Transit through Bangladesh: The health factor

FOR the umpteenth time, allowing transit to neighbouring India has become the hottest topic of all political discussions. It continues to evoke strong opinionated responses, both for and against, from people of all sects and classes -- politicians, intellectuals, businessmen, teachers, students, artists, and concerned citizens.
The pros and cons of such an agreement between the two countries have been dissected many a time from social and economic perspectives. However, this sort of an agreement may also have significant implications in terms of public health, which has not been discussed elaborately by the national media or the experts in the health field.
Migration, population mobility, international trade and communication are all fast becoming significant determinants of global health. "The relationships between these globalising processes and health are introducing health into foreign policy discussions (WHO bulletin 2007)." It has been estimated that more than 700 million people cross borders annually for the purpose of business, pleasure, tourism, and temporary or permanent migration.
Transnational mobility, both short and long term, allows mixing of people and micro-organisms at an unprecedented rate and can be an important factor in the spread of infectious and communicable diseases. Historically, public health policies and healthcare activities in different regions of the world have been enhanced to incorporate this issue. The basic principle was to enact regulations and undertake activities to protect the health of the host population.
The trans-border mixing of populations becomes a significant health issue when there is a difference in prevalence of infectious or communicable disease between the two communities. Individuals from high prevalence areas can bring new infection to the low prevalence community.
Usually, the diseases that cause concern are HIV/Aids, syphilis and other sexually transmitted diseases (STDs), tuberculosis and, more recently, Severe Acute Respiratory Symptoms (Sars). According to a UNDP report, population movement across borders is one of the key factors in the spread of disease in Southeast Asia.
In the case of Bangladesh-India cross-border trade and transit, the biggest concern should be, and is, the spread of HIV and other STDs; not only because of the difference in the prevalence of HIV between the two countries but also because this will allow continuous passage to a very high-risk group through our country. According to the 2007 UNAIDS estimates, there were approximately 12,000 individuals with HIV in Bangladesh; this number is more than 2.4 million for India. However, both of these numbers are assumed to be gross underestimations as there is no comprehensive surveillance system or screening for HIV in place.
In both countries, along with commercial sex workers, injection drug users, and men that have sex with men, long distance truck drivers and their helpers have been independently identified as a high-risk group for HIV infection. The prevalence of HIV and other STDs is higher in this group compared to the general population. This group has been shown to be more likely to have sex with commercial sex workers, have multiple sex partners, and have unprotected sex.
Studies have found that only a small proportion of people in this group are aware of HIV prevention measures. Therefore, they are more likely to spread these infections. In fact, both in India and Bangladesh, this high-risk group is considered a major force behind the spread of HIV. This has significant implications since Bangladesh has been identified as one of the countries most at risk for an HIV epidemic and the national HIV/Aids prevention programs and activities are still in the budding phase.
Transit agreement with India will allow a large number of truck drivers, helpers, and associated personnel to move back and forth through Bangladesh. This group of people, their health and health behaviour, should be brought under the national public health framework in order to minimise health risks associated with such large-scale mobility.
The objective of this article is, by no means, to create alarm or to negate any socio-economic-political advantages Bangladesh may gain from this transit agreement, but only to raise awareness and highlight the need for vigorous immigration health policies at the borders and possibly throughout the country.

Shahed Iqbal, PhD, MBBS, is a fellow at the Centers for Disease Control and Prevention, Atlanta, USA. Views expressed in this article belong solely to the author.