from the BOMA database to inform an analysis of malaria mortality in Africa from 1900 through the 1990s (Snow et al., 2001). They took mortality reports from areas with documented, stable endemic transmission, where the prevalence of parasitemia in children was at least 30 percent, and which had recorded both all-cause mortality and malaria-specific mortality. Thirty-nine studies in 13 countries of sub-Saharan Africa ² met the criteria, spanning the period from 1912 to 1995. A year-by-year analysis was not possible with these scattered, sparse data. Instead, the time span was divided into three periods, corresponding approximately to changes of probable significance to malaria control. The period before 1960 represents a time of limited access to primary health care and hence, to effective antimalarial drugs. From 1960 until 1990, after the beginning of independence for most countries, health care expanded across Africa and chloroquine became widely available, both from health services and as self-medication. The 1990s saw the widespread emergence of chloroquine resistance in many parts of Africa.

The picture painted by these data suggests a continuing downward trend in total child mortality over the three periods, but a downward and then ascending course for malaria-specific mortality, with the lowest rates in the middle period, and similar rates pre-1960 and post-1990 (Figure 7-1). With a 34 percent decline in overall mortality from before 1960 into the 1990s, and the fall and rise of malaria death rates into the 1990s, the proportion of all deaths due to malaria first fell from 18 percent pre-1960 to 12 percent in 1960-1990 but rose to 30 percent during the 1990s. Snow and colleagues (2001) cite data from Tanzania, Senegal, and Kenya comprising more detailed time series, which are consistent with the findings overall.

The data used to describe these trends, are by their nature, limited and not entirely comparable. The pre-1960 data are mainly from colonial Anglophone Africa, where malaria deaths were tracked through civil notification systems operating in defined populations. The pre-1960 systems probably missed a greater proportion of deaths than the later prospective surveillance studies, which have high rates of ascertainment of the fact of death. However, identification of deaths from “malaria” may actually have been more accurate in the earlier period because deaths often were followed up by a medical officer to determine their cause. The later surveillance systems rely on assigning cause of death retrospectively, mainly through verbal autopsies.

The declines in childhood mortality during the second half of the 20th