Polio‐philanthropy in Africa: A narrative review

Abstract Background and Aim Polio eradication efforts including polio‐philanthropy have been coordinated and sustained since 1988, with the introduction of the Global Polio Eradication Initiative (GPEI). The polio fight is sustained in the name of evidence‐based benevolence or beneficent philanthropy from which Africa has benefited immensely. With the recorded polio cases as of 2023, more efforts and funds are required to eradicate polio. Hence, it is not yet “Uhuru.” Using the Mertonian lens, this study examines polio‐philanthropy in Africa, its unintended consequences, and crucial dilemmas, which could impact the polio fight and polio‐philanthropy. Methods This is a narrative review that relies on secondary sources obtained through a thorough literature search. Only studies published in English were utilized. The study synthesized relevant literature in line with the study objective. The following databases were consulted: PubMed, philosopher's index, web of knowledge, Google Scholar, and Sociological Abstracts. Both empirical and theoretical studies were utilized for the study. Results Despite significant achievements, the global initiative has shortcomings when examined through the Mertonian lens of manifest and latent functions. The GPEI sets a unilinear goal within multiple challenges. The activities of the philanthropic giants manifest in disempowering rigor, multisectoral neglect, and parallel (health) systems, sometimes, inimical to the national health system. Most philanthropic giants often operate vertically. It is observed that, apart from funding, the last phase of polio‐philanthropy will be defined by some crucial factors, the 4Cs: Communicable disease outbreaks, Conflict, Climate‐related disasters, and Conspiracy theory, which could impact the prevalence or resurgence of polio. Conclusion The polio fight will benefit from the persistent drive to reach the finish line as scheduled. The latent consequences or dysfunctions are general lessons for GPEI and other global health initiatives. Therefore, decision‐makers should calculate the net balance of consequences within global health philanthropy for appropriate mitigation.


| INTRODUCTION
Polio has been a major global health issue for more than a century.
Unfortunately, it will be a crucial health discourse beyond 2023. Viral diseases (such as polio, Ebola, Zika, and coronavirus disease 2019 ), which characteristically relapse and re-emerge, have been a hard nut to crack within the global health space. Hence, polio is still a significant public health challenge. Unvaccinated children have the highest risk of polio, which could attack their nervous system leading to paralysis. The major transmission route, among people, is through nasal and oral secretions, but more commonly through contact with contaminated feces. 1 The concern that polio poses might remain for some time despite the drive to eradicate it. This is not to undermine global health philanthropic efforts to eradicate the disease. The concern is informed by the pitfalls experienced over the years. There is, however, the hope of a glorious triumph over polio through the global eradication efforts.
Although unmet deadlines raise the fear that polio might be a test for global health philanthropy, polio eradication efforts consti- The concerted efforts to eradicate polio have been relatively mounting and sustained over several decades. It is common to celebrate the certification of "zero case" as polio-free at national or continental levels, with Asia and Africa almost reaching the landmark.
The status of polio in Africa status has fluctuated many times, with the possibility of a resurgence. This signifies that the polio fight will be protracted going beyond the reasonable future, due to repeated "heartbreaks" (threats and resurgence). However, the good news is that the fight is sustainable as global health efforts against polio have been strengthened in the name of evidence-based benevolence, which is easier represented as beneficent philanthropy. The only difference is that beneficent philanthropy considers the possibility of risk even in a "good" action. "Doing good according to vulnerability" is the hallmark of beneficent philanthropy. Specifically, in the polio fight, the global strategic alliance mobilizes both material and nonmaterial resources to stop polio transmission. This is one of the cases of global health support signifying beneficent philanthropy.
In spite of the foregoing argument concerning beneficent philanthropy, with a significant focus on the Global South, especially Africa, how has the polio fight fared? How much has been committed to the fight globally and what amount will be required to stop polio?
What are the crucial dilemmas, which could impact the polio fight and polio-philanthropy? It is essential to evaluate or assess the state of the polio fight in Africa. It is important to examine whether it has been a resounding success, like the global fight against smallpox. It is imperative to think of the efforts in the fight against polio in light of philanthrocapitalism. This study gets inspiration to examine poliophilanthropy in Africa within the realm of Mertonian thinking and evaluation. 2 Irrespective of how critical the discourse might be, Africa has "benefited" immensely from global health efforts against polio.
More importantly, however, the relics of the polio fight come with essential lessons for global health. But conceptually, "benefit" can be conceived in light of possible latency or dysfunctions (using the Mertonian lens) inherent in all human efforts. This discourse of inherent latency is typically monikered as a "critical approach", but at least, its relevance as a lens is indubitable. There is always the "other considerable side." Some pertinent questions have been raised earlier, which constitute the crux of this article. The article will also assess whether it is Uhuru or not, that is, whether the end of polio has come or not.

| LITERATURE SOURCES
This study is a narrative review that relies on secondary sources obtained through a thorough literature search using several relevant search terms, such as "Polio," "acute flaccid paralysis," "AFP," "funding," "eradication," and "Africa." The literature utilized included  In the 1990s, polio was extremely devastating that it accounted for almost 75,000 paralyzes annually in Africa alone. 6 The late 1990s marked a significant increase in polio vaccination efforts in the African region, with a high record of vaccine saturation in all African regions, especially within the National Immunization Programs. At this point, the main concern of the protectionist approach (vaccinating them to protect us) was that some African countries were responsible for the just two (Afghanistan and Pakistan), after Africa was certified poliofree. 8,9 Unfortunately, the COVID-19 pandemic cut short the celebration following some new cases of polio as of January, 2023.
Ekwebelem et al. 10 11 It was bad news for all global health initiatives, including GPEI. The Lancet 12 described it as falling at the final hurdle to the finish line. It is unfortunate, but not surprising, that a possible polio resurgence was imminent in Africa, 9 with cases of wild poliovirus (WPV) reported in Malawi and Mozambique, apart from over 600 cases of cVDPV2. 13 However, before the COVID-19-induced polio vaccination disruption, the problem of resurgence had always been there.

| THE PROBLEM OF REINTRODUCTION AND VACCINATION COVERAGE
The year 2005 marked a significant improvement and a resurgence or re-emergence of polio in countries previously declared polio-free.

The Centers for Disease Control and Prevention mentioned that 21
previously polio-free countries, mostly in Africa (including Burkina Faso, Cameroon, Chad, Ethiopia Ghana, Guinea, Mali, and Togo) and in Asia (Saudi Arabia and Yemen), reported imported cases of WPV type 1, specifically from the remaining six polio-endemic countries (primarily Nigeria) where WPV was endemic. 14 The threat of imported cases has always been a major global issue in respect of infectious diseases. Countries bordering polio-endemic areas have a higher risk of sporadic importations. 15 Hence, every country should improve its polio importation preparedness. The multicountry spread underscores the immunity gaps and weak vaccination response among children in the affected countries. The threat of possible global WPV spread or importation will continue to remain until there is total polio eradication. Globalization and international connectedness will continue to pose risks for the re-emergence of certain diseases, including WPV. Hence, surveillance systems and immunization programs must be strengthened and sustained to keep track of the possible spread or re-emergence of WPV.
The most significant measure is to improve vaccination coverage, which is partly marred by vaccine hesitancy and, recently, by the COVID-19 pandemic. The recommendation suggests a minimum of 95% vaccination coverage of children in endemic countries to prevent the importation and re-emergence of WPV. There is still a significant polio vaccination gap-in terms of incomplete vaccination and zero-dose vaccination among under-five children, especially in sub-Saharan Africa (SSA). For instance, a study analyzed the National Demographic Health Survey of 25 countries in SSA and reported that full vaccination coverage (not only for polio) ranged from 24% in Guinea to 93% in Rwanda, with some socioeconomic determinants responsible for coverage inequalities. 16 The analysis used prepandemic data and the pandemic might have, even if slightly, adversely affected the coverage. Low vaccination coverage, such as the rate observed in Guinea, and observed coverage inequalities pose significant polio risks to the unvaccinated, which could also facilitate possible mutation and reintroduction to other countries. In spite of AMZAT ET AL. | 3 of 9 the situation, it is important to acknowledge the remarkable achievement in terms of vaccination coverage and imminent eradication due to polio-philanthropy.

| THE STATE OF POLIO-PHILANTHROPY
The polio-philanthropic journey has been a marathon, not a sprint. Since the launch of the robust polio eradication program in the form of GPEI in 1988, slightly over US$18 billion has been expended through the multilayered and collaborative partnership championed by the WHO and UNICEF. 18 There have been tremendous intervention activities in over 70 countries. Table 1 shows the top five donors in various categories. This is not to underrate donors with lower donated amounts as every cent counts. The G7 countries (Germany, France, Canada, Italy, Japan, the United Kingdom, and the United States) have been major stakeholders in providing the required support in the fight against polio.
Other non-G7-The Organization for Economic Cooperation and    Figure 2). The goals remain to stop poliovirus transmission in endemic countries and stop cVDPV transmission and prevent outbreaks in nonendemic countries. The timeline, which functions as a budget and planning tool, is subject to review from time to time ( Table 2).
The important milestone will be the year the world records its last case, and then, a possible global polio-free certification after 3 years. Table 2  changing the logic of health governance in terms of priority setting and resource allocation. The aforementioned produces a passive recipient subjected to a wider redefined and reconfigured responsibility within the "collaborative" alliance. 20 22 The program comes with intervention fierceness ensuring deeper penetration and saturation which account for the achieved outcome-that is, over 99% reduction in polio incidence.
The ultimate costs include an altered sense of responsibility, balance of power, and induced vulnerability within the health systems. Although the core of the health system's goal is the horizontal or multisectoral approach to maximize efficiency, there is always the presence of strong vertical programs on diseases like polio, malaria, HIV and tuberculosis-the result is a nonintegrative or nonmultisectoral system. 25,26 The consequent danger (observable in the GPEI) is the skewed concern with vaccine provision, intergovernmental relations and considerably low levels of health sector-wide support and civil partnerships. 27 In the skewness, the social determinants of health and water, sanitation, and hygiene (WaSH), which are strongly connected to polio emergence have no space or place.
The vertical approach creates separate resources for specific purposes, resulting in poor harmonization of health priorities, strategies, surveillance, and response systems (Figure 1). The vertical approach is a product of the global health initiative in the form of purposive development assistance for health. 24 Beyond these latent consequences, there are other confounding dilemmas that could adversely impact the polio eradication timeline in Africa.
F I G U R E 1 Latent consequences of poliophilanthropy.

| CONFOUNDING DILEMMAS IN THE POLIO FIGHT AND PHILANTHROPY
The future of polio-philanthropy will be defined by several confounding dilemmas, specifically, the 4Cs (Figure 2 Disaster risks, in the form of extreme weather events, happen occasionally but wreak havoc affecting millions of people. 31,32 Drought, a protracted dry period in the climate cycle, is another climate-related event that has adverse effects on child vaccination programs. 33 In the face of severely limited access to water and food, a The result is reduced agricultural production, which is the main economic activity in the region. As drought leads to financial and food insecurity, it induces child malnutrition, limits access to healthcare and leads to poor health outcomes. 34 outbreaks at different times in the conflict-affected areas. Therefore, the conflict situation in the last phase of the polio fight will determine if and when the eradication goal will be reached.
The polio vaccination program has been marred by rumors and mis-/dis-information, or in short, infodemic-all embedded in the conspiracy theory, mostly due to insufficient civil/public engagement.
F I G U R E 2 Four significant factors militating against the polio fight.
This accounted for the initial vaccine hesitancy or resistance, which has drastically reduced but not completely subdued. The initial conspiracy theory was that polio vaccine was contaminated with antifertility substances meant to reduce the population of some lowincome countries, especially in Muslim-dominated regions. 39  With the recorded cases as of 2023, more efforts and funds (an estimated $4.5-$5.5 billion) are required to reach the finish line.
Hence, it is not yet Uhuru. Apart from funding, reaching the polio eradication goal will be affected by some factors, including the 4Cs, which could significantly affect the prevalence or resurgence of polio.
Despite some significant achievements, the global initiative has some shortcomings when examined through the Mertonian lens of manifest and latent functions. The GPEI sets a unilinear goal within multiple challenges. The activities of the philanthropic giants manifest in disempowering rigor, multisectoral neglect, and parallel (health) systems, which are sometimes inimical to national health systems.
The observed shortcomings and confounding factors are relics from the polio fight, which should be considered in other global health efforts. There is strong optimism that with sustained resources (both human and nonhuman), the end of polio only remains a few years.

DATA AVAILABILITY STATEMENT
Data sharing is not applicable to this article as no new data were created or analyzed in this study.

ETHICS STATEMENT
Not applicable. This study did not collect data from human or animal subjects but from an open research repository.

TRANSPARENCY STATEMENT
The lead author Kehinde K. Kanmodi affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.