potential for vector control. Houses that have integral walls and screened windows and doors will greatly limit the risk of indoor infection, particularly when used in conjunction with other measures, such as application of residual sprays. By contrast, houses constructed with semi-open bamboo or stick walls will admit insects of all sorts and are much less suitable for spraying with residual insecticides.

WATER STORAGE PATTERNS may influence malaria transmission through the provision of breeding sites, particularly in urban settings. For example, water tanks on the roofs of houses, common in many urban centers in India, may become larval development sites for An. stephensi and enhance the chances that malaria transmission will be maintained.

HEALTH SEEKING BEHAVIORS of populations affected by malaria will affect the outcome of clinical infections. For example, people accustomed to seeking initial treatment from traditional healers may suffer greater mortality from malaria than do those who go first to well-supplied health centers stocked with effective drugs. This is particularly true for young children, in whom the disease may rapidly become life-threatening.

SLEEPING HABITS, i.e., whether people sleep indoors or outdoors, at what time they retire in relation to the peak feeding times of vector mosquitoes, and whether or not they are accustomed to using bednets, will influence the risk of malaria infection and the choice of various antimosquito measures.

CUSTOMS AND TABOOS may affect both the risk of acquiring malaria and the outcome of infections. For example, taboos against pregnant women using drugs may influence the success of prophylactic or treatment regimens aimed at women pregnant for the first time, who are at high risk for severe and complicated malaria.

INCOME AND WEALTH clearly affect the severity of the malaria problem. If the population has the financial resources to build housing inhospitable to mosquitoes, is knowledgeable about the use of personal protection measures such as mosquito repellents, understands the importance of seeking effective treatment at the first sign of illness, and can pay for health services and drugs, the rates of severe morbidity may be low and malaria mortality nonexistent, despite being in an area of intense malaria transmission.

LOCAL UNDERSTANDING of malaria will affect decisions about whether and when to seek treatment and behaviors influencing exposure to infected mosquitoes. Populations exposed to malaria may know that the disease is transmitted by a mosquito, may feel that it is a consequence of “spirit anger, ” or may simply accept it as an unavoidable part of life. Whatever view is held, it will influence the degree of acceptance of measures designed to limit transmission or to increase the use of health services.



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