Analysing malaria events from 1840 to 2020: the narrative told through postage stamps

The role played by postage stamps in the history of malaria control and eradication has largely gone unrecognized. Scientific investigators of malaria, especially Nobel laureates, were commemorated with special issues, but the work of the World Health Organization (WHO), which promoted an ambitious and global philatelic initiative in 1962 to support global eradication, is generally overlooked. This review examines the philatelic programme that helped to generate international commitment to the goal of malaria eradication in 1962 and established philatelic malaria icons that had worldwide recognition. Malaria-related postage stamps have continued to be issued since then, but the initial failure of malaria eradication and the changing goals of each new malaria programme, inevitably diluted their role. After the first Global Malaria Eradication Campaign was discontinued in 1969, few Nations released philatelic issues. Since the Spirit of Dakar Call for Action in 1996 a resurgence of postage stamp releases has occurred, largely tracking global malaria control initiatives introduced between 1996 and 2020. These releases were not co-ordinated by the WHO as before, were more commercialized and targeted stamp collectors, especially with attractive miniature sheets, often produced by photomontage. Having a different purpose, they demonstrated a much wider diversity in symbolism than the earlier stylized issues and at times, have been scientifically inaccurate. Nonetheless postage stamps greatly helped to communicate the importance of malaria control programmes to a wide audience and to some extent, have supported preventive health messages.

domestically and internationally, reaching even remote areas. By use of symbols, slogans, and pictures, a message can be dispersed far and wide. Despite its small size and discrete purpose (letter or parcel), the stamp is postulated to capture a more concentrated health message density per sq. cm than any other cultural form [15]. Others have referred to stamps as 'icons' , meaning that, like icons in art more generally, they have the ability to capture depictions and symbols that speak to different cultures about the same health event, although the impact of such messages through postage stamps would be almost impossible to measure.
Malaria postage stamps are prolific. A descriptive presentation volume on parasitological topics, which included a pictorial listing of malaria postal issues, was published in 1981 to commemorate the 80th birthday of Professor P.C.C. Garnham [16]. Subsequently a descriptive philatelic outline of parasites on stamps, which included malaria themes, was published [17,18]. These collections do not reveal the extent to which the malaria themes they encapsulated had changed over time, or how they related to international malaria control initiatives. Since 1996, malaria control strategies were revised in line with the lessons learnt from the successes and failures, and postage stamps tracked this progress and proved useful in broadcasting new messages. This paper aimed to document and critically examine the messages and stamp designs that accompanied and were used to broadcast to the public the changing initiatives to investigate, control and/or eradicate malaria up to the present time.

Search strategy
All countries included in the most recent six volume Stanley Gibbons Stamps of the World (1840-2014) catalogue were screened for stamps directly related to malaria [19]. Specific annual catalogues published by Yvert and Tellier were reviewed [20]. Catalogues had listings of stamps from verified national postal agencies (i.e., stamps issues for use on mail, not as collector's items) since 1840. Excluded from this review were unofficial 'special' stamps produced by private organizations, which require additional Government postage for mail transmission, and are not catalogue listed. It was noted that for 20th century issues up to 2007, Borgsteede had identified 539 malaria-related stamps, and 567 with a general theme related to protozoa, including malaria [17]. On-line listings of national postal administrations were checked to March 2021 using Web search engines. Pub-Med.gov was searched for references in English or French using the terms malaria, philately, stamp, postage stamp, paludisme, timbre, quinine, cinchona, Laveran, Ross. Private collections, including the Prout reference stamp collection at the Wellcome Trust Library, were consulted [21].

Analytic approach
Five historical periods were considered: the 19th century with a focus on investigators' contributions to malaria research; the 20th century pre-1955 and prior to the commencement of the first WHO Global Malaria Eradication Campaign;1955, the period of the first Global Malaria Eradication Campaign [22]; 1970-1996, covering discontinuation of this campaign up to the date of the Spirit of Dakar Call for Action [23,24]; and 1997-2020, the period following the Spirit of Dakar Call for Action to the present [25]. Analysis of stamps designs was informed by semiology, such that postage stamps were examined as unique signs, with the capacity to convey messages in a confined space. The country and date of issue, face value, overprints or surcharges were assessed, as were the variety of symbols, images, slogans, recurring themes, national campaigns, historical scenes and personalities, expressions of solidarity, and colours used. Examples used for illustration were selected on the grounds of clarity, technical innovation, or simplicity of expression, or based on the First Day Cover envelope for a selected postage stamp.

Terminology
Commemorative refers to a stamp designed to commemorate an event or personality. The term is often used loosely to cover all postage stamps issued for special occasions for a limited period, and for a specific theme. Overprint refers to an inscription added to the stamp design after the basic stamp has been printed and does not alter the value of the stamp. A miniature sheet is a single or small group of postage stamps still attached to the sheet on which they were printed. The margins of the sheet may have ornamental designs, emblems and logo(s) which are not the part of stamp(s). Icon is defined as a pictorial sign; and symbol as a conventional sign-for example a picture, letters, or numbers. A symbol can become an icon when it receives a noticeable degree of typographical definition or is placed in a prominent and isolated position [15].

Historical discoveries
Postage stamps contain historic images of individuals and national identifiers that are archives of both scientific and international heritage [26]. They form an important visual record of the history of medicine and its commemoration. Table 1 summarizes 19th century contributions of twenty investigators who made significant advances in malaria knowledge, twelve of whom were philatelic subjects [27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45]. Maillot and Laveran, who were both  [41] serving officers in the French army in Algeria, were represented within a set commemorating pioneers of military health services (Fig. 1 Laveran's, rather than Manson's views on the hypothesis and Grassi eventually became an adversary of Ross. A strong sense of competition between German bacteriologists and Italian malariologists followed Robert Koch's 1898 visit to Italy, which produced further interest in the mosquito theory [48]. Koch was appointed as a 'neutral arbitrator' for the 1902 Nobel committee and threw the full weight of his considerable authority in insisting that Grassi did not deserve the honour. The argument on the Italian contribution to the discovery of the malaria transmission cycle still rumbles on [48]. A recent 2015 postage stamp from the Central African Republic shows Ross separated by a mosquito from Grassi, suggesting equivalence in their contribution (Fig. 3). Koch became a major national and international icon, since celebrated on more than forty commemorative stamps from different countries, numerically exceeding those honouring even Louis Pasteur. Less famous, Dr. Julius Wagner-Juaregg (1857-1940), who was awarded the Nobel Prize in 1927, was shown in an Austrian stamp in 1957 [49]. He had successfully used inoculations of infected blood from patients with tertian malaria as fever therapy for treatment of syphilitic dementia paralytica.
Arguably the effects of quinine were first discovered when an earthquake caused cinchona trees to fall into a Peruvian lake (the Lagunade De Las Curaciones Maravillosas) near Loxa and whose waters cured febrile illness. The lake was credited with miraculous healing [50]. In 1820 in Paris, the toxicologist Pierre Joseph Pelletier (1788-1842) and a pharmacist Joseph Caventou (1795-1877) successfully isolated the quinine alkaloids, demonstrating their efficacy in intermittent fevers ( Fig. 1) [27]. In 1935 the Peruvian postal administration issued two stamps showing the 'miraculous' lake in a set commemorating the tercentenary of quinine's arboreal origins (Fig. 4). Charles Marie de La Condamine (1701-1774), the celebrated French explorer, geographer and mathematician who unsuccessfully endeavoured to bring Cinchona trees and seeds from Ecuador to France [51] (Fig. 4). It is unclear why emphasis is given to a non-human primate in this stamp image, which provides a confusing message.

From 1932 to 1954 prior to first global malaria eradication campaign
Mosquito control measures proved successful in the American South in the 1910s. New approaches to malaria control in the first half of the 20th century were driven by The International Health Board (1913)(1914)(1915)(1916)(1917)(1918)(1919)(1920)(1921)(1922)(1923)(1924)(1925)(1926)(1927)(1928) and the Rockefeller Foundation (1913-present). World War One further demonstrated the risks of epidemic malaria [52], which was treated with quinine [53]. The evolving knowledge on malaria was accompanied by malaria-related stamps utilizing an extraordinary variety and range of themes, formats, and design characteristics.
The first postage stamp to promote a malaria control strategy was issued in 1932 by the Italian Government, although it formed only one 60 cent stamp within a large anniversary series to commemorate the 10th anniversary of the March on Rome by the Fascists in 1922. It showed three hand spades and was inscribed 'paludi redenti' (marsh reclamation) (Fig. 5). The stamp was designed to demonstrate that land reclamation was required to reduce marshland and mosquito breeding and improve land use [53]. In 1939, the Mexican government issued a blue, one centavo stamp, which was obligatory on all mail. Effectively this was a charity stamp surcharge to facilitate malaria control activities. The stamp portrays a kneeling man with a monstrous mosquito on his back, symbolizing the heavy malaria burden, and it was reissued in 1944 and 1947 (Fig. 5). This stamp issue and its 'fiscal tax' financed 15% of malaria control activities and reflected the Mexican Government's early commitment to malaria control [54]. From 1942 to 1958 malaria mortality and morbidity in the country went respectively from 129 to 44 and 847 to 21 per 100,000 population, a decrease that largely preceded the Global Eradication Programme in 1962 [54].
Paul Müller (1899-1965) a Swiss chemist, first developed and tested dichlorodiphenyltrichloroethane (DDT) as an insecticide (Nobel prize Physiology and Medicine, 1948) and patented the product in 1940 [55]. His work was commemorated in a stamp in 2015 from the République de Guinée. A clear strategic technical solution emerged in favour of preventive anti-mosquito regimens in preference to curative medical approaches.
The international Rockefeller malaria control programme began in Italy from 1923 to1951, with projects in India from 1936 to 1942, and trials of DDT commencing in Mexico in 1942. The Rockefeller Foundation promoted an insecticide-based global attack on malaria, and by 1943 industrial DDT production had commenced in the USA and Great Britain [53]. This use of DDT, including its strategic role during World War Two, inspired the newly founded WHO (1948) to begin national antimalaria campaigns. These anti-mosquito campaigns were successful in many low-income countries. Aspirations towards unity in variety, a sharing with the world of national, cultural, and scientific achievements embodied the spirit of the newly founded WHO [15]. The Haitian government in 1949 issued a series of seven postage stamps which embraced these values, the price of which included a surtax for malaria control operations and tuberculosis. They all showed a TB sanitorium along with a mosquito (species not stated), reflecting two infections with high health costs (Fig. 5).
The demonstrable effectiveness of DDT strongly appealed to those who wanted to eradicate malaria and influenced the WHO global anti-malaria eradication programme that began in 1955 [22]. By 1953, the WHO, with UNICEF, had established 35 Malaria Control Demonstration Teams and malaria was eliminated in countries where the mosquito was easily controllable (USA, Italy, Guyana, Greece, large parts of Venezuela) [22]. George Giglioli (1897Giglioli ( -1975, who successfully promoted its use in Guyana from 1946, is shown on a later Guyanese stamp issued in 1978 [56].

The first global eradication campaign from 1955 to 1969
Images of insecticide spraying were first shown on stamps from Afghanistan in 1960 promoting the United Nations Malaria Eradication Day, and on a First Day Cover showing the WHO Logo. In the same year, similar images were used in an Iranian stamp (Fig. 6). Images of residual insecticide spraying were widely used as a theme elsewhere in later issues in the 1960 s as well as in the omnibus issues of the 1962 Global Malaria Eradication Campaign (Fig. 7).
In 1955 the first WHO Global Malaria Eradication campaign was launched as a worldwide effort to eradicate malaria. In that year, the 8th World Health Assembly (WHA) held in Mexico passed a resolution calling for malaria eradication within five years (although it excluded Africa) [57][58][59]. Early reports from Venezuela, which had the highest number of malaria cases in Latin America before 1935, supported scientific assurances that eradication was feasible and fired the imagination of many distinguished and experienced specialists [60]. Use of the residual insecticide DDT seemed an almost miraculous way of depleting Anopheles numbers and longevity [58]. Over the next 20 years an immense effort was deployed by some 20 countries, co-ordinated by the WHO and generously supported by bilateral funds [61].
Postage stamps accompanying this major initiative illustrated the variety of ways in which malaria icons could be adapted, transformed, and promoted. In 1955 the government of India issued a 6 anna stamp that depicted an anopheline mosquito, a caduceus (an ancient Greek or Roman herald's wand, typically one with two serpents twined round it, carried by the messenger god Hermes or Mercury) and a factory, possibly representing the chemical production of DDT (Fig. 7). Postage stamps proved a popular method to depict the war on malaria. Also, in 1955 Italy issued a stamp to commemorate the 30th anniversary of the death of Giovanni Battista Grassi (1854-1925) (see Table 1), showing his image, an Anopheles, and a microscope (Fig. 1). Portugal and its colonies in 1958 issued stamps to commemorate the 6th International Congress of Tropical Medicine and Malaria held in Lisbon (Fig. 7). This  [62].
In October 1960, the 26th Executive Board of the WHO resolved that postage stamps devoted to the Global Malaria Eradication Programme would be a valuable contribution to the dissemination of information and would stimulate interest in the battle against malaria [63]. It approved a plan for the issue of malaria eradication stamps and invited Member States to take part. It expressed its hope that Member States would find it possible to give the Organization either a percentage of the proceeds from the sale of such stamps, provide quantities of stamps for the WHO to sell internationally to philatelists, or make other suitable donations. The resolution was endorsed by the 14th WHA and the Universal Postal Union was invited to co-operate with the WHO and extend assistance and advice in the implementation of the proposed plan. [64] In May 1962 the Director General reported on progress at the 15th WHA, noting the number of collaborating countries issuing stamps and philatelic material [65]. The philanthropic character and equitable distribution of these anti-malaria issues was stressed (Fig. 8).
The stamps acted as advertisements and facilitated hemispheric good will, with success resting on universality of participation. International cooperation was facilitated with the assistance of the Pan American Health Organization and UNICEF, as well as non-malaria endemic donor countries [62]. A strict timeframe arose because issues produced after 31st December 1962 would not be considered part of WHO's postage stamp initiative [65]. As the campaign emphasized the global importance of the malaria eradication effort, it was undertaken by more than 80 countries and included States with no indigenous malaria transmission (e.g., Lichtenstein). The temporary exclusion of sub-Saharan Africa was neither mentioned in the WHA resolutions that started the campaign, nor in those of following assemblies [22]. A partial or limited campaign took place in only three African countries, as from pilot projects it was not considered feasible to extend the program to the rest of the continent [66]. In a philatelic paradox, the first sub-Saharan African malaria stamps ever issued, which was on 6th April 1962, were as part of the campaign, and 30 African Nations made contributions (Table 2). While West African States issued stamps, East African countries used only special postmark cancellations (Kenya, Tanganyika, Uganda, Rhodesia, and Nyasaland). A few countries overprinted other non-malaria stamp issues (Guatemala, Mauritania, Mongolia). Two unauthorized overprinted stamps were produced from Sud Kasai, an unrecognized secessionist state within the Republic of the Congo.
Arrangements for the sale of donated stamps were made and communications maintained with partners and philatelic organizations, the stamp trade, and collectors. Publicity was increased by involving the International Boy Scouts Movement, chemical and pharmaceutical companies, together with mass information through radio and television. The WHO Headquarters printed visual material at its own expense and its sales agent, the Philatelic Agency for Malaria Eradication Postage Stamps, produced 720 short television films and 3180 phonographic records, which were distributed to radio and television stations for the 'Stamp Out Malaria' programme. Preparations were made for philatelic exhibitions in Geneva, Switzerland, and organized in Belgium, Germany, France, Korea, India, Iran, Philippines, Venezuela, Canada, UK, and several cities in the USA. In March 1962, the United Nations headquarters hosted a ceremony in New York marking the first day of issue of United Nations anti-malaria stamps. By the time of the 16th WHA in May 1963, 114 countries were involved, of which 98 postal administrations issued one or more malaria eradication postage stamps [67]. Some issued related philatelic material, such as Publicity was strengthened through press coverage and mass information media activities. The WHO Division of Public Information recorded press coverage by 30 countries, 1529 articles on the anti-malaria stamp campaign, the eradication programme, or the problem of malaria in general [67]. Many stamps carried the sign 'World United Against Malaria' , and mail appeared with similar slogan postmarks. The UK postmark cancellation was applied to 200 million items. The quantity of stamps printed was enormous: USA 100 million, Vietnam 7 million, Niger 4.8 million, Czechoslovakia 4.5 million, Poland, 3.8 million, India 3.5 million, and Saudi Arabia 600,000 sets [67].
Three alternative model stamp designs were made available to all WHO member States in 1961. Most nations closely following these suggested designs with many incorporating a mosquito supporting a globe and a caduceus symbol (Fig. 10), allowing typographical definition. West African countries widely used this design, and in the context of the presumed success of the programme, added a laurel corona surrounding the globe for embellishment (Fig. 8, Senegal). The Indian stamp which used this emblem represented what was probably the largest and most successful anti-malaria campaign in history. As shown in Fig. 10, to give emphasis to the importance of vector control, expressive power was reinforced by making the mosquito equivalent in size to the globe, suggesting that, despite its minute size, it challenged the greater whole on which it stood. Other designs, as well as including malaria symbols, embellished them-symbols of peace (Czechoslovakia); Red Cross emblems (Vietnam and East Germany); artistic and cultural representations of malaria (Lebanon); the USA showed its national symbol the eagle   Achieving design coherence across so many widely different cultures was challenging, because of an instinctive appeal to make use of culturally specific icons [15]. The problem could be held in check over the short period of one year, with the mosquito effectively accepted as the representative icon of the campaign. The Anopheles species, which illustrated the Portuguese Territories issues, were an outstanding example of use of this icon (Fig. 11).
Some countries managed to shape the stamp's imagery. The Nigerian anti-malaria issues retained the mosquito, but used text as an unfussy framing device, along with a capitalized text for the country name to establish a clear Nigerian identity (Fig. 12) [15]. Unfortunately, in this issue a design error showed the larva with a siphon, which meant it was not an Anopheles species. Similarly, the Polish issue had an error showing only white cells and no parasites in the microscopic image of a blood film (Fig. 8).
This huge ambitious philatelic contribution to the history of malaria control and eradication was not indexed, described, or mentioned in the standard reference textbook on malaria published in 1988 [68]. Was it later thought to be an irrelevance? Towards the end of the 1960 s the WHO campaign achieved malaria eradication in all developed countries where malaria was endemic, and interrupted transmission in most areas of tropical Asia and Latin America (e.g., in Brazil the number of cases decreased from 6 million to 37,000) [53]. These were extraordinary results, although in subsequent years the programme stalled. Vector insecticide resistance to DDT and the Plasmodium to chloroquine, heavily reduced the effectiveness of the eradication goal, to the point where malaria re-emerged in many areas. For the time being, the WHO abandoned the strategy of timelimited eradication and replaced it with that of the control, although eradication remained the goal, as reiterated at the 22nd WHA in 1969. The focus was now to be on reduction of morbidity and mortality [69]. The campaign cost an approximated 230 million dollars from 1955 to 1974. The final percentage contributed from postal revenue is unknown. The need to abandon the attempt was a major embarrassment to many governments and the eradication programme ceased to be mentioned [59]. Far fewer postal issues were released between 1965 and 1969. An exception was Gabon, which in 1966 produced an issue promoting malaria prophylaxis (Fig. 7). Iran in 1968 commemorated the 8th International Congress of Tropical Medicine and Malaria held in Tehran, and Nigeria and Cambodia commemorated the 20th Anniversary of the WHO, all themed around mosquitoes, although the Nigerian stamp used text promoting 'inoculation against malaria' . In 1969 Jamaica, which was certified free of malaria in 1966, issued a single stamp from a set of three, without reference to its newly certified malaria-free status (Fig. 7).

From 1970 to 1995 and the shift from malaria eradication to malaria control
In 1975, the WHO European region (excluding Turkey) was considered malaria-free but from 1973 to 1978 a resurgence of endemic malaria occurred in in Central and South America, and notably in South-East Asia. Despite achievements by the global programme, a large reservoir of endemic malaria remained over most of the tropics. Reasons for failure were discussed in the Manson Oration by Bruce Chwatt in 1979 [70]. During the 1970 and 1980s international support for malaria control had   (1996) can be seen in Fig. 13. Table 3 only twelve countries released issues during this quarter century, compared to 110 countries during the preceding 14 years of the Global Eradication Campaign. Annual incidence for country The declaration by the WHO that Brunei Darussalam had succeeded in eliminating malaria (achieved in 1970 with malaria transmission no longer occurring in this specific geographic area, certified in 1987) was also commemorated on the 40th anniversary of the WHO. This was the only country achieving elimination that subsequently issued a malaria related stamp, other than Jamaica in 1969 (Fig. 13).

As shown in
In the late 1970 s WHO decided to incorporate antimalaria work with the promotion of primary health care. This shift in strategy was captured in a series of health education stamps from Nicaragua released in 1973, with one dedicated to malaria showing a Daraprim (pyrimethamine) bottle and with text on the reverse side of the stamp on use of DDT and Daraprim prophylaxis (Fig. 13) [71]. During the 1980 s two further issues were released, from the Maldives in 1988 to commemorate World Heath Day, and from Kenya during the 7th International Congress of Parasitology held in Nairobi (Fig. 13). The 4th International Congress of Parasitologists (Warsaw) in 1978 showed Anopheles and red cells infected by a malaria parasite, in a commemorative Polish release, and Laos insecticide spraying in issues in 1988 and 1992. In 1992, the WHO drew up a new strategy with emphasis on early diagnosis and immediate treatment in the context of programmes managed by the basic health care system. Many countries, such as Thailand, China, Brazil, Solomon Islands, Philippines, Vietnam, obtained good results in terms of control. For many others, and especially for those in sub-Saharan Africa, the malaria situation was still critical. Malaria control became a pivotal issue in the late 1990 s during election of a new WHO Director General [72].

From 1996 to 2020 during the Roll Back Malaria Initiative and the second global campaign
The Global Malaria Control and Elimination Initiatives of 1996-2020 are outlined in Table 4. There were few malaria-related stamp releases in this period before 2010. Early Mali stamps on the management of severe malaria (2000), and issues from Uganda, Tanzania (2003) and Liberia (2006), highlighted Millenium Development Goal Six to combat HIV/AIDS, malaria, and other diseases. Malaria management and control were integral to reductions in child mortality and to achieve this the international community aimed to scale up control measures. A new eradication strategy was developed based on: (1) aggressive control in highly endemic countries, (2) progressive elimination from the endemic margins, to shrink the malaria map; and (3) research into vaccines, drugs, diagnostics, insecticides, genetic vector studies, and delivery methods that could reach at-risk populations [73,74]. The WHA in 2015 adopted a Global Technical Strategy of achieving a malaria-free world, including a goal of at least 35 countries eliminating malaria by 2030 Fig. 10 The WHO Global Malaria Eradication Campaign postage stamp emblem [74]. The agenda addressed resistance of Plasmodium falciparum to anti-malarial drugs, resistance of Anopheles to insecticides, asymptomatic malaria infections, and community level involvement. By the end of 2020, 24 countries had reported interrupting malaria transmission for three years or more. Of these, 11 were certified malaria-free by the WHO [75].
Control initiatives were represented across a wide range of philatelic issues mostly from African states. Many were aimed principally at the stamp collector, and unlike the 1962 omnibus issue, there was little emphasis on the WHO. Some of the smallest countries produced the largest number of stamps, which were often extravagant in colour, form, and imagery. Although some issues clearly and simply outline surveillance and diagnostic methods, latterly, sophisticated photomontage techniques have been used to contemporize images. Differences can be observed when comparing illustration of insecticide bed net issue in the issue from Burkina Faso (2010), with those of the Solomon Islands (2013) and Angola (2019) (Fig. 14). In the Angolan and Solomon Island miniature sheet images, the challenging expressions of the workers and children appeal to the observer to utilize bed nets. In contrast the Burkina Faso stamp is almost simplistic, but homely, which could appeal in more rural settings. The Angolan stamp highlights Plasmodium malariae which is a neglected species in Africa. The size of the Solomon Islands miniature sheet, the range of iconographic images and the inclusion of text stating the sheet's purpose to demonstrate use of bed nets, creates the impression of a poster.
Of twenty-three countries issuing malaria-related stamps since 1996 (Table 3), many issued miniature sheets with a montage of figurative images. The issue from Guinée-Bissau presented a palimpsest of the 1962 anti-malaria campaign stamps within the later 2012 stamp issue, which marked the 50th anniversary of the campaign, and served a specific indexical function [94]. Some African countries produced annual malaria issues between 2015 and 2020, a regularity that had not occurred after the omnibus issues. Also different was that the earlier Global Malaria Eradication Campaign omnibus issues favoured a single motif and an absence of human images. While visually attractive, later use of multiple images within the same stamp may have undermined the clear message of a single key iconic image. A good example is the 2019 miniature sheet from S. Tomé e Principe, which shows a non-human primate (implying zoonotic transmission with simian malaria), Red Cross symbols and Ronald Ross, making for a confusing and mixed take-home message (Fig. 15). This is also demonstrated in the Guinée-Bissau issue of the same year, which has a montage of pictures of syringes, indicating either venepuncture, vaccination, or parenteral injection, with images of the Red Cross and Crescent, a healthylooking child, an electrocardiograph, microscope, cardiac and hepatic anatomy, and a mosquito (Fig. 15).
Modern productions are specialized philatelic items with decorative margins and boldness of design, and although designed mainly for collectors, have normal postal validity. Designers have used considerable ingenuity, such as devising issues showing a stamp within a stamp, to provide continuity with the 1962 omnibus issues. The stamp in Fig. 15 from Togo shows Princess Diana (1961-1997) alongside a global map of endemic malaria. These stamps are likely to have limited postal use in the home country. Possibly some go straight from the printing presses of London, New York, and South Africa to collectors, and may not be easily available through the post offices of the countries that issued them. They are aimed primarily at first world collectors and provide a source of Government revenue, with a tendency for numerous high value stamps. Images picked up from the media, science or other cultural sources are used, and can offer authentic information about malaria in their country. These stamps are documents of enduring fascination and significance.
Two contrasting issues were forthcoming from Europe during this period. In 2009 a stamp of the United Nations Postal Administration was released on a First Day Cover for World Malaria Day promoting the Economic and Social Council (ECOSEC), which co-ordinates the work of 14 UN agencies, although the stamp highlighted HIV, AIDS, and malaria recognizing the interplay between malaria and other infections. The cover was titled 'Malaria: Blood, Sweat and Tears' (Fig. 16). In contrast the UK, in the same year, issued a stamp celebrating medical breakthroughs of a colour transmission electron Campaign. Scott commented on this specific stamp issue that 'the role of typography in assuring legibility and visual impact is fundamental to its design and reflected in the choice of lettering, their integration of it into the overall design, and in the way the typography strengthens and enhances pictorial elements' [15]. A typeface is selected that enhances the message of the issue with well-spaced modern typewriter typefaces micrograph of a red cell infected by a malaria parasite, which had small font text stating mosquito transmission of malaria was proved by Ross in 1897 (Fig. 16). This more academic/scientific approach as captured in this recent UK issue differs from the 'Stop Malaria' stamp released in the same year as part of a Dutch multimedia fundraising event for the International Red Cross hosted by radio stations in the weeks before New Year 2010.

Discussion
Over the decades, malaria postage stamps have helped to establish, not simply awareness, but commitment to malaria control. Malaria stamps have reached an international audience, using familiar icons, embellished with cultural signs and symbols. This success was a substantial accomplishment that had no forerunner. The role of the WHO was critical as it undertook technical co-ordination of national responses and endeavoured to harness a global philatelic initiative in the promotion of its goal for eradication. In the beginning, the 1962 WHOendorsed stamp issues were a unique philatelic event on a grandiose scale, echoing the spirit that 'we are all in this together. ' It was a call to countries to get involved. Between 1948 and 1982, the incidence of WHO-related stamps issued by Member States, other States, and the United Nations was considerable [8]. Stamps also raised funds although this would have been a relatively small financial contribution to the overall costs, and the final amount of the philatelic component is uncertain. In present day terms, it would be negligible in the context of the US$ 6.6 billion per annum needed by 2020 to achieve global malaria targets by 2030 [95].
Stamps have been studied very little as a tool to communicate health awareness although their use is assumed to be beneficial. There is only limited evidence they are an educational and knowledge resource, although they may act as a vehicle for philanthropic contributions [96]. It is difficult to judge the impact of stamps in promoting health awareness within countries, as issues are generally available for only a limited period, and it is questionable how many of these penetrate the poorest rural areas, where electronic forms of communication have increased rapidly. Yet communities need health awareness programmes [97], especially as malaria goals have changed and stamps have not always given accurate information. That mass communication strategies, including postage stamps, could be effective in delivering general health messages was suggested in the 1970s by David Morley and Maurice King [71,98]. As postage stamps index World Health Days, they can reference a variety of interventions and newly emerging public health problems [99]. An example of this was the recent issue by the UN and 21 countries to honour healthcare workers and patients during the COVID-19 pandemic [10].
Postage stamps played a minor role in the WHO Smallpox Eradication Programme, which commenced in 1966 [100], but for the WHO Polio Eradication Programme, (1988-onwards), many issues were released on immunization. Immunization is a relatively simple message to convey and is a single intervention for a single virus, in contrast to the multiple messages required for malaria eradication [101]. Malaria is not a specific pathogen, as it comprises seven distinct species infecting humans, with P. falciparum and Plasmodium vivax as the focus of eradication efforts. While it has been convenient to use the term 'malaria eradication' for funding and advocacy purposes, this is technically incorrect [102]. The term 'elimination' is used when malaria transmission is no longer occurring in a specific geographic area, whereas 'eradication' describes world-wide zero incidence of a specific pathogen due to deliberate efforts with no risk of  Overview of country/regional progress to elimination with focus on 21 countries [91] High Burden to High Impact approach HBHI 2018 WHO and RBM initiative with focus on 11 highest burden countries (10 in Africa) to achieve GTS targets for 2025 through country-owned initiatives [92] Malaria Vaccine Implementation Programme MVIP 2019 Implementation of first malaria vaccine in Africa in child immunization [93] re-introduction. The messaging on stamps mostly does not correspond with these definitions. Very few national postal administrations have issued stamps commemorating malaria elimination. Recent malaria issues that have focused on bed nets could increase their acceptance and use (Fig. 14). Other recent philatelic themes have included spraying with insecticides and diagnostics, but intermittent preventive treatment with anti-malarials, malaria control in pregnancy, asymptomatic malaria, or malaria vaccination have not yet been addressed. It may be argued that the public pays only passing attention to stamp design and messages, but they do represent a form of massproduced art, seen daily or frequently by many citizens. To raise health awareness requires wide stamp circulation, low face value for use, and an attractive design. They must be accurate, with focused themes that avoid multiple messaging, highlight priority interventions, and maintain thematic continuity between sequential annual issues.
Today more than 90 countries remain endemic for malaria and none from sub-Saharan Africa have received a WHO Certification of Elimination (three consecutive years of zero indigenous cases). In 2018, around 68 % of the estimated case burden and 65% of the estimated deaths globally occurred in 10 countries in sub-Saharan Africa and in India. Nigeria accounted for the highest proportion of cases globally (25%) [101]. The current Global Technical Strategy to support a High Burden to High Impact approach focuses on the 11 highest burden countries (Nigeria, Democratic Republic of the Congo, Mozambique, India, Uganda, Burkina Faso, Ghana, Niger, Cameroon, Mali, United Republic of Tanzania) to achieve the 2025 targets to reduce malaria cases and deaths by at least 75 % through country owned initiatives (Table 4). A number of these countries have not used philatelic  Table 4) demonstrating use of a net products during the current initiative, in particular Nigeria, which has the highest malaria burden (25%) and last issued a malaria-related postage stamp in 1968.
In conclusion, stamps can make an impact. Some stamp designs have an established provenance, and some stamp icons are well known, even by non-collectors. These include the Maltese Cross on the world's first stamp, an emblem of the Knights Hospitaller, who established the great hospitals during the time of the crusades from western Europe to the Levant, and a symbol that is shown on the 1840 'Penny Black' [26]. In 2022, as 60 years is approached since the first WHO co-ordinated omnibus issue, perhaps an official rallying cry of encouragement could again draw on the aid of the humble postage stamp.