Now, at the beginning of the 21st century, there is good reason to believe that inroads against malaria can be made in Africa and elsewhere, using the control measures described in this report, if effective combination antimalarials are made widely available.

Malaria in Africa

The extent of the challenge is illustrated by the map of Africa (Figure 1-1), showing a vast swath between the northern coastal countries and the most southerly ones (excluding most of the horn of Africa) where malaria transmission is intense and malaria is ever-present. This area is ringed by a region prone to seasonal malaria transmission or periodic epidemics—with often devastatingly high mortality rates. More than half a billion people—more than two-thirds of the African population—live with malaria year in, year out, most of them where transmission is intense. The vast majority of the million or so deaths from malaria occur in Africa, mostly among children who have yet to acquire sufficient immunity to protect them from heavy malaria infections. The prevalence of malaria varies with levels of endemicity, but it averages to at least one acute clinical episode per year for which some treatment is sought, or on the order of half a billion treated episodes.

It is worth remembering that the malaria map would have looked very different half a century ago, and that control measures are largely responsible for shrinking the highly-endemic zone. The low- and no-transmission areas of southern Africa (including Namibia, Swaziland, South Africa, Botswana, and Zimbabwe) were previously highly endemic—and could become so again, if control measures fail.

The map lays out the boundaries of a very large problem, but does not tell the whole story. Who becomes sick and who dies is what is important. Once the discussion moves beyond acknowledging that malaria is a “big” problem, however, estimates of the relevant numbers—malaria cases, deaths from malaria—and the distribution among the population, geographically and by age, vary so widely that they can appear unusable for policy and planning. This lack of specificity is at least part of what makes tackling the problem so unsettling.

Malaria in Asia

There are about 27 million cases and 30,000 deaths from falciparum malaria in Southeast Asia each year, with no perceptible decline over the last decade (WHO Regional Office for South-East Asia,). Unlike Africa, where acquired semi-immunity protects most adults from severe clinical disease and death, intermittent infections in Asian endemic areas are usu-

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