Sm. Sci. Med. Vol. 20, No. 12, pp.

1281-1287, 1985 0277-9536/85

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MALARIA IN LIBERIAN CHILDREN AND MOTHERS:

BIOCULTURAL PERCEPTIONS OF ILLNESS VS CLINICAL
EVIDENCE OF DISEASE
LINDA COLLIERJACKSON
Department 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 to
determine the relationships between their indigenous perceptions of malaria illness with on-going
Plusmodium parasitemia and annual incidence of clinical malaria. Eleven pediatric and 14 maternal signs
and 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 -C0.001). Clinical, parasitological and cultural concordance were observed for ‘anorexia’, ‘joint pain’,
‘abdominal tenderness’, ‘nausea’, ‘chills’, ‘severe headache’, ‘stomach pain’, and ‘dizziness”: Five other
symptoms 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 of
pediatric clinical malaria of 3.12; and a mean annual incidence of maternal clinical malaria of 2.42. Clinical
malaria demonstrated a very early onset among newborns and a shift in acute parasitemia to a chronic
status around 2.3 years of age. A significant positive linear correlation (r = 0.75, P < 0.01) was observed
between parasitological and clinical measures of malaria in children.
The indigenous perspectives on malaria and the biomedically predictive powers of various biocultural
symptoms are discussed and evaluated as an integrative and valuable means of assessing the impact of
malaria in an endemic region.

1NTRODUCI’lON clinical disease incidence and parasite prevalence is

One of the most perplexing problems facing clinicians
and health planners working in areas of endemic
malaria is that of accurately assessing the impact of
malaria morbidity in non-Western societies. This
difficulty is to a great extent a by-product of the
narrow parameters of most biomedical inquiries
which emphasize the quantification of parasite loads
and hospitalized cases, yet devalue or ignore indigen-
3~s perceptions of illness and knowledge of disease.
The literature on malaria in Liberia consists of
surveys of the high parasite prevalence [l-7] and
reports 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 assessments
which motivates individuals to seek biomedical evalu-
ation and treatment in the first place. Thus, under-
standing the cultural and biological parameters of
symptomatology 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 the
environment. The illness is readily identifiable and is not
seen as an expression of any particular supernatural
phenomena. Malaria is usually not one of the maladies
a sorcerer would inflict upon his or her victim. The
‘naturalness’ of malaria, particularly among adults, is
probably a reflection of its longstanding and dominant
presence, its high level of endemicity, the population’s
early exposure, and their rapid acquisition of a semi-
immune status.
1281
crucial. This paper represents a first attempt to
identify 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 are
the result of a series of studies carried out in the
Republic of Liberia between 1978 and 1982 among
1046 autochthonous Liberians and other West Afri-
cans. The research was designed to test the hypothesis
that the indigenous perception of malaria illness and
ranking of symptom severity is significantly associ-
ated with clinical evidence of disease.
The Republic of Liberia was selected for study
since it is an area in which Plasmodium protozoa,
particularly P. falciparum and P. malariae, continue
to maintain a high level of endemicity [ll, 121. Al-
though not all indigenous groups subscribe to identi-
cal notions of malaria’s etiology [13], they consider
malaria to be a natural* illness, and its signs and
symptoms are broadly recognized interethnically. Yet
with 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 a
major obstacle in assesssing the impact of this patho-
gen. Under these conditions an acknowledgement of
the patient perceptions of malaria is particularly
important.
METHODSAND MATERL4I.S
Description of the sample
523 pairs of low income Liberian and other selected
West African children and their biological mothers
1282 LINDA COLLIER JACKSON
(1046 individuals) who were attending pediatric or
well-baby outpatient clinics within rural and urban
Liberia were studied over the course of 20 months.
With the informed consent of mothers, participants
were sampled in both the wet and dry seasons
opportunistically (as they were available) at five
different sites within the country. Clinics were located
at the Kennedy Maternity and Mamba Point Health
Centers in Monrovia, at the Firestone Medical Cen-
ter and Harbel Health Clinic in Harbel, and at the
Clinic of the Liberian Institute for Biomedical Re-
search in Robertsfield. Three of these clinics were
public, government-run centers, while two clinics
were owned by the Firestone Plantations Company
for the use of resident agricultural workers and their
families. Children studied ranged from newborn to 9
years 11 months with 97.7% of all children (511
children) under 5 years of age and 76.6% (400
children) under 1 year of age. The mean age of
children was 10 months; the mean age of mothers was
24 years with an age range of 14-47 years. Mothers
and children of Liberian ethnic groups comprised
91.9% of the total sample (961 individuals) with the
remaining 85 mothers and children from other neigh-
boring West African communites. All major Liberian
ethnic groups were represented in the sample and at
proportions significantly similar to their proportions
in the larger population (p = 0.75, P = 0.01). The
largest ethnic groups represented included 169 Kpelle
(16.2%) 129 Bassa (12.3x), 94 Grebo (9.0x), 88
Gissi (8.4%) 73 Kru (7.0x), 71 Loma (6.8x), 61 Vai
(5.8%) and 56 Gio (5.4%). Other Liberian groups
included 40 Gbandi, 39 Mano, 34 Krahn, 28
Mandingo, 26 Gola, 23 Mende, 19 Congo, 7 Belle
and 4 Dei.
Definition of terms
Without a cultural context, distinguishing between
disease and illness is frequently problematic. In tiiis
study, the term malaria illness is used to identify the
indigenous ethnomedical perceptions of malaria-
caused ill health. These perceptions are expressed by
specific symptomatologies which have both biological
and sociocultural dimensions. Among Liberians, a
broadly recognized constellation of signs and symp-
toms form the basis for the biocultural identification
of malaria. These include a high fever of regular
periodicity and the simultaneous occurrence of joint
pain, general body weakness, headache and other
events. The term malaria disease, on the other hand,
is restricted in use to the parasitological confirmation
of Plasmodium protozoa in the red blood cells of
affected individuals. In this usage disease equals the
presence of pathogens whether or not illness is ex-
pressed. Given the high endemicity of malaria in
Liberia, many individuals infected with low levels of
these pathogens may remain relatively asymptomatic.
When malaria is diagnosed by cliniciaps using largely
non-indigenous parameters of infection and illness,
the term clinical malaria is applied. This designation
is evidenced by the presence of selected signs and
symptoms, usually quantitative, which are expressed
in conjunction with microscopic evidence of Plas-
medium parasitemia. Thus, clinical malaria equals the
presence of pathogens plus selected symptoms.
Sources of cultural, clinical and parasitological data
Data on malaria symptomatology were obtained
from all mothers, many of the older children, and
approximately 40 Liberian health personnel by means
of interviews and participant and non-participant
observations. Ethnographic data were collected at
clinics, villages, markets, homes and local pharma-
cies. The discussions with health personnel were
usually conducted in English, the national language,
while the exchanges with most rural mothers were
conducted in a local language familiar to the mother.
Translating the expressed malaria symptomatologies
was not difficult since the majority of the mothers
studied were fluent in several local languages. Indig-
enous assessments of the severity of specific signs and
symptoms were elicited prior to biomedical assess-
ment. These cultural evaluations were based upon the
perceived power of particular symptoms to cause
death or profound illness in children or adult women.
Individual severity rankings were then grouped and
the consensus rankings used in further statistical
tests.
Past malaria histories were reconstructed for chil-
dren and mothers based upon mothers’ recall and
clinic or health center documentation of clinical
evidence of disease. Clinical examinations of study
participants were conducted by medically trained
personnel at each of the research sites. Deter-
minations of clinical severity were based upon the
number of times malaria was experienced (and
treated biomedically) within the preceeding 12
months.
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 and
thin blood films were made from two microscope
slides, allowed to air dry and stained with a good
quality Giemsa solution. Triton X-100 was added to
the 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 species
identification were noted for positive films. A 94%
diagnostic reproducibility was obtained when indis-
tinguishable duplicate control films were examined.
Assessments of parasitological severity were based
upon 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 IBM
370/168 computer. Chi-square, one-way ANOVA,
rank order correlation and linear regression are the
primary 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 which
frequently incapacitates and causes a loss of vigor but
very rarely produces death. Malaria’s presence is
 Malaria in Liberia 1283

Table 1. Symotomatoloav of malaria illness for children and mothers

Biocultural signs and symptoms Frequency distribution

Children Mothers

Clinical Number % Number %

Indigenous expression equivalent reporting Affected Severity* reporting Affected Severity*
‘Body cold all over’ Chills 129 24.7 2 343 65.6 2
‘Head hurting too bad’ Severe headache - 339 64.8 2
‘Body hot all over’ Fever 250 47.8 2-3 332 63.5 2-3
‘Body can be weak’ Body weakness 91 17.4 2 293 56.0 2
‘All (my) bones can be hurting’ Joint pain 70 13.4 l-2 270 51.6 l-2
‘(I) can sweat plenty’ Excessive sweating 157 30.0 3 258 49.3 3
‘Belly can hurt’ Stomach pain 216 41.3
‘Belly can be sore’ (to the touch) Abdominal tenderness 90 17.2 146 21.9
‘(I) can be sick’ Nausea 117 22.4 -
‘(I) can throw-up’ Vomiting 109 20.8 111 21.2
‘Body can jerk and shake’ Convulsions 26 5.0 21 4.0
‘Can lose (my) appetite’ Anorexia 11 2.1 16 3.1
‘Eyes can be turning’ Dizziness 15 2.9 2
Psychological distress 2 1.0
Other svmotoms Other svmotoms 35 6.7 25 4.8 3
*Severity designations: 1 = high; 2 = moderate; 3 = low.

linked to the environment and is felt to display a tom experienced in connection with malaria illness
distinct seasonality in prevalence and severity. Most was fever (47.8%). Among mothers, the most fre-
cases of malaria-caused illness, irrespective of their quently cited symptoms were chills (65.6x), severe
precise etiology, were thought to occur during and headache (64.8%) and fever (63.5% percent). Other
just following the rainy season. Informants felt that symptoms reported by more than 40% of the mothers
exposure to the causative agents were inevitable, that included general body weakness (56%) and joint pain
contracting malaria was determined largely by fate, (41.3%). Table 1 summarizes the numbers and per-
and that the chances of exhibiting illness were unpre- centages of children and mothers encountering each
dictable. No subgroups of the adult population were sign and symptom, and the relative severity of each
felt to be particularly susceptible but a number of based upon the consensus of indigenous perspectives.
informants expressed the view that the wealthy in No significant ethnic variability was found in the
their country did not suffer as much from malaria malaria symptomatology profiles for children or
because they lived in screened houses and had access mothers. Interethnically, there was a high degree of
to Western and traditional medicines*. When malaria uniformity, particularly among children. Among
caused a protracted or severe illness it was felt to be mothers, these similarities in symptoms persisted
operating in conjunction with other factors. In these although a non-significant but ostensible difference
cases a ‘country doctor’ would be consulted to deter- was observed in the frequency of stomach pain.
mine the spiritual basis of the situation and to obtain Mothers from the related Kru, Grebo, and Bassa
more powerful herbal preparations and ritualistic ethnic groups reported the highest prevalance of this
directives. symptom.
For children malaria is viewed as a more serious
illness and was cited as the 5th leading cause of death.
Although malaria shares the cultural and clinical Influence of age on symptomatology
spotlight with other infectious diseases, it was felt to Among children, the probable appearance of vari-
be an ever present threat to the health of children and ous malaria-related symptoms was perceived cul-
most mothers reported routinely giving their children turally to be influenced by the child’s age. Although
teas and baths containing special plant extracts as the age ranges for each sign or symptom were fairly
both a prophylaxis and curative regime for malaria broad, as shown in Fig. 1, each displayed a peak age
and fever in general. In spite of malaria’s acknowl- of intensity. The mothers studied suggested that
edged role in producing severe illness and even death younger children around the mean age of 11 months,
in children however, no special charms or amulets are were most likely to exhibit convulsions in response to
worn exclusively for this illness. malaria illness. Vomiting appeared with greatest fre-
quency among slightly older children of mean age 1
Symptomatology of malaria illness year 2 months. Around this same age, malaria ill
A total of 11 malaria-associated signs and symp- children could be expected to demonstrate excessive
toms were reported for children and 14 malaria- sweating, nausea, and fever as well. At 1 year 6
related symptoms were cited for mothers. Among months of age mothers reported an increased like-
children, the most frequently reported sign or symp- lihood of joint pain and abdominal tenderness in
their sick children. Chills were expressed maximally
one month later and body weakness perceived most
*Medicines: in Liberian usage ‘medicine’ is a very broad frequently at mean age 1 year 9 months. Anorexia
term encompassing pharmaceuticals, psychic knowl- based feeding problems were clearly associated with
edge, and technological innovations. In this context older children, of mean age 2 years 7 months.
medicine is secret. Access to it is limited and it is usually The distribution of symptoms among mothers did
obtained by its users after some sacrifice. not display important variation by age.
1284 LINDA COLLIERJACKSON
Mon?h YOOr
Fig. 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 the
illness were considered by the majority of informants
to be more severe and life-threatening than were
other signs and symptoms. Anorexia was perceived as
the most serious consequence of malaria among
mothers and children. It was viewed as a signal of
profound morbidity. Vomiting followed anorexia in
seriousness. This symptom in adults was viewed as
particularly repulsive and indicated an extreme con-
dition. Convulsions were also indicators of severe
malaria illness. Gradations of joint pain were ex-
pressed which spanned a continuum of high to mod-
erate severity. The most severe cases were said to
make walking impossible; joint pain of moderate
distribution and intensity was largely tolerable and
treated with common herbal preparations such as
bitter leaf juice (Veronia amygdalina) and mango tree
bark tea (Mangifera indica). Joint pain was usually
experienced in association with chills and body weak-
ness, although these latter symptoms were thought to
indicate less severe malaria. Another symptom in
mothers associated with moderate illness was severe
headache, usually expressed in conjuction with
dizziness. Mothers of very young infants appeared
particularly susceptible to this combination. Fever
maintained a more ambiguous connection with
serious illness in both children and mothers, although
it was the most frequently cited sign or symptom
overall. Excessive sweating was associated with high
fever, and in children was felt to intensify when
Western anti-malarials were given. Among mothers,
psychological disturbance associated with malaria
was cited by only two individuals and did not appear
to be a regular part of the indigenous symptom-
atology.
Age
The Clinical Evidence
Annual incidence of clinical malaria
Among the 521 children (99.6%) for whom clinical
records were available, the annual incidence of bio-
medically confirmed malaria ranged from 0 to 12
times per year (mode = 0; median = 1). At the high
end of this distribution (10 or more cases of malaria
per individual per year) were perhaps incidences of
recredescence due to subcurative chloroquine, am-
odiaquine and pyrimethamine therapy, and therefore
not ‘new cases’. When the effect of age on clinical
incidence was controlled using a standard covariance
analysis, the mean annual incidence of malaria
among these children was 3.12 with no significant
ethnic or sex-based differences observed. Age
(& MO= 13.50, d.f. = 20, P = 0.0001) and current
residence (F,,5,, = 17.38, d.f. = 2, P = 0.0001) were
significantly associated with the annual incidence of
clinical malaria in children, however. As shown in
Fig. 1, malaria incidence climbs fairly rapidly from
birth through the early months with most children
experiencing at least one biomedically confirmable
case by 3 months of age. This trend continues
through the first and second years until children reach
the age of 2 years 8 months and older when essen-
tially none escape at least one annual bout of clinical
malaria. Rural children (n = 149) experienced a
higher mean incidence of annual malaria (2.43 times
per year) than did their 372 urban counterparts (1.12
times per year) in spite of their age similarity.
Among the 519 mothers (99%) for whom clinical
documentation was available, the annual incidence of
clinical malaria ranged from 0 to 12 times per year
(mode = 1; median = 2). The mean annual incidence
was 2.42 with no significant differences attributable
 Malaria in Liberia
to age or residence although rural mothers tended
to experience less annual clinical malaria than did
mothers living in urban areas.
Parasite loads in children
To provide a cross-sectional measure of malaria
disease, thick films from 411 children (78.6%) and
thin films from 500 children (95.6%) were evaluated
microscopically and the density and species of Plas-
medium noted. All but a small minority of affected
children were culturally and clinically asymptomatic
at the time of testing. Although no significant ethnic
differences were observed in the number of parasite
asexual forms per microliter whole blood, significant
differences 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 children
aged 2 years 2 months and older (x2 = 12.14,
d.f. = 5, P = 0.021). The overall parasite rate was
68.8% 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. falciparum
gametocytes (sexual forms) were rarely seen and P.
malariae gametocytes more commonly encountered.
A positive linear correlation (r = 0.75, P = 0.01) is
observed between the cross-sectional measures of
prevalence and the longitudinal measures of annual
incidence in children.
Symptomatology us Biomedical Evidence of Malaria
A significant rank order correlation is observed
between 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 that
most biocultural signs and symptoms are quite useful
predictors of biomedical evidence of disease. Of the
signs and symptoms judged culturally as most severe,
‘anorexia’ (feeding difficulties) and ‘joint pain’ corre-
sponded to high annual incidences of clinical malaria
and elevated proportions of on-going parasitemia. Of
the symptoms defined culturally as being moderatly
severe, ‘abdominal tenderness’, ‘nausea’ and ‘chills’
corresponded well with both clinical and para-
stiological findings. Of the signs and symptoms deter-
mined culturally to indicate low severity, ‘excessive
sweating’ 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 and
biomedical concordance included ‘convulsions’ and
‘vomiting’ (which overpredicted biomedical severity),
‘body weakness’ (which underpredicted the clinical
and parasitological measures of malaria severity) and
‘fever’ (which overpredicted the annual incidence
of clinical malaria and the prevalence of malaria
disease).
A significant rank order correlation is also ob-
served between malaria illness and clinical malaria in
mothers (p = 0.875, P -C0.001). Of the symptoms
identified culturally as most life-threatening, ‘an-
orexia’ and ‘joint pain’ corresponded to high inci-
dences of clinical malaria. Of the symptoms judged
by mothers to be of moderate severity, ‘chills’, ‘severe
1285
headache’, ‘stomach pain’ and ‘dizziness’ were associ-
ated with moderate annual incidences of clinical
malaria. Of the symptoms regarded culturally as least
severe, ‘excessive sweating’ and ‘other symptoms’
corresponded to similar low annual incidences of
clinical malaria.
In contrast to this high level of agreement between
cultural and clinical measures of severity, six other
symptoms did not demonstrate concordance. ‘Con-
vulsions’, ‘vomiting’, ‘psychological distress’ and ‘fe-
ver’ all tended to overestimate the annual incidence
of clinical malaria whereas ‘abdominal tenderness’
and ‘body weakness’ tended to underestimate the
annual incidence of clinical malaria.
DJSCUSSION
Since malaria is indigenously perceived as a natural
illness 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 symptom
severity is greatly influenced by the people’s cultures.
This is a potential source of incongruence between
symptomatology and biomedical evidence of disease,
and is of vital importance to scientists and clinicians
in understanding malaria’s impact on the indigenous
groups.
The parasitological and clinical status of the
sample elaborates patterns evident in previous re-
ports [l-12]. Yet there were a few surprises: the early
onset of malaria in young infants was an unexpected
finding; earlier studies among other West Africans
[16, 171 suggested that clinical malaria and even
malaria disease occur very rarely, if at all, in the
newborn. In this sample, signs of illness in very young
infants were recognized by mothers and diagnosed
clinically by health personnel in at least 22% of all
newborns. In these microscopically-confirmed cases,
the malaria was possibly acquired congenitally. The
process of sampling newborns and young infants
outside the hospital environment, in village and small
town clinics permitted a more accurate documen-
tation of malaria transmission than is usually made
for this age group. In at least ten cases of newborn
clinical malaria the mothers also evidenced clinical
malaria; seven of these mothers suggested that their
own malaria illness had precipitated labor. It is
important to note that no children or mothers in the
sample had received blood transfusions within the 6
months prior to testing. Under these conditions
transfusion malaria could not have been significant.
Another interesting biomedical finding was the
relatively early exposure of children to Plasmodium
parasites and the children’s early control of parasite
density. Around age 2.3 years parasitemia shifted
from an acute to a chronic status. Many older
children seemed to demonstrate almost cryptic on-
going disease, although their annual incidence of
clinical malaria was higher than among younger
counterparts who were 4 months-2.2 years of age.
This suggests that among older children a major
reliance on parasitological data is insufficient for a
valid diagnosis of clinical malaria. As the child
matures and is able to articulate the cultural symp-
tomatology of the illness, this information becomes
increasingly essential diagnostically.
1286 LINDACOLLIERJACKSON
The diversity of signs and symptoms expressed
indicates a cultural awareness of malaria’s ability to
induce chills, fever, sweating, convulsions and gastro-
intestinal disorders, but not delirium, coma or jaun-
dice. The absence of these latter sings or symptoms
in the cultural definition of malaria needs further
study. The ability of Liberians to recognize internal
physiological changes associated with chronic ma-
laria is remarkable. Malaria-related anemia was ex-
pressed as ‘body weakness’ and splenomegally as
‘abdominal tenderness’. The traditional symptom-
atology did not accommodate leukopenia or erythro-
cytic parasitemia, however.
The medically predictive powers of most cultural
signs and symptoms suggests that clinicians treating
Liberian patients should pay particular attention to
their complaints of malaria-induced anorexia, joint
pain, abdominal tenderness, nausea, chills, severe
headache, stomach pain and dizziness. Since these
symptoms demonstrated biomedical and cultural
agreement in perceived severity, their recognition by
clinicians is of diagnostic value. Medical anthro-
pologists, epidemiologists and medical geographers
concerned with the population-level impact and dis-
tribution of malaria can benefit by examining the
extent of predictive signs and symptoms in endemic
areas and by including these data in theoretical
models and statistical analyses.
The evaluation of the indigenous symptomatology
also provides insights into other intervening cultural
and biological variables which may influence disease
severity in this region. The early expression of ‘con-
vulsions’ among infants and young children in this
study tended to overpredict biomedical malaria and
may reflect the high regional prevalence of neonatal
tetanus. Strong cultural judgements concerning ‘vom-
iting’ may account for its lack of concordance with
biomedical data. ‘Fever’, which also overpredicted
biomedical malaria, is a response to a plethora of
pathogens. The reliability of this sign or symptom in
the diagnosis of malaria is limited. ‘Body weakness’
underpredicted biomedical measures of malaria
among children and mothers, suggesting a cultural
accommodation to parasitemia, as observed else-
where in Liberia [ 181. ‘Psychological distress’ appears
at such low frequency that its mention appears to be
at variance with the established cultural parameters
of malaria illness. It is possible that ‘psychological
distress’ may be a new, emerging, and as yet un-
synchronized addition to the traditional symptom-
atology.
In assessing the anthropological and biomedical
data, it is clear that the significance of malaria in this
biome is only partially revealed by knowledge of the
number of cases occupying hospital beds and being
treated in outpatient units or knowledge of the levels
of parasitemia from peripheral blood films. These
quantitative biomedical measures are essential, yet
alone they are inadequate to explain the overall
health impact of malaria in endemic areas. Illness is
more than a purely biological phenomena. By inte-
grating an appreciation of the biocultural integument
of symptomatology with the parasitological and clini-
cal data, it is possible to develop more viable models
of endemic disease.
In Liberia, malaria remains the foremost cause of
sickness in clinical and nonclinical settings. Since the
responsible pathogens are transmitted throughout
the year, the overwhelming majority of regions re-
main untouched by effective malaria control pro-
grams. Given this situation, malaria disease, clinical
malaria, 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 study
patients under their general care, Professor Emmett Dennis
for providing laboratory space and supplies for my para-
sitological analyses, and Kate Bryant, M.D. and J. Robert
Ellis, M.P.H., Ministry of Health and Social Welfare for
permission to undertake this project in the Republic of
Liberia. Professors John Ogbu, Alan Dundes and Nancy
Scheper-Hughes are also warmly thanked for their com-
ments on preliminary drafts of this manuscript.
This paper is dedicated to my mentor Professor Emeritus
John H. Whitlock.
REFERENCES
1. Strong R. P. (Ed). The African Republic of Liberia and
the Belgian Congo. Harvard African Expedition,
19.X-1927. Harvard University, Cambridge, 1930.
2. Anigstein L. Medical exploration in Liberia. Q. Bull.
Hlth Org. 6, 93-127, 1937.
3. Young M. D. and Johnson T. H. A malaria survey of
Liberia. J. natn. Malaria Sot. 8, 247-266, 1949.
4. Barber M. A., Rice J. B. and Brown J. Y. Malaria
studies on the Firestone Rubber Plantation in Liberia,
West Africa. Am. J. Hyg. 15, 601-633, 1932.
5. World Health Organization. Malaria me-eradication
programme. Q. Rep. March-May, 29, i964.
6. Willcox M. C. Thalassaemia in northern Liberia. A
survey in the Mount Nimba area. J. med. Genet. 12,
563, 1975.
7. Swamy M., Du L. and Mason B. Malaria control in
Monrovia and its environs. National Public Health
Service. Ministry of Health and Social Welfare, Mon-
rovia, Republic of Liberia, 1976.
8. National ‘Public Health Service. Ten Year National
Health Plan. 1967. Ministrv of Health and Social Wel-
fare, Monrovia, Republic of Liberia, 1976.
9. Gauldfeldt F. and Gangloff L. Syncrisis. The dynamics
of health in Liberia. U.S. Deuartment of Health. Edu-
cation, and Welfare, Washington, DC, 1973.
10. Division of Vital and Health Statistics, 1977. Bureau of
Planning, Research and Development Annual Report:
Communicable Diseases. Monrovia: Ministry of Health
and Social Welfare, Republic of Liberia, 1977.
11. Hedman P., Brohult J., Forslund J., Sirleaf V. and
Bengtsson E. A pocket of controlled malaria in a
holoendemic region of West Africa. Ann. trop. Med.
Parasit. 73, 317-325, 1979.
12. Willcox M., Brohult J., Sirleaf V. and Bengtsson E.
Malaria and haemoglobin A2 levels in northern Liberia.
Trans. R. Sot. trop. Med. Hyg. 73, 209-211, 1979.
13. Clarke J-A. K. Nutritional Status of Children in Rural
and Urban Liberia, p. 23, 1973.
14. Boyd M. F. and, Kitchen S. F. Observations on induced
falciparum malaria. Am. J. trop. Med. 17, 213-235,
1937.
15. Jeffery G. M., Young M. D., Burgess R. W. and Eyles
D. E. Early activity in sporozoite-induced Plasmodium
falciparum infections. Ann. trop. Med. Parasit. 53,
51-58, 1959.
16. Pazzaglia G. and Woodward W. E. An analysis of the
relationship of host factors to clinical falciparum ma-
 Malaria in Liberia 1287

laria by multiple regression techniques. Am. J. trop.
Med. Hyg. 31, 202-210, 1982.
17. Edington G. M. Pathology of malaria in West Africa.
Br. med. J. 1, 715-718, 1967.
18. Henderickse R. G., Hansen A. L., Ohmide L. 0. and
Akinkumani A. Malaria in early childhood. Ann. bop.
Med. Parasit. 65, l-20, 1971.
19. Brohult J., Jorfeldt L., Rombo L., Bjorkman A., Perh-
son P.-O., Sirleaf V. and Bengtsson E. The working
capacity of Liberian males: a comparison between ur-
ban and rural populations in relation to malaria. Ann.
trap. Med. Parasit. 75, 487494, 1981.
20. Liener I. E. (Ed.) Toxic Constitutents of Plant
Fooakrufi, 2nd Edition, p. 151. Academic Press, New
York, 1980.