Despite advances in the response to malaria, the death toll among children, particularly in Africa, remains unacceptably high, according to a public health expert. Kathryn Maitland, a pediatric infectious disease specialist at Imperial College London, is calling on the global community to do more to advance the understanding and treatment of the mosquito-borne, tropical illness. From her outpost in Kenya, Maitland sees the tremendous toll malaria takes on the population in endemic regions in Africa, particularly among young children. It’s been reported that 631,000 people on the continent succumb each year to the disease. Most, says Maitland, are children under the age of five. In a Perspective article in the New England Journal of Medicine, Maitland notes that about 1,200 children in the hardest hit regions die every day. That's one in ten children, even with the best care. But, Maitland writes, not all of the news is bad. Over the past ten years, she says, there's been an increase in funding for malaria control efforts, such as the distribution of insecticide-treated bed nets and the widespread introduction of artemisinin combination therapies, the most effective treatments at the moment. As a result, the burden of malaria has been reduced in some parts of the world. But it remains a serious threat in parts of Africa. And Maitland is calling for a greater focus by the research community on the treatment of malaria. “So, a modest improvement in outcome from any one of the complications of severe malaria could have a substantial impact on mortality across Africa,” said Maitland. Maitland writes that there has been relatively little progress made in the treatment of malaria, including vaccine development and the best ways to tend to victims of the mosquito-borne illness. She notes that few large-scale clinical trials of malaria treatments have been conducted, and Western assumptions about the best way to manage the disease in children, such as fluid resuscitation therapy, to treat coma and shock, have proven to be ineffective or even harmful. A study led by Maitland showed that the therapy increased the risk of mortality in children with severe malaria by 3 to 4 percent, for reasons that remain unclear. Finally, Maitland worries about the problems with emerging drug resistance, both to the insecticides that are used to treat bed nets, to guard against biting mosquitoes at night, and to the most effective tool in the medical arsenal, artemisinin-based compounds. Resistance to the drug has begun to show up in Cambodia. For these reasons, Maitland says the global health and research community needs to elevate malaria on its list of priorities. “You can’t give up on thinking malaria is now solved, that we are on our last phase to sort of controlling this disease. It is still a very huge problem in Africa. We need to do more large trials to actually improve the outcome because even on the best anti-malarial treatment, which is artesunate, the mortality is still 10 percent,” said Maitland. Maitland calls the slow progress in the field “astonishing,” but says high quality, large-scale trials can be done that could generate dramatic improvements in malaria care in Africa and throughout the world.