Editorial [Hot Topic: Fighting Malaria in the 21st Century (Executive Editor: Pedro L. Alonso) ]

The global malaria situation is a desperate one, and in some circumstances becoming worse, particularly in sub-Saharan Africa. The reasons for this are multiple and run the gamut from the emergence of widespread resistance to available, affordable, and once highly effective drugs; the breakdown and inadequacy of health systems; and the lack of financial, human, and institutional resources for anti-malaria efforts. Controlling malaria is essential to global efforts to reduce poverty, minimize childhood mortality, and strengthen the most vulnerable societies. Despite many words of commitment, the world is failing to meet this challenge. The realization that world malaria eradication was beyond reach, off at the time available tools and logistic and technical capacities, led to the era of control and to a certain skepticism and abandonment of energies and momentum. Over two decades, malaria control programmes were abandoned throughout much of sub- Saharan Africa, leading to a massive resurgence of the disease. Since that time, global and regional groupings of political leaders and health ministers have repeatedly called for greater action against malaria, and new institutions have been created to strengthen malaria control efforts, such as the Roll Back Malaria initiative and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) (WHO 2000). But 100 years beyond Laveran described plasmodium species and Ross confirmed that they were transmitted by female anopheline mosquitoes, malaria remains not only a leading cause of morbidity and mortality worldwide but also a scientific challenge. Although the areas where transmission takes place have reduced, and they are by now confined to the inter tropical areas, the number of people living at risk has grown to about 3 billion, and is expected to go on increasing. This issue highlights the emerging scientific opportunities to improve our understanding and help us create new tools for the future control of malaria. Hopes for such new tools emerge from vast new data and information about the genomes of the three organisms that interact in an ancient and intricate dance to produce malaria - the human, the parasite and the mosquito vector. Together with modern immunonology and molecular biology we should better understand the pathophysiology of this interaction and the acquisition of immunity. The challenge of malaria is for the multiple sectors and communities that must be involved to move beyond targets and calls for action by designing programs that best impact malaria now; by mobilizing more resources while, at the same time, assuring that programmatic and intervention options that are better suited to the realities of inadequate resources evolve. That requires a difficult balance between passion and practicality. The world needs to raise new resources, while the public health community finds better ways to assure that, whatever resources are available, have their maximal impact. We need to deploy current tools while we also invest in the creation of new tools whose effectiveness, affordability and delivery are designed to deal with resource and structural inadequacies that, while we may strive to have them go away, won't, at least in the near term. In short, the scientific and public health communities must work with developing countries and donors, within the current inadequacies of both available interventions and available resources to act now while improving both the tools and the resources. In doing all of this, we must also remain humble and retain the lessons of the past that leave little space for content: "The history of special antimalarial campaigns is chiefly a record of exaggerated expectations followed sooner or later by disappointment and abandonment of the work. This record of failures and disappointed hopes makes it clear that the only prospect of real progress lies in renewed activity in the continuous study of the disease in all its aspects". Malaria Commission (1927) Principles and Methods of Antimalarial Measures in Europe. 2nd General Report of the Malaria Commission of the League of Nations, Geneva. This same Commission insisted: "that the fight against malaria must be waged not as a separate and isolated task but as part of a general social, economic and sanitary campaign by an enlightened public health service and to secure continuity of action and unity of purpose". League of Nations: Second General Report of the Malaria Commission (1927). With new tools, improved financing mechanisms, political support and improved understanding of the parasite and its relation with the human host, the world has a unique opportunity to improve the unacceptable global burden of malaria.