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INTRODUCTION
Although there have been detailed descriptions of nervios from case reports and
from specific regions, few attempts have been made to compare descriptions of
the illness across cultures. Nervios is often glossed as “nervousness” or “anxiety”
(Trotter 1982), although it is not synonymous with formal definitions of anxiety,
nor is it generally recognized by biomedical practitioners. Low (1985) attempted to
compare published descriptions of nervios in different populations, but found that
methodological differences in how individual studies were conducted made gen-
eralizations difficult. She suggested, however, that the similarity between nervios
and susto (a folk illness glossed as fright or shock) might mean that they were
both expressions of distress, but labeled differently by different segments of the
population. As such, unresolved issues include whether the term nervios means
the same thing in different cultural contexts, and the extent to which nervios and
susto represent similar or distinct illness entities.
Not simply part of the exotica of different cultures, folk illnesses have been
linked to morbidity and mortality. Susto is associated with an increased risk of co-
morbidities and a higher mortality rate (Baer and Bustillo 1993; Baer and Penzell
1993; Rubel et al. 1984) and nervios is now noted in the DSM-IV (American
Psychiatric Association 1994: Appendix 1). The study of these folk illnesses in
relation to physiological symptoms has not been for the purpose of reducing the
Culture, Medicine and Psychiatry 27: 315–337, 2003.
°
C 2003 Kluwer Academic Publishers.
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folk illnesses to their biomedical equivalents, but rather to understand the meaning
of these ethnomedical diagnoses for increasing risk of morbidity and mortality.
Since susto has been linked with increased morbidity (Baer and Penzell 1993) and
mortality (Rubel et al. 1984), if nervios and susto are really just different names
for the same problem, nervios sufferers may similarly be at increased health risk.
This paper explores inter- and intracultural variations in descriptions of the
folk illness nervios. Four diverse Latino populations are studied: Puerto Ricans
in Hartford Connecticut, Mexican Americans in South Texas, Mexicans in
Guadalajara, Mexico, and Guatemalans in rural Guatemala. Since a first step is to
understand an illness in its cultural context (Guarnaccia and Rogler 1999:1322)
and then analyze its relationship to co-morbidity, this study first describes nervios
within each of the four populations. One aim is to see if there is a distinct description
of nervios that is shared by culture members—a community explanatory model
of the causes, symptoms, and treatments for nervios. A second aim is to compare
descriptions across the four diverse sites to see the extent to which descriptions are
similar and different in different cultural contexts. Finally, we compare detailed
findings for nervios with those for susto in order to determine if these two folk
illnesses are synonymous or distinct.
BACKGROUND
One problem in our understanding of nervios is that studies have used a variety
of terms for the problem, including “nerves” (Finkler 1989; Krieger 1989; Sluka
1989), “nervousness” (Camino 1989; Koss-Chioino 1989), and “nervios” (Barnett
1989; Finerman 1989; Kay and Portillo 1989; Low 1989). The literature indicates
that the label “nervios” covers a broad range of problems in the mental health
realm, from depression to schizophrenia (Jenkins 1988). In some cultures, the term
nervios may be preferred over the term “mental illness,” and may be interpreted
much more broadly (Baer 1996). The similarity between nervios and susto suggests
that they may both be expressions of distress or stress, but the two different labels
may be used in different contexts (Low 1989).
Nervios has been studied in a variety of locations (including Latin America, the
Mediterranean, northern Europe, and the United States) (Davis and Low 1989).
But among some cultural groups, scholarship about nervios is less well developed
than for many of the other folk illnesses. This is particularly true for Mexican
and Mexican American populations (Trotter 1982). This pattern is curious, in that
Trotter (1982) found that in the lower Rio Grande Valley, nervios was the third
most frequent ailment reported (stomach ache and cough were first and second),
and the most frequent folk illness.
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(Low 1985) and may reaffirm an “urban, upwardly mobile Ladino identity” (Low
1989:133).
In Mexico, as in Guatemala, there is a higher prevalence of nervios among fe-
males; this is attributed to their inferior social position (Finkler 1991:43). This
is further illustrated by reports that nervios is associated with stressed, harassed,
abused, and/or neglected women in rural Mexico (Davis and Low 1989; Salgado
de Snyder et al. 2000). In Mexican populations, nervios is simultaneously an ex-
planation of illness, a symptom of illness, and a state of illness. However, those
suffering from the symptoms of nervios report a wide variety of symptoms, in-
cluding feelings of desperation, headaches, chest pains, abdominal pains, high and
low blood pressure, and various familial, social, political, and economic concerns
(Finkler 1989; Salgado de Snyder et al. 2000). Patterns of treatment in Mexico in-
clude home remedies, especially herbal teas, frequently used in combination with
physician-prescribed medications (Finkler 1989).
Among Mexican Americans, Jenkins (1988) found that the term nervios is used
to cover everyday problems causing distress, serious family conflict, as well as
schizophrenia. Symptoms associated with nervios included irritability, hopeless-
ness, nervousness, depression, physical effects, and difficulty in functioning in
social or occupational roles. For Mexican and Mexican American farm workers in
Florida, nervios was the label that covered many conditions considered biomedi-
cally to be mental illnesses. However, nervios was not considered to be a mental
illness by the farm workers (Baer 1996). Causes of nervios included money, food
and work problems, and accidents; treatments suggested were talking to some-
one about the problems or getting medical or psychiatric help. Among Mexican
Americans, nervios has been reported as being more common in women (Jenkins
1988). In a study of widows, Kay and Portillo (1989) found that the more bi-
cultural a woman was, the less she was troubled by nervios. Both somatic and
nonsomatic symptoms were reported, but it was primarily the nonsomatic symp-
toms (fear, worry, anguish, anger, separation sorrow, loneliness, disorientation,
feeling empty, confusion, and a feeling of being in the way) that distinguished
nervios.
Although these findings suggest similarities among these populations in their
definitions of nervios, each study used a somewhat different approach and re-
search instrument that limits our ability to tell how similar nervios is among
diverse Latino populations. To systematically study and document regional vari-
ations in descriptions of nervios, we undertook a multisite comparative study of
nervios. Using four distinct geographic and cultural locations, we examined de-
scriptions of nervios to see the degree to which individuals within a community
reported similar causes, symptoms, and treatments for nervios, and then compared
descriptions across sites. We also conducted a parallel study on susto (Weller
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METHODS
Data collection
Four Latino populations were sampled. In the United States, people were inter-
viewed in the Mexican American community of Edinburg, Texas, and the mainland
Puerto Rican community in Hartford, Connecticut. The other two research loca-
tions were the rural ladino community of Esquintla, Guatemala, and the urban
Mexican community of Guadalajara.
The Mexican American interviews were conducted in the lower Rio Grande
Valley community of Edinburg, Texas. This region is among the poorest metropoli-
tan areas in the United States. Located 15 miles from the US–Mexico border, the
area, although a mixture of urban and rural, is predominantly agricultural. The
population is 80% Mexican American. Hartford, Connecticut, is a medium-sized
city in the northeast United States. While only about one-third of the city’s pop-
ulation is Hispanic, children of Puerto Rican descent make up 47% of those in
the public school system. The interviews for this study were conducted in the
two census tracts that have the majority of the Puerto Rican population. The
Guatemalan interviews were conducted in the department of Esquintla, located
on the Pacific coast. This area is agricultural; primarily cotton and sugar cane
are grown. The population sample was Spanish-speaking ladinos in four rural
villages, each of which had a population of about five hundred. The Mexican
sample was drawn from the modern industrial city Guadalajara, which has a
population of approximately three million. Predominantly mestizo, residents of
Guadalajara are from both rural and urban backgrounds. In order to capture the
variation present in the city, three neighborhoods were sampled, one middle class,
one working class, and one poor; all of those interviewed were Spanish-speaking
mestizos.
To ensure representative samples in each community, a two-stage random sam-
pling design was employed. First, a village, neighborhood, or census tract was
chosen, and then blocks and households were selected. The inclusion criteria were
that the respondent be an adult and recognize nervios as an illness entity (respon-
dents were asked simply if they ‘had heard of nervios’). Additionally, in Edinburg,
respondents had to self-identify as being of Mexican descent, and in Connecticut
they had to self-identify as being of Puerto Rican descent. The preferred respon-
dent in each household was the female head of household, since we assumed
that women have more responsibility for health. Interviews were conducted by
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Questionnaire development
Ten to twenty initial key informant interviews at each of the four Latino sites
were used to develop the questionnaire. We focused on the term nervios, which
is recognized in all of the cultures studied, as opposed to the more extensive
variants of the condition seen among Puerto Ricans (Guarnaccia et al. 2003). Using
open-ended interviews and free listing techniques (Weller and Romney 1988),
qualitative data were gathered on the explanatory model of nervios, including
perceived causes, symptoms, and treatments of nervios (Table I).
In Mexico, respondents were also asked about similarities and differences be-
tween nervios and susto. On the basis of the open-ended interviews (any response
mentioned by at least 10% of the sample), symptoms from the Cornell Medical
Index, and the anthropological literature, a true-false questionnaire was developed.
The final questionnaire1 contained 125 items addressing the causes, symptoms,
and treatments for nervios. The questionnaire also included basic demographic
data on the respondent, as well as questions about experiences with nervios. Fi-
nally the questionnaire was translated into the form of Spanish (or English) spoken
at each particular site being studied.
Data analysis
Our goal was to determine the descriptions of nervios in the four Latino groups
as well as the degree of similarity and difference among the groups. This was
accomplished with a type of data analysis called consensus analysis. Given a set of
related, closed-ended questions, a consensus analysis accomplishes three things.
First, it provides an assessment of the agreement among respondents to see if
there is sufficient agreement to warrant aggregating responses. Then, if there is
sufficient agreement, it provides estimates of how well each person’s responses
correspond to the “group ideas.” Third, it provides estimates of the answers to the
set of questions.
A consensus analysis is an analytic tool that allows one to determine whether
there is group agreement—or consensus—in responses to structured questions.
Identifying or creating a reliable description of community explanatory models
includes an assessment of variability of ideas. If variability is high—that is, if
respondents do not agree with one another and do not seem to have similar ideas—
then it does not make sense nor is it accurate to create a unitary, simple aggrega-
tion of responses. If, however, informants report similar or identical information,
then one is justified in pooling the information to create an overall description of
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TABLE I
Nervios
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11 Se mueren
2 Se puede torcer la boca
2 Se empeora la enfermadad
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5 10 years and older 2 Getting angry; overreacting 7 Very emotional; gets agitated easily 7 Go to Curandera
4 People who are weak 1 An evil spell 5 Pacing, rushing around 7 Relax; rest
321
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TABLE I
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(Continued)
322
3 People who worry constantly 4 High blood pressure 5 Tea, herbal tea (manzanilla)
MEDI.cls
2 Headache
Hartford, Connecticut (n = 10)
3 Adults 3 Not contagious 2 Loss of control (of one’s nerves) 2 Medication
2 Everyone 1 Being overwhelmed with problems 1 Screaming 2 Pills prescribed by doctor
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1 People with a lot of stress in their lives 1 Problems dealing with life 1 Crying hysterically 2 Tranquilizers
who are unable to cope with problems 1 Depression 1 Not a physical illness; more mental 1 Bring to a doctor
1 Mainly women 1 Anxiety 1 Lots of crying and screaming upon 1 Therapy
1 Weak people who take their problems hearing bad news, especially if 1 Walking
too seriously someone dies 1 Speaking to another person
ROBERTA D. BAER ET AL.
RESULTS
The sample
The final sample consisted of 40 respondents in Connecticut, 41 in Texas, 38 in
Mexico, and 40 in Guatemala. Respondents were primarily women (100% in the
Mexican and Texas samples, 90% in Guatemala, and 87% in Connecticut). All
of the informants in the Mexican sample were born in Mexico, and all of the
informants in the Guatemalan sample were born in Guatemala. In the Connecticut
sample, 90% were born in Puerto Rico; 70% of the interviews were conducted
in Spanish, 3% in English, and 28% in combined English and Spanish. In the
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TABLE II
Sample Demographics
Sample size 40 38 40 40
% female 90 100 100 87
Age in years (range) 42.9 (17–83) 38.5 (20–85) 42.2 (18–81) 37.1 (20–58)
Total children (range) 6.3 (0–14) 4.4 (0–16) 2.8 (1–7) 2.8 (0–12)
Household size (range) 5.4 (1–9) 5.7 (1–11) 3.8 (2–9) 4.1 (1–8)
Education in years (range) 1.8 (0–9) 5.5 (0–13) 11.2 (0–16) 10.3 (0–15)
Knows someone with nervios 95% 82% 90% 90%
Family member had nervios 88% 74% 71% 80%
Respondent had/has nervios 65% 63% 46% 52%
Texas sample, 95% of the respondents were born in the U.S., and 66% of the
interviews were in English, 7% in Spanish, and 27% in combined English and
Spanish. Respondents’ educational levels varied significantly between samples,
reflecting normative rates for each region: 1.8 years in Guatemala, 5.5 years in
Mexico, 11.2 years in Texas, and 10.3 years in Connecticut (Table II).
Actual experience with nervios varied somewhat by community. Most respon-
dents knew someone with nervios (95% in Guatemala, 90% in Connecticut and
Texas, and 82% in Mexico) and had experienced it in their family (88% Guatemala,
80% Connecticut, 74% Mexico, and 71% Texas). Of our respondents, about two-
thirds of those in Guatemala and Mexico had experienced nervios themselves;
46% of those in Texas and 52% of those in Connecticut also reported it.
Descriptions of nervios
Analysis of responses to the 125 items concerning the causes, symptoms, and
treatments for nervios revealed that a single, shared system of knowledge about
nervios exists for each sample of respondents. The cultural consensus model fits the
response data (the eigenvalue ratios all exceeded the recommended 3:1 ratio: 9.85
in Connecticut, 8.81 in Texas, 6.51 in Mexico, and 5.48 in Guatemala). Responses
were the most homogeneous in the Texas and Connecticut samples, resulting in
the highest levels of sharing (the average cultural knowledge scores were 0.73
in Texas and 0.62 in Connecticut). The Mexican and Guatemalan samples also
exhibited shared ideas, although at a somewhat lower level (0.52 in Mexico and
0.43 in Guatemala). Analysis with all four samples together indicated that they
share a single description of nervios, with about 52% of ideas in common (cultural
knowledge level = 0.52, eigenvalue ratio 6.45). A comparison of knowledge lev-
els across samples indicated that there was a greater degree of shared responses
in Texas than in Connecticut, significantly greater sharing in Connecticut than
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TABLE III
Susceptibility
Susto Nervios
GMT GMTC
someone get killed or being in an accident) can cause nervios. Also important in
causality are strong emotions, anger, worry, family problems, and family fighting.
Nervios is not considered to be contagious. A relationship between susto and
nervios is evident, as susto was considered to be a cause of nervios. In addition,
several situations that are usually cited as producing susto—seeing someone killed,
seeing or being in an accident, or a surprise or shock—were also considered to
be causes of nervios. While the four sites agreed that a cause of nervios might
be not eating well (three sites also thought hunger could cause it), food stuck in
the stomach (usually associated with the folk illness empacho) was not considered
to be a cause of nervios. Three sites also agreed on a lack of hot/cold causality
of nervios. There was also agreement among three sites that witchcraft was not a
cause of nervios, but that the Devil might be.
For the symptoms of nervios (Table V, columns 4–7), there was agreement across
at least three of the samples on 62% of the questions (24 out of 39 questions), and
among all four of the sites on 44% (17 out of 39) of the questions. Symptoms
agreed upon by all four sites included depression or sadness, a feeling of no hope
in life, crying, hysterical crying or crying attacks, and shaking or trembling. Other
symptoms agreed upon by all four sites were headache, a feeling of choking, cold
sweat, weight loss, bad temper, insomnia, and anger caused by small things. There
was also agreement that runny nose, fever, slow healing wounds, and a swollen
stomach were not symptoms of nervios. Additional symptoms agreed upon by
three of the sites included lack of appetite, agitation, and convulsions or seizures.
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Susto Nervios
GMT GMTC
For treatments (Table VI, columns 4–7), at least three of the samples agreed
on 73% (30 out of 41) of the questions, and all four samples agreed on 51% (21
out of 41) of the questions. For all four of the sites, over the counter remedies
(such as aspirin, Vicks, cod liver oil, Alka Seltzer), antibiotics, and treatments
used for other folk illnesses (such as barrida, or sweeping with herbs, rubbing
with an egg, a spoonful of oil, pulling the skin of the body until it pops, or binding
the waist) were not indicated for use in the treatment of nervios, nor were the
services of the folk healers, curanderos, or spiritualists. Other treatments rejected
by all groups included spearmint tea, enemas, scaring the affected person, drinking
alcohol, warm towels on the body, and drinking milk. Sedatives, praying, and
trying to relax were the only suggested treatments agreed on by all four samples.
Additionally, three of the sites recommended the use of physicians and psychiatrists
or psychologists, and rejected the use of holy water sprinkled on the body in the
shape of a cross, as well as the use of a pharmacist, herbalist, wise old woman, or
grandmother. Three sites reported that nervios would go away by itself.
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TABLE V
Symptoms
Susto Nervios
GMT GMTC
Susto Nervios
GMT GMTC
is not as closely linked to gender. While there is some overlap in causes of susto
and nervios (including seeing someone get killed, seeing or being in an accident,
and a sudden surprise or shock), susto seems more related to a particular incident
or accident. In contrast, causes of nervios are of a continual nature in one’s life,
and include family problems and fighting, drugs, alcohol, worry, anger, and strong
emotions (Table IV). Note, however, that susto can cause nervios and that nervios
can cause susto.
A similar pattern is seen with regard to symptoms of nervios and susto, with
overlap in symptoms such as crying, shaking, and difficulty sleeping (Table V).
However, there are many symptoms that are unique to each illness. Paleness may
be more restricted to susto, while headache, a feeling of choking, cold sweat, and
weight loss are associated more with nervios. Neither illness seems to manifest
solely with somatic symptoms. While praying is recommended for both susto
and nervios, the most striking difference between the two illnesses is the use
of Western versus folk treatments. While a doctor or psychologist or psychi-
atrist is recommended for nervios, they are not considered effective for susto
(Table VI). In fact, home treatment and folk healers are used more often for
susto.
Patterns of regional variation similar to those found for nervios also appear
for similarities and differences between susto and nervios. Only the Mexican and
Guatemalan samples report that weak people and people with a weak character
are more likely to get either illness (the Texas sample did not) and that the Devil
could cause both susto and nervios. Similarly, these two sites saw diabetes as a
possible outcome of both untreated susto and untreated nervios. Guatemala was
the only site to feel that drafts were a cause of these illnesses. Finally, only the
Texas sample reported that both nervios and susto would go away by themselves.
We also compared the differences between nervios and susto which emerged
from the analysis of the structured questionnaire data to those differences reported
in the initial open-ended interviews in Mexico. In those open-ended interviews,
respondents were asked about the similarities and differences between nervios
and susto. We found that both sets of interviews contained similar themes: susto is
considered to be briefer than nervios, and nervios is more chronic and is a continual
stress. Susto is caused by an identifiable event—a “susto”—while nervios is caused
by persistent problems.
In summary, there is an overlap in many aspects of these two illnesses. Both
tend to occur more in adults; both are caused by surprising, shocking, or disturbing
occurrences. Both present with symptoms of distress; neither presents solely with
somatic symptoms. However, nervios is a much broader illness, related more to
continual stresses. In contrast, susto seems to be related to a single stressful event.
There are a few broadly recommended treatments for nervios, while those for susto
show more regional variation.
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The core description of nervios agreed on by all four sites supports the patterns
reported in the literature for these individual populations. Nervios is felt to oc-
cur more often in women. It is caused by emotion and interpersonal problems; its
symptoms are primarily nonsomatic. Interestingly, although treatment by psychol-
ogists and doctors is recommended, the most broadly recommended treatment is
neither biomedical nor folk, but spiritual, i.e., praying. However, at all four sites,
nervios covered a broad range of mental health conditions. It would seem of great
importance for mental health professionals working with these populations to un-
derstand the way the term nervios is used and the types of conditions it covers.
It should be noted, however, that the literature suggests that nervios may not be
considered a “mental illness” by these populations (Baer 1996).
Almost everyone approached to be interviewed for this study considered nervios
to be an illness. Thus, there is an interesting contrast in prevalence between nervios
and other common Latino folk illnesses. We have carried out parallel studies to
those described here for susto and nervios for the folk illnesses caida de la mollera
(fallen fontanelle) and mal de ojo (evil eye) (Weller 1997; Weller and Baer 2001).
These studies indicated that in the Mexican sample, in which 100% of respondents
considered nervios to be an illness, recognition of susto was 87%, caida de la
mollera 85%, and for mal de ojo only 63% However, recognition of susto, mal de
ojo, and caida de la mollera varied by social class. Recognition was highest in the
lower class, intermediate in the working class, and lowest in the middle class. But
unlike other folk illnesses, recognition of nervios in Mexico was not class related.
Similarly, we found no meaningful variation in relevant themes for nervios by
degree of acculturation. In the Texas and Connecticut samples, a very crude index
of acculturation can be estimated by birthplace and language preference. Responses
did not differ significantly on either of these variables.
Nervios and susto are distinct entities. While it has been suggested in the liter-
ature that nervios may be the “illness of choice” among ladinos (Low 1989:133)
for expressing stress or distress, our data do not totally support this hypothesis.
Among the ladino/mestizo populations we studied, susto is also an illness category,
and it can be distinguished from nervios. The two illnesses appear to overlap, but
nervios is a much broader illness and is widely recognized. People in the same
communities recognize both illnesses, and nervios appears to transcend social
class. Specific research would be necessary with indigenous groups to determine
whether the same pattern holds in those populations. However, in Mexico it ap-
pears that the recognition of susto as an illness, unlike that of nervios, may be class
related.
Recognition of susto also varies by region. It is also important to note that
although nervios was considered to be an illness at all four sites, susto was not
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However, the reliance on mental health surveys for data on nervios has
limited the type of information that is available on that illness. In contrast,
for susto there has been an explicit exploration by Rubel and colleagues
(1984) of the possible relation between susto and stress, depression, physio-
logical symptoms, and mortality. They found that although susto is associated
with psychological symptoms, it is also associated with physiological out-
comes. The overlap between susto and nervios suggests that more needs
to be understood about the relationship between nervios and physiological
outcomes.
In conclusion, we see the need for collaboration between anthropologists and
psychiatric epidemiologists in the study of nervios, susto, and other folk illnesses.
Susto (and possibly other folk illnesses) needs to be included on mental health
surveys; nervios (and possibly other folk illnesses) needs to be investigated in terms
of its relationship to stress, depression, physiological symptoms, and mortality. We
cannot continue to assume the separation of the health problems of the mind and
the body when the evidence suggests that such a division may just be an artifact
of our own creation, which obscures rather than illuminates the reality of patterns
and causality of human illnesses.
ACKNOWLEDGMENTS
This project was funded by the National Science Foundation grants BNS-9204555,
SBR-9727322, and BC-0108232 to S. Weller, and SBR-9807373 and BCS-
0108228 to R. Baer.
NOTES
1. The final questionnaire is available from the authors RDB or SCW upon request.
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Roberta D. Baer
Department of Anthropoloty
University of South Florida
Tampa, FL 33620
Susan C. Weller
Department of Preventive Medicine
University of Texas Medical Branch
Galveston, TX 77555-1153
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Mark Glazer
University of Texas Pan American
Edinburg, TX 78539-2997
Robert Trotter
Department of Anthropology
Northern Arizona University
Flagstaff, AZ 86011
Lee Pachter
Department of Pediatrics
University of Connecticut School of Medicine
St. Francis Hospital and Medical Center
Hartford, CT 06105
Robert E. Klein
Medical Entomology Research Training Unit/Guatemala (MERTU/G)
Centers for Disease Control and Prevention