“….the foundation’s investment in vaccines for malaria and the other infectious diseases is to ensure their elimination by 2030… the vision is in line with the Sustainable Development Goals of the United Nations.”^[1]

Dr Susan Desmond-Hellman

(CEO, Bill and Melinda Gates Foundation).

Malaria is an ancient disease known throughout human history: Ancient to Antiquity; to the Middle Ages; to the modern era and even to the New Age now. Some of the known references in the history of Malaria include the following:

• Malaria was mentioned in a Chinese document (about 2700BC); in the clay tablets of Mesopotamia (about 2000BC); in the Egyptian papyri (about 1570BC); in the Hindu texts (in the 6^th century^)[1] all these belong to the Ancient era.
• The early Greeks including Homer (about 850BC), Empedocles of Agrigentum (about 550BC) and Hippocrates (about 400BC) were aware of the features of malaria fevers in people living marshy places^[2]. The Romans also associated marshes with fever and pioneered efforts to drain swamps ^[3]. This development belongs to the antiquity era.
• The idea that malaria fever was caused by miasmas rising from swamps persisted for over 2500 years until 1676 when Antoni van Leuwenhoek discovered bacteria. The incrimination of micro-organisms as causes of infectious diseases and the development of the germ theory of infection (1878-1879) were products of endless search for the cure to malaria. The results of this search in the Middle Ages were crowned in the 19^th century by the discovery of parasites by Charles Louis Alphonse Laveran in 1880; incrimination of mosquitoes as vectors by Ronald Ross in 1897 and the inputs of five Italian scientists (1898-1900)^[2] .
• The full harvest of these efforts was seen during the modern era (20^th century). The two World Wars helped in the search for the cause of malaria and the way out of it. The efforts put after the Second World War will have eradicated it if the tempo had been globally sustained.
• The New Age input in the 21^st century had finally set a target to totally eradicate malaria before the middle of the century – which is the object of study in this article.

Whenever a war is declared, the target of the opponent is elimination by eradication. Therefore, the War Against Malaria is an all round warfare to root out this ancient disease. Failure by the human race to win the battle will be counterproductive on urbanism as it has been through history:

• Malaria became widely recognized in Greece by the 4^th century and it was said to be responsible for the decline of many of the city state population. Moreover by the age of Periclas, there were extensive references to malaria in various literatures and depopulation of rural areas by it were heavily recorded^[4].
• The city of Rome was affected by a type of malaria known as “Roman fever” and it affected the public health of the city at different time in history.
• The coastal plains of Italy fell from international prominence when malaria came into it in the 16^th
• Malaria caused huge loses to the British forces in the south during the Revolutionary wars as well as the Union forces during the American civil war.
• The construction of the Panama canal was made possible only after yellow fever and malaria were controlled in the area. These two diseases were the major causes of death and diseases among workers in the area. In 1906, there were over 26,000 employees working in the canal, of which over 21,000 were hospitalized for malaria. But after necessary measures were taken, it was recorded that in 1912 over 50,000 employees were working there with only 5,600 were treated for malaria^[4]. The impact of this effort affected the US military in Cuba and also in the US southern states after the intervention of the Army and the US congress^[4].
• An organized and effective malaria control program in the Tennessee River Valley (1930’s and 1940’s) produced total elimination by 1947 which is a far distance from 1933 when 30 percent of the population were under malaria attack^[4]. The Public Health Service played a vital role in the research and its control.

Therefore, the interest in this article is to outline the importance of the already declared War Against Malaria in the 21^st century in the context of the SDG’s Agenda (sustainable development) for 21^st century urbanism. In this New Age, malaria is by far the world’s most deadly tropical parasitic disease, and it kill more people than any other communicable disease, except tuberculosis. It occurs in nearly 100 countries globally, thereby exacting a huge toll on human health with the attendant social and economic burden in developing countries, especially in Sub-Saharan African and South Asia. It is now a public health problem today in many parts of the world especially in the developing countries inhabited by a total of about 2.4 billion people (about 40 percent of the world’s population)^[6].

The global prevalence of malaria is put to be within the range of 300-500million clinical cases each year of which 90 percent of such cases are in Sub-Saharan Africa. Mortality due to it is estimated to be 1.5 to 2.7 million deaths each year; and majority of the deaths occur among children especially in the remote rural areas with poor access to health services. Other high-risk groups include women during pregnancy, and non-immune travelers to endemic areas, refugees, displaced persons and laborers entering endemic areas. Malaria epidemics related to political upheavals, economic difficulties and environmental problems also contribute in the most dramatic way to death tolls and human sufferings.

In 2012, an estimated 207 million people suffered from malaria globally; of which about 627,000 died. About 90 percent of the deaths were in Sub-Saharan Africa and 77 percent of them occurred among children aged 5 and below^[5]. The actual material cost of malaria might not be available but (in Africa especially) malaria exacts an enormous toll in lives, in medical costs and labor lost. The impact of this ancient disease seems to be much more on children as malaria kills one child every 30 seconds; which is about 3,000 children per day for children less than five years of age^[6] (this mortality rate is far above that of AIDS) especially for African children. Usually, fatally afflicted children dies less than 72 hours after developing symptoms. In the surviving ones, malaria drains vital nutrients thus impairing their physical and intellectual development as it is one of the principal reasons for poor school attendance.

The geographical area affected by this ancient disease has shrunk over the past 50 years, but in the age of globalization, control has become more difficult and the previous gains are being eroded. It is this situation that is calling for the total eradication of this killer disease. According to Bill Gates, “I believe it not only possible to eradicate malaria; I believe it is necessary. Ultimately, the cost of controlling it endlessly is not sustainable. The only way to stop this disease is to end it forever^[5].” Therefore in the global age of sustainable development, the need to carry the War Against Malaria (WAM) to a complete eradication in order to achieve Goal 3 (Good Health for all) of the SDG’s Agenda which will in turn guarantee Goals 1, 2 and 8 (poverty, food security and sustainable economy) is not negotiable. The sum of these achievements will not only strengthen the individual members of urban settings, but also empower them (economically and socio-culturally) and the resulting built environment as the end product of all human activities.

The following are some of the factors accounting for the increased risk of this ancient disease:

• The changes in land use to activities like road building, mining, logging, agricultural cum irrigation projects particularly in frontier areas like the Amazon and Southeast Asia. These activities are in themselves the route to urbanism.
• The spread of global climatic change including El Nino events that aids the transmission of the disease.
• The disintegration of health services.
• The multiplication of armed conflicts and mass movements of refugees.
• The emergence of multi-drug resistant strains of the parasites.
• The easy of international travels in the age of globalization which paved way for the importation of cases of malaria to developed countries. In today’s international world, the phenomenon of “airport malaria” (importation of malaria by international travelers) is becoming a common place e.g. in 1992, 2,364 cases were recorded in United Kingdom^[6]. We also have what is termed “Weekend malaria” which happens when city dwellers in Africa return to their rural settings, is also becoming an increase problem^[6].
• The re-emerging of the disease in areas where it was previously under control or eradicated e.g. Central Asian Republic of Tajikistan and Azerbaijan and in Korea.

Malaria is an infection caused by single-celled parasites (known as plasmodia) that enter the blood through the bite of an Anopheles mosquito. The life cycle of this a parasite takes place in both human and the mosquitoes, during which it infects and multiplies inside the liver cells and red blood cells of the human. The symptoms of this disease can begin as early as six to eight days after a bite by an infected mosquito which may include all or some of the following^[7]:

• High fever with shaking chills;
• Profuse sweating when the fever suddenly drops;
• Fatigue;
• Headache;
• Muscle aches;
• Abdominal discomfort;
• Nausea, vomiting; and
• Feeling faint when you stand up or sit up quickly.

Sometimes, when the treatment is delayed more severe complications may include^[7]:

• Brain tissue injury, which can cause extreme sleepiness, delirium, unconsciousness, convulsions and coma.
• Pulmonary edema (a dangerous accumulation of fluid inside the lungs that interferes with breathing).
• Kidney failure.
• Severe anemia resulting from the destruction of the infected red blood cells and the decrease in the production of new blood cells.
• Yellow discoloration of the skin;
• Low blood sugar level.

Malaria is preventable and treatable and history shows that it can be eliminated because less than a century ago, it was prevalent across the world including Europe and North America. Malaria was eliminated in most of Western Europe by the end of the 1930’s and the United States achieved elimination of this disease in 1951. Therefore, the task for the New Age is to eliminate the same globally (latest by 2050) which is very feasible by deploying a multi-dimensional strategy. Majorly, the features of such policy should include THREE main ingredients:

• Robust financial investment;
• Sound global political will; and
• Innovation

If the Ebola crisis was globally tacked as well as polio and small pox among many other killer diseases that had been contained globally, then with the right inputs, it is possible to eradicate malaria as well. According to the Bill and Melinda Gates foundation (a major stakeholder in the War Against Malaria in the New Age) the strategy that is been deployed against malaria has three components (Complete Detection, Complete Cure and Complete Prevention):

• Complete Detection: This is a departure from the current approaches, which focuses on finding and treating only those people who have active malaria cases. To achieve eradication, health workers need to find all the people who have the parasite in their blood, regardless of the fact that they might be showing symptoms of malaria or not. The foundation is currently supporting many efforts to develop and bring to the market a new generation of diagnostic tools that are more sensitive than the RDTs now in use and can identify the presence of malaria parasites in all infected individuals.
• Complete Cure: This means using treatments that clear all malaria parasites from the body. The best available anti-malaria treatment now (ACT) cures the patient clinically but does not eliminate all forms of the parasites that are responsible for continued transmission. Towards this, efforts to develop long-lasting, single-dose treatments for malaria that can completely clear the malaria parasites from the body and provide a period of protection following the treatment are in process.
• Complete Prevention: This means reducing opportunities for mosquitoes to pass the parasite onto humans and preventing the emergence of strains that can resist drugs and insecticides. The next generation vaccines that block transmission for six months to a year is the target, so that once an area is cleared of the parasite, it remains cleared. New insecticides to destroy the widespread emergence of mosquito resistance to the chemical compounds in use frequently today are currently been worked on. The introduction of a special fungus into the mosquito populations to kill them off and the introduction of modified genes that can stop mosquitoes from reproducing are in process.

The atmosphere to fight the war against malaria is very clear as willing private sector donors such as The Gates Foundation have committed about US $2 billion till date to combate malaria in addition to the US $1.6 billion committed to the Global Fund to fight AIDS, Tuberculosis and Malaria (which provides 50 percent of international funds for malaria control worldwide). Such private donors are still willing to do more as the results are encouraging. Some of the weapons in the armory for this warfare include:

• A new class of drugs derived from a flowering plant called Artemesia annua (sweet wormwood) which can cure malaria now.
• The availability of Rapid Diagnostic Test (RDT) to test if a person has malaria or not which can then be managed by the community health workers.
• The availability of modeling systems (a digital revolution product for tracking the disease).
• The Innovative Control Consortium (ICC) is developing new and improved insecticides to control the mosquitoes that transmit malaria.
• The Medicines for Malaria Venture (MMV) is researching treatments to overcome resistance to existing drugs, has developed the largest malaria drug portfolio in history and expects regulatory approval soonest for an improved treatment in children.
• New study results from PATH Malaria Vaccine Initiative shows that the experimental malaria vaccine RTS,s is safe and may reduce the risk of malaria infection in infants. Decades of UNICEF reports show an impressive progress of malaria control efforts of the annual supply of insecticides treated bed nets to prevent malaria has more than doubled (i.e. 30 million nets in 2004 while it 2006 it was put at 63 million nets). Also the global procurement of artemisinin combination therapies (the most effective treatment for malaria for now) has grown from 3 million doses in 2003 to 100 million in 2006.
• The New Malaria Partnerships is drawing together new actors to pull together the needed robust global investment to fund the fight including Gates Foundation; Global Fund to Fight AIDS, Tuberculosis and Malaria; The World Bank Malaria Booster Program; and the U.S. President’s Malaria Initiative. As the partners have committed about 3.6 billion to malaria control in more than 70 countries.
• General advances in science and medicine, promising research and the rising concern of people around the world represent a historic opportunity not just to treat malaria or to control it but to chart a long-term course to eradicate it.
• Malaria R & D Alliance (an international group of anti-malaria organizations) is also at work.

In conclusion, the War Against Malaria needs to be won in order to meet the vital Goals of the SDG’s Agenda. This is because the success of this war will strengthen 21^st century urbanism in various ways which include:

• Population of urban and rural areas will not decrease monumentally again due to any major disease epidemic. The recently gone Ebola crisis is a pointer to the fact of what happens in the old Greek city states can repeat itself in the 21^st century if care is not taken. Therefore, all killer diseases starting from Malaria should be tackled headlong. This group of killer diseases includes Tuberculosis, HIV, Ebola, Zika and so on. Hence, work needs to be done on Neglected Tropical Diseases (NTD) like snail fever, hookworm, river blindness and sleeping sickness with the mindset of crushing all of them.
• The War Against Malaria (WAM) needs to be tackled at all fronts concurrently: remote causes- which includes poverty and hunger due to the lack of food security; the environment that is not neat and healthy enough due to poor sanitation; and finally at the clinical level. It is in this strength that WAM should be fought within the context of the SDG’s Agenda.
• The developing nations need to put their home front in order and be willing to cooperate with the global community who have spear headed this WAM by setting their MDA in charge of their health sectors in a workable and functional path. The FUND available for this WAM are hard earned income of people who are obviously not ready to waste such precious FUNDS. For example the Global Fund (GF) recently (2016) accused Nigerian MDA’s of not accounting for part of the allocated FUND which is not the first time such an accusation is being made as the same occurred in 2014. Recently, (July 2016), 5 heads of MDA’s in the Federal Ministry of Health were relieved of their posts due to the mis-management of this Global Fund. The need for transparency with the FUND management is a key issue that must be addressed.
• “Every life has equal value, therefore the need to help all people lead live healthy, productive lives”. (Gates Foundation Motto)^[5]. This should be the operational strength of WAM if it will be won in 21^st century urbanism. Globalization has turned the whole world into a village. Therefore, without a mindset like this-the needed helping hand will not be given to achieve the SDG’s Agenda Goals without which getting a sustainable built environment will be practically impossible in the 21^st
• Once health improves, it will give the chance to lift themselves out of hunger and poverty^[5]. Here lies the link among Goals 6, 1 and 2. The achievement of 6 will open the door to the achievement of 1 and 2.

References:

1. The Punch Monday June 20,2016 pg 10 (Health Wise – We want to eradicate malaria in Africa by Gates Foundation by Bukola Adebayo).
2. Journal of Negative Results in Bio-Medicine (History of Malaria).
3. John Hopkins University “Malaria History”.
4. The History of Malaria – an ancient disease.
5. Malaria Treatment by Gates Foundation.
6. Nobel Prize Org: History of Malaria (Global Impact of Malaria).
7. Harvard Public Health Publications (What is Malaria?)