work in a construction or other development project). Climate change also contributes to the development of epidemics. In terms of population effect, two common features of nearly all malaria epidemics are: 1) an equal risk of clinical disease and death among children and adults, and 2) a clinical burden that outweighs and overwhelms available health services (Snow and Gilles, 2002).

On the fringes of endemic areas, climate often restricts malaria transmission—i.e., normal conditions are either too dry, too wet, or too cold for propagation of vectors or parasites. In such sites, small environmental changes can trigger an epidemic. The El Niño Southern Oscillation (a weather event that originates in the Pacific Ocean but has wide-ranging global consequences, in particular droughts and floods) has been particularly well studied in this regard (Kovats et al., 2003). For example, El Niño-related droughts have been associated with malaria outbreaks in Sri Lanka (Bouma and van der Kaay, 1996), Colombia (Poveda et al., 2001), and Irian Jaya (Bangs and Subianto, 1999). Conversely, in highland regions, elevated temperatures due to El Niño may increase malaria transmission, as occurred in Northern Pakistan in 1981-1991(Bouma et al., 1996). Higher than usual temperatures, and heavy rainfall also have contributed to short-term increases in highland malaria in Rwanda (Loevinsohn, 1994) and Uganda (Lindblade et al., 1999).

Despite the effect of climate change on highland malaria, emerging evidence suggests that drug resistance has influenced highland epidemics in east Africa to a far greater degree than any other environmental factor (Hay et al., 2002). For example, chloroquine resistance has been identified as a key factor in the resurgence of malaria on the Kericho tea estates in Kenya where climate, environment, human population, health care provision, and malaria control measures remained stable (Shanks et al., 2000). Similarly, the malaria resurgence in the Usambara mountains of Tanzania has now been linked to the rise in antimalarial drug resistance (Bodker et al., 2000) as opposed to previously postulated climate change (Matola et al., 1987).

There are many reasons for mass migration: war and civil strife, economic resettlement, environmental and natural disasters. Under appropriate conditions, this mobility can affect malaria transmission. Among 20 countries with a high risk of malaria transmission in the Americas, 16 identified human mobility as a major cause of persistence of transmission (PAHO, 1995). Migration also has been associated with the spread of drug-

Front Matter (R1-R20)

Executive Summary (1-16)

Part 1: A Response to the Current Crisis1 Malaria Today (17-60)

2 The Cost and Cost-Effectiveness of Antimalarial Drugs (61-78)

3 The Case for a Global Subsidy of Antimalarial Drugs (79-111)

4 An International System for Procuring Anitmalarial Drugs (112-122)

Part 2: Malaria Basics5 A Brief History of Malaria (123-135)

6 The Parasite, the Mosquito, and the Disease (136-167)

7 The Human and Economic Burden of Malaria (168-196)

8 Malaria Control (197-251)

9 Antimalarial Drugs and Drug Resistance (252-298)

Part 3: Advancing Toward Better Malaria Control10 Research and Development for New Antimalarial Drugs (299-311)

11 Maximizing the Effective Use of Antimalarial Drugs (312-328)

Acronyms and Abbreviations (329-333)

Glossary (334-346)

Index (347-364)