevermaintained a more ambiguous connection withserious illness in both children and mothers, althoughit was the most frequently cited sign or symptomoverall. Excessive sweating was associated with highfever, and in children was felt to intensify whenWestern anti-malarials were given. Among mothers,psychological disturbance associated with malariawas cited by only two individuals and did not appearto be a regular part of the indigenous symptom-atology.

The Clinical Evidence

Annual incidence of clinical malaria

Among the 521 children (99.6%) for whom clinicalrecords were available, the annual incidence of bio-medically confirmed malaria ranged from 0 to 12times per year (mode = 0; median = 1). At the highend of this distribution (10 or more cases of malariaper individual per year) were perhaps incidences ofrecredescence due to subcurative chloroquine, am-odiaquine and pyrimethamine therapy, and thereforenot new cases. When the effect of age on clinicalincidence was controlled using a standard covarianceanalysis, the mean annual incidence of malariaamong these children was 3.12 with no significantethnic or sex-based differences observed. Age(& MOresidence

13.50, d.f. = 20, P = 0.0001) and current(F,,5,, = 17.38, d.f. = 2, P = 0.0001) were

significantly associated with the annual incidence ofclinical malaria in children, however. As shown inFig. 1, malaria incidence climbs fairly rapidly frombirth through the early months with most childrenexperiencing at least one biomedically confirmablecase by 3 months of age. This trend continuesthrough the first and second years until children reachthe age of 2 years 8 months and older when essen-tially none escape at least one annual bout of clinicalmalaria. Rural children (n = 149) experienced ahigher mean incidence of annual malaria (2.43 timesper year) than did their 372 urban counterparts (1.12times per year) in spite of their age similarity.

Among the 519 mothers (99%) for whom clinicaldocumentation was available, the annual incidence ofclinical malaria ranged from 0 to 12 times per year(mode = 1; median = 2). The mean annual incidencewas 2.42 with no significant differences attributable


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to age or residence although rural mothers tendedto experience less annual clinical malaria than didmothers living in urban areas.

Parasite loads in children

To provide a cross-sectional measure of malaria

disease, thick films from 411 children (78.6%) andthin films from 500 children (95.6%) were evaluatedmicroscopically and the density and species of Plas-medium noted. All but a small minority of affectedchildren were culturally and clinically asymptomaticat the time of testing. Although no significant ethnicdifferences were observed in the number of parasiteasexual forms per microliter whole blood, significantdifferences in parasite load were evident among chil-dren of different ages (F20,48o 12.85, d.f. = 20,P = 0.0001) and between urban and rural childrenaged 2 years 2 months and older (x2 = 12.14,d.f. = 5, P = 0.021). The overall parasite rate was68.8% with P. falciparum dominant (71.7%) and P.

malariae (44%) and P. ovale (9.3%) also evident.Among children less than 2 years old, P. falciparumgametocytes (sexual forms) were rarely seen and P.malariae gametocytes more commonly encountered.

A positive linear correlation (r = 0.75, P = 0.01) isobserved between the cross-sectional measures ofprevalence and the longitudinal measures of annualincidence in children.

Sym ptom atology us Biomedical Evidence of Malaria

A significant rank order correlation is observedbetween the indigenous perceptions of sign and symp-tom severity for children and clinical and para-sitological measures of severity. Among children(p = 0.713, P c 0.01) this association indicates thatmost biocultural signs and symptoms are quite usefulpredictors of biomedical evidence of disease. Of thesigns and symptoms judged culturally as most severe,anorexia (feeding difficulties) and joint pain corre-sponded to high annual incidences of clinical malariaand elevated proportions of on-going parasitemia. Ofthe symptoms defined culturally as being moderatlysevere, abdominal tenderness, nausea and chillscorresponded well with both clinical and para-stiological findings. Of the signs and symptoms deter-mined culturally to indicate low severity, excessivesweating predicted a similar clinical evaluation al-though it underpredicted parasite infection rates.Other symptoms evidenced agreement between cul-tural and parasitological evaluations but under-predicted the annual incidence of clinical malaria.

Exceptions to this general pattern of cultural andbiomedical concordance included convulsions andvomiting (which overpredicted biomedical severity),body weakness (which underpredicted the clinicaland parasitological measures of malaria severity) andfever (which overpredicted the annual incidenceof clinical malaria and the prevalence of malariadisease).

A significant rank order correlation is also ob-served between malaria illness and clinical malaria inmothers (p = 0.875, P -C 0.001). Of the symptomsidentified culturally as most life-threatening, an-

orexia and joint pain corresponded to high inci-dences of clinical malaria. Of the symptoms judgedby mothers to be of moderate severity, chills, severe

headache, stomach pain and dizziness were associ-ated with moderate annual incidences of clinicalmalaria. Of the symptoms regarded culturally as leastsevere, excessive sweating and other symptomscorresponded to similar low annual incidences ofclinical malaria.

In contrast to this high level of agreement betweencultural and clinical measures of severity, six othersymptoms did not demonstrate concordance. Con-vulsions, vomiting, psychological distress and fe-ver all tended to overestimate the annual incidenceof clinical malaria whereas abdominal tendernessand body weakness tended to underestimate theannual incidence of clinical malaria.

DJSCUSSION

Since malaria is indigenously perceived as a naturalillness in Liberia, the recognition of its symptom-atology by the affected populace is generally uncom-plicated. However the specifics of sign and symptom

expression and the hierarchy of sign and symptomseverity is greatly influenced by the peoples cultures.This is a potential source of incongruence betweensymptomatology and biomedical evidence of disease,and is of vital importance to scientists and cliniciansin understanding malarias impact on the indigenousgroups.

The parasitological and clinical status of thesample elaborates patterns evident in previous re-ports [l-12]. Yet there were a few surprises: the earlyonset of malaria in young infants was an unexpectedfinding; earlier studies among other West Africans[16, 171 suggested that clinical malaria and evenmalaria disease occur very rarely, if at all, in thenewborn. In this sample, signs of illness in very younginfants were recognized by mothers and diagnosedclinically by health personnel in at least 22% of allnewborns. In these microscopically-confirmed cases,the malaria was possibly acquired congenitally. Theprocess of sampling newborns and young infantsoutside the hospital environment, in village and smalltown clinics permitted a more accurate documen-tation of malaria transmission than is usually madefor this age group. In at least ten cases of newbornclinical malaria the mothers also evidenced clinicalmalaria; seven of these mothers suggested that theirown malaria illness had precipitated labor. It isimportant to note that no children or mothers in thesample had received blood transfusions within the 6months prior to testing. Under these conditionstransfusion malaria could not have been significant.

Another interesting biomedical finding was therelatively early exposure of children to Plasmodiumparasites and the childrens early control of parasitedensity. Around age 2.3 years parasitemia shiftedfrom an acute to a chronic status. Many olderchildren seemed to demonstrate almost cryptic on-going disease, although their annual incidence ofclinical malaria was higher than among youngercounterparts who were 4 months-2.2 years of age.This suggests that among older children a majorreliance on parasitological data is insufficient for avalid diagnosis of clinical malaria. As the child

matures and is able to articulate the cultural symp-tomatology of the illness, this information becomesincreasingly essential diagnostically.


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1286 LINDA COLLIER ACKSON

The diversity of signs and symptoms expressedindicates a cultural awareness of malarias ability toinduce chills, fever, sweating, convulsions and gastro-intestinal disorders, but not delirium, coma or jaun-dice. The absence of these latter sings or symptomsin the cultural definition of malaria needs further

study. The ability of Liberians to recognize internalphysiological changes associated with chronic ma-laria is remarkable. Malaria-related anemia was ex-pressed as body weakness and splenomegally asabdominal tenderness. The traditional symptom-atology did not accommodate leukopenia or erythro-cytic parasitemia, however.

The medically predictive powers of most culturalsigns and symptoms suggests that clinicians treatingLiberian patients should pay particular attention totheir complaints of malaria-induced anorexia, jointpain, abdominal tenderness, nausea, chills, severeheadache, stomach pain and dizziness. Since thesesymptoms demonstrated biomedical and cultural

agreement in perceived severity, their recognition byclinicians is of diagnostic value. Medical anthro-pologists, epidemiologists and medical geographersconcerned with the population-level impact and dis-tribution of malaria can benefit by examining theextent of predictive signs and symptoms in endemicareas and by including these data in theoreticalmodels and statistical analyses.

The evaluation of the indigenous symptomatologyalso provides insights into other intervening culturaland biological variables which may influence diseaseseverity in this region. The early expression of con-vulsions among infants and young children in thisstudy tended to overpredict biomedical malaria andmay reflect the high regional prevalence of neonataltetanus. Strong cultural judgements concerning vom-iting may account for its lack of concordance withbiomedical data. Fever, which also overpredictedbiomedical malaria, is a response to a plethora ofpathogens. The reliability of this sign or symptom inthe diagnosis of malaria is limited. Body weaknessunderpredicted biomedical measures of malariaamong children and mothers, suggesting a culturalaccommodation to parasitemia, as observed else-where in Liberia [181. Psychological distress appearsat such low frequency that its mention appears to beat variance with the established cultural parametersof malaria illness. It is possible that psychologicaldistress may be a new, emerging, and as yet un-synchronized addition to the traditional symptom-atology.

In assessing the anthropological and biomedicaldata, it is clear that the significance of malaria in thisbiome is only partially revealed by knowledge of thenumber of cases occupying hospital beds and beingtreated in outpatient units or knowledge of the levelsof parasitemia from peripheral blood films. Thesequantitative biomedical measures are essential, yetalone they are inadequate to explain the overallhealth impact of malaria in endemic areas. Illness ismore than a purely biological phenomena. By inte-grating an appreciation of the biocultural integumentof symptomatology with the parasitological and clini-

cal data, it is possible to develop more viable modelsof endemic disease.

In Liberia, malaria remains the foremost cause of

sickness in clinical and nonclinical settings. Since theresponsible pathogens are transmitted throughoutthe year, the overwhelming majority of regions re-main untouched by effective malaria control pro-grams. Given this situation, malaria disease, clinicalmalaria, and the biocultural symptoms of malaria

illness will continue to be important factors in Liber-ian health.

Acknowledgements--I thank the late H. Nehemiah Cooper,M.D. and Edwin Jallah, M.D. for permission to studypatients under their general care, Professor Emmett Dennisfor providing laboratory space and supplies for my para-sitological analyses, and Kate Bryant, M.D. and J. RobertEllis, M.P.H., Ministry of Health and Social Welfare forpermission to undertake this project in the Republic ofLiberia. Professors John Ogbu, Alan Dundes and NancyScheper-Hughes are also warmly thanked for their com-ments on preliminary drafts of this manuscript.

This paper is dedicated to my mentor Professor EmeritusJohn H. Whitlock.

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