Resistance of Plasmodium falciparum to the antimalarial drug sulfadoxine-pyrimethamine is a result of extremely rare mutations that have spread over large geographical areas. This pattern was completely unexpected because mutations encoding resistance occur commonly in laboratory conditions, leading to the expectation that resistance would originate locally on numerous occasions. This can be reconciled with basic P. falciparum biology and epidemiology, and it is concluded that this pattern of extremely rare mutations and subsequent spread should be regarded as the most likely pattern of resistance to future antimalarials. Consequently, strategies to slow the spread of resistance need to be designed on regional, rather than national, considerations.