286 
MALARIA 
(of application), paralysis, cerebral hemor¬ 
rhage, tuberculosis or other pulmonary 
diseases or chronic bronchitis, asthma, can¬ 
cer, pellagra, or any disease of the heart, 
liver or kidneys or any venereal dis¬ 
ease. ...” These exclusions, to which 
homicide is commonly added, leave a com¬ 
paratively limited series of causes, includ¬ 
ing malaria, from which a negro may die 
without forfeiting his life insurance. Of 
late years the effect of this stipulation is 
offset to a considerable extent by another 
which provides that, after a stated period 
of one or two years or more, the policy 
shall be incontestable except for non-pay¬ 
ment of premiums; nevertheless, in some 
contracts payment is not made under any 
circumstances if venereal disease is in¬ 
volved. The net effect of such policies is 
to influence the physician to write in 
malaria rather than tuberculosis or syphilis 
as the cause of death to insure payment to 
the beneficiary. 
On the other hand, some true deaths from 
malaria are not reported as such. Mistakes 
in diagnosis, as indicated by Meleney 
(1937), may be responsible for missed ma¬ 
laria deaths. Very poor families, remotely 
situated, who cannot afford doctors, fun¬ 
erals, or caskets, frequently bury their own 
dead without any official record of the 
event. 
As a rule, cases of malaria are not as well 
nor as adequately reported as deaths. 
Whereas death reporting suffers mainly 
from errors of commission, case reporting 
suffers from errors both of commission and 
of omission. In endemic areas, malaria is 
commonly regarded as a trivial, insignifi¬ 
cant complaint which rarely justifies the ex¬ 
pense of calling a physician. In those in¬ 
stances where the doctor is consulted, the 
patient or his family observes that the diag¬ 
nosis is usually based on a meager combina¬ 
tion of case-history and physical examina¬ 
tion. Some physicians make a conscientious 
and thorough investigation—including a 
blood examination—before they arrive at a 
diagnosis of malaria, but all too frequently 
the doctor merely inquires how long the 
patient has been ill and if he has had a 
fever or a chill. He then feels the patient’s 
pulse, looks at his tongue, suggests that he 
may have a “touch” of malaria and pre¬ 
scribes quinine or atabrine—perhaps with 
calomel and a purgative. There is nothing 
in this pattern of diagnostic procedure that 
the patient or his family cannot do them¬ 
selves, and so the next time the same set of 
symptoms appear, the doctor is by-passed 
and the quinine or atabrine—or a substi¬ 
tuted chill tonic—is obtained without pre¬ 
scription. Thus the great majority of what 
the laity believes to be cases of malaria are 
self-diagnosed and self-treated; they never 
come to medical attention and so cannot be 
reported. Boyd (1930c) states that not 
over 35 or 40 per cent of the cases studied 
in southeastern Missouri had consulted a 
physician. Unfortunately, many of these 
which have sought medical advice are not 
reported, especially if the diagnosis was 
made on a purely clinical basis. 
Case-reporting is subject to local influ¬ 
ences which may affect statistics without 
having true morbidity significance. The 
arrival of a new doctor accustomed to re¬ 
porting malaria or of making blood smears 
as a diagnostic aid may suddenly increase 
the apparent malaria morbidity in a 
county, whereas the “increase” is only in 
the reporting of morbidity. This improve¬ 
ment in reporting malaria—as well as other 
communicable diseases—invariably follows 
the establishment of an active local health 
agency. In some states, it is customary to 
include in routine morbidity statistics all 
blood positives found in malaria surveys. 
This adds appreciably to the apparent mor¬ 
bidity in surveyed counties in contrast to 
other counties not surveyed but in which 
there is every reason for believing that ma¬ 
laria is as serious a problem. Thus the 
malariologist reviewing statistical evidence 
of malaria morbidity must carefully scru¬ 
tinize and satisfy himself as to the circum¬ 
stances behind each reported increase. 
It must not be supposed, however, that, 
because of their defects, mortality or mor¬ 
bidity statistics are entirely useless. Fig. 1 
shows the reported annual case and death- 
rates for a single malarious state, Georgia, 
