Disease control is a major issue in India which demands not only medical attention but social and political action as well. This is especially true in the bordering areas where the intensity of communicable diseases is markedly higher than in those States which form the hinterlands. However, as diseases are not hindered by political boundaries, the problem remains not only of borders alone but becomes one of borderlands, encompassing areas beyond the common geopolitical dividers.
This point was emphasised during the Consultative Workshop on "Beyond Borders: Issues and Concerns in Public Health Hazards in India’s Eastern and Northeastern region", organised by Observer Research Foundation, Kolkata on 15 November 2018. The workshop sought to identify various areas of public health management on four major communicable diseases, namely, HIV AIDS, Tuberculosis, Malaria and Kala Azar, across the borders India shares with Bangladesh, Nepal, Bhutan and Myanmar
The workshop began with an enriching inaugural session. It was explained that any disease is caused by the favourable interaction of three factors; agent, host and environment. Time and place further characterise the disease determining if it occurs seasonally and is endemic/epidemic in nature. As the environment is similar in the cross-border areas, communicable diseases easily spill over into the neighbouring countries through migrating hosts. Climate change further aggravates the problem. This issue has now become a key non-traditional security concern demanding behavioral changes and more cross-border cooperative efforts for managing this trans-national threat.
Following the inaugural session the first and second business sessions, entitled ‘Border diseases: Analysing key concerns’ and ‘Voices from the Field’, attempted to explore the existing state of the border diseases along with the prevailing frameworks, based on both secondary data analysis and extensive field experience of the delegates present. In the border areas of BBIN countries plus Myanmar, the prevalence of diseases like HIV-AIDS, Tuberculosis and Malaria is quite high. Such predominant vulnerabilities are often recognised as emanating from several factors like poverty, illiteracy, lack of health facilities, non-availability of essential drugs coupled with migration and psychological stigmatisation. Meaningful prevention, intervention and risk management of diseases demand proper recognition and response to promote an empowered public health system.
The porosity and openness of the concerned borders also play an important role. Often regarded as conflict prone zones, such areas witness illegal migration, human trafficking, disrupted treatment of patients, and prevailing disparity in the medical facilities on either side together with a general lack of awareness. On the one hand, official labels, such as, “disturbed areas” also hinder humane administration of available facilities compounding the existing problems. On the other, terrorist activities severely hinder health-related activities.
The latter point was highlighted in the discussion on Manipur where, as pointed out, targeting of health workers by both state and non-state actors was frequent. The nature of attacks on health facilities involves threats of explosives, occupation of facilities, etc. Citing South Asia Terrorism Portal (SATP) figures, as many as 26 incidents of attacks on health facilities of such nature were mentioned from 2010 to 2016. Attacks on health workers were also reported by the SATP, the nature of which included abductions and killings of health workers. First hand narratives of challenges faced by health workers in Manipur included health workers being unable to send samples for testing after collection from the patients. Also, cases where children living with HIV have been initiated with random ART in absence of a functional CD4 Machine were highlighted. If such social determinants of health are not identified, further progress in governmental collaboration in combating diseases would not be possible.
Taking a cue from the morning’s deliberations on inter-country cooperation to improve public health in borderlands, the last business session of the day focused on ‘Facilitating Disease Management (with special reference to West Bengal)’. As each element of the Epidemiological Triad is mobile, diseases spread easily. Also at times, availability of these health services does not necessarily imply its accessibility. It so often happens that people migrate unlawfully to neighbouring countries for better treatment. They are apprehensive of revealing their identity out of fear of not receiving proper medical attention. In such cases their country of residence is frequently unaware of their case histories as there are few means of tracking their treatment.
Also the problems of incomplete therapy and medicine trafficking reduce the chances of effective mitigation of diseases. It also happens that if a disease is found to have been ‘imported,’ state agencies tend to become complacent about its management. In the process, the possibility of its further transmission by local vectors is overlooked and diseases like Malaria and Kala- Azar spread. Lack of control over misuse of drugs also creates resistance in the parasites rendering the maladies difficult to cure. Hence a regular system of drug resistance monitoring and proper diagnostic arrangement is necessary. In addition to this, Public Health services must monitor source, destination and transit points of migration. As climate change also in some cases affects the longevity and reproductive elements of the disease carrying vectors favorably, efforts to improve public health services must include this problem in its ambit of considerations.
Among the countries included in this study, India has the strongest public health service but several bottlenecks remain at the implementation stage. There exists a discrepancy in public health services between eastern and western Nepal. In Bangladesh, public health services are controlled by donor agencies. Bhutan is too sparsely populated to provide effective services and in Myanmar it is very difficult to access data.
The workshop was marked by frank exchange of views and ideas which led to deeper understanding of the salient issues and an appropriate methodology for the successful completion of this very important policy relevant project.
This report is compiled by Sohini Nayak, Research Assistant, Observer Research Foundation, Kolkata
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