Life expectancy at birth has gradually improved from an average of 37.5 years for men and 38.3 years for women in 1966 to an average of fifty-two years for men and fifty-five years for women in 1990 (for a combined average of fifty-four). Malaria remains the most serious tropical disease, although eradication campaigns against mosquitoes waged since 1948 initially resulted in spectacular declines in incidence and a dramatic decrease in the island's mortality rate during a twenty-year period. Indeed, in some regions, especially the central highlands, these campaigns were almost completely successful, although malaria continues to be prevalent in the coastal regions, especially the east coast. As prevention practices faltered during the late 1970s and throughout the 1980s, the mosquito staged a comeback. The effect on a population with a significantly reduced resistance to malaria was devastating. For example, the Malagasy Ministry of Health reported 490,000 cases and 6,200 deaths from malaria in 1985, but these figures rose--to 760,000 cases and 11,000 deaths--in 1987.

As of 1994, other serious diseases included schistosomiasis, tuberculosis, and leprosy. The prevalence of schistosomiasis, a parasitic ailment that spreads primarily through the passing of human wastes into ponds, irrigation canals, and slow-moving streams, reflects the continued lack of adequate sewage facilities, especially in the rural areas. Occasional outbreaks of bubonic plague occur in urban areas, the most recent of them in 1990. Yet Madagascar has been spared many of the diseases common in tropical countries, such as trypanosomiasis, cholera, brucellosis, and yellow fever.

The occurrence of sexually transmitted diseases (STDs) has increased during the 1980s and the 1990s. It is estimated that 287 of 100,000 inhabitants have gonorrhea, and 220 of 100,000 have syphilis. According to data collected from 9,574 inhabitants treated for STDs in 1987, the breakdown by type of disease was as follows: gonorrhea (38 percent) syphilis (33 percent) trichomoniasis (20 percent) and candidiasis (8 percent). According to data compiled by the World Health Organization, only three cases of acquired immune deficiency syndrome (AIDS) were reported in the 1990-92 period, and six cases in 1993, earning Madagascar a 0.0 "case rate" (reported cases per 100,000 population).

The government has committed itself to the principle that good health is a right of each Malagasy citizen, and has made significant strides in the area of health care. A number of new hospitals and medical centers were built in various parts of the country during the 1970s and the first part of the 1980s. However, about two-thirds of the population reside at least five kilometers from a medical center, resulting in the May 1993 finding of UNICEF that 35 percent of the population lacked adequate access to health services.

Economic decline has led to a deterioration in medical services during the late 1980s and the early 1990s. In 1976, of the national budget, 9.2 percent was allocated to health care this percentage dropped to 6.6 percent in 1981, 4.5 perce87d cent in 1990, and 2 percent in 1994. For example, as of 1993, according to UNICEF, the country had only one physician per 17,000 people. Important regional differences also exist. For example, in some provinces the ratio was as low as one physician for 35,000 persons. For the entire island, in 1993 a total of 234 medical centers were under the direction of one doctor, and the remaining 1,728 centers were under the direction of paramedics, midwives, nurses, health aides, or sanitarians. For those unable to obtain modern medical treatment, traditional medicine--the use of herbs or the exorcism of malicious spirits--remains popular.

Additional factors contributing to health problems include overcrowding (in some areas five to eight persons live in a room fourteen meters square), contagious diseases such as the plague, and inadequate garbage disposal facilities. Infant mortality has risen from sixty-eight per 1,000 births in 1975 to 109 per 1,000 in 1980 and 150 per 1,000 in 1990. Malnutrition, diarrheal diseases, respiratory infections, and malaria are major causes of infant deaths. Madagascar had a serious malaria epidemic in 1990 causing the death of tens of thousands efforts are underway for annual antimalarial campaigns, especially in the Hauts Plateaux.

Data as of August 1994