Cross-border contagions

Pakistan is in the midst of a massive outbreak of dengue fever. With tens of thousands of patients affected, mostly under the age of 15, dengue is arousing much chaos and paranoia. While dengue is fatal in few cases (less than 1%), it results in a severe bleeding disorder in about 20% of cases (due to a dramatic reduction in patients’ platelets), and in many cases, symptoms such as fatigue and depression persist long after the acute infection has subsided. Therefore it is a source of severe debilitation and its rapid spread is a source of great public panic. Dengue has spread like wildfire throughout the country, with cases being reported in all four provinces. However, modern means of transportation (cars, trains, airplanes) mean that not only can an infectious disease spread easily within the borders of a given nation-state, pathogens can overcome both geography and nationality with much ease. Consider the H1N1/swine flu pandemic of 2009 which within a matter of three months spread to 214 countries and territories, affecting millions, and causing about 18,036 deaths. The flu pandemic spurred the recognition of the need for cross-border collaboration to curtail the spread of infectious diseases. However, these important lessons have not been recognized by the governments of India and Pakistan, which share a 2,308km long border.

While Pakistan’s border with India is certainly not as open as the one it shares with Afghanistan or China, reflected by the transit of polio cases across these two fronts, it is certainly far from airtight. Research into the subtypes of the dengue virus has shown that the strains circulating recently in India and Pakistan are similar, and an epidemic caused by one strain is usually followed by an epidemic with a similar strain across the border. Such a relationship was clearly reported in the temporally linked epidemics of Delhi and Karachi in 2006. Therefore, there is substantial evidence indicating cross-border spread of dengue, and possibly indicating the spread of other infections as well. Modern means of transport, which have far more mileage than the tiny wings of a mosquito, have made it much easer for infections such as dengue to spread from one side of the border to the other. The threat of cross-border HIV infection has also been reported, and is an important one to keep in mind as the painful memory of the Mumbai attacks recedes, thawing diplomatic relations, thus reopening the door for more people-to-people contact. Furthermore, a case of polio was recently detected at the Attari-Wagah border, raising fears of the spread of polio to the Indian side of the border. 

In spite of the overwhelming need for collaboration in health and infectious diseases between India and Pakistan, no official channel is in place to conduct such an exchange. Currently, the Attari-Wagah border is used as a quarantine of sorts to vaccinate children crossing the border to prevent the spread of polio infection. During the H1N1/swine flu pandemic, the train that crosses the border – the Samjhauta Express – is frequently fumigated with insecticide. Custody was sought of animals being transported to India such as pigeons, donkeys and dogs for fear of spread of diseases ‘eradicated from India’. While the issue of cross-border infection has been used for rhetorical purposes, no constructive step to overcome this deficit has so far been taken from either side. While Pakistan has sought medication and insecticide from India to combat the dengue epidemic, there is no robust mechanism to ensure that such positive exchanges can occur on a regular basis.

Pakistan and India face similar public health challenges. Both are third world countries faced with similar geography, population demographics, and infectious diseases such as pneumonia, measles, malaria, and tuberculosis, accompanied by widespread malnutrition.  Pakistan and India are also two of only four countries in the world where polio remains endemic, though India has made substantial progress in eradicating polio within its borders this year. Importantly, dengue is also a challenge shared by both Pakistan and India, which in itself is reason enough for close cooperation to occur.

Pakistan’s healthcare system is decrepit by any standard. Healthcare remains a luxury reserved for those who can afford expensive services provided by largely privatized providers. Furthermore, the formerly federal responsibilities of coordinating healthcare and health-related services have recently been devolved in both India and Pakistan. This devolution poses similar challenges to Pakistan and India, since the lack of internal systematization of health information precludes international collaboration. According to Dr. Sania Nishtar, president of the Pakistani NGO Heartfile and a leading authority on health systems in the developing world, "The inadvertent fragmentation of health information as a result of health devolution in Pakistan is further undermining the country’s ability to share information with its neighbors." However, she suggested a way forward to overcome the disintegration of a central health in order to facilitate international collaboration. "Options are available, however, to cast an institutional construct that will enable Pakistan to step up its capacity so that the country is compliant with International Health Regulations, 2005", she added.

The lack of collaboration between Pakistan and India with regard to infectious diseases is only reflective of the thorny history shared by these two countries and the level of prevalent distrust on both sides of the border. The World Health Organization is a large platform with regional organizations that help countries collaborate in their neighborhood. However, in a move representing a snapshot of the bigger picture, Pakistan opted to be a member of the Eastern Mediterranean region as opposed to the more natural South-East Asia region, which is headquartered in New Delhi. This move away from the South-East Asia region was political and was made so that Pakistan does not have to compete with India, which dominates the regional organization. Therefore, composite dialogue carried out bilaterally by Pakistan and India is the only platform for a health partnership to be forged. A fresh start needs to be sought to elevate the relationship from quarantining birds and other animals on the border to sharing research, disease surveillance data, vector control strategies and health communication material with institutional support. However, this can only occur under the umbrella of wide ranging confidence-building measures. Not only will it be extremely difficult to initiate collaboration, but the sustainability of any initiative might be an even greater issue given that it will always remain hostage to politics.

Haider Warraich, MD, is a research fellow at Harvard Medical School. He is a graduate of the Aga Khan University in Karachi, Pakistan, and the author of the novel, Auras of the Jinn.