measured the clinical value and cost-effectiveness of this practice. In one placebo-controlled trial in the Gambia, malaria chemoprophylaxis (dapsone plus pyrimethamine) administered by traditional birth attendants resulted in lower levels of parasitemia, fewer cases of anemia, and fewer low birth weight babies, but only in women experiencing their first pregnancy (Greenwood et al., 1989).

RESEARCH AGENDA

Pathogenesis

Despite a partial understanding of the host-parasite interactions in malaria, it is not known why some patients die from the disease. The remarkable recoveries enjoyed by most patients with cerebral malaria suggest that much of the pathology of this condition is reversible. If the pathogenic processes could be interrupted, or if the vulnerable organ systems could be supported until antimalarial drugs exerted their effects, the mortality rate due to serious malaria infections likely would decrease. Parasite sequestration, a characteristic of all P. falciparum infections, is associated with multi-system organ impairment in only a small proportion of patients. Similarly, severe malarial anemia develops in only a few of those at risk. In addressing these questions, a focus on the determinants of malaria disease, as distinct from the factors involved in malaria infection, may suggest new preventive and therapeutic options (Playfair et al., 1990).

RESEARCH FOCUS: Determination of why some patient groups suffer severe disease (cerebral malaria and life-threatening anemia), while other, seemingly similar groups tolerate high parasitemia with only mild symptoms.

RESEARCH FOCUS: Continuation of investigations into the pathogenesis of severe malaria (cytokines, parasite sequestration, hypoglycemia, increased intracranial pressure) and development of treatments targeted at the important mechanisms.

Treatment

Travelers to endemic areas who get malaria despite complying with a particular chemoprophylactic regimen occasionally are used as sentinels to detect the spread of drug resistance. Since their levels of exposure and degree of immunity differ significantly from those of the local population,



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