BHOPAL THE IMAGINATION OF A DISASTER
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BHOPAL THE IMAGINATION OF A
DISASTER
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An extract Froms
BHOPAL? THE IMAGINATION OF A
DISASTER
community h"* ' "H CEU
-^■6, V Main, 1 oiucfc
Koranicngala
y
3angaloro-56Q034 p/
Shiv Visvanathan
with
Raj ini Kothari
Ma
V
Between the muteness of the victim and the propogadistic
erasure of the State stands the voluntary organization*
Voluntarism attempts to create an ethical space, an eco
logical niohe where the victim as survivor marked by the stigma
of the disaster can grieve, mourn, remember and recover.
But the voluntarist is more than a mourner. He realizes that
the victim becomes in the aftermath of a catastrophe, the
focus of a grid, the huge apparatus of health and social wel
fare seeking to diagnose, survey and map him out. He seeks
humanize and even alter the structure of such an expertise^
One example of such an attempt is the effort to alter the re
1ation between doctor and victim in Bhopal*
lation
Bhopal
The voluntarist
realizes that much of the formal language of medical expertise
is caught in the mechanics of cause and effect. He seeks. to
.
transform the iciea
i^ea of a< clinical gaze? 'where the patients is
--- x.—
lnt0 speech with its
spread out like a~ table of symptoms,
more encompassing concern for signs, symbols and symptoms.
Through this he hopes to articulate the victimrs conception
of his own pain. One strategy adopted in Bhopal was to move
the site of the analysis from a formal organization like ah
hospital into the bastee itself. In the hospital, the patient
is an isolated unit. Now he is a part of the community. Rather
than being based ona formal reading of svmptoms, cure and relief
• now become part of the socio-drama of a. community. The doctor
listens while the patient enacts out his pain amidst a chorus
of familiar actors, Typical _of
of sucha strategy is the work of a
the Medico Friends Circle. (MFC.)\ Its report completed in May
1985 is probably the most sane, compassionate piece of scholarship on the problems of relief in Bhopal
-i
—
. i
.
«
~
i
-
z
- o
The MFC describes itself as a circle of health interested
professionals united bv the belief that the medical system is
skewed in preference for the rich. It seeks tc demystify
medical expertise, d'^ky^unudvi-LcuL-i.^'^
decommercialize medicine, emphasiz-ing community orientation of health care* It£ basic survey was under-t
taken between 19-25 March, 1985.1ts alm was three fold, It
sought to uphold the idea of an e xpert as trustee , of science
knowledge
as publicly available knowledge.
It articulated the pain of the
victim and^his/her idea of relief into a more integrated plan
for medical rehabilitation.,
— Thirdly, with true anthropological
reflectiveness 9 it shows how conceptions of the patient, ideas
of cause and effect , diagnoses and cure form an integrated
consciousness, a gestalt as it were.
The survey began by studying the impact of the gas and in
problemso Firstly,
F’
pursuing this they faced two .sets of problems.
little
was known about the properties of MIC and secondly what little
'.:z.z
_„Ti9 was kept secret, It obtained with d ifficulty,
was lzns
known,
Carbide’s manuals which showed MIC to bd a toxic gas under
going runwaway reactions when contaiminated* The voluntary
groups publicized data available in such manuals. The MFC also
launched a survey of the literature available. The doctors
realized that the information available in them was incomplete
and flawed. They referred to lung fibrosis and corneal damage
as the only two long range problems of survivors. The voluntary
groups also realized that government research, despite the
* •« o 2«
- 2 fanfare, was sketchy and unsystematic, The ICMR’s research
appeared, as ’’twenty or so vertical programmes, without inte
gration into a wider conception of epidimeological community based
endeavour” What was missing was a systematic rationale for
detoxification by Sodium Thiosulphate.
.
It was in this context that MFC with the aid of other
groups planned a community survey. It included a people’s
perception of medical services. The doctors also decided that
a summary of findings and technical recommendations would be
handed over to oach person in the sample. The surveys of the MFC
and those of the Delhi Science Forum and the Morcha showed the
enormity of the crisis as a social situation. The studies of
Jai Prakash Nagar showed that income levels had fallen drastically 9
that.rat.es of interest wore high. They proved that compensation
was inadequate, even though at tho high point of -the crisis,
it was the only source of income for many disabled p*eople« Tho
report argued.th at doles were not enough. Tho mechanical
hydraulics.of tho dole could not return the community to it ori
ginal condition. What was required was an imaginative scheme of
occupational rehabilitation. Such a: scheme could not be
based on the wage that was earned before the exposure as indcetor• It had to take into account long range physical disability, the mental traumas, the persisting sense of insecurity.
The MFC and othergroups were thus challenging the restrictive
notion of health articulated by tho government. The latter seomod
to read the disaster in more physical terms. What it refused to
see was the psycho-social dimension of the disaster. -’Thousand s
of people have experienced mass death, mass morbidity, mass
migrations, disruption of family and social life, escalations
into an acute socio-economic financial crisis and literally a
loss of mooringsin society._ Such an experience is bound to
psychological, somatic and psychosocial mor
bidity whoso long term management will probably be more crucial
than t reatmea.t of physical ill health and disability”.
The doctors of the MFC wore true listeners, sensitive to
the word and the sheer detail with which Patients outlined these
inP°stance of this is brought out in the report
Tbo words and examples used by the patients while describing
their sysmptoms clearly showed the gravity of the symptom as well
as its effect on the person’s day-today work. Tho different
manner in which the symptom was described also showed that tho
person was informing us of a problem based on his/her own experi
ence and not just.vague hearsay exp^ressions. This is particuarly important since in tho absence of signs in the same pro
portion as symptoms, doctors attending on those people in, busy
government hospitals.were often passing of‘these symptoms reported
as compensation malignering’ or not-^o^clinical significanco.’
-Aie have every reason to b elieve that- those symptoms wore real ex
pressions of physical and mental ill health and many should
bo accorded the.same significance as the use of patterns of
cough with or without expectoration on the diagnoses of Chronic
brouchities or the use of Anginal history in the diagnosis of
Ischaemic Heart Disease”.
-p 4-iA^k° conception.°f disease as a problem of the community9
0Patlent as diagnostician in his ov/n right, contrasts
with.the conventional notion of the doctor as the solo intoroeter
of signs and symptoms, to which must be added tho attitude of
many.doctors who perceived tho behaviour of patients as malignering or compensation neurosis. These doctors prescribed ’’whole
c°lorful capsules in a routine manner”. The x
sy^voy eventurally shows how such contrasting perceptions
quietly link up to two separate views of diagnoses and cure.
o o o 3.
- 3 tW° ?a^ic theories were the Pulmonary theory and the
yanogen pool theory. The Pulmonary theory is based on the
On !,lc’9 "hl<=h ^naleatMtSt“looses
o?
ot the lungs and corneal damage are the only long term effects
Uob^TPeCtld*
imPsct on an sny other system is, it holds,
th! UnDn+O?dary4-eff^Ct^’-n The Cyanofen pool theory contends that
cdiinhar
not °ne
Pulmonary fibrosis alone but a deeper
hi!
i ’ •n°^ m®rely confined to lungs. What is important
theorDeh
1S. ls th-3 style of research underlying the two f o1 Of nan ThDf pU °pe£stss ln terms of the direct mechanics
of cause and effect, the second in terms of deeper relations.
F°Ory °f Pulm°nary. impact is advocated by the
establishment and government hospitals. The cyanogen pool theory
sident doctoV°CeteS am°n8 voluntai‘y health specialists and dis- '
is Most fascinating is the manner in which text
p^r,C?niext fre re1"tedo Voluntary health specialists have
advocated that the focus of study should be suffering
n the community, rather then the patient as an isolate in the
hospital. The first they argue, leads to a holistic view of di-^
sease while, the latter propagates a reductionist view of illness
Yi3W °f thG P?ti3n-t. The latter view which
studUs rnthir pulmonary model, is based on numerous vertical
t„Uthf>n an lnt3grated search for interconnections,
m a telling
MFC report
”Tho accroach of
sSy paragraph
200 eyes the
or 2001ung?
ona supf'ests,
s§ on WoMentTf^nV
another lacks this integration. Strange it may sound, but it
seems to derive the rat ionale-unconsciously-from the pulmonary
tOXD EssJdirGGtly hits the target organ (lungs,
^yes, etc.) to produce damage without any intrinsic connectionswhich is at the heart of the'Cyanogen Pool' model”.
It is this anthropology of gestalts that is fescinpting
about the report. TWh?t
’l
it offerod wre two clusters which
deserve further exploration?
lo
Patient as an analytical
grid
2. Clinical gaze of the
doctors
3. Focus of diagnosis is
the hospital
Patient as Parson
Victim’s speech aids
diagnosis
Focus of diagnosis is the
Community
4o Diagnoses as mechanics
of cause and effect
Diagnosis as an analysis of
inter-relations
5. Pulmonary Model
Cyanogen Pool Model
60 Anti Thiosulphate
Use of Sodium Thiosul
phate as a critical tool
VI
The experiences
of
the x MFC Uli
_L
o.i.X'-/
4—' rixJ
1 Lyj 1
___
_
the
Morcha
and
othor
grouns
demand
thPt
this
has
to
bo
located
within
<_
v
„
.
,
,
- - ---------- a wider oolitical
context. The problem of voluntarism has acquired a dramatic
focus within a span of two months. The November riots and
the December gas leak created a new objective situation which
Wddf^st°od within the theory of the State. The 'riots'
in D^lni saw the icrmal emergence of the State as terrorist.
. The Bhopal gas.leak revealed the complicity of the State in an
act of industrial genocide. In both cities, the traditional
corporate groups-tho trade unions, the political parties, the
kv
A
- 4 -
the universities-failed to act as a cushioning medium between
state and the people. In Delhi, it was the civil rights groups,5
along with a network of feminists,z journalists, university teachers^and Jesuit priests which brought
_
analytical clarity to
w v the
v u. e
violence of the State and even provided relief to the victims.
The situation in Bhopal was similar
similar.
Caught in the grid of modernity, which sees industrialism
as good and inevitable, the traditional corporate grouns saw
the victim as an embrassment. Wo must add however that political
parties like the CPI did ginerly conduct a few dpmonstrations.
Some student wings of leftist grouns responded by conducting sur
veys and providing some medical relief. But one’felt a whiff
of self-congratulation here, as if a'few dozen injections had
transformed them to the status of a Kotnis. Most'pathetic wore
the trade unions. So^startling was the disaster, and yet so usd
were they to negotiations with the management, that they refused
to see that the normalcy of coll ctive bargaining was inadequate
to this situation. Eventually Carbide declared closure of the
factory, offering the workers a nominal compensation. To add to
this the railway unions had failed to claim even workmen’s
Dcompensation for the railwaymen who died on duty on December 3.
versa
The Railways passed the buck to the factory and vice versa.
But
the.Workmen’s Compensation Act is clear on this s the victims are
entitled to relief irrespective of the source of damage. Such
lethargy was typical of almost all the corporate groups as organi
sations, even if some of the individual members discarded these
routine scripts.
The voluntary organizations had to substitute for these
groups though one must add that few were self consciously
equipped for such a task. Volurrtarism in this contxt required
a double responsiblity. It had toredeem not only the traditional
idiom of power but also the repressive nature of modern knowledge.
This point is crucial. As mediators between State and the. neocbe
they are.not only refractors of power but proponents of an
alternative ecology of knowledge. It is not only the victims as
politically defeated people that they had to protect but also
their vd-ice, their memory, their right to their own vernacular,
pain and distress.
highlighting
One fact needs highlighting.
There is a distinctive
quality about voluntarism in these new contexts. The voluntarism
of the old Sarvodaya-social service kind no longer occupies a
central place. In Bhopal, certain church groups , the RamaKrishna Mission and the SEWA did perform important service but
stuck grimly to traditional styles. They accepted the official
procedures of medication, basically symptomatic treatment,
including use of steroids and antibiotics and looked to the
leadership of the government in all these activities. The
Hoalth Secretary’s question ’’why can’t the Morcha be like the
SEWA ?” sums up this traditional and dedicated style. These
organizations work as extensions of government relief and
avoided confrontationist stances. The litmus test for such an
attitude in Bhopal was the Sodium Thiosulphate controversy.
All the above mentioned groups refused to administer these injec
tions. The point we wish to make is that the new voluntarists
were.not content with relief. What they also sought seek was i
justice for the victims. In this, the importance of socially c
conscious professionals became obvious. In the Delhi riots,
university social scientists, researchers and journalists
provided an enormous data base which the State has found diffi
cult to refute. In Bhopal too, the role of the professional as
’counter expert’ has been crucial. These include health groups
environmentalists, Lawyers’ collectives and peoples science
movements.
REPRINTED FROM LOKAY^N BULLETIN9 Vol
13 Alipur Road
----- n
39 No.4/5
I
I-
A report From Bhopal
Learning from the Relief Work
abhay bang *
<1
An article in mfc bulletin on the Bhopal disaster
is qxpecjted, by tradition, to focus on the political
and economic reasons behind the tragedy. For such
analysis the readers are recommended to read two
excellent papers by Barry Castleman**. I shall also not
attempt to investigate and describe the chronology
of Events. Newspapers have published a lot of infor
mation on that and I air.1 no wiser than the journalists.
As ithe title suggests I shall restrict myself to the relief
aspect, that too mostly in relation to public health,
for thcre were ample things to learn from that alone.
of people with respiratory symptoms. Many also had
vomiting. The medical personnel were in the dark
about the harmful effects of methyl iso cyanate
(MIC). They were not even certain whether it was
MICS or phosgene gas: so the fear of the corr.ing
unknown effects was looming on everybody. 19 cases
of CNS involvement were reported in the Hamidiy'a
Hospital. This gives credit to the rumour that on
autospy, cerebral oedema and haemorrhage were often
found.
When the Gas Struck
When we reached Bhopal on the morning of 5th
December, the administration had overcome the
initial shock and relief operations had begun. Hospi
tal staff, interns, and medical students; various social
and religious organisations had responded quickly.
Food and blankets were being distributed freely.
Dead bodies were being removed.
The Ongoing Relief and its Criticism
When the gas struck at about 1.00 a.m. on 3rd
December, people woke up with a severe sense of
suffocation, cough and irritation in the eyes. Most
of (he deaths were instant due to suffocation or pulmo jiary edema. The worst hit were children, many
of Iwhon? died in bed. The result of this cruel pre
ference of the gas was that very few children remai
ned orphan, because usually children died before their
parjents.
The first instinct of the medical profession
naturally was to offer symptomatic relief to the
sufferers. As the hospital was full with the dead or
very serious, most of the relief work was done from
temporary tents. About 100 such medical relief clinics
were opened in the premises of the hospital or on the
roads near the affected areas. Doctors were treating
long queues of patients. -The method was typically
uniform everywhere, with some obvious shortcomings.
It is almost a universal law that the poorest live
in dangerous areas. When a flood strikes, the people
who live on low land and are the most affected are
always the poor. Bhopal was no exception. People
living in the immediate vicinity of this Chemical volcarjo. were mostly slum dwellers. But besides this
fact, two other disturbing
pieces of information
explain the very striking class distribution of the
victims :
No case papers were made. Hence the identity
of the patients, physical signs and the treatrr.'enl
given — nothing was being recorded. The reason
offered was that the doctors were too busy treating
people and records were not the priority in such a
situation. The result of course was that medicines
were distributed like toffees. One of us saw a child
taking an injection and then running.to his friends to
boast that it was his sixth shot that day.
The residents of Jayaprakash Nagar slum which
is the closest and the worst affected area, categori
cally state that at about 12 O’Clock midnight, all the
workers in the union Carbide plant fled away in the
factory buses but no siren was blown. It means
factory staff came to know about the impending
danger at 12 and safely escaped without warning
people or the police. This may explain the strange
fact that only one worker of the factory was injured
by the gas when hundreds were working in the night
shift.
People were the first to recognise this deficiency
and started losing'faith in such totally adhoc and
symptomatic treatment.
Interns and doctors running these clinics were
not given any guidelines for treatment by the senior
doctors. Hence they were using medicines in the
most bizarre way.
Similarly, it is alleged that on coming to know
of the danger, most of the police and other govern
ment officers and the ministers escaped out of Bhopal
by the government vehicles at their disposal, instead
of trying to warn or help the people. Rich also fled
in their private vehicles. Those who did not have
any vehicles, obviously the poor, had to face the gas.
No attempt was made to train or involve non
medical volunteers or family members. Thus for con
junctivitis, even eye drops were put in the eyes by
the doctors alone.
This resulted in an unending
burden on the doctors; and the patients were able to
The immediate effect of the gas on the survivors
was irritation of the mucus membranes of eyes and
thq respiratory tract, leading to severe and widespread
conjunctivitis, sometimes keratitis, and a large number
* Gopuri post, wardha dist Maharashtra-442112
• International Journal of Health Services Vol. 9, No 4 (1979)
and Vol. 13, No 1 (1983)
3
get eye drops in their eyes once a day whenever they
could reach the doctor through the long queue.
3.
'No certificates of death or disease were being
issued. There did not even exist a reliable method of
recording and counting deaths, which resulted in
widely varying estimates of death from 2000 to 6000.
This neglect may become a tremendous handicap to
the poor to get compensation whenever that comes.
4.
5.
Besides the sheer magnitude of the problem,
another reason for such erratic medical relief was
that it was put in the hands of clinicians. When
100,000 people w’ere affected, it was absurd to control
the medical relief operation from the hospital by the
medical superintendent. Though a very decent man,
he thought that respirators were the most important
need of the hour. The whole operation was carried
out from the clinician’s point of view. This resulted
in such decisions as offering treatment in clinics
expecting victims to come there. Clinicians can only
see those who com-e to them and never know about
those who don’t come. This deprives them of the
total view of the situation. We found that a large
number of victims were not going to the clinics due
to reasons like despondency, inability to walk because
of severe eye problem or loss of faith in the quality
of the relief offered.
(B)
This also meant that the real number of the
people affected would never be known. The estimates
of the number of patients treated varied from 65000 to
1,50,000 and each estimate may have counted the
same patient many times and totally missed those
who did not attend the clinics.
(C,
A quick and crude survey of the remaining
residents of JP colony showed us that about 50%
had eye problems and about 25% had respiratory
symptoms. Surprisingly a large number of people,
even those with minimum respiratory symptoms, had
rhonchi and coarse crepitations in the chest. It
seems that the irritation by the gas had produced
chemical bronchitis and bronchopneumonia on a large
scale. As many of such ‘mild cases’ were not being
examined, clinicians in the OPD could fail to appre
ciate the widespread nature of the respiratory involve
ment. Unfortunately all these facts were not docu
mented and hence, it seems, the real' epidemiology of
morbidity may never bs known.
........
r
We thought that the treatment should be
provided at home so that all the population
will be identified, examined and treated, which
can not happen in an OPD set up. This was
specially important for the documentation of
morbidity as many victims did not go to OPD.
All the population to be followed up for coming
few weeks to provide continuous care and recor
ding complete impact of the tragedy.
Two doctors, three interns, four nurses
and about ten female social workers could be
mobilized and were explained the deficiencies
of the ongoing relief operations; and the con
cepts and methods involved in the one planned
by us. Forms for population enumeration and
case records, and guidelines for survey and
treatment were prepared and explained. Un
fortunately I could not stay longer but felt that
the plan was well explained and agreed upon
by the team.
•l:
The experience of the next 10 days work, as
reported by the social worker in charge of the opera
tion was as follows:
____ ....__
—
We planned a relief program to be run by
SEWA, a local Women’s organisation for a small but
defined population. The maitr features were:
—
Fem-ale social workers from SEWA visiting all
the houses in a slum et WOO families for
I.
2;
Doctor visiting all the houses, examining those
with respiratory symptoms and suspected kerati
tis (identified by social worker), recording phy
sical signs and treatment given. We thought
that all the persons with rhonchi and/or crepi
tations should be given an antibiotic cover
(preferably inj. benzathene penicillin) as they
carried a great risk of catching secondary infec
tion, similar to one after an attack of measles
or influenza.
The experience
Alternative Plan
(A)
screening of all persons for the presence
of symptoms which started with the gas
exposure and recording these
uncomplicated conjunctivitis and gastritis
to be treated by the social workers, involing and training the family members in eye
care and handing over a tube of eye oint
ment to them
identifying patients with suspected kerati
tis and patients with respiratory symptoms
to be examined by doctor
—
population enumeration
ideniitymg dead., lost or moved out persons
for compensation and economic..rehabilita
tion of the family
—•
On the first day when the team went to the
slum and started home visiting, doctors pro
tested that it was not their job and they set up
an OPD. At least half of the doctors could be
pursued to continue home visiting
Doctors could not accept the idea of social
workers treating conjunctivitis and kept all
the clinical work to themselves
The doctors in OPD refused to write physical
signs and diagnosis in the case papers on the
ground that it would take time and the fact
that the diagnosis could be guessed from'
their treatment
The typical treatment given was:
4
1
,
Lessons
: eye drops put once in a day by doctor oi
nurse;
.......... —
: cap tetracycline one TDS for one day;
: tab B Complex;
: tab multivitamin;
: corticosteroid injection
1.
2.
All the time saving devices in the plan like
training and delegating easy tasks to social
workers; using eye ointment which has longer
duration of action than eye drops; using benzathene penicillin to ensure week long antibiotic
cover, were stubbornly refused by the doctors.
It was not possible for the social worker -to
over rule the medical supremacy.
3.
4.
5.
I The physical signs recorded by the doctors by
home visiting were usually of poor quality. Some
examples are:
t—
r—
chest clear, crepts present
i—
slight coarse crepts -|- vc
mild crepts found (there is nothing like ‘mild
crepts’)
6.
Each doctor used his pet expression and the
recorded signs were monotonously the same in all the
patients examined by the same doctor. Obviously the
doptors did not examine sincerely or they were not
at jail sure of their findings of physical examination.
In spite of these short comings, this relief
approach gained instant popularity mainly because it
wais the only place in Bhopal where case papers were
being prepared and records maintained. People quickly
realized its importance and even asked for records
to; be given to them'. The relief authorities in the
city brought foreigners to proudly show this operation.
7.
i
Surprisingly and fortunately the tide of secondary
infection did not occur anywhere and hence the
dehth toll did not continue to rise after the first 3-4
days. The reasons for this reluctance on the part of
micro organisms to invade damaged respiratory tracts
are not understood.
Antibiotic cover was either
4not given or was very inadequate for most of the
afTpcted persons; and hence, cannot explain the
phenomenon.
Organising mass medical relief in a disaster
situation should be done not with a clinical
approach
but
a
popuJation/comm'unity
approach;
Persons in responsible positions should be
trained for disaster management in anticipa
tion;
There should be continuity in the planning
and implementation of any program, the lack
of which was responsible for improper imple
mentation of our plan;
Record keeping and documentation is vital in
all such operations;
Besides their well known bias against delega
tion, even the clinical performance of the
doctors was a sad commentary on the outcome
of medical education and the standard of the
profession. One tends to question the right
of objection by the medical profession to the
use of auxiliaries or village health workers on
the ground of the lack of professional training
to them.
The Bhopal tragedy acts as a warning signal
to all socially conscious persons that industrial
hazards and pollution are no longer a remote
problem restricted to the developed countries.
As Barry Castleman points out in his earlier
mentioned papers, developed countries are
rapidly exporting their technology, production
processes and products to the third world
without proper safety measures or information
and education to the people.
The Bhopal tragedy can be a powerful tool in
the hands of environmentalists and consumer
and citizens rights groups. A careful documen
tation of the ill effects — medical, social, eco
nomic and ecological —• will go a long way
to support the efforts of such groups.
Bangalore Meetings
1
After 10 days of working when the operation
neutralization of the stored MIC started most of the
reljief work was wound up as the people fled away.
At that time, eye problems had considerably reduced
but the respiratory ones had continued, though at a
reduced level.
I recently learnt that the ICMR has declared a
decision to develop a pl^n of long term surveillance to
find out the effects of gas exposure. That would be -a
stupendous but very valuable task, specially because
industrial toxicologists in the West are predicting
that 5 to 10 percent of the affected will have chronic
respiratory diseases.
2:.
The compensation for death and disease may not
be, fully available to all due to lack of records or
evjdenqe.
5
mfc annual meet — 1985
Venue: Indian Social Institute
24 Benson Road, Benson Town
Bangalore 560046
Date: 27-28 January 1985
Theme: Tuberculosis and Society
(All are invited)
29-1-85: mfc annual general body meeting
(only members)
For registration, background papers, return
reservations and other information, write to
mfc Bangalore office, immediately.
AIDAN Meeting.............................
The next meeting of the All India Drug Action
Network will be held in Bangalore (same
venue as mfc meet) on 30 & 31 Jan 1985.
For further details, agenda and information,
write to Mira Shiva, C-14 Community Centre,
SDA., New Delhi 110016. For local arrange
ments and return reservations, write to .mfc
Bangalore office.
r
The Health and Safety Movement in the U.S.
— Loy Rego*
and discuss citations, penalties etc., and finally to
receive a statement as to why a citation is not issued.
Each citation of a violation along with the hazard
abatement period must be. prominently displayed at
or near the place of the violation for atleast three
days and subsequently till the hazards are removed.
The period of hazard abatement can be contested
by the union. The Act provides that employees
should not be discharged or discriminated for filing
complaints or otherwise exercising their rights.
Those who experience discrimination can file a com
plaint with local OSHA office.
There is not much literature on the health and
safety movement in the U.S., and access to what
there is,’is limited, but, so little is known here, that
spreading this information itself will serve a useful.,
purpose of seeing the thrust and direction certain
specific movements developed. The article focuses on
some incidents, experiences and organisations that
formed part of the Health and Safety (H & S).move
ment. The sketches provided are short, and limited,
but will give readers some idea of the kind of activi
ties thatTwent and are going on! Analysis as to why
these happened at the time they did and linkages with
the broader socio-economic conditions are avoided
— primarily because of the lack of information
available.
Standards are set by OSHA, on the advice of
National Institute of Occupational Safety and
Health (NIOSH). Workers have a right to request
NIOSH for an evaluation of hazards in their work
place (eg exposure to.toxic chemicals.) and a standard
form (called as a Request for Health Hazard Evalu
ation) exists. And finally under the Freedom of
Information Act, workers are entitled to receive
most of OSHA inspection reports pertaining to their
workplace.
OSHA What it is
The black lung movement and its successful
advocacy of compensation was one of the most overt
actions during the sixties which placed occupational
H & S on the agenda of Society. Various other unions
wer.e active on^this front and had a number of activi
ties and struggles geared to better working conditions.
The environmental movement, the general social up
heaval in society and a number of governmental pro
cesses** were other influences during this period. Pres
sure for reform in the law governing H & S was grow
ing, and when such legislative proposals were under
discussion. Unions in the chemical, steel and auto
mobile industries, AFL-CIO and Ralph Nader’s
Consumerists pressed for a strong law — while em
ployers associations. Chambers of Commerce as well
as representatives of the H & S ‘professionals’ were
together in calling for much weaker laws.
While the above features project a very rosy
picture OSHA has not been able to secure improve
ments in working conditions commensurate with its
powers. “Only a small proportion of workplaces are
inspected every year, and inspections are fairly corrjmon only in workplaces of over 500 workers. Penal
ties have not been much. During the 4 years 19711975, OSHA made a total of 206, 163 inspections
resulting in 140, 467 citations alleging 724, 582 vio
lations with proposed penalties of $ 18, 186, 627, an
average of $ 25 per violation”. While this number is
considered low by radical commentators, it indicates
an agency more active than in India.
The Occupational Safety and Health Act (OSH
Act) was passed on December 29, 1970. The Act
requires employers to provide a workplace free from
violations of federal safety and health standards and
also free from those recognised hazards that are
causing or are likely to cause death or serious harm
even when there is no specific standard. To ensure
compliance, the OSH Administration (OSHA) has
the power to inspect workplaces, make citations for
violations and propose penalties, where there is
“imminent danger” and power to apply to a court to
shut down the offending operation.
Appeals by companies against citations and penal
ties is common. Original standards set by NIOSH
were mainly based on private standards adopted by
industry sponsored organisations, and of those
freshly promulgated, stringent standards have been
passed for only a few substances, and on the whole,
only 400 of the thousands of chemicals existing are
covered by any standards at all.
The years of the Reagan presidency, have meant
further cutback on welfare expenditure, which
obviously includes OSHA. The Reagan years have
seen the number of inspectors cut by 29% and a
fall in citations of 27%.
A welcome feature of the law is the explicit
provisions designed to involve the workers in hazard
identification, and protect them1 against victimisation.
This includes the right to file complaints, point out
hazards, to the inspector and remain anonymous.
The law provides that workers can call in the inspec
tor without advance notice to their employer*** desig
nate a . union, representative, and where no union
exists, an employee nominee — to “walk around”
with the inspector pointing out hazards. At the end
of lais visit, workers have a right to meet the inspector
* 27 Amar Society, 44/2 Erandwane. Gulmc har Park, Pune-4.
‘ * In 1964, a President’s Conferencejon Occupational Safely was
held In 1965, Dept of Health Education and Welfare publhhcd
a report on new chemical- hazards while in 19(8, ihcic were
extensive senate hearings on af; proposed H & S legislation.
OSHA’S ability to inspect withoutFwarning was reversed by
a Supreme Court decision in 1978. Now all inspectors must
have a court issued warrant authorising a search
6
■')
Among professionals, there are those who take
active part in COSH groups, as well as associations
of such people who have less of a pro-management
bias. For example. Dr. Irving Selikoff, famous for
his path breaking work on asbestosis, founded the
Society for Occupational and Environmental Health
__concerned with promoting research and training in
Occupational Health “without fear or favour”.
While the limitations of the law as well as its
enforcement are clear, the overall impact on H & S
has ito be taken into account while assessing it. In
comparison with Indian laws, the clear incorporation
of specific worker rights stands out in sharp contrast.
OSHA was resisted by employers since its incep
tion and many subsequent attempts to strengthen it
(stricter standards, tighter enforcement) have been
thwarted by business. For example, in the reversal
of OSHA’s surprise inspection right, legal expenses
were raised by a group called STOP OSHA — spur
ned by the American Conservative Union, which
raised $ 200,000 by mail subscription from businesses
which had been inspected by OSHA. The desire to
roll back the law — provides evidence of the fact
that- laws like OSHA act as irritants to companies,
at least, interfering in the way they want to run their
business.
Of the “new activists” as he calls them, Daniel
Berman says “They have well developed technical
skills, with a set of operating assumptions almost diacetridally opposed to establishment views. They blame
injuries and diseases primarily on the unwillingness‘of
the corporation to spend money to design a safe and
healthy workplace and on the constant drive to speed
up production. They believe workers should partici
pate in the design and control of production equip
ment; that progress can be won only by educating
workers and unions to take strong and informed
positions on H & S, and that workers should have the
right to walk off Unsafe jobs until conditions are
corrected”.
* 'U*
On the positive sideyv there is the definite irr>
pact of OSHA, in ways bqth direct and indirect of
placing the problems of work environment on the
ageiida for workers, unions and the public. As
Daniel Berman (Death on the Job) says “It is possi
ble jo point to specific advances for working people,
the establishment of their rights under OSHA, the
general acceptance of higher and more realistic esti
mates of the size of the problem, questioning the
traditional role of company doctors, the new interest
in occupational disease*, the increased number of
collecdve bargaining and research initiative in H & S,
and the gains of compensation, particularly in the coal
fields”. And in an era and over an issue where knowledgje is a source of power, and suppression of infor
mation to workers actively sought by companies, the
increased information generation and access through
the law, have been one of the ways of strengthening
workers action on H &S.
A recent listing'‘of COSH groups lists 29 of them
spread all over the US. Speaking of CACOSII
(Chicago Area COSH) Berman writes, "CACOSH a
coalition of workers, unions and activists have led the
fight for better working conditions in Chicago area.
It was formed in 1972, at a conference of a number
of unions, the Medical Committee for Human Rights
and the Illincis School of Medicine. CACOSH’s
first head was Carl Carlson, a blacksmith and safety
chairperson at United Auto Workers local, who had
earlier investigated noise and other hazards at the
International Harvester plant since 1959. CACOSH
holds an annual conference with a different theme
every year. It has given dozens of classes to unions
on H & S, led campaigns against Illinois OSHA daw
and for a law for compensation of partial hearing loss.
It has also testified for stronger federal r>oise and
power press standards.
COS H Groups—How effective?
What have been the organisational developmentswithin the union movement around H & S? Industry
basdd unions have opened or strengthened their
H & S departments. Professionals in occupational
hygiene and medicine, safety, etc., are employed by
Unions to organise the H & S activities of the Unions.
This consists of providing information on hazards,
drafting contract language on H & S, facilities for’
monitoring and measuring toxins in the workplace,
and^ conducting intensive medical examinations.
Another activity is coordinating training of workers.
Besides this there are area based COSH (Committee
on Occupational Safety & Health) groups which are
groups of union representatives, workers and sympa
thetic professionals coming together from a particular
city or State They do many similar functions as the
above. And at the factory level there are Health and
Safety Committees ■— sometimes joint worker-mjanagemerit committees, sometimes consisting purely of
Union local members. At this level many innovative
initiatives take place. As for campaign organisations,
the example of BLA has been dealt with at length.
Mike Gaffney, from UAW Local 6 and chairperson
of CACOSH in 1979 says, “It takes work at the local
level every day of the year, to accomplish anything in
safety and health. The working people do it^ with
a trained safety committee to find out the problems
and keep after them. COSH gives us this training
and backs us up when we run into technical things”.
What do COSH groups do? Training in hazard
recognition and control, law, compensation and
H & S bargaining. Researching hazards and control
measures. Helping to file and follow up complaints,
assisting in drafting H & S clauses in contracts. 'Refer
ring medical and .compensation .cases to non-compariy
doctors and pro-labour lawyers. Publicising through
the media about H & S problems to unorganised
workers and the general public. Coordinating action
for struggle for new laws, stricter standards and less
tortuous worker compensation codes.
* One government source estimates the number of cases of
work related diseases at 100,000.
7
mfc bullelin: JANUARY 1985
RN. 27565/76
A few examples of how COSH groups helped
local union initiatives are given below. Local 619
of the International Chemical Workers send workers
to training programmes conducted by PH ILA COSH
(Philadelphia COSH). Ernie Herbscht^ H & S Com
mittee member at the plant reports “We were specific
in our complaint to OSHA so they sent us an inspector
familiar with our type of work. With what our COSH
had taught us, we just took charge of the inspection
and madt sure everything was getting seen. At the
end, OSHA had nailed the company with 82 violations.
Aihd in some cases they get more serious citations
becaues our records showed that the company already
knew about the hazards and did not do anything to
clear up”.
United Electrical Workers Local sent their
members tc training sessions organised by MASS
COSH (Massachussetts COSH). Based on the infor
mation they received, they demanded and got their
exposure to benzene and cutting oils reduced.
; Shcp stewards of the International Ladies Gar
ment Workers Union reported complaints of back
pains stress, noise and lighting to NYCOSH (New
York COSH) who arranged for industrial health
specialists to work along with stewards to develop
evidence of hazards and develop solutions.
(Continued from page 2)
PEOPLE UNITE NOW: NO MORE BHOPALS
Movement fcr a Safe Environment
1. Lok Vidnyan Sanghatana; 2. Medico friend
circle; 3. Committee for Protection of Democratic
Rights; 4. Khad Kamgari Union; 5. Inquilab Com1munist Sanghatana; 6. Shramik Mukti Morcha: 7.
Kashtak;:.re Sanghatana; 8. ITU; 9. Navjivan Bharat
Sabha; 10. MARD (KEM); 11. Doctors for Peace
and Life; 12. Forum for Science, Technology tnd
Society; 13. Mazdoor Mukti Morcha (West Bengal);
and 14. Yuva Kranti Dal.
(Contact Address: Padma Prakash, 19 June Blossom
Society 60A, Pali Road, Bandra East, Bombay-50).
CITIZEFS RESPONSE*
Bhopal: A joint front under .he banner of the
Zahreel' Gas Kand Sangarsh Sar.aiti has been formed.
The morcha has set up cells to study, analyse and
disseminate information on the technical, legal and
medical aspects of the event. It is also undertaking
ar? intensive door to door surve / and is attempting
to organise the affected people to fight for their rights
.Contact address: Anil Sadgopa; c/o above morcha
Chhola Naka, Bhopal or 9/14 South TT Nagar,
Editorial Committee :
kamala jayarao
anant phac'jke
padma prekash
ulhas jaju
dhruv mankad
iditor *
ravi nara/an
Regd. No. L/NP/K.RNU/202
COSH groups have brought unions at the local
level together even though on a limited programrrje
to work collectively on common problems. The local
H & S Committes plus the greater number of pro
worker specialists have all helped in the struggle for
better working conditions.
References
“Death on the Job—Occupational Health and Safety Strugxgles in the United States’’ Daniel M. Berman, Monthly
Review Press, 1978.
2. “Protest and Change in the Coal Fields”, Chapter from
“Voices from the Mountains” Life and Struggle in the .
Appalachian South,’Alfred Knopt., New York 1975.
3. “Rank and File organisations in the United Mine Workers
of America” Paul Nyden from “Essays on the social rela
tions of work and labour”, Insurgent Sociologist, Vol VIII,
Nos II & III, Fall 1978.
4. Inliet Merrifield, Health Activist, Highlander Research and
Education Centre, Tennessee, USA, discussion during her
visit to India in Jan-Mar 1984.
5. “Job Safety and Health Protection”, Ray Marshall, Secret
ary of Labour, OSHA Publication, Washington, 1977.
6« “Your OSHA Rights” TNCOSH Pamphlet 1979
7. “If other Unions can do it, so can yours’’—COSH groups
American Labour, American Labour Education Centre,
No. 1, Nov 1979.
8. “Workers Guide to Information Sources on OH & S” —
TNCOSH, Tennessee 1982.
1.
Bhopal).
Bangalore: PAR1SARA (Movement for environ
mental Protection) is a forum of professionals, poli
tical action groups, voluntary agencies, civil liberties
groups and other individuals (mfc is also a part of it)
formed in response to the Bhopal incident and plans
to fight the . threat to ecological life and people’s
health due to location/use of harmful technology,
chemicals and so on. It will do this through media,
theatre, discussions, seminars, marches and other
means. A memorandum of demands has been sent
to the Union Government and Go ver meats of Madhya
Pradesh and Karnataka after a protest march and a
torch light rally.
Madras: Several groups have formed the “Move
ment for Environmental Protection”. • They had a
protest march on 14th Dec. 84 and submitted mcmorandam to the Government of India, Government of
Madhya Pradesh, Union Carbide and US Government.
(Contact address: 54 Johnny John Khan Road,
Royapettah, Madras-600014 or PVS Giridhar, Stu
dents for Protection and Care of Environment, Y-54,
Anna Nagar, Madras-600040.
* We request mfc members/bulletin subscribers to keep us in
formed of other initiatives.
Views and c.
’ ’
opinions
expressed ii the bulletin are those of the authors and not necessarily
'>f the organisation.
/ nnual subscription — Inland Rs. 15-00
F.^reign ; Sea Mail — US S 4 for all countries
Air Mail : Asia — US $ 6; Africa & Europe — US S 9; Canada & USA — US $ 11
edited by R. vi Narayan, 326, Vth Main, 1st Block, Koramangala, Bangalore-560 034
Printed by T1 elma Narayan at Pa dine Printing Press, 44. Ulsoor Road, Bangalore-560 042
Published by '.’helma Narayan fot medico friend circle, 326, Vth Main, 1st Block
Koramangala, Bangalore-560 034
■i
medico friend
circle
bulletin
ii
A^RIL
1)
1985
Medical Research in Bhopal
—Are we forgetting the people?
Concern for man himself and his safety must
Always form the chief interest of all technical endea) ours. Never forget this in the midst of your diagrams
\znd equations.
—Albert Einstein
Preamble
In a tribute to the medical relief workers
nvolved in service to the Rhopal disaster victims the
ICMR has noted (1) that a disaster of such magniude, of such suddenness and caused by the release
of a highly toxic chemical methyl isocyanate (MIC)
mto a densely populated habitat is unparallelled in
auman history. The doctors, medical students, civil
servants, governmental, public sector and voluntary
>odies and the people themselves rose to the occasion
in a human gesture equally unparallelled’. . .
In the absence of authoritative information on
he released gas; the unwillingness of the company to
part with authentic information; the unpreparedness
nf the local bodies^and the government health autho
rities to understand the consequences of the disaster;
and the absence of technical or toxicological experise on MIC among our scientific community, it was
imperative that a national body like the Indian
Council of Medical Research through its own initia
tive would have to harness the scientific medical
expertise in the country including the local medical
college community to meet this challenge. Conside-ing that the affected population was over 2 lakhs
and that the dead were over 6000 (though official
estimates are 2000!) this research initiative had to be
qually unparallelled in meeting the phenomenal
challenges of the world’s worst recorded ecological
lisaster. Do the records of events in the past four
months since the disaster bear this out?
The Plan
A report on the first nine days of the Bhopal
Jisaster identified (1) three objectives for the ICMR’s
research programme:
1. To establish a clinical and patho-physiological profile of the hazard which would
also provide clues for improved patient
management and clinical outcome
2. To study the long term sequelae of toxin
exposure to lung, tissues, foetus, genes and
cancer induction
3. To obtain a basic understanding of the
biological alterations associated with MIC
exposure.
Strangely enough there is no mention in this
report of a strategy by which conclusive research
data as and when available would be transmitted to
the relief and rehabilitation effort in Bhopal, ie., to
the treating doctors and through a health education
effort to the affected public.
A report of projectization of ICMR supported
research effort (2) lists out 17 study projects which
covers acute and long term health effects, lung func
tions, follow up of children aged 5-15 years, ocular
changes, pulmonary and neurological changes,
growth and development of new borns, clinical and
forensic toxicological studies, pathological and
microbiological Investigations, radiological studies,
biochemical and immunological studies, carcino
genicity, mutagenicity, teratogenicity and chromo
somal changes, data management information system,
,^hospital based cancer register, cytofluorometric
-■
i
—-------------------------------------------
INSIDE
The KEM Study
4
Women’s Health
4
The mfc Bhopal Study
5
Dear Friend
6
Scientific medicine
6
Introducing the Third Anthology
7
Consumer Alert — Action
7
$
Issues of concern
studies and blood gas analysis. The studies ranging
from a time span of 6 months to 5 years would incur
a total financial outlay of 1.07 crore rupees.
An mfc fact finding team which visited Bhopal
in mid February at the request of various non govern
mental agencies and action groups published a report
on the realities of medical research and relief which
has been widely circulated and is now well known(9).
In mid March an mfc team of 16 members camped
in Bhopal and undertook an epidemiological survey
which included detailed history taking, physical exa
mination, lung function tests, haemoglobin estimation
of a 10 percent sample of a severely affected area and
a control area(lO).
Some surprising omissions in the list were the
assessment of psychological stress and its manifesta
tions in the affected families, studies on health oi
women (not obstetrical outcome but gynaecological
effects) and the assessment of medico social e.ttects
like reduced earning capacity and functional disabi
lity which would affect rehabilitation efforts. Though
there were references to an epidemiological and
community based outlook the research endeavour atleast as on paper did not seem to be a coordinated
holistic effort in understanding the total problem
but basically a series of vertical research programmes
initiated and funded according to the interests of the
professors involved in the exercise.
Results
It is four months since the tragedy and about
three months since many of the research programmes
got underway.
I
Bii
r
>I
The team also met decision makers, relief and
service providers, medical teams of voluntary agencies
and others, apart from undertaking a survey of the
people’s perceptions of relief services and an overview
of the services itself. 1 he findings of the team are
being analysed and will be reported shortly (a presses
release is published in this issue) but the experience
of the third week of March in Bhopal strengthened
the findings of the earlier fact finding team and^
identified a whole series of issues of concern in the J
ways in which research efforts were becoming^
exploitation of peoples* suffering rather than expres-^H
sions of support to programmes of human welfare. M
Is
As far as a communication strategy goes three
press releases and two lectures by the director
generalsand a minutes of the meeting on the thio
sulphate controversy are the only freely available
literature on the research (3-8) efforts. From these
all that any member of the scientific community or
the general public can gather are:i. that there is no evidence of irreversible
eye damage or blindness
ii.
___ _the
___autopsy
_x
that
findings are indicative
of severe respiratory damage caused by
pulmonary odema and asphyxia
Hi.
that studies of exposed persons with lung
symptoms/signs have shown obstructive
and or restrictive abnormalities
iv
that a double blind clinical study under
taken using sodium thiosulphate and
a placebo has established that sodium
thiosulphate administration results in
symptomatic improvement and in increa
sed excretion of thiocyanates in the
urine. On the basis of clear cut results,
the State government has been advised
to administer sodium thiosulphate to the
exposed population and detailed guide
lines have been drawn up and circulated.
v.
w I
-I
i:
The medical relief services vontinue to be
starved of authentic and authoritative scientific
medical information to support clinical judgment and
patient management. In the absence of clear cut
guidelines from the seniors in the profession treat
ment continues to be ad hoc, symptomatic anc
unstandardised. Findings of autopsies, lab investi
gations and x-rays and other tests are not available tc
the treating doctors. Doctors have not been alerted
to the fact that a wide range of symptomatology like
fatigability, weakness^ memory problems are all pan
of the MIC syndrome. In the absence of such
information peoples’ sufferings have often been passec
off as malingering or compeniation neurosis.
2.
Pill distribution
The treatment basically consists of a whole
series of pills which are efficiently and actively
prescribed to the people in a sort of conditioner
reflex. In the absence of proper record linkages each
patient is collecting large amounts of pills and no
feeling the better for it. apart from the dangers of
over drugging. Other forms of care, counselling anc
non-drug therapies have not been thought of.
that two visiting psychiatrists have
found that 10—12% of the affected indi
viduals attending the medical clinics in
Bhopal are presenting with psychiatric
manifestations — symptoms of anxiety
and depression are foremost.
3.
The Thiosulphate controversy:
Even after the ICMR studies establishing th
validity of thiosulphate administration and the pre
paration of clear cut guidelines for its administration
(6,8) this specific antidote is not being used as
effectively as it should be. It has become a casualf
in a medical controversy between cyanogen ano
carbon monoxide lobbies and the victims rather than
being informed and helped arc being confused am
neglected.
Why this secrecy? or is it administrative over caution?
A more updated report prepared in mid March
collating all data’as of that date has again become a
casualty in the commitment to secrecy (caution!) and
no press release has followed.
2
V-—
Lack of dissemination of technical guidelines^
4.
Women’s health
IMA, voluntary agencies, action groups that there
are urgent needs to be actively met :
The mfc fact finding team had highlighted the
problems of women who have suffered abortions, still
births, diminished foetal movements, suppression of
lactation, abnormal vaginal discharges and menstrual
disturbances. The studies undertaken by two doctors
of mfc reported in this bulletin (11) establish the mag
nitude and severity of the problem. It, however,
continues to be neglected by the concerned authorities.
5.
* Need to evolve a bold, imaginative and open
communication strategy to all the doctors and health
workers (treating the disaster victims) who are present
ly starved of authentic technical/medical informatipn
hampering clinical judgment.
* Need to evolve a creative, relevant health
education and awareness building public education
strategy to meet the expectations of the disaster
victims and to help and reassure them through the
crisis and prepare them for the eventualities.
Absence of Health Education efforts
Whatever the other validity of the research efforts,
in the ultimate analysis it should get translated into a
strategy of health education and awareness building
of the affected people. As of date there are no
official guidelines or efforts in this direction. The
range of areas is phenomenal—advice to mothers of
the risk to the foetus and preparation for conse
quences including options for MTP, advice to couples
on contraception till detoxification is over, breathing
exercises and antismoking advice to those with
fibrosis of lungs, avoidance of overdrugging of
pregnant mothers, advice to mothers regarding feeding
of infants/children as lactation suppression has taken
place, availability of thiosulphate and other medical
relief measures. None of this has even been recognised as being necessary.
6.
* Need to ensure that research efforts are geared
to supporting relief and rehabilitation efforts and
not become esoteric exercises for institutional deve
lopment and career advancement.
* Need to make the commitment to patient care
and human welfare primary and to ensure that it does
not get bogged down by professional rivalries, inter
departmental incoordination, procedural constraints
and administrative protocols.
* Need for closer coordination between voluntary
agencies, action groups, citizen committees, medical
and health workers and the people oriented and
socially sensitive sections of the medical profession
and government authorities to ensure that the peoples*
suffering are not exploited and made pawns in the
games played by politicians, multinational compa
nies, and misinformed professionals—all symptomatic
of an exploitative social system.
Poor epidemiological and medico social orien
tation of problem assessment
The general impression is that research and
relief efforts are suffering from an acute clinical and
institution based orientation rather than a community
based epidemiological orientation.
An authoritative Lancet editorial (12) had
mentioned that ‘In a year’s time we will have learned
a lot more about methyl isocyanate at an appalling
price’. With the prevalent medical anarchy in Bhopal
in relief and research, this price may be immeasurable.
—mfc team. Bangalore
Only if all data is field based and is related to
known available morbidity patterns (or comparison
with controls) can early problems and special trends
be identified and urgently acted upon. The danger
of getting into the pursuit of a very neat and fool
proof epidemiological planning exercise can be equally
counter productive.
7.
References
1. ICMR, The Bhopal disaster — current status (the first nine
days) and programme of research
2. ICMR. Projectization of ICMR supported Research
3. ICMR, Medical Research problems in Bhopal (V Ramalingaswami)
4. ICMR, Pathology and clinical toxicology of the Bhopal
disaster (S Sriramachari)
5. ICMR, Medical research on Bhopal Gas Tragedy — press
release 31st Jan 1985
6. ICMR, ibid, press release, 12 Feb 1985
7. ICMR, ibid, press release, 27th Feb 1985
8. ICMR, Thiosulphate therapy in MIC exposed—minutes of
meeting at ICMR, 14 Feb 1985
9. mfc, Medical Relief and Research in Bhopal — the realities
and recommendations.
10. mfc. Approach document of a project to evolve a strategy
of medical relief and rehabilitation which best meets the
peoples’ medico social needs and expectations
11. Rani Bang, Effects of the Bhopal disaster on the women’s
health — an epidemic of gynaecological disease: reports
I & II
12. Lancet editorial, Calamity at Bhopal, 15 Dec 1984
Lack of informed consent
The people are not being informed about the
tests being done. Nor is consent being taken for
being included. in the studies or for procedures to
which many of them are being subjected to. This is
a minimum medical ethic.
8.
'I
Lack of coordination
This is a universal problem and the ultimate
sufferer’s are the disaster victims themselves. This
incoordination is occuring between goverment
services and research efforts in the medical college,
between the different research workers themselves,
between government and non-government relief
efforts, between voluntary agencies involved in action,
relief, rehabilitation and of all these groups with the
disaster victims themselves.
While a more detailed report is awaited, we in
the mfc appeal to government decision makers in
Bhopal, medical college professors, ICMR scientists,
3
'h
I
Study
The
Bhopal needs You
Results of a limited but thorough study of
113 MIC affected people carried out at K E M
Hospital (the only available comprehensive source
of hard medical evidence of the degree of destruc)tion caused by MIC).
Sample
Your support, donations and in
volvement are urgently needed for
mfe’s interventions in Bhopal.
Please don’t let us down.
(Cheques in favour of mfc Bhopal
fund)
Relatively mildly affected middle class peo
ple living in pucca houses at a distance of 2 kms
from Union Carbide Plant who voluntarily presented
to K E M Hospital, Bombay —8 to 53 days after
exposure to MIC.
Women's Health
Salient findings
♦
------ an epidemic of gynaecological diseases
Breathlessness on exertion 95%
Sample study
218 women in field clinics established by a.
gynaecologist in Bhopal (114 gas affected group
and 104 controls).
Salieht features
(C= Controls)
* Leucorrhoea 90% (C=27%)
* Pelvic inflammatory disease 79% (C=27%)
* Cervical erosion and endocervicitis 75%
(C =44%)
* Excessive menstrual blcedihg 31% (C=l .2%)
* Suppression of lactation 59% (C= 12%)
* All above arc statistically significant when
compared with incidence in controls.
* Spontaneous abortions (7); still births (4);
incomplete abortion (1); and threatened abor
tion in affected group, Nil in controls
* Severe pallor in control group 36% and in
affected group 3%
Persistent dry cough 97%
*
Throat irritation 66%
Chest Pain 68%
* Vomiting 42%
* Muscular Weakness 22%
* Altered conciousness 28%
♦
Low vital capacity of lungs 27% (less than
60% of normal)
•h
Impaired oxygen uptake 55%
4t
Central airway obstruction 43%
Respiratory alkalosis 59%
*
Abnormal low oxygen pressure in blood 23%
♦
*
Neurological conditions such assensory
motor loss, depression, tremors, loss of
concentraton, irritability in a signifiilcant
number of cases.
s
X-ray—97% had abnormal findings
*
Carboxyhaemoglobin—96% high
*
Methaemoglobin—79% hdgh
•
Percentage showing no improvement at all
despite medication and carefully adminis
tered treatment 30%.
—‘Bhopal’s unending tragedy’
Praful Bidwai
Tiirjes of India, March 25—27, 1985.
Conclusions
The exposure to the gas has produced excessive
gynaecological disease in women apart from suppres
sion of lactation and pregnancy wastage.
These aspects are presently unstudied and
uncared for. Immediate relief and research need to
be initiated for the silent suffering women.
Suggestions
1. Need to study gynaecological diseases
2. Need for field clinics and involvement ol
female paramedics
3. Need to health educate women on theii
gynaecological problems.
4. Advise on supplementation/weaning foods
for mothers who have suffered lactation
suppression
5. Information to women regarding risk to the
foetus
6. Need for voluntary agencies and women‘f
organisations to help slum women build
pressure on authorities to implement care
services
—rani bang (wardha)
—mira sadgopal (hoshangabad)
(copies of detailed study reports I & II are
available from Rani Bang, Gopuri PO, Dist Wardha
442114)
Note:
A much more thorough project consisting of
a medical survey and treatment of the gas affected
people Jias been organized by the Nagrik Rabat
Aur Punarwais Committee, a local! refief and re
habilitation group and the Voluntary Health Associ
ation of India. This study includes many important
investigations and was undertaken by a group of
over 20 doctors and paramedical personnel drawn
from K E M Hospital of Bombay and VHAT. The
results are eagerly awaited!
4
A
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THE BHOPAL
TRAGEDY
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APPENDIX
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APPENDIX 5.3
Jana Swasthya Kendra Documents
Sodium Thiosulphate Therapy:
Report On Symptom Improvement In
The Pilot Series
(June 3rd To June 10th, 1985)
1
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’ana Swasthya Kendra, Bhopal.
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Background
1'he recommendation of Sodium Thiosulphate as a specific drug in the treatment of gas
victims at Bhopal was made thrice during the earliest days ol the disaster. Firstly, on
December 3rd itself, the Professor of Forensic Medicine at Bhopal's Gandhi Medical Col
lege, after diagnosing a “cyanide-like” poisoning from postmortem examinations, suggested
immediate use of Sodium Thiosulphate, the known non-toxic antidote to cyanide. Secondly,
a telexed message sent on December 4th by the Chief Medical Officer of U.C.C. in West
Virginia advised the administration of Sodium Thiosulphate preceded by Amyl Nitrite “if
cyanide poisoning is suspected”, although he later repudiated this as a mistake. Fhirdly, a
well-known German toxicologist and expert on M.I.C. poisoning, who reached Bhopal on
December 8th carrying several hundred doses of the. antidote, stated that his suspicions
about “cyanide” and the need for-the drug had been confirmed immediately on seeing the
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autopsies.
.
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jFor reasons which are still ill-understood, this treatment was not instituted tor ordinaly
gas victims, although it was administered unofficially to a few hundred medical personnel
and to privileged citizens most of whom were only mildly exposed Io the gas. 1 he treatment
was and remains today the subject of unresolved controversy. In the early days, the senior
W.H.O. Regional Advisor stood beside the Professor of Medicine of the Medical College in
agreeing with the experts sent by the Union Carbide Corporation that Sodium Thiosulphate
was uncalled for in the treatment of gas victims.
Scientists of the Central Government-sponsored Indian Council of Medical Research (ICMR), which had been observing the drama from the first week of December, attempted to
resolve the controversy in the interests of the gas victims conducting a double-blind clinical
trial in January at a special 30-bedded Hospital set up in the heavily gas-affected area.
Although the trial showed Sodium Thiosulphate to be effective even as a delayed treatment,
the local medical community and State Government Health Services authorities failed to ac
cept the results or to give any significance to the guidelines for administration of Sodium
Thiosulphate issued in mid-February and reissued on the 4th of April by 1CMR,
Strangely, the controversy itself was suppressed and open scientific debate could not
take place. It was only in March that organisations working among the gas victims for relief
and rehabilitation realised the possible importance of Sodium Thiosulphate in the light of
the ICMR trial and began to demand wide administration of the drug through Government
hospitals and dispensaries. However, the controversy somehow thrived unabated, and thus
the mobilisation of the State Government health services for this purpose was effectively
blocked. Because of ICMR’s recommendation, the public sector pharmaceutical firm IDPL
manufactured special stocks of the drug. A small amount was deployed al Government
polyclinics, but was given to very few gas victims on a ‘ selective basis left to the discretion
of the treating doctor. (Gas victims who observed this say,that one of the apparent criteria for
a person’s selection for Sodium Thiosulphate treatment was whether he w»as wearing a
while shirt and wrisbwatch.) Due to mounting public demand, the State Government quietly
opened the stocks of Sodium Thiosulphate for indent to non-Government dispensaries
towards the end of May. Most non-Government relief agencies were understandably hesistant to start using the drug so late amidst the history of unresolved controversy. Even more,
they could not get the local doctors working with them interested in giving the drug. In an at
tempt to break this stagnation, our group prepared and circulated in early June a scientific
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review paper laying out the available evidence and rationale in support of using Sodium
Thiosulphate and encourgaging Government and non-Governnient agencies to take up
wider administration of the drug.(l)
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The Pilot Detoxification Tria! at Jana Swasthya Kendra
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Administration of intravenous Sodium Thiosulphate injections to ambulatory gas vic
tims was begun at our centre, the Jana Swasthya Kendra, on June 3rd, 1985, six months after
exposure to toxic gas. Glose interviewing of the first one hundred patients was attempted in
order to help understand the effect of the drug in relieving the presenting symptoms.
Clinical examinations and collection of urine samples for urine thiocyanate level estimation
were also carried out. This is a report of the effect on symptoms as reported by the patients.
Before proceding further, it is to be noted that there was a high drop-out rate. Out of the
first one hundred patients, post-thiosulphate interview data is available for only 54, and of
these only 26 sat for interview after completing the full course of six daily injections.
Because of a lapse in planning as well as operational problems, it was not possible to follow
up each patient to ascertain the cause for dropping out. Among the possible reasons could be
either achievement of relief, no benefit at all. or aggravation ol symptoms. Also, in those for
whom relief was obtained, we have no data reconling relapse of symptoms which we had
been warned to expect to a varying degree. Therefore, it is recognised that this data has
severe limitations and is being offered only as an indicator of the trend in incidence of par
ticular symptoms and relative relief alter the administration of three and six injections of
Sodium Thiosulphate among those who were interviewed. Speculation about those persons
who dropped out serve no purpose.
The plan called for three interviews - prior to the first injection and twenty-four hours
after the third and sixth injections. (Urine samples were also collected thrice, twelve hours
before and six hours after the first injection and overnight for twelve hours after the sixth in
jection.) People who had been exposed to the gas were taken on a first-come-first-serve basis.
Most of them were residents of the colonies in the immediate vicinity of the factory which
were most heavily exposed. No children under fourteen were taken in this series.
An exhaustive list of symptoms had been compiled in advance by doctors familiar with
the typical complaints of gas victims which were said to have begun or to have become
worse since the toxic gas exposure. The questionnaire of symptoms was arranged roughly
systemwise, i.o. mental, eye, respiratory, digestive, muscu-loskeletal, etc. Each person was
asked whether she or he suffered from the symptom or not, and, if so, was it mild, moderate
or severe in intensity; the answer was recorded by number code ‘O' meaning ‘nil’, 'T mean
ing 'mild', '2' meaning ‘moderate’ and ‘3’ meaning 'severe'. The interviewers consisted of a
group of volunteers from (he bastis and from outside; under the circumstances, with high
volunteer turnover and little opportunity Io properly explain the procedure, there was less
than optimal uniformity in the recording of symptoms and their intensity. In addition, the
very nature of symptom reporting is highly subjective on the part of the sufferer, and subject
to variability due to many factors.
The common symptoms have been graded according to percentage of incidence in the
persons who came for treatment, in other words, the percentage of persons who complained
of the particular symptom. The data examined here was of 54 persons. Muscle fatiguability
and muscle pain, headache and anxiety wen; the most frequent symptoms (96-98%) followed
closely by dizziness, tingling and numbness of limbs, chest pain, breathlessness, burning of
eyes, loss of appetite, palpitations and dimness of vision in (90-95%). Sore throat was sur
prisingly common (87%). Poor memory, pain in abdomen, burning passing urine, abdominal
distension, loss of sleep, watering of eyes and nausea were complained of by many (all
around 70%). Itching, cough with or without expectoration and runny nose were complain
ed of by about half of those who came, and diarrhoea or constipation, and soreness of the
mouth by about one quarter to one third of persons.
Improvement was reported in every symptom. This was seen most obviously in the drop
in the number of persons with severe symptoms, a shift from severe to moderate or mild, and
an increase in the number of persons without symptoms.
By calculating a composite score for each symptom according Io the number of symp
tomatic patients and the intensity ol the symptom, it is possible to compare the response.
The simple formula used was as follows:
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(N' x 1) + (N2 x 2) + (NJ x 3) - Symptom Score
where N’ is the number of persons with the symptom in mild intensity, N2 is the number
with moderate intensity and N ’is the number with severe intensity. The mean symptom im
provement was calculated by dividing the difference in pre-and post-treatment Symptom
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APPENDIX
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Scores by the number of patients who had the symptom before receiving Sodium
Thiosulphate. This was compared with the initial mean Symptom Score to assess percentage
of benefit.
There was an average overall improvement of 48% alter three injections (46 patients) and
70% improvement after six injections (26 patients, of whom 8 had missed the interview after
three injections). Among the most frequent symptoms, there was a total improvement after
six injections of roughly 60% in muscle weakness (fatiguability) and calf muscle pain, 70%
in headache and 80% in anxiety. Among the next group in frequency, there was a 60% im
provement in breathlessness, tingling and numbness, burning of eyes, dimness of vision and
poor memory; 70% in chest pain, palpitation, pain in abdomen and loss of sleep; 80% in diz
ziness, loss of’appetite, sore throat, burning on passing urine and watering of eves; and 90%
in abdominal distension and nausea. Among the less frequent symptoms, there was more
uneven improvement reported, for example, over 90% improvement in runny nose, dry
cough and constipation, about 60% improvement in itching, feeling ol feverishness and
cough with (expectoration, and only around 50% in soreness of mouth and diarrhoea.
In order Io better visualise the comparative improvement between first, second and third
interviews, the data of the 18 persons who sat,for all three interviews is presented herewith
in graph form (see figure 1 to 11). We have shown the graphs for some of the more impor
tant symptoms only.
Thus according to change in symptoms reported by those who received treatment al our.
centre, there appears to have been rather dramatic improvement in long standing com
plaints even after six months of the toxic gas exposure. There does seem to be definite advan
tage in giving more than three injections al a stretch, as seen by the substantial enhancement
of response after six injections.
On the basis of these findings, we recommend the continuation of administration of
Sodium Thiosulphate to exposed symptomatic persons who desire to obtain the treatment.
There is no reason to withhold the treatment from children if adequate care is maintained.
Improvement in the monitoring is mandatory to ascertain whether the reported improve
ment is a consistent effect and to determine the degree and' rate ol relapse, il any.
The role of ascertain urine Thiocyanate levels is unclear at this point, and is left lor a
separate discussion, as are other physical and physiological measurements which have not
been available Io us.
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It is to be emphasised that the question of Sodium Thiosulphate administration is lar
from resolved. Medical volunteers administering this drug have worked according to the
guidelines laid out by the 1CMR following its double-blind clinical trial carried out in
January 1985 (2,3,4) and with the encouragement and consultation of doctors working al the
special ICMR-sponsored 30-bedded Government Hospital lor Gas Victims who consistently
reported to us that patients have continued to respond positively to treatment. Ironically, the
policy in the special MIC Ward of llamidia Hospital is not to adminster Sodium
Thiosulphate to any patient, as it is believed to be of no use following the trial conducted
separately there in February by the Department of Medicine of Gandhi Medical College.
Aside from whether the drug is effective or not, another crux of the matter is that the pre
sent mechanism of action of the drug is unclear. Could it still be acting as an antidote to
cyanide remaining trapped in the body since the possible massive inhalation of cyanide gas in
addition to MIC on the night of 2nd/3rd December) I (this is so. then why has amyl nitrite not
been recommended by the ICMR to precede Sodium 1 hiosulphate.'’ Any why hasn t the
body's natural detoxification mechanism completed its work by now.'1 What is the evidence
that a single-point exposure to cyanide gas could result in such long-term toxic ellectsf
Or, as ICMR scientists have hinted, is Sodium Thiosulphate helping to "shear off" isocyanate/cyanate radicals resulting from carbarylation ol Haemoglobin and other protein
molecules by MIG. contributing indeed to a slow process of detoxification? (5) II it is true,
then presumably we are doing an important service for the gas victims and should speed up
our efforts once and for all.
Or is it acting as a placebo to the gas victims and to ourselves as medical workers? If this
is true, then we have no right to go on with this unfortunate exercise, wasting time, money
and energies better spent in other tasks of health care at Bhopal.
The urgency of solving this controversy, therefore, cannot be understated. We tail to
understand why the competent Government scientific agencies have not been more active in
collecting and consolidating the answers. They must realise that it is not merely a matter of
scientific prestige, but also that field workers attempting to render medical relief to gas vic
tims are being kept in the dark, the public is bewildered, and a crucial aspect in the treat
ment of gas victims remains uncertain.
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Crucial Unresolved Questions
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Submitted by Mira Sadgopal’. M BBS, on behall'ol'lhe JanaSwaslhya Kendra. Bhopal.
10th August, 1985
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Refarnnces
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Narayan, T., el al. Rationale for the use of Sodium Thiosulphate as an antidote in
the treatment of the victims ol the Bhopal Gas Disaster - A Review, 7 June, 1985.
(cyclostyled - available from the Medico Friend Circle)
1CMR. Health Effect of Exposure to Toxic Gas al Bhopal, (an update on ICMR
-sponsored researches), 10 March,.1985.
1.
2.
3.
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* Address for correspondence:
Dr. Mira Sadgopal (Member, MFC)
Kishore Rharati Group
P.O. Bankheri
Dist. Hoshangabad
M.P. 461 990
BBS
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Note:
The work reported here is the result of the joint effort and co-operation of many persons
and several organisations. The |ana Swasthya Kendra was established on lune 3rd by the in
itiative and hard work of four locally based organisations which joined to form the Jana
Swasthya Samili the Nagrik Rabat aur Purnavas Sainit’i. the Union Carbide Karmachari
Sangh, the Trade Unions Relief Fund and the Zahreeli Gas Kami Sangharsh Morcha. They
received additional technical support and volunteers from the Medico Friend Circle
(Bangalore), the West Bengal Drug Action Forum (Calcutta), the B.H.U. Junior Doctors
Association (Varanasi), and the Voluntary Health Association of India (New Delhi). Further
help in compiling and analysing the data was given by individual members of Eklavya
(Bhopal), the Centre for Cellular and Molecule Biology (RRL, Hyderabad) and others. The
stock of Sodium Thiosulphate along with disposable syringes and needles was received from
the Health Department of the Government of M.P. Thiocyanate level estimation of urine
samples was done at the Medico-Level Institute, Gandhi Medical College. Member of the 1GMR team al Bhopal and Delhi were helpful in welcoming our queries and discussing their
research findings since the gas leak disaster.
Although the work was stopped abruptly on June 25th after only three weeks of operation
due to the unfortunate police action aimed primarily against one of the participating
organisations, the Jana Swasthya Kqndra plans to continue and expand it activities in the in
terest of the health of the gas victims.
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ICMR, Press Release, Updated guideline for administration of Sodium
Thiosulphate to gas victims, 4th April. 1985.
ICMR. Minutes of the Third Meeting of the Working-Group. on Thiosulphate
Therapy of the MIC exposed Population, 4th April. 1985.
ICMR, Press Release, important toxicological findings... 5th May. 1985.
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LPPENDIX
Reductions In Severity of Symptoms
In Gas-Exposed Persons
After Intravenous Sodium
Thiosulphate Therapy
jteno Swosthya Kendra, Bhopal
Dcie of 18 persons from the Pilot Series,
Un€3rdto 10th, 1985.
18t
Key To Figures
1
16--
1st Interview
(before injection)
2nd Interview
(after 3 injections)
3rd Interview
(after 6 injections)
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Figure 1
Symptom: Headache
1412--
10--
II
8 --
Severe
6 -■
2 --
No Symptom
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Symptom: Poor Memory
18t Figure 2
Symptom: Dizziness
16-
12
12-
10-
10--
8
8 -
6
6 --
2
2 --
0
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Symptom: Sore Throat
16--
0
18t Figures
Symptom: Burning of Eyes
16-
14
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6 -
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14-
14
12
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8
8
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Figure 7
Symptom: Chest Pain
18
16
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Figure 6
Symptom: S reathlessness
3
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18t Figure 9
Symptom: Pain In Abdomen
16
14--
14--
12-
12--
io--
IO-
8 --
8 --
Figure 8
Symptom: Loss of Appetite
18
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2
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18 Figure 10
Symptom: Pain In Call’Muscle
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(Continued.)
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APPENDIX
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18 Figure 11
Symptom: Muscles Numbness
16
16
14--
14-
12
12-
10-
'10-
8-
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In Disgust
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Yogesh Jain
1/30, Gents Hostel
AIIMS
Ansari Nagar
New Delhi: 110 029
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4.45 p.m.
June 26th 1985
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In utter disgust, I, Yogesh Jain an M.B.B.S. student of All India Institute of Medical
Sciences, am leaving Bhopal where I had come to offer my services in the medical relief
work here. This disgust has its basis in the humiliating and thoroughly illegal way in which I
was treated by the police. With the apprehension of being harassed further (none know the
ways of irrational men) by the police, I decide to leave the city at the earliest.
1 had come to Bhopal to help the JANA SWASTHYA KENDRA in its endeavour to ad
minister Sodium Thiosul])hale to the gas affected people and also to launch a peoples health
movement. All seemed well until, when last night I was taken away from my now residence
in Bhopal (10/C, civil lines, Professors colony). 1 was manhandled and badly bruised my left
little toe. I was kept in the police lock up in inhuman conditions with my other medico
friends. It should be noted that no written summons was produced even when demanded
(violating of - section 160 of Or. P.C.). With blatantly false allegations of having disturbed
peace I was sent to the Central Jail and kept there till 9.30 p.m.
I recall this harrowing experience with a shudder. I appeal to your good senses to restore
law in your state so that doctors and other professional people can offer their services to the
needy in times of need. If you don't, you shall be fuelling the already rampant fatalism in our
people.
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Drug Action Forum, West Bengal
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S/3/5, Sector III, Salt Lake
Calcutta — 700 064.
Press hand-out at the Press Conference held on 11th July, 1985, at the
Health Service Association Office.
At the .dead of night (1 a.in.) of 24-25th June 1985, the Police of the Govt, of
hya
Pradesh raided the residence of the Doctors and health workers of the ‘Janasasthya Samiti' of
Bhopal, without any warrant, dragged them out, manhandled the Doctors and health
workers including the ladies, and incarcerated them for 20 hours in the thana lock-up and
Central Jail of Bhopal. Among the victims were two Doctors of Drug Action Forum, West
Bengal.
While our Doctors were released without producing them before a judicial authority, the
others were falsely implicated with various offences including the attempt tb murder. In a
simultaneous move, the M.P. Police raided the Medical Clinic of the ‘Janasasthya Samiti’,
confiscated all drugs, equipments and treatment records of the patients, and closed the
clinic. Doctors of West Bengal were forcibly turned out of Bhopal.
The motive of such terroisl and anti-national act has become clear to us. The Union Car
bide and its ally, the Govt, of Madhya Pradesh have been trying for the last six months to sup
press the fact that, alongwith MIC, Hydrogen Cyanide also leaked out on the black night of
the Bhopal Disaster and as a result, about one lakh Gas victims of Bhopal have since been suf
fering from CYANIDE POISONING. The Scientific evidence of Cyanide Poisoning has been
detected, confirmed by the findings of Indian Council of Medical Research and Central
Pollution Control Board of the Govt, of India. The Govt, of M.P. failed in its attempt to reject
such evidence and ultimately had to officially declare the acceptance of Sodium
Thiosulphate (NTS) therapy to treat the patients suffering from Cyanide Poisoning. Drug ac
tion forum has been assisting the Janasasthya Samiti in this NTS therapy programme in
which the drugs and equipments have ironically been supplied by the Govt, of M.P.
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APPENDIX
97
The NTS therapy has not only dramatically cured almost all the treated Gas victims but
also confirmed the earlier scientific evidence of Cyanide poisoning and the news of this
beneficial effect of the NTS therapy has quickly spread all over India. The suppression of
evidence of Cyanide Poisoning exposed the cruel character of the Union Carbide manage
ment who, as we guess, panicked and pressurized the M.P. Govt, to move and destroy the
Janasasthya clinic. Needless to say, the evidence of Cyanide Poisoning adds the new Dimen
sion to the litigation of compensation to the gas victims.
Drug action forum believes in the inalienable right of the Medical profession or for that
matter, of the citizens of India, to provide Medical relief to the ailing patients and has decid
ed to resume NTS therapy to the thousands of victims of Cyanide Poisoning of Bhopal. The
forum can not abandon its obligation to the expectant patients of Bhopal and will soon
resume its Medical relief»programme defying all brutality that the M.P. Govt, may decide to
employ.
Drug Action Forum appeals to the Govt, of West Bengal and all the democratic Citizens
of our beloved State to please come forward and help in this endeavour. The forum appeals
to the Political parties, Medical profession, Mass organisation, the mass media the students
and the Trade Unions to protest against this terrorism oflhe M.P. Police and to help us with
finance and volunteers so that we can at once undertake the task of saving gas victims of
Bhopal with delay.
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(Dr. Sujit K. Das)
Convenor, Drug Action Forum.
West Bengal.
Calcutta,
11th July, 1985.
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Jana Swasthya Samiti, Bhopal
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Address for correspondence:
do Prushant Puthuk,
D-WO, Sunt Kan war Ram Nugur
Colony Off. Berasia Road,
Bhopal Pin — 4(i2018
B 1
Dear Friends,
I hanks to the solidarity extended by social action groups and support offered by our con
cerned sympathisers, )ana Swasthya Kendra continues to function. The police repression on
25th June, the seizure of medical records, putting the doctors and the health-workers behind
the bars and subsequent stoppage of government supply of sodium thiosulphate on irrational
grounds, all these have not been able to suppress our efforts. Our efforts towards re
establishing the Kendra and pressurising the Govt, to resume sodium thiosulphate supply in
cluded campaign in the local and national press, rallying support from concerned citizens in
the form of delegations to the Chief Minister and then filing writ petition in the Supreme
Court, lhe consequence of filing the writ petition is of considerable significance and needs
elaboration as this would demonstrate the callous attitude of lhe Government and the
machinations to justify it.
After the suppression of the J.S.K. on 25th June, many attempts were made to get Inj.
Sodium Thiosulphate from the Govt, by shifting to a permanent structure. But the M.P. Govt,
persistently and adamantly refused to resume the supply of Sodium Thiosulphate.
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The writ petition in the Supreme Court
Dr. Nish.it Vohra (who was working in the Jana Swasthya Kendra) and two gas victims
had to launch a writ petition in the Supreme Court on behalf of the Kendra against the state
of Madhya Pradesh for not supplying Sodium Thiosulphate to J.S.K. and to the large number
of gas victims. The M.P. Govt, filed a counter-affidavit, in which it was stated that J.S.K.
does not have equipment for blood and urine examination. Whereas, the l.C.M.R. guidelines
(dated 4th April) for administration of Inj. Sodium Thiosulphate, which are accepted by the
M.P. Govt, do not mention anything about these facilities.
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This counter-affidavit put unreasonable conditions like stipulating that the represen
tative of the clinic run by voluntary organisations shall satisfy himself regarding the quality
of the stock being issued and received by the clinic. How can any doctor do that? No time
bound scheme of administering Inj. Sod. Thiosulphate Io all the needy gas-victims was
presented by the M.P. Govt. Its scheme only lays down*'how and to which institutions/organisations (Govt, hospitals, voluntary groups etc.) the stock of Injections would be
given.
Dr. Nishit Vohra filed a response to this affidavit, in which it was pointed out that the
I.G.M.R, guidelines of 4th April do not require any blood or urine examination, that the
counter affidavit only mentions about ‘adequate supplies of Sod. 1 hiosulphate without
specifying that 600,000 doses of 1 gm. each would be available; that the health card prepared
by the M.P. Govt, does not specify the symptoms (of cyanide-poisoning) required to be
record; etc.
A time b'»und, concrete scheme of administering Inj. Sod. Thiosulphate to about 100,000
gas-victims within six weeks, as enclosed. Based on the experience of the Jana Swasthya
Kendra, it was argued that one center can detoxify at the most 150 patients in a week (6 injec
tions per patients) and it would require about 100 such centres to detoxify all 100,000 gas
victims in a period of about 6 weeks.
It seems that the Honourable Judges were convinced by the petitioner's statement, and
on 28th August, gave an interim order that the J.S.K. be supplied Inj. Sod. Thiosulphate sub
ject to the condition that a registered medical practitioner would be in charge of this treat
ment. It also directed the M.P. State Govt. Io submit by 11th September, a time-bound
scheme of giving Inj. Sod. Thiosulphate for all gas-victims.
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Activities of the Kendra during last one month
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1. Running a General Clinic
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After the arrival of Dr. P.V. Goon and Dr. I). Chakraborty from Drug Action Forum, West
Bengal, it was decided to run a general clinic till Thiosulphate was available. Accordingly, a
general clinic was run from 25th August to 7th September. This offered some relief, proper
consultation to gas-victims and gave us an idea about the extent and range of suffering even
nine months after the disaster - breathlessness on accustomed exertion, poor appetite,
fullness of stomach after meals, tenderness of upper abdomen, weakness, fatigue, infections,
disturbed sleep etc. Patients complained of long queues in the Govt, clinics, nepotism, insuf
ficiency of free medicines, lack of proper concern and proper examination.
111
2. Administration of Sodium Thiosulphate Injections
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Thanks to the Supreme Court Order, this activity was resumed from 9th September. As
per the order, a registered medical practitioner is required. Dr. Anant Phadke (Medico
Friend Circle) has been in charge of this activity till his stay in Bhopal (26th September).
Some other arrangement is being made after 26th September till Dr. P.V. Goon gets his per
manent regn.Tio. Dr. Goon will stay here till mid-November. Dr. D. Majhi and Dr. R. Mandal
from D.A.F. have joined on 16th Sept, for a period of two weeks.
This time thiosulphate-lreatment has been organised much more systematically. A batch
of about 50 patients is selected, interviewed, examined and given a daily course of injections
from Monday to Saturday. An interview after the 3rd injection, an interview and examina
tion after the 6th injection are done. Dr. Mira Sadgopal with the help of other friends had
prepared a method of grading the symptoms and to calculate the amount of improvement in
symptoms in her report on the first 100 patients treated at the J.S.K. in June, 85. 1 he same
method is being followed. (The drop-out rate this time is very low since we are now able to
conduct the activity in a more systematic manner.) Initial calculations give an impression
that thiosulphate is still effective. Tenderness of upper abdomen, an objective sign also
shows improvements in many patients. However a rigourous double blind clinical trial
alongwith estimation of urinary thiocyanate level alone can tell us definitely about it.
Preparatory discussions are going towards launching such a rigourous authentic trial in
dependently. Results of the second trial conducted by I.G.M.R. in the 1st week of Sept, are
eagerly awaited.
.
The aim of this activity is to evolve a method of conducting mass detoxification. We have
chosen three bastis, go house to house, try to interview each person on the basis of I.G.M.R.’s
guidelines and provisionally select persons in this interview. The idea is to demonstrate a
method how to reach every house in a systematic way. Local Health-workers are conducting
this and other works - Sayeed and Sudama (N.R.P.G.), Santosh and Suresh Kumar (T.U.R.b.),
Krishna Bai and Kanhaiya Lal (Z.G.K.S.M.). A pamphlet has been written by Dr. Anant
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Phadke, explaining whys and hows ol Sodium Thiosulphate. It is being published by the
Samiti.
The pamphlet would be tape-recorded. Health education would be conducted with this
and a pictorial exhibition for those who can not read. Preparations are under-way towards
this end.
We would demand from the Govt., that when it does mass-detoxification according to
I.C.M.R. guidelines, it should adopt the method evolved by the J.S.K.
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3. Medical earn for children
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It was decided in the meetings of the Samiti in Inly that when resources are available,
J.S.K. would extend its activities to other important aspects of medical care. In a recent
meeting it was decifled to conduct child-care activities when thiosulphate work is not going
on, on certain afternoons. Accordingly the clinic for children is being run.
A random sample survey would be done in the bastis to find out the amount and type of
illness now present in children in the affected survey. Some definite demand can be made to
the Govt. A pictorial health exhibition is being prepared on child-care to be shown in the
bastis in systematic manner. Attempts are being made to get measles-vaccine since this is not
available in the Govt, set up, though it should be priority number one.
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Appeal
All these activities requires lol of support from you. We are extremely hard-pressed for
funds. Apart from drugs, at least four thousands rupees are required per month towards the
general expenses (rent, printing, expenses of doctors and health-workers). We appeal to you
to mobilise funds for us.
Our drugs are almost totally exhausted and we have been buying medicines for children
in bits and pieces. This can not go on for longer than a couple of weeks. We urgently solicit
yotlr help in this regard.
The Kendra can fulfill its plans for extension of the range of activities only if sufficient
number of health personnel are available. Also due to the Govt. Regulations that Sodium
Thiosulphate administration can only be carried out by a registered doctor, though we have
young doctors who are doing their internship, we still face crisis when a registered doctor is
not there. Arrangements have been made to lake care of the train fares and lodging of the
doctors who wish Io work in the Kendra, also partial contribution to their daily expenditure
are made. We appeal to non-medical persons to work for health educational programmes of
Jana Swasthya Kendra. We appeal Io you lo make arrangements for sending health personnel
who can work in the Kendra at least for a period of 15 days.
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Expecting your response,
(Dr. I’unya Vrata Goon)
on behalf of
Jana Swasthya Kendra.
Bhopal
26.9.85.
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Jana Swasthya Kendra Bhopal
Press Statement
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The doctors of the Jana Swasthya Kendra (Peoples Health Clinic) have stated in a press
release issued to-day that some of the senior state Government officials are continuously and
deliberately obstructing the Kendra’s programme of detoxifying the gas-victims of cyanidelike poisoning and are also spreading confusion amongst the people regarding the efficiency
of sodium thiosulphate therapy.
The doctors of the Jana Swasthya Kendra have stated that the state Government was forc
ed to resume the supply of sodium thiosulphate injections on September on receiving orders
from the Supreme Court.
However on September 14, the officials of the Health Dept, cleverly managed to give one
hundred ampoules Batch No. ST 1 985 as part of the total supply of 300 injections on that
date. This specific batch is the same batch regarding which serious doubts were expressed
by the Kendra’s Doctors in the month of June following the reactions caused by the ampoules
of this batch in certain Gas-victims. The doctors had at that time recommended to the
Government that a ban be placed on the further distribution of Batch No. ST I 985. The mat
ter was raised even in Vidhan Sabha and doubts expressed regarding the presence of
pyrogen toxins in this particular batch. Despite all this public uproar the State Government
did not confiscate this batch- and the health Dept, supplied it once again to the Kendra
without any warning whatsoever.
According to the Kendra, the Supreme Court had ordered the State Govt, six week ago to
submit a detailed time bound scheme for detoxification of 2.5. lakh gas-victims. Since then
the concerned Government officials have been trying to find all kinds of lame excuses in
order to avoid committing themselves to such a scheme. At the Supreme Court hearing held
on 25th Sept., the Govt., for the third time did not submit the detoxification scheme and has
thus deprived the gas victims from receiving the treatment recommended by ICMR scien
tists.
The press release issued by the Kendra states that following the use of the ampoules of
Batch No. ST I 985 on 24th and 25th'of Sept., reports were received from 9 out of 32 patients
of fever, chill, shivering and headache. These symptoms typical of pyrogen reaction were
also noticed in certain gas victims when this batch was used earlier on June 15th. Dr. Anant
Phadke, medical officer in-charge of the Kendra has sent a strongly worded letter of com
plaint to the Dept, of Health and has also announced that samples of this batch have been
sent for independent and reliable analysis. More than 300 injections of sodium thiosulphate
were administered between 9th and 14th Sept, without anyone complaining of such symp
toms. Similarly, more than 2000 injections were administered in the 3 weeks of June by the
Kendra with no complaints of this kind except on June 15 when Balch No. S f I 985 was used.
The supply of this suspected batch by the Health Dept, to the Kendra for the second time
amounts to a criminal act against the gas victims. The concerned senior Govt, officials are
apparently doing this to spread confusion regarding thiosulphate therapy so that medical
and chemical evidence of cyanide-like poisoning may nqt accumulate against Union Car
bide.
The doctors of the Jana Swasthya Kendra have deplored this callous behaviour of the
Govt, officials and have further stated that the act of supplying batch No. ST 1 985 cannot be
explained away as on oversight, but were a conspiracy to malign the Kendra and Jeopardise
the detoxification programme. The Kendra has demanded that the Batch No.^985 be im
mediately withdraw from further distribution and be sent for scientific investigation. I he
Kendra appeals to the Chief Minister Sri Vora that the guilty officials be severely punished
for their criminal act which is adding to the suffering of gas victims and also protecting
Union Carbide.
(Dr. Punyavrata.Goon) . , '
Jana Swasthya’.Kandra
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Kainchi Chh'ola Bhopal.
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Dated Sept 28, 1985
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APPENDIX
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In a press release, issued here today by the Jana Swasthya Kendra (Bhopal), it has been
stated that the Kendra has started functioning since last Monday, 21.10.1985 at Kainchi
Chhola, which is one of the severely affected bastis. At present the Kendra is being sup
ported by Zahreeli Gas Kand Sangharsh Morcha, Bhopal, and some concerned citizens of
Bhopal. The activities of the Kendra currently include administration of Sodium
Thiosulphate injections, paediatric care and dissemination of health information.
In the Thiosulphate clinic of the Jana Swasthay Kendra (Bhopal), 29 gas victims have
been treated with injections of Sodium Thiosulphate this week for cyanide-like poisoning.
The Doctor-in-charge of the clinic has slated that his week’s experience shows that injection
Sodium Thiosulphate is still effective even after 11 months of the gas exposure in alleviating
some of the sufferings of the gas-victims. The doctor-in-charge, Dr. Punya Brata Gun, has
observed that Sodium Thiosulphate therapy definitely brings about considerable relief to the
gas victims in the symptoms of breathlessness, heartburn, abdominal pain, fullness of
stomach after taking meals, loss of appetite, fatiguability and generalised muscle ache.
The paediatric clinic run in the afternoons on four days a week has attended a number of
children who have been suffering from a variety ol infections in addition to those problems
that can be directly related to cyanide-like poisoning. To protect the large number of gas af
fected children from infectious diseases it is essential that a systematic time bound im
munisation drive is undertaken by the Government without any delay.
It has been further stated that in the Kendra, emphasis is being put on health educational
activities as well particularly in view of the total lack of information dissemination among
gas victims regarding the damage to their bodies, the prevention and cure if any, the long
term effects etc. by the Government. Two sets of poster exhibitions on child care and on eye
care have been shown to the gas affected people. A pamphlet in simple hindi on cyanide like
poisoning and the role of sodium thiosulphate therapy will be published shortly for distribu
tion among the gas affected people.
It has been mentioned in the press release that the supply of sodium thiosulphate injec
tions to this clinic has been made by the M.P. Government after the issuance ol an order by
the Supreme Court on 18.10.85 to this effect. This order among other orders have been
issued in the process initiated by the filing of a writ petition in the Supreme Court with
regard to the inadequacies and failures of the Governmental health care system.
The Jana Swasthya Kendra (Bhopal) has appealed to all concerned groups and in
dividuals in Bhopal as well as from other parts of the country to extend support for the func
tioning of the Kendra with contributions' in terms of medicines and funds, as well as with
volunteers who can work in the Kendra. The address for communication would be D-137,
Firdous Nagar, Off. Berasia Road, Bhopal — 462 018.
Bhopal
26.10.85
(Dr. Punya Brata Gun)
Doctor-in-charge,
Jana Swasthya Kendra (Bhopal)
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Jana Swasthya Kendra (Bhopal)
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' lJ’at the Bh°Pnl Gas victims get correct information and proper health care.
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Overcoming the initial problems that it faced, the Jana Swasthya Kendra (Bhopal)
started
unctioning since 21st October and is gathering increasing support from the gas victims
Operatmg from a modest accomodation in one of the worst gas-affected bastis - Kainchi
Chhola. it is fast emerging as a centre where the gas-affected people know what all has gone
wrong with their bodies, what is being done about them, what should be done and voices of
concern, voices of dissent take shape slowly.
In the first three weeks of its functioning, the Kendra has been run with the technical
support provided by the doctors of Medico Friend Circle and Drug Action Forum, W.B. and
the organisatmnal support provided by Zahreeli Gas Kand Sangharsh Morcha
Killer Carbide still haunts the people of Bhopal people continue to suffer and death still
sta ks over the shanties Carbide continues to suppress vital information such as the nature
of the toxic gases that leaked and their possible effects, thus criminally obstructing proper
health care of the gas victims. The Government on one hand colludes with the Carbide infor
mation suppression and on the other responds to such a situation of mass suffering through
grossly inadequate health care system.
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In a situation such as this, the Jana Swasthya Kendra (Bhopal) endeavours to bring out
important issues m health care of the gas victims, put forward what needs to be done in
terms of the total relief-rehabilitation in general and medical intervention in particular The
information generated towards this end and the involvement of gas-affected people in the
process help and support any movement that builds up and takes these issues as rallying
points. The effort of Jana Swasthya Kendra (Bhopal) is directed towards the evolution and
demonstration of an alternative approach to health care of the gas victims. Involvement of
gas victims in health care, dissemination of health information, rational therapy, training of
health workers, community based health activity etc. are the constituents of this alternative
approach.
In the first three weeks, Kendra’s efforts towards these objectives included administra
tion of sodium thiosulphate injections to the gas victims, care of children, care of adults with
acute illnesses, dissemination of health information, monitoring of the existing health Care
delivery system m Bhopal. A brief report of the above activities follows.
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Sodium Thiosulphate Clinic
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The issue of cyanide like poisoning and administration of sodium thiosulphate for detoxitication of the gas victims has been an issue fraught with Carbide-Government criminal con
spiracy, people s resistance and demand and successful intervention of the voluntary bodies.
It is understood that sodium thiosulphate therapy is not the cure-all for all the problems
the gas victims suffer from. It is one of the things that should be carried out and there are sufhcient scientific substantiation on this count. The need for obtaining information
generating information regarding other possibilities is of significant importance and we are
directing our endeavours in that direction as well.
In the sodium thiosulphate clinic of the Kendra, it has been shown that even eleven
months after the gas episode, injection sodium thiosulphate is still effective in alleviating
some of the symptoms of the gas victims namely breathlessness, loss of appetite, pain in the
abdomen, fullness of stomach after taking meals heart burn, fatiguability and muscle ache.
n the three weeks the total number of patients detoxified in the clinic is 185-30,61 and 94
m the 1st 2nd and 3rd weeks respectively. The age-sex distribution of these 185 patients
with number of injections received follows.
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No. of
patients..
No of
injections:
6
5
4
3
2
Male
adults
Female
adults
Male
children
Female
children
Tola
6
1
2
46
10
4
4
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41
2
15^
4
0
0
15
1
0
0
1.2
15
5
2
114
5
1
0
14
35
1
Total
80
14
66
The youngest child detoxified during this period was a baby who was exposed to the
killer gases when she was 11 days old.
To assess the improvement after, thiosulphate therapy the symptoms were graded (as
severe, moderate, mild) before and after the therapy (i.e. before 1st injection and after 3rd in
jection). In 88 patients who were thus interviewed and examined the percentages of im
provement in symptoms were as follows.
Symptoms monitored
Breathlessness
Loss of appetite
Abdominal pain
Fullness of stomach after meals
Heartburn
Fatiguabilily
Muscle ache
Improvement in%
42.8%
48.4%
56.7%
65.9%
51.4%
40.3%
49.2%
Paediatric Care
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In the paediatric clinic, 27 children have been treated so far. The exposure of this
vulnerable age group to toxic gases is understood to have damaged their body defence
mechanism and children thus have become prone to a variety ol infections. Children coming
to the clinic suffer from a variety of communicable infectious diseases, lung infection,
gastro-intestinal diseases and skin diseases. A pilot survey carried out recently has indicate a
large percentage of children who have not been immunised. This becomes a matter of
serious concern and demands immediate attention from the concerned authorities.
Treatment of Adult Patients with Acute Illnesses
Jill
In this clinic, 41 patients have been treated so far mainly for respiratory problems, viral
fevers and malaria.
Monitoring and Guidance Centre
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In the monitoring centre, monitoring of the existing governmental as well as non
governmental health care delivery facilities is being attempted by talking to the patients who
have undergone treatment in government clinics or under private physicians, by looking at
the prescriptions and recording them whenever necessary and thus trying to arrive at some
understanding of the prevalent health care delivery system. It is understood that a critique
needs to be developed regarding the best manner in which the existing system can respond
to the health requirements of the only 88 patients turned up for post-treatment interview.
The % improvement in each symptoms has’been calculated by comparing the mean symp
tom improvement with initial mean symptom score. These figures may not be confused with
percentage of patients who found relief gas affected population. This can positively con
tribute in demanding a rational therapy for the gas victims.
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Dissemination of Health Information
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Two poster exhibitions on paediatric.and eye care are being shown in the clinic. A simple
pamphlet in Hindi on thiosulphate therapy was written by Dr. Anant Phadke of Medico
Friend Circle (MFC) for the Bhopal gas victims. It will be published by the Kendra this week.
Dr. Narendra Gupta of MFC has spent a week for training the health workers, be will be here
again in the last week of November.
In the above mentioned activities, the major share of the responsibility has been horned
by the health workers who are gas victims themselves - Ashoke Rana, Suresh Kumar, Santosh Singh, Narmada Prasad and Sheelu Malhotra. During this period, Dr. Punya Brala Gun
(Drug Action Forum, W.B.) has been the doctor in charge, Dr. Saibal Jana of Shaheed
Hospital Group (Dalli Rajhara) will take over the charge from him on 14th November. Two
doctors. Dr. Bijnan Bera and Dr. Bhabani Shankar Das from Medical Service Centre, Calcut
ta have joined the Kendra on 8th November for a period of 7 days. Junior doctors from
Maharastra Association of Resident Doctors and Drug Action Forum, W.B. are expected to
reach here shortly.
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The Writ Petition and After
The Madhya Pradesh Government had stopped the supply of sodium thiosulphate to the
Jana Swasthya Kendra since 25th June in its attempt to scuttle any efforts leading to the
establishment of the facts related to cyanide like poisoning of the gas victims. In response a
writ petition was filed in the Supreme Court by two gas victims and Dr. Nishith Vohra who
was working in the Kendra. Organisational support for this was given by the Trade Union
Relief Fund, Bombay and the Zahreeli Gas Kami Sangharsh Morcha, Bhopal. The petitioners
were represented in the court by Ms. Indira Jaisingh of Lawyers' Collective, Bombay and
Ms. Kamini Jaiswal, Delhi. This writ petition has to some extent exposed the gross inade
quacy and ad-hocism in the government's health care delivery system and the machinations
to cover these up.
On 28th August the Supreme Court gave an interim order directing the state government
to resume the supply of sodium thiosulphate to Jana Swathay Kendra. The Court also
ordered the state government to submit a time bound scheme for large scale administration
of sodium thiosulphate to the gas victims according to the l.C.M.R. guidelines. The govern
ment did not submit such a scheme on several hearings and has not done it yet. Recently on
4th November, the Supreme Court has appointed an independent committee for ‘quick relief
(medical) and compensation of the gas victims’. The committee comprise of 2 represen
tatives each from the state government and l.C.M.R., Dr. Heeresh Chandra, Head of the
Department of Forensic Medicine, Gandhi Medical College, Bhopal, Dr. Anil Sadgopal of
Zahreeli Gas Kami Sangharsh Morcha, Bhopal and one more representative from another
voluntary organisation. This committee is empowered to obtain information already col
lected regarding the condition of the gas victims as well as to conduct necessary
epidemiological or socio-economic surveys for ensuring proper medical facilities and deter
mining the compensation payable to the gas victims. The decision of the committee the
Court has said would ‘final and binding’. It is expected that the proceedings of the commit
tee once it starts functioning would be of considerable interest for all concerned.
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Future plans
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We strongly feel that the Kendra should continue its function to contribute towards the
struggle of the gas victims for correct information and proper health care. A proposal has
been made regarding the activities for the next four moYiths. The highlights of this proposal
are:1.
Work Hazards and Work Capacity Assessments which will include:Identification of jobs requiring hard manual work (both in domestic and industrial
a)
conditions)
Identification of hazardous working environments (both domestic and industrial)
b)
Assessment of the impact of the gas exposure on their capacities to do work and ef
cl
fect of the work on the health of the gas affected workers.
d)
Suggestion of alternative employment on basis of a), b), c) as well as on taking into
consideration factors such as existing skills, facilities and willingness of the
workers.
2.
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Double Blind Clinical Trial to scientifically test efficacy of sodium thiosulphate
'B'
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APPENDIX
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therapy in relieving the symptoms of chronic cyanide like poisoning alter more
than 11 months of the gas exposure.
■ This proposal is available on request from the contact address. Though respiratory and
gynaecological care need immediate attention, they are not included in the pro|)osal as we do
not have the resources.
3.
4.
Monitoring and Guidance Centre
It would be a mean for cutting pressure on the existing health system and thus of
ensuring proper health care to the gas victims.
Child Care
Besides paediatric: clinic, the-plans are to conduct:a) Survey of immunisation states ol gas affected kids
h) Survey of their morbidity status.
The date generated from these surveys and information dissemination about child
health and care will help the people to demand proper health care for their
children.
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Appeal
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Jana Swasthya Kendra (Bhopal) requires funds, vol1 ulcers and constructive criticisms
from all concerned groups and individuals.
The thiosulphate clinic needs at least 2 doctors at a time (one registered medical practi
tioner, the other may be an intern) who can work here at least lor 15 days in turn).
The personnel required for other programmes are as follows:Work hazards and work capacity assessment2 doctors preferably with experience in occupational health. 4 persons with engineering
and marketing background, 9 other persons ol whom 2 should have experience in assess
ment of work hazards.
Double blind clinical trialOne co-ordinator doctor, 4 other doctors, 6 health woi kers.
Monitoring and guidance cenlre2 doctors well versed in practices of rational therapy. Paediatric careOne paediatrician for running the clinic. 2 doctors and 4 health workers lor conducting
the surveys.
All the persons interested to work in the Kendra may write to Mr. Satinath Sarangi at the
contact address.
Till more formal arrangements are made, monetary help should be sent by M.O. in the
name of Mr. Satinath Sarangi.
Stand by the side of the gas victims
to fight for the right of proper health care
to fight for the right of correct information.
11H
ill
Issued by Dr. Punya Brata Gun, Mr. Satinath Sarangi and Ms. Sadliara Karnik on behalf of
/ana Swasthya Kendra (Bhopal).
w
I
Contact address:
D 137, Firdous Nagar
Off Berasia Road. Bhopal.
’ll.
Kendra:
Makan No. 66, Gali No. 3
Kainchi Chhola, Bhopal.
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An Unfortunate Setback to
Voluntory Health Workers in Bhopal
H
Gas Victims Health Work Goes On
I
After the 25th June police repression upon the people’s Health Clinic, the People’s health
programme has once again suffered an unfortunate setback
RhA’ fuprfi “ware four organisations working among'the gas victims namely Nagarik
r a I i T 1 u,,TaS eomf(NRPC>’ 'rra,1,! Union Rn'inf Fund (TURF) Bombay Union
i r 'in nrmac han Sangh and Zahreeli Gas Kami Sangliarsh Morcha (Z G K S Mi Bhooal
hX. adadiff °n 181 Une tD f°rm ?',a ?wasth.Va Sa|niti (People's Health Committee) 'Though
h ,y had differences over a number of issues they came to some common understanding in
the matter of health care On 3rd June a People's Health Clinic (Jana Swasthya Kendra) tas
opened on a portion of the Carbide Plant Premises which was declared liberated area bv the
struggling gas victims. I'his Kendra was to be run by the Jana Swathya Samiti.
’
h°m 31f Unf 10 2i4lh JtUne’ detoxifica,i°n of the gas victims off cyanide like poisoning
was being carried out by administration of Inj. Sodium Thiosulphate. Then came the police
lepression closure of the clinic-refusal of health officials to supply JSK with NATS Public
pIaverd1aOtnNATS8?Vt-Wri!.P?t(i,iOt’
Sl,pr"m‘! C°Url ’«•>'"»“'>« <'ovt of M P wi
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I rayer that NA I S be supplied by the Govt, to JSK and ask that the Govt, submit a timebound
=51
I
“ng ,he E°Vt',0 resUme
NATTTOJSMSKXmd agamSUPremB
°f
■
indFfrom2q;qmV t0 a/9'851it Wf r.Un ' 5S a 8,!nRral clinlc sin“ NATS had not been obtained
tion Papdiaf9
?nwards ,'’10slllphall: theral’y was taken up. Along with NATS administraA?, ,.P d ,
cl,nl<: was bfJ,'|8 run and health educational materials were being prepared
All this work was going on at the NRPC Premises which they (NRPC) had offered for the run
ning of the Kendra after the police had made it difficult to run the clinic inside UCH
III
■I
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NATSdi'
‘S °Ur °r’ln’on' i"’[l olher dons wl'O have previously work in JSK share it that
NA TS clinic requires a i ucca accomodation with at least 4 rooms (registration examination
inietdKm drug dtspensaries). In this respect the premises offered by NRPC was quite adm
1
Though a lot of encouraging work was going on trouble started creepeing up
1.
One of the constituents
constitimnts NRPC called a meeting on Sth August and circulated paper
whichi essentially made 3 points that can be said to be objectionable.
a)
11
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b)
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ShMAT^TritheiraPy iS 1,01 I'equirod bV raisin8 doilbts regarding the efficacy
ol NA IS Ihis becomes a matter for concern as NATS therapy coupled with
cyanide ike poisoning is an issues of much significance with the carbide
( v3^ idn 1
,ryin^()
,5ff°1rtS t0Wards establisBing the presence of
n*
nn 0X111
10 8<1S aBncled population by raising doubts on NATS
innn1<:y‘
‘n the JSK of administering NATS to more than
k
S v,f:tlrns has (:Ieariy demonstrated that NATS workers and yet
NRIC maintained in the paper that NATS is not effective
1 he paper said that NRPC believed in a comprehensive health care imply
ing as if the other constituent organisations of JSK did not believe in it
wheres the record of the deliberations of JSK would show that all the consti
tuents believed in a compreshensive approach and it was only the lack of
doctors and resources which made it imperative to set periorities and
mobilise resource accordingly.
NRPC also stated that there was a need for the formation of another health
Committee that would work with a comprehensive understanding of health
care. This was rather disturbing considering that the People's Health Com
mittee of which NRPC was a number was already working and it was
necessary that each constituent organisations contribute to their fullest extanl to the working of such a committee.
When the Govt, has stopped the supply of NATS it
tinn
o •’ 1II1 - I • • 1 /■ »
the supply of N/A fS it was proposed that a writ peti
J•
tion L»
be»» (*filled
in the Supreme Court to force the Govt, to supply NATS for the JSK
Such
uch a writ petition was prepared in the presence of one NRPC member among
oroved A
4 7 aiSin8in °f LnWyerS’ Cdlective Bombay and commonly ap
P^ved. An understanding was reached that JBS will file the writ, two weeks later
but when the petition was about to be filed Tapan Bose of NRPC said that NRPC
does not agree with the writ Petition and withdraw.
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APPENDIX
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NRPC had affected its four roomed Pucca Premises for the 1SK. Once the premises
were inspected by senior Govt. Health officials (as per Supreme Court order)
NRPC started asking for two rooms for their own purposes alter representatives
of TURF and ZGKSM as well as doctors working in JSK had reasoned with them,
NRPC finally agreed to Shift their office from the premises and make all lour
rooms fully available for JSK by the 10th of September. This was not done. On 16th
September. 2 of the important executive Committee members ol the NR1 C came to
Bhopal and oversuled the Local agreement. They informed other constituence
through a letter that NRPC will not be able to spare the premises for JSK and on
alternative arrangement must be sought. However, they offerred the use of the
NRPC: premises till such an arrangement was available. 1 hey assured that NRt C
would not use the premises for their office purposes during this period and thus let
3.
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JSK run smoothly.
Contrary to the agreement NRPC continued to operated their office in the same
premises. The NRPC Members would carry out loud and vicious campaign against
the other JSS Constituent organisation in the clinic premises among the people
visiting the clinic. They always would give the impression to the people that the
clinic was being run only on behalf of NRPC. Other doctor working in JSK also
witnessed this state of affairs.
On the 3rd of October the doctors on reaching the Kendra found two of the rooms
locked Some how NATS clinic was run in the remaining two rooms. However, all
four rooms were necessarily required from Monday (7th October) as Monday was
the first day for the next batch of gas victims to come lor NA 1 S administratiopn
and the days work involved regislration examination, administration ol NA I S and
supply of drugs. In view of this an informal meeting was arranged by us on a/l( /85
in which representatives of both NRPC and ZGKSM were asked to attend. Then
NRPC members assured us that all the rooms will be made available tor the JSK
1
i. 4
work from Monday-7th Oct. 85.
On 7th we found the two rooms locked again and an NRPC member informed us that m a
NRPC meeting on 6th October it wass decided (mainly by the intervention of Liyagat and Jai
Prakash) that'the said rooms were not to be made available for JSK purposes It was not
possible to run the clinic in just two rooms, and we were lelt with not othei choice but to
close the clinic. We consulted the health workers and shilled the materials lying in the
unlocked rooms to TURF clinic premises to fasilitate NRPC’s running their office since
there was not much sense in keeping the place occupied without the clinic running.
Then the most unfortunate things-started happening NRPC Lodged a complaint
6.
with the police against the two of us and Mr. Satinath Sarangi, a ZGKSM activist
(who happened to be present at the time of shifting but was involved neither in the
decision making nor in the actual shifting). They threatened on behalf of Sb
without consulting other constituent organisation which reported the incident ot
shifting as one of robbery Perpetrated by Mr. Satinath Sarangi and associates.
Things have now come to a dead and where we the doctors are not in a mood on position
•i
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If
l° To start with we have decided to work in a new center with the support of ZGKSM and
several concerned utizons of Bhopal who have agreed to raise the resources lor initiating the
l't To lake the health activities forward, to continue the struggle for proper treatment and
scientific information we need your help. We appeal to all concerned groups and individuals
to send us support in terms of fund and personnel (Medico. Paramedics and
till more formal arFunds can be sent in the name of Dr. P.B: Gun through M.O. or cheques
(
rangement are made.
Issued by Dr. Sanjeev Kulkarni and Dr. Punya Brata Gun on 15th 10.65 at Bhopal.
d I
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Address for correspondence:
[Jr. Punya Brata Gun
c/o Mr. Khan
ID-137, Firdous Nagar
Off. Berasia Road
Bhopal.
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appendix
« - 5.2
member fl
of the
'be Executive
I.. .tfttivis0I.y Board,
Our Personnel Manager is a
Red Cross and has been in the II- ugH’.()nv(!nor’oi lhe Labour Sub Committee of
Regional Council lor Workers Educatn .
■ ■ 11Klllslnes and has been nominated by
!! 1
..... ............ ......... ................ <"
□15.3
5.4
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organisation established for the propogation of Hindi.
8we represent ISI in the Pesticide Sub Committee.
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•©.6.1
Sports Activities
• ■ ; organised by the Bhojpur club
We have been taking part in various
sportsinactivities
donations
the past, in 19B2, book shelves were also
where UCIL have been giving adhoc t
'“"wel^^deTnaUons for the Tennis tournaments organised by the Arera Club an-
IC 6.2
nUa”U takes active interest in the
30.6.3
'll
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for which a
members of
KrZcolf Cbb wh-they IZ active par, in the game.
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APPENDIX 5.4
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10.0
Jig • t
Contribution of UCIL —
APD Towards Community Welfare
Extract from Submission to the Bhopal
Poisonous Gas Leakage (1984)
Enquiry Commission made by C.P. Lal of
Union Carbide
■ - ’
10.1
Medical Care
Donation of the following equipments were made to the Intensive Care Unit of the local
Hamidia Hospital in the year 1981:a)
Respiralory Care Unit
b)
Blood Gas Analyser
c)
Cardiac Monitor/defibrillator
d)
Nebullizer
BO
EH
10.1.2
k* 1
10.1.3
10.1.4
10.1.5
10.1.6
10.1.7
10.1.8
10.3.2
10.3.3
10.3.4
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10.4
10.4.1
10.4.2
10.4.3
10.4.4
10.4.5
10.5
10.5.1
A private ward block consisting of two suites was constructed and handed over to the
Hamidia Hospital authorities in February, 1984.
Rare drugs were supplied from time to time at the request of the Hospital authorities.
Blood donations have been made from time to time each year by our employees for the
Hamidia Hospital Blood Bank, the last camp was held on 12.2.85.
Donations have been given to Indian Red Cross Society whenever they have made any
campaign etc.
I he Company participated in the Family Planning Camp organised jointly by Hamidia
Hospital and India Red Cross Society by donating incentive prizes to the volunteers who
underwent Vasectomy operations.
Prior to 1979, suitable donations were made to Asha Niketan Nursing Home for the care
of handicapped children.
Chairs have been donated for the Gandhi Medical College Library.
ladies^11311011 haVe
tO Van’,a Sarna1, a •social welfare organisation run by the
We have made donations to the M.P. film society in.their annual function.
We have made donations to Bhopal Jaycees, a social organisation.
Cultural Activities
Donations given and hospitality extended to Indira Sangeet.
t
Kala University, Khairagarh whenever they have organised any function at Bhopal.
Various Music Clubs like Sangeet Kala Sangam in the City have been patronised by UCIL
and suitable donations have been given during their annual function.
•MANJUSHA’ a club promoted by wives of UCIL-APD staff has been quite active in
organising ‘FETES' and collections were donated to Hospitals, Flood relief fund etc
Some of our employees have given programmes in All India Radio.
The DCII. Recreation Clubs have been organising cultural programmes where prominent
citizens of Bhopal are also invited.
Membership of Institutions
Our Works Manager is a member of the Executive Committee of the State Red Cross
Society and actively participates in its deliberations.
He is also a member of the Executive Committee of the Federation of M.P. Chambers of
Commerce and Industries and has been nominated by the Chamber to represent it al the F1CCI in its Technical Sub Committee.
O-
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medico friend
circle
bulletin
FEBRUARY
IMS
Reporting from Bangalort
Annual
Meet 1985
About one hundred and ten friends consist
ing of doctors, nurses, social science professionals,
social workers, journa’ists, developmental
and
political activists, undversity students and others
from the States of Maharashtra, Gujarat, Rajasthan,
Punjab, Delhi, Bihar, U.P, West Bengal, Andhra,
Karnataka, Tamilnadu, Kerala and Nepal met at
the Indian Social Institute, Banga’ore, from the
26 to29 January 1985 in a series of Informal
meetings which formed part of the packed annual
meet of the medico friend circle.
On the 26th, there were two impromptu plan
ning sessions by the mfc early arrivals to finalise
the tentative programme drawn up for the two day
discussions on' TB AND SOCIETY’.
On the 27th morning, after a short introduction
of the mid (Abhay Bang), the venue—Indian Social
Institute (Stan Lourduswamy) and the annual meet
(Ravi Narayan), al1 the friends were involved in a
short self introduction which brought out the rich
diversity of the assembled group. Then we divided
into six groups to pull together the expectations of
the friends on the meet, the issues in TB that they
were concerned about and the focus and scope of
the discussions.
After lunch the expectations and issues to
btf discussed were reviewed and suitable changes
were made in the programme to ensure that many,
if not most, of these areas of interest expressed
and identified were included. We then divided into six
groups to make a critical review of the Nati
onal Tuberculosis Programme based on field obser
vations knd field experiences. Questions and issues
to be put to a panel were also identified. A panel
consisting of tnree of our senior resource persons
from the National Tuberculosis Institute, Bangalore;
(Dr. Gbthi, Dr. Chandrashekar and Mr. Nair) two
visiting TB Specialists from Sweden^ (Dr. Hernborg
and Dr. Sjogren) and Dr. Vaaant Talwalkar of
Bombay, then began to respond to the questions of
tne various groups. This session soon advanced into
an intense, emotion-packed, dialogue and discussion
deftly handled by our NTl coI1 e agues. For many
old mfcites, it wa# remnascent of the earlier intense*
reunions. A lot of heat some light and much com
mitted intervention made it a memorable evening
which went on till 7.30 p.m.
After dinner those who still had stamina
reassembled to [listen to many of our new members
and young friends share their general field experi
ences, perspectives Und their IndMW quots.
These included short reports from SEWA rural
(Gujarat), MHtraniketan (Kerala) INGRID (Kar
nataka), CMC (VeHlore),
Calicut
Medical
College team, Chetna (Ahmedabad) and others.
On the 28th morning, we began with a sharing
of seven case studies in Tuberculosis Control. They
were—TB in the Tibetan refugee Camps in Coorg
(Kelkar> Nagpada Neighbourhood House TB Pro*
gramme, Bombay (Mona Daswani); TB Work among
the Santhals of Bihar (Roser Montagut); TB
programme for children organised by Save the
Children Fund of UK, in Nepal (Susannah Graham
Jones); Shanti TB Centre in Urban Calcutta (Joseph
Vazhakdla), West Bengal TB Associatiorf Programme
(Ganguly); Sewa Rural Health Programme in Jhagadia, Gujarat (Rajesh Mehta).
All of them shared their rich experiences
and described the [little innovations they had made
to make their programmes more, sensitive and
*
I N SI DI
Annual General Body Meeting
2
Industrial Hazards—Double Standards
4
Drugs Alert—Are you harming yourself
$
Book Review
4
Dear Friend
7
Bhopa! Disaster—Citizen* reaponsea
I
responsive to rhe patients needs. Later during the
morning wp divided ourselves int<> seven groups to
discuss tlic following iipccifL areas relevant to the
TB pro rarnme in India:
(I) Case Finding and
Case Holding; (2) TB rational’ chemotherapy and
rational drug policy; (3) Childhood Tuberculosis,
BCG immunization and extra pulmonary TB (4) TB
in medical education; (5) TB in the training of Com
munity Health Workers; and paramedical workers
and in public education; (6) TB—socio-economic
and po’itical factors. The sixth group further sub
divided mto two sub-groups—one < roup considering
the occupational/env iron mentai and legal aspects
and the second the overal’l socio-political and eco
nomic setting of the health programme.
the mfc made important decisions for responding
to this national calamity (see decisions).
The whole of 29th was spent discussing
various matters on the circulated agenda of the
annual general meeting. Those included the annual
report, the statement of accounts the annual bud
get, the bulletin, the anthologies, the rational drug
policy cell, mfe’s involvement in the All India Drug
Action Network, the NETEN campaign, mfe’s stand
♦
on capitation fees, issues raised by junior doctors
Strikes and other issues. The meeting concluded
at 12 midnight. The key decisions for information
of members, subscribers and readers of the bulletin ’
are given below. A more detailed note on the GBM
will be circulated to the members separately. On the
30th and 31 st, many members stayed back to partici
pate in the AU India Drug Action Network Meetings
that followed. The report of this meeting will be
featured in the March issue.
Reports of all these groups were presented
at a penary meeting after which all the participants
once again divided into two main groups to spend
the remaining time (continuing well after supper on
the 28th) to discuss fol’ow up action. Taking into
account the nature of the participants work involve
ment and also Anant Phadke's suggestions in his
article on ‘Why Discuss TB’ in the December 1984
issue of mfc bulletin, it was decided that the discus
sion on fofow up action would be undertaken in
two groups. The first consisting of all the friends
who were involved in field programmes and com
munity health projects would identify all the alter
native approaches and innovative ideas that had
been shared or identified during the meet for mem
bers to try out or introduce into their projects when
they return. The second group consisting of all those
who were not directly involved with community
health programmes or TB control- programmes would
Identify areas of intervention and action at all the
flotr-project but equally significant levels-be they
medical education, feed back to government, further
study, raising public awareness, involvement of mass
media and so on. On the 29th morning, there was a
abort plenary session at which both these groups
presented their final reports and the TB meet was
OOttcluded.
decisions
(1) The Bhopal Disaster
a. A team of mfc members consisting of
Amar Jesani, Mira Shiva, Daxa Patel, Anant Phadke
Narendra Gupta, Padma Prakash, Girish Godbole,*
Dhruv
Mankad,
Karuna
Pattanayak
Marie
D’Souza, Manisha Gupte, Ravi Duggal, Ashvin
Patel and Abhay Bang was formed to explore
the possibility of responding to the invitations
by various groups to undertake medical/heaith
related studies — both short and .long term
to support the struggle of the victims of Bhopal.
Tentatively this group will put together re
levent information by the 20th of February and
start the study in early March.
(For further details, information, participation,
contact Ashvin Patel, 21, Nirman Society, Alkapuri,
Vadodara 390005 andfor Ravi Duggal, D-3, Refinery
View, 62-63, Mahul Road, Chembur, Bombay-400074
A detailed report of the plenary and group
dfocassions on ‘TB AND SOCIETY’ and final follow
up p'an will appear in the March 1985 issue of the
bulletin.
b. The mfc GBM fully endorsed support to
the team—financially and otherwise to undertake
this work and initiated the Bhopal Fund. All members/subscribers/readers of the bulletin may send
donations by cheque in the name of 'medico friend
circle—Bhopal Fund’ to the mfc office in Bangalore.
(All rapporteurs of small group dteewsiom
Md plenary sessions as well as participants who took
notes are requested to send in their reports latest
by 25th Feb’ 85, if they have not already done so.
—Ed)
Urgently needed
XI
Annual General Body Meeting
(•
All members/subscribers who have (a) acc.tt*
to any important medicai/healtfa information regarding MIC/phosgene, any relevant toxicolodcal infor
mation; (b) any details about possible/probable
study methodology; (c) any information, papers, re
ports that may be of use to the team; may please
send copies of it immediately to Ashvin Patel and
Ravi Dugval at the Baroda and Bombay addreaaea
given earlier.
The ‘Bhopal Disaster’ was the first matter
taken up at the annual general body meeting on the
J9th morning. Many requests from the 2AI.hreeli
Gas Kand Sangarsh Morcha and other organi^tions
for mfe’s involvement in a long term study and
Other plans were considered. Reports by Abhay
Bang and Narendra Gupta who had visited Bhopal
id response to these requests were presented and
2
;^i
GBM also endorsed full lsupport
t
.a
to
I
4. Rationa]
Pol|cy
Sas ra Sahitya Parishad and Madras Citizens Grouw
S.WS.EK<£I52.“’™’' •
s
2. Anthologies
, J?1'
edition of rnk s third antholniru—
^LirUN.Da^D,CIN&UNDER THrh^L-ENS
ty ™.y
nations' bv^amfe^hrk^nd °pn *A,“’’ ri"’0 combIbe ready for despatch in a
?aw8on
details & the bX^rfM^cV^ Awa“ furthw
contracepgroup
5. Organisational:
ded. Money Orders or Demand Drafts may be sent
to the mfc office till 1.3.85.
y W
’
£!! members/subscribera are requested to
a rSa'eS’
A P^Phiet will be availaLor J1 f^fficewyi
about the three an‘iw“gtes •>„ \iHs,tAMarch
potentiaf readers on request. Please send us names
tha »HUa88e8i,I^aDles.of “’d^duols who will review
!anth<>lo®r1for various journals/bulletins
ana magazines are also welcome.
3. Bidletin
PmhAr
bulletin subscription list as of Dec
ember 1984 is as follows. Maharashtra __ 20163J GVjaTat ~59; West Bengal—31
Andhrf 2?;i 5trala ““ 28; TamU Nadu — 27;
21bBiar T 21 Madhy'a P^desh —12;
Ra^sthan — 9; Punjab — 8; Orissa — 6; Uttai
Hradesh--6; 2 each from Mehalaya and Goa and
one each from Nagaland and Haryana and 34 foreign
subscribers. Total — 560.
A COIlcert^ subscription drive is necessary
year16^81
membcrs t0 participate actively
♦»
6. Execntive Committee
A,}?nt Phadke» Amar Jesani and Amar Sinri>
ntlni^d
the execut>ve committc for thefr
second year. Kartik Nanavati, La’it Khanra and Mira
Sadgopal who competed their second year were
Narendora GTtl’ Da*a Patel and '
The ma Narayan. Satyamala who completed her
econd year was re-elected for another two year term
and continued on the Committee. Ravi Naray™
continued as Convenor.
Narayan
7. Annuai Meet
The mid-annual EC/core group meeting will
On —28th July 1985 at Patiala. Amar
bingh Azad and group agreed to host the meeting.
During these three days we shall dicuss Ashvin/
Anants articles on the role of mfc (refer mfeb
100—1), the report of the mfc team going to
Bhopal, and the approach papers on the themr of’
the annual Meet 1986. Three case-studies on this
theme will be presented viz.
a) Occupational hazards of agricultural
workers — Amar Azad, Satish GoguJwar, Lalit
Khanra, Marie D’Souza.
b) Occupational and environmental hasmrds
of viscose—rayon factories in India ■— Thelma
Narayan.
c. Some areas to be covered in the bulletin
are occupational and environmental health, nonalldpatluc system of medicine, unnecessary surgery
clinical mvestigaition business’; health of urban
slums, retum/rise of epidemics of infective hepati
tis, dysentery and malaria, and capitation fee medi
cal colleges. Contributions, letters, fillers on these
and any other relevant topic are welcome.
d. To maintain a certain continuity, follow
the TB me£t, the
Bhopal study, the NET-EN campaign and the evolvTS 7??
the Rational Drug Po’icy Cell and the
All India Drug Action Network will be featured
from time to time.
as before
(c) Occupational »ung di^ -3 — Textile
factories, asbestos etc—the Bonx>ay nitu g»oup. •
3
<•
The tentative them will be “Ocupational and
Environmental Health”. The focus and scope of
the annual meet discussions will be clarified at the
Core group meeting. The dates for the next annual
meet have been tentatively fixed for 27 — 29 Jan i
1986 and the venue will be Bombay. Further details
Hill be* finalised at the nud-^nnu&l meeting*
8. * Mid-annual Core group Meeting
b. A readership survey will be undertaken
this year.
e. The editorial board continued
with one addition —— Abhay Bang.
v
The annual report for 1984
the
statement*
a^^0"’”8 f?ruthe Period 1-4.84
to 31.12.84,
gC‘ fQr 1985 we« presented and
The Double Standard In Industrial Hazards
— Barry I CMtteman
very hazardous materials.
However, deSpite the domination Jwortd marketscarc,n^en,c
or .be
«eSpP„.a
e.»lr
Double Standard Cases*
__
Industry
Asbestos friction product
and textile manutactuie
Asbestos cement
manufacture
Asbestos brake
Hning manufacture
I\e manufacture
Mercury cell
Chlorine plant
Steelmaking
Polyvinyl chloride
manufacture
Arsenical pesticides
manufacture
intermediates, mercury. a»tf other
Location
Bombay
Ahtaedabad
Type of Hazard Muhinatiooai
Reported
affiliation
Numerous workplace
hazards uncontrolled,
failure to inform
workers and. tel] them,
of medical exam findings
Water poDmion, solid
waste dumping, no
warnings ow products
Madras
Solid waste dumpiny
Bombay
Water pollution
Mercury
poisoning, water pollution
Malaysia
Malaysia
Malaysia
What to do about Hazard Export
Air pollution, work
place hazards
High worker exposure ta
carcinogen vinyl chloride
Arsenic poisoning
symptoms in workers, no
monitoring of exposure
Type of affiltarion
Turner and Newaii
Lt<f (UIQ
75%, ownership
Johns-Manville
(US)
Minority ownetship oxclv
sive marketing of exports,
raw material salesy plant
design, and construction
supervision
25% ownership
Cape Industries
(UK>
Monrediion (TtdyJ
Pennwafc Corp
Partial ownership
40% ownership an£
management oC the plant
Minority ownership and plan
design
Partial ownership
Nippon Steel
(Japan)
‘Japanene”
companies
Diamond Shamrock
Subsidiary
(US)
* Paly Indiaa and Malaysian examines are cited.
Workers education and alert.
Environmental appSs^ wTre^gr^ting of indust
Development of expertise in toxic substances
rial licenses.
eranung ot mdust
• Fx7r^^7kon7two— ----------- ———-
control.
Ongoing and competent appraisal of world
wide movement
of hazardous industries.''
Trade unions to press for regulations to protect
workers health.
Are you Harming Yourself?
PAIN KILLER DRCGS
patient Leucocyte count dropped down to 300/cu.
Analgin, a pain
l..’
killer drug (Novalgin,
mm m 12 hours and patient succumbed. Identical
Baraigan, Ultragin etc)) can cause damage to bone
story was repeated in another patient with the
inanow cousing
<
'
same drugs but fortunately the patient recovered.
deficiency of white blood cells
“AgranuIocytosTs”, a potemiaHy fata) condition;
In my 25 years of medical practice, I have never
A doctor who had himself taken just two tablets
^dTdJPyT%?ru°ther d^ugs «>ntafoing dipyrone,
jeontajfiini, analgin* developed agranulocytosis and ' and I do not think my patients have been worse off
could survive with difficulty after a fight of nearly ‘ Without them. However majority of the medical
Six months under intensive medical care. Analgin ’ jwofeseion has been so much conditioned to use it
has been banned in a number of countries including
that it really needs strict vigilance to make a resi
Bangladesh but continues to be manufactured even
dent doctor in. a hospital discard the habit of usin>
by public pharmaceutical companise and is freely
dipyrone when he works with me after working els*-’,
available in the market without any warning system
where from where he has picked up the habit of
prescribing ‘gins’.
to consumers. Pain is a subjective phenomenon
and certain natural methods like taking rest, mas
.1
—-Dr. BC. Mehta
- • j
sage with gentle hands, going out for a walk for
Hon
Prof
&
Head
diversion of mind etc., are preferable to taking
Dept of Haematology
drug*. Similarly sponging of the body with water or
KEM Hospital, Bombay
..... i
ice cold packs are better for symptomatic relief of
fever and should be used as a primary measure.
ofIndia)
India*"*tO
B<,ltPr* Jaurnal Atsoctatlon ef Physldatt
Fever is basically the body’s defence mechanism
of
.. i
and stress should be on proper diagnosis of the
t-tmii jh
cause of fever and specific treatment of that cause.
BANNING BRANDS (U. K)
Paracetamol (Metacin, Crocin, Pyrigesic etc) ls a
relatively safe drug and can be used for relief of
Some 300 branded medicines will be banned
pain or fever. Aspirin, another drug (eg., Disprin)
from
National
Health Service prescriptions irom
when taken should be consumed with * a • lass
next April, as the government attempts fp cut its
full of water or milk and preferably after food.
£1400 million medicines bill. Most of the dru-s
Uhfortunately the market is being flooded by drug
are for minor ailments and are usually available In
combinations of either useless or harmful medicine?
chemists’ s’hops-at a price. A study of the 31 medi
and it may be sometimes difficult to get a single
cines listed by the health minister Kenneth
drug preparation.
Clarke last week as replacements for the banned
brands- reveals, for the first time, the emergence of
Botaract Ccoiunfcr Guidance Sootay of India
a government medicines policy.
:*
A WARNING
Twenty-eight of the 31 approved medidineS are pharmacopoeial preparations, that is medicines
Bharani et al (Journal of the Association
for which composition and standards are laid down
of Physicians of India, 1984, 32:382^383)
have
in the British Pharmacopoeia (BP) or the British
done a singular service to patients and the profession
Pharmaceutical Codex (BPC). The other three are
by highlighting marrow; toxicity of dipyrone (anal
benzodiazepines, such as Valium, for which no
gin) and various combinations containing dipyrone.
standard yet exists.
In my hematological practice, I encounter an average
about 12i-15 cases oi agranulocytosis in a year. Of
Nearly 100 cough medicines with names that
these 10-12 are caused by dipyrone or dipyrone con
tell nothing will disappear from NHS prescriptions.
taining drugs. Agranulocytosis in existing circumThey will be replaced by six medicines with such
Manoee carries mortality of 50-60%. Unfortunately
sample titles as Diamorphine Linctus BPC or
in almost all cases the drug is used by otherwise
Methadone Linctus BP. Alkaline Gentian Mixture
healthy individual for a trivial symptom and that
BP alone will replace the various “tonics” to improv©
the appetite.
use could have been ^easily avoided withdut any
inconvenience to the patient. Medical personnel
The numerous multivitamin preparations
who prescribe some of these drugs- are unaware
With
fancy
names will give way to straightforward
that a jwrticular drug contains analgin because the
Vitamin Capsules BPC, or to single substance
brand, name does not end in ‘gin*. This ignorance
preparations such as Ascorbic Acid Tablets B?
can be disastrous and cost a patient his life. To
(Vitamin C) or Pyridoxine Hydrochloride Tablets
illustrate this point the following case would
BP
(Vitamin B 6) or Vitamin B 12 (cyanocobulamin;
miffice. A patient with ’Nova! gin’ induced agranulofor the treatment of pernicious anaemia.
cytoaie was recovering gradually with leucocyte
count rising from 500/emm. to 2000/cmm over a
Two BP laxatives and five antacids will do NHS
period of 6 days. At that stage the patient com
service for the 65 brands and more than 100 pro
plained of abdominal discomfort for which he was
prietary preparations listed in the x>narmaci*u’
given Inj. Baralgan by the doctor in charge of the
bible, MIMS.
'
-5
■
■
-
' — ■1 i
1 "■|"
,.ui
1 ive aspirin and paracetamol preparations
replace the 34 brand named mild analgesics listed
in MIMS, though some doctors think they will
be able to go on prescribing the branded products
for arthritis. Ministers' opposition to benzodiazenines will remove the money^pinner Valium from
NHS prescriptions in favour of plain diazepam,
Mogadon as nitrazepam.
ries of industry. For instance, the health effects in the
electronic industry are dermatitis, dizziness, damage
to the nervous system and the liver, skin burns, heart
disease, eye, nose and throat irritation.
The booklet exposes some commonly held can
cer myths which have often been used to counter
workers’ demands for a healthier environment. One
oft quoted argument is that any substance can cause
cancer in animals if given in large enough quantities
and so, animal studies are not sufficient proof that a
substance is carcinogenic. This is untrue because only
some cheiracals are carcinogenic although high doses
used in animal studies increase the likelihood of
cancer in the experimental animals. But this does not
mean that all chemicals are carcinogenic if consumed
in sufficient quantities. Animal studies are the only
available means of screening potentially hazardous
chemicals. It is also untrue that most cancers are
caused by personal lifestyles. If a woman is exposed to high levels of benzence she will run the risk of
developing cancer no matter what her lifestyle.
A score of other brand-named “sedatives and
tranquillisers” will also
disappear, including
bluzodiazepine bypaotics. Last week’s THE LANCET
reported once again on the inappropriate prescrib
ing of prochlorperazine as a tranquilliser, particul
arly for the elderly suggesting that* non-bluzodiaaepine tranquillisers should also be considered. I
___ __________________
FRANK LESSER
Source : New Scientist—15th November, 1984.
BOOK REVIEW
OUR JOBS, OUR HEALTH —A Women's Guide
to Occupational Health and Safety, Boston Women’s
Health Book Collective, 89 pp.
A major chapter in the booklet is devoted to
reproductive issues in the work place. How do subs
tances in the workplace affect the reproductive
system of men and women? Impotence, lose of sexual
desire, infertility and mutation of the germ cell are
listed in answer. The growing concern for ‘the un
born child’ has led many US companies to formulate
policies which effectively prevent women between ‘18
and 60 from gainning access to a wide range of
jobs which were open to
them
s0 far.
The authors
point out
that
“removing
women from these jobs instead of cleaning up the
workplace divert attention from the real issue: protec
ting all workers from reproductive and other health
hazards”. Mostly of academic interest to us here,
but nevertheless heartening, is the information about
the pregnancy disability amendment of the Federal
Civil Rights Act in the US which provides for the
protection of the right of pregnant women to work.
It ensures among other things that employers treat
pregnancy disability just like any other disability by
providing light work, modified tasks or leave. Women
cannot be denied unemployment benefits merely
because of pregnancy.
In recent years health issues at the work place
have generated considerable research, literature and
action. The status of women’s health at work —
inside the home and outside — has become a cause
for concern only since women’s work became recog
nised as contributing to social and economic develop
ment. In other words, health problems of women at
work became visible only when women s work became
Visible.
This book offers a good guide to the health
hazards women face at work. The basic premise of
the Collective in writing the book is that health and
safety concerns of working women are not especially
different from those of working men. At least not
most of the time. But the reason why work
related health problems of women cause distinct
concern is because they are defined by the kind of
work that women do. And that, is in turn deter
mined by women’s status in society. The authors
point out that traditionally in any sphere of activity
women have been performing the most tedious, tiring,
monotonous, lowly and ill paid jobs. They are thus
exposed to a larger numbet of hazards and more
frequently than men.
Another important and informative chapter Is on
controlling hazard once they are identified. Although
some of the suggestions may not be applicable to
Indian conditions, the method involved in dealing
with workplace hazards would be very illuminating
to activists and to workers. It would, in fact be, a
good idea to adapt this book to Indian situations and
to translate and distribute some of the chaptera.
This booklet offers much needed information on
health and safety hazards, how to recognise them and
how to do something about getting rid of them. It
Contains 12 short chapters beginning with a short
father too brief note on women’s work through
history,
Mention must be made here of the work being
undertaken by the Union Research Group, some of
which has been presented in the URG Bulletins. It not
only throws light on the health hazards in some mdustries, but also suggests possible and practicable
solutions.
Do you come home with a headache everyday?
Do you find that you are gradually growing deaf?
Have you lately heard of higher incidence of cancer
tn the plant? If you have, then it is time you realised
that you might be working in a hazardous environ
ment. The authors classified hazards under catego
— padn*Ji praluuh, Bombay.
6
' l)eai ifriend. . ,
nient of the medical profession to the effect that
the movement caused such an unprecedented up
surge of public involvement that a good number of
Mass Organisations have since taken up the issue
of health care and a sustained campaign on Health
is still going on.
The critical comments regarding the im
mature and opportunist conduction of the movement
by the leaders of the MA RD s trike appear to be
simplistic. It was rather expected that the leadership
might fail to grasp the po'itical realities and ft
they did, they atleast did not reveal less wisdom
than that of the big Left Po'itical Parties and Trade
Unions via-a-vis the Bombay Textile Strike.
On the other hand, the author himself could
not make much headway in analysing the po'itical
realities except making some nebulous observations
popular among the 'eft circle. The class interest
behind the move of Capitation Fee, the class charar
cter of the different sections of the organised medical
profession, the out-look, attitude and the tevel of
awareness of the organised working class to this
issue in the perspective of health care, the quantita
tive and qualitative impact of Capitation Fee system
on the medical profession—these were the issues
which should have been ana'ysed and discussed ih
order to understand the political rca ities. In fact
it is jiot even clear what motivated lihe resident
doctors to orc anise and agitate and what wias their
rea1 cause of grievance.
The author made another faux pas in, on the
one hand, looking down upon the MARD for calling
off the movement just in exchange of a no-victi
misation assurance while on the other, advocating
compromise at an early state of the movement with
a partial concession of percentage of merit seats.
While agreeing with the author that ’’poi’itical moves
have t0 be fought Tolitica'ly’, it may be worthwhile
to suggest that political fights should also be fought
on principles and material concessions may often
erode the very basis of politics of a movement.
The suggestion of the author to broaden the
base of the struggle by involving the trade unions,
mass organisations, science movement groups etc
will be welcomed by all but we, from our own ex
perience, feel that this could only be done by
clarifying the relationship and impact of these issues
with regard to hea'th care service. In any case, I
must express my satisfaction in finding an article of
this nature in the pages of mfc bulletin and I hope,
in view of the apologetic observations of Padma
Prakash and Amar Jesani in the “Dear Friend”
column of the same issue, that article on such
subjects will continue to appear in future.
SUJ1T K. DAS
CALCUTTA.
THE MARD STRIKE.
1. Sanjay Nagral gives us an interesting
internal view of the MARD strike, But did I perceive a note of pessimism in his essay?
The recent strike In Kerala, azainst capita
lion-fee Medical Colleges, was a grand success. This
Strike too was Spearheaded by interns and medical
students, very few senior dodtors openly supported
the strike, though it had tlheir tacit approval
The mass contact programme was carried
out With enthusiasm. A few non-professional
colleges had token strikes. Jud ing from Che letters
to the Editor*' column of virtually every newspapei
and magazine in Kera'a, the people were very much
interested in what was going on. Finally it was the
subtle but powerful support of the strike by the
masses that caused even senior pofitibians and
parties t0 change their stance, and the government
hn’d to withdraw.
We tend to underestimate the power of the
people. MFC, VHAI, CHAU, & similar associations
can do little unless they not only work in partner
ship but also broaden their base and stop striking
an elitist pose.
MFC, VHAI, CHAI etc must vitalise the
apathetic, and guide the pentup anger and frustra*
tfons of the massess into proper channels. But it
is ultimately the masses that produce change, not
'fhou^ht currents’ and associations.
NEWTON LUIZ,
COCHIN.
2. I am constrained to make some observa
tions on the article ‘The MARD strike — a view
point* by Sanjay Nagra,! in the mfc bulletin no 108. .
The evaluation of the impact and the criticism of
the conduction of the strike appear to be superficial
and incomplete. It is difficult to agree with the
IconcjWion that the “strike was a failure**. The
MARD strike was, in a sense, a unique one. Agita
tions of doctors on causes of social interest is
only a decade old and is now fast attracting public
attention, but the issues were usua'Hy related to
medical care and health policy. MARD strike
lias added a riew dimension in drawing attention to
the malpractice prevailing in the administration of
medfcal education. Failure or success of a move
ment can hardly be judged by the instant impact or
itamediate return. Th© strike of the state-emp’oyed
doctors of West Bengal in 1947 ended in an agfeemortt which the Govt., taking advantage of the
EMERGENCY in the country, did not keep. But
after the emergency was lifted, the resurging pub
lic opinion pressurised the Govt., to concede some
of the deepands. Similarly, the present Left Front
ignoring the protests of the medical profession,
launched their half-baked ‘Barefoot Doctor’ scheme
but had to terminate it after 3 years admitting their
mistake. The latest Junior Doctors* movement In
Bengal had failed to achieve any significant con
cession but we consider it the most successful move-
III ANTHOLOGY
medico friend circle are glad to announce that our
third anthology of articles (covering bulletins 53..
95..) and entit’ed ‘HEALTH AND MEDICINE—
UNDER THE LENS” wi'l be published by March
1985. Price Rs. 15/-
7
,
«N. 27565/76
mfc bulhtin; FEBRUARY
Bhopal Disaster: Citizens
Response
Regd. No. L/NI7KRNU/2B2
•J?
1. The Delhi Science Forum had sent a
team to Bhopal and have published a report on the
•Bhopal Gas Tragedy’. It is available for Rs. 3.00
from B-l, 2nd floor, J. Block. Saket, New Delhi
110017.
DSF have a’so prepared an exhibition with
40 modules which is being taken to schools, colle es,
pub’ic sector offices and factories. Xerox copies of
these are available. For details write to the above
address.
2. Kerala Shastra Sahitya Parishad (KSSP)
have launched a campaign for the boycott of
Eveready Batteries manufactured by Union Carbide.
Posters and Post-cards for this campaign are avai
lable for Re. 1.00 each from KSSP,
p. Parishad
Bhavan, Trivandrum 695037, Kerala.
3. Eklavya who are active’y involved with
the Zahreeli Gas Kami Sangharsh Morcha in Bhopal
have published a report on BHOPAL: CITY OF
DEATH, a people's view of death, their right to
know and live. A reconstruction of the gas tragedy,
it$ background and aftermath from press reports and
local information. It is available at a contributary
price of Rs. 3.00 from Eklavya, E 1/208 Arera
Colony, Bhopal.
4. The Zahreeli Gas Kand Sangharsh Morcha,
Bhopal are organising a Solidarity March on Feb
16, 1985 and a National Convention in Bhopal on
Feb 17 & 18, 1985 on Lessons from Bhopal, environ
ment, science and democratic rights (in the context
of the role of foreign capital and the Indian State).
Contact address: Vibhuti Jha,
Advocate, 49
Shyama'a Road, Bhopal 462002.
Dear Friend.
I^et us begin this New Year with a firm resolve to
flight the Killer Union Carbide, who murdered and
maimed thousands of our brothers and sisters at Bhopal.
Let us fight with all might the Multinational blood
suckers who exploit the third world poor.
Kerala Sastra Sahithya Parishad
Parishad Bhavan
Trivandrum-695037
5. ad erratum — mfeb 109 — Citizens Res
ponses
—The note from Madras should read as —
SPACE — Students for Protection and Care of
Environment (Y-54, Anna Nagar, Madras 600040)
look out a protest march on 14 Dec 1984 and pre
sented memorandum to the government, Union Car
bide and the US govement. The Movement for
Environmental Protection (54 Jani Jan Khan Road
Madras, organized a public meeting and a demonstra
tion by Children at Basin Bridge on 5 January and
a dharna outside the Union Carbide Office. Anna
Salai on Sth January.
Editorial Committoe :
katnala jayarao
anant phadke
padma prakash
ulhas jaju
dhmv mankad
abhay bang
editor : ravi narayan
Announcement
In July 1984, the Indian Women Scientists
Association (IWSA) arranged a seminar on 'SOCIO
ECONOMIC
AND HEALTH IMPACT
OF
EMPLOYMENT GENERATION SCHEMES FOR
WOMEN' at the Third All India meeting of Women
in Science. A few copies of the proceedings are availab’e for distribution. All those involved in sucl
projects and interested in the proceedings should
write to Mahtab S. Bamji, Convenor, IWSA, Hydera
bad Branch, National Institute of Nutrition,
Hyderabad 500007.
and ?P*n*ont expressed ifi the bulletin are those of the authors and not necessarily
of the organisation.
Annual subscription — Inland Rs. 15-00
Foreign ; Sea Mail — US $ 4 for all countries
Air Mail : Asia — US $ 6; Africa A Europe — US S 9; Canada A USA — US J 11
Edited by Ravi Narayan. 326, Vth Main, Jet Block, Koramangaia, Bangalore-560034
Printed by Thelma Narayan at Pauline Printing Press, 44, Ulsoor Road, Bangalore-560042
Published by Thelma Narayan for medico friend circle, 326, Vth Main, 1st Block,
Koramangala, Bangalore-560 034
pres s
r e 1 e a s e
medico friend circle
organization & bulletin office
326 V Main I Block Koramangala
Bangalore 560034
30.3.1985
The medico friend circle (mfc), an All India group of socially
conscious doctors and health workers has just completed a
systematic study of the continued effects of toxic gas in two
bastis in Bhopal.
The observations of the study conducted between March 18-25
in the highly affected Jayaprakash Nagar and the less affected
Anna Nagar are yet to be fully analysed. However, the initial
findings definitely indicate that : (i) the affected population
is already showing signs of reduced breathing and working capacity
which is likely to be permanent unless remedial measures are
urgently introduced; (ii) pregnant women who had been exposed to
the gas in the first three months of pregnancy or have become
pregnant since the disaster have still not been informed about
the possible dangers to the foetus, Moreover, detoxification
measures recommended by the ICMR over a month ago—the administration of sodium thiosulphate has not been implemented, The mfc
is deeply concerned and agitated about the situation.
Reduced breathing and working capacity among the affected
population■
The mfc’s study team has observed that men are not able
to go back to work because of breathlessness on accustomed
exertion (exertional dyspnoea). Those who have'returned to work
report definitely reduced working capacities. Most women find it
difficult to carry on their usual household chores. The team
has noted with particular, concern that very few of. the children
can even play or participate in normal physicial activity in
the affected bastis.
It is well known that a large proportion of the MIC affected
population is likely to develop fibrosis of the lungs (develop
ment of scars) following inflammation of the lungs due to
irritation. This condition permanently affects1 breathing and
hence working capacity. Such a condition is already in evidence
in the population covered by the mfc study.
Simple breathing exercises are known to help to reduce
this disability. Information about these exercises must be
widely known and their importance stressed.
. . .2
2
Mass detoxification by sodium thiosulphate
More than a month ago the ICMR had recommended the administra
tion of sodium thiosulphate for detoxification of all patients
suffering from symptoms of MIC poisoning. This recommendation
was based on conclusions drawn from a double-blind clinical
study. But as yet, there appears to be no strategy in action
with regard to administration of sodium thiosulphate to the
vast majority of affected people. Only a tiny fraction, consisting of the seriously ill are receiving the injection.
mfc emphatically feels that as suggested by the ICMRZ all
patients suffering from symptoms of 'mid poisoning should be
urgently administered sodium thiosulphate so that their
suffering is reduced and they may go back to work. This service
and other medical facilities should be urgently provided in
a decentralised way, close to the bastic in affected areas.
The insight that sodium thiosulphate may well be
effective was known even in the first week after the disaster.
It is extremely disturbing and deplorable that decisions on
vital issues like this which affect the lives of thousands of
people should have been so long delayed. Even more shocking is
the ..fact that even now, a month after the recommendation was
publicised, mass detoxification of MIC victims has not begun.
Possible risks to the foetus
Another disturbing feature is that pregnant women who have been
exposed to MIC have not been given any advice regarding the
possible risks to the foetus. Given the fact.that the first
three months of pregnancy is the most sensitive period, it is
likely that these women as well those who .became pregnant
immediately after the disaster are likely to give birth to
deformed babies, since MIC or its breakdown products are
very reactive chemicals. Moreover many of these women have
received several types of drugs when as a rule in the first
three months no drug should be given for fear of. drug induced
deformations. Somce of these drugs, especially steroids are
known to cause deformities.
There is an urgent need to inform people, especially
women about these dangers and to advise them to undergo
medical termination of pregnancy. Adequate and free facilities
should be made available to those women who opt for it without
i
...4.3
3
coercing them to undergo sterilisation. Further, those couples
who have lost children and want reversal of 'sterilisation must
be offered these facilities free of charge.
Doctors belonging to mfc had pointed <out‘ these
:
dangers
in anearlier .note
sent to the” concerned authorities
month ago. But to date nothing seems to have been done.
Many of these womfen have by ]now crossed the five month limit
Of pregnancy beyond which MTP is unsafe. But
But there
there are
are some
who can still terminate their pregnancy although the risks
are greater than in the first weeks. Facilities for'ultra
sonographic examination should be made available to these
women immediately to■ detect gross abnormalities in their foetuses.
That this, is not being done is 'a reflection of the indifference
of health authorities towards the health problems of poor women.
Moreover mfc feels that the ICMR study designed to follow
up these women on a long term to assess the percentage of
deformities without informing women about the possible risks
or the advisability of MTP is unethical. The dangers to pregnancy
are well known and poor Women should not be used as guinea pigs
in medical research.
Contraceptive advice to affected ^couples
Most of the MIC affected population is still suffering
from symptoms of cyanide like ]_poisoning
‘
indicating, therefore,
the persistence of the biochemical
--- changes which have occured
due to MIC poisoning. It is safer to avoid pregnancies till
complete detoxification has
taken place. Since a large
proportion of the women are suffering from menstrual disorders
and other gynaecological problems, male, contraceptives (Nirodh)
should be/recommended rather than Copper T or oral contraceptive pills by the women.
We demand that the health authorities should give serious
and urgent consideration?to the issues raised here.
released by the convenor of mfc
r'- 1
manuscript
only
not to be quoted
.L .:
THE
B H 0 F A L
DISAbTEk
A F T S R k A T H
—an epidemiological and socio—medical study
15—25 March 1985
medico friend circle
Dedicated to the thousands
who died or were disabled
by the Bhopal Gas Disaster
—one of the worst industrial
accidents in
recorded history.
with a
resolve to prevent
ne di c al r e s e ex ch
froio becoming an exploitation
of human suffering
■with a
resolve to make
medic el r es e arch
an expression of
human e cone er n
CoBpajrisons of some of the important characteristics of
J P Hagar and Anna Hagar populations (study/control
populations )
Table IL
1- =& -r b £=-£23 ex
11-15 years
16-45 years
46 +
J P Nag ar
%
- 148
Anna Hagar1
M
8.10
10.14
F
9.46
4.35
M
35.81
34.78
F
33.78
31.88
1.4
6.08
10.14
%
138
n
F
Table IB
History of smoking and chronic
di seem es
A
S.uoking
Chronic
(b)
di seas es
+
+
J P Hagar
Anna Hagar
n = 148
n = 138
%
%
22.75
25.0
77.24
75.0
9.58
10.37
90.41
89.62
(a) a. snokcr is ^-ne who has smoked at least one ciga- rette per day lor at leejst one year ir a life time.
thna,
(b) chronic diseases specifically included
chronic bronchitis, tuberculosis and others.
Table 1C
Occupations anc income
levels
>. — —-r_—
J P Na^ar
Occupation
./jana Nag ar
%
%
n = 148
n
138
Unskilled
18.91
27.73
Skilled
7.43
8.73
Seli-employed
13.51
15,32
Service
14.18
10.21
Hous ework
29.72
24 • 08
Others
16.21
13a86
boss than Its.50.00
4.68
4.58
.“,s . 51-75
10.93
22.93
lie ,76-100
16.40
21.10
;is .101-125
14.84
13.76
lis . 12 6. C 0 am a bo ve
53.12
37.61
Per c ap it a i nc me per
month before ^as exposure
Percentaqe change in income of individuals of both communities after gas exposure
Figure 1.
Income (in rupees) per person per month
o
o o
o O
o
O
O
o
o
O
o
o o
o O
o
O
O
o
CX]
o
O
vH
O
CM
iP
CO
rH
I
kD(
co
o
o
r-l
J
kk ~kk
k
★X
*
kk 'kk
Income (in rupees) per person per month
o
o
O
O
co
kkk
k
k
o
o
O
O
CM *
k-kkk—kk
kkkkk kk
** kk
O
O
O
O
(o
<o
O
O
O
O
----- k<k
K k kk
n f kk
k
** *
k
o
o
O
O
'Jr^r
o
o
o
_nl
g
IQ
ANNA
*
20
*
★
3C
X
*
**
G
•H
•k
kkk
k
0
o 50o
G
★
kk
kk
*
•h 60_
(D
W
JU
o
G 70U
<D
Q
*
★
*
*
k
*
80.
**
*
*
9a
100J *
kk
k
k
kkk
kk
k
kk
•Jr k
k
k
k
★
*
*
o
o
co
Ti4. -ji.—rl___
kk
J.P.N AGAR
o
o
N A G A R
CM
9T
£8
£
T
AT
■qipsQP ON
T
qqi‘20S
x'3^3N 'sntrr
eg
"9T
zz
g
OT
T- T°l5
St
ST
OS
Z
8
^'3 0P ON
TT
t
Z
8
Z
LTQ-'^OQ’
x^b?n gi
r? tcq
a'9oi
c v jh a
lt^ct
EflOESIB^.......... ac-j^^c-co------
"~^T^
u^ci
^rac^.T^
areci
TI^tm
g'S'OJ'iS G/JA4 LIT
< PN)
AiT2 3TTST{$521S 0-zIOi'A gOOLIO XO.T TT 3
A*q oo?.go?r o;i?fA SiVSS
3 J VPS mo-: U1T
ut
(90•3) SS’T
J
9S’T
rl
(g'3'O) WT
(SO’O) XS’T
J
(30’0)
Sfi'T
(wo) OS'T
(3T'O) SE*T
(wo) LS'T
J
(WO) TS’T
(60’0)
H
(ST’O)
SVT
(3T’O) -^g’T
d
(6T*0) SS’T
(tvo) es*T
(go“o) 8S*T
(9T'0>
8£,T
AST = a
^auv
(WO)
nT T^
OJ
ucTcnoaod’ico qfj.'30S
X'2 '-.1C Tg-T pm C|LnC'7?-TL“
i Ti
r
9ST
%
a
Tr-3 2OT JTU9TC-aC 11
Tf^ -
Q.SGs'.
go oxo,t jt o oLjJj
*QQ-O' l
SX30^ s- T9
SJ'3GA 09-9T7
3X39Z gt-ST
•3X30A 2T“TT
7.T bp LIT
? (usob)
'2 o x*2 o 03 j xn g Ap cn
(0*8
f2-c ””n
-it ooxhOtj) :i9g-o°3 cqi 8utp
-XCOO'E X'30'2H '6UW pm X'.3?'3H SP UT (j'l)
'3?\r3 OOVTvTaO ^pca □OOf’QOQ <1C GTX'3dVC[)
£
Table ? 3 A
Comparison of Symptoms reported by individuals in
J.P. Nagar and Anna Nagar. (Expressed in percentage.
Numbers of cases are shown in bracket.)
SL o
NO.
Symptoms
JoP.Nagar %
Ao Nagar %
_ _7 .. * (a)
P„ Value
1.
Dry Cough.
27.70 (41)
14.49 (20)
P
2.
Cough with Expectoration.
47.29 (70)
23.91 (33)
0.001
3.
Breathlessness at rest.
10.13 (15)
2.89 (04)
0.025
4.
Breathlessness on
usual exertion.
87.16 (129)
35.50 (49)
0.001
5.
Chest pain
(74)
26.08 (36)
0.001
6.
Weakness in Extremities.
65.54 (97)
36.95 (51)
<<0.001
7
Fatigue.
81.08 (120)
39.85 (55)
C< 0..001
8.
Anorexia.
66.21 (98)
28.26 (39)
«0.001
9.
Nausea.
58.10 (86)
16.66 (23)
10. Abdominal pain.
53.37 (79)
25.39 (35)
11. Flatulence.
68.91 (102)
25.36 (35)
/ <0.001
12. Lacrimation.
58.78 .(87)
42.62 (58)
<0.01
13. Blurred vision/photophobia
77.02 (114)
38.40 (53)
<<0.001
14. Loss of memory
45.27 (67)
11.59 (16)
«o.on
15. Tingling/numbness.
54.72 (81)
30.28 (28)
<<0.001
*(a)
tightness.
50.0
P Values were calculated by X
2 method.
0.01
Table s 3 B
Comparison of Symptoms reported by individuals in
J.P.Nagar and Anna Nagar. (Expressed in percentage.
Numbers of cases are shown in bracket.)
(Symptoms significantly different but not analysed further)
*
P. Value (a)
SL.
NO.
Symptoms
1.
Skin problems
29.05 (43)
11.59 (16)
<0.01
2.
Bleeding tendency
9.45 (14)
2.89 (04)
ZJ3.025
3.
Headache
66.89 (99)
42.02 (58)
4.
Muscle ache
72.97 (108)
36.23 (50)
-0.001
5.
Impotence
8.10 (12)
0.72 (01)
.05
6.
Anxiety/Depression
43.92 (65)
10.14 (14)
A. Nagar %
J.P.Nagar %
Table s 3 C
Comparison of Symptoms reported by individuals in
J.P.Nagar and Anna Nagar. (Expressed in percentage.
Numbers of cases are shown in bracket.)
( Symptoms-- Non - significant )
★
SL.
NO.
Symptoms
J.P.Nagar %
A.Nagar %
P.Value (a)
1.
Blood in Sputum
10.13 (15)
7.24 (10)
N.SO
2.
Fever
27.70 (41)
28.98 (40)
N.S.
3.
Jaundice
0.67 (01)
00
N.S.
4.
Blood in vomit/stool/
malena
12.16 (18)
10.14 (14)
N.S.
5.
Vomit-ing
11.48 (17)
5.79 (08)
N.S.
*(a)
P Values were calculated by X
2 method.
I.
—-J*-
a!'<^ *--r
’ ’’
Table 3D
Symptoms
-___ =___ 5S
No ./Total
9^
p + G.I. + Eye + CNS
92/148
62.16
p (Pulmonary only)
4/148
2.7
p - NIL (ie G.I./CNS/Eye)
52/148
35/4J
Symptom groups
zi— =— = —= —= -c= — —
(For symptoms included in grouping please refer 5.4 2.2
Table
Symptom Complexes other than
Pulmonary System
No ./Total
°io
G.I. (with or without eye/CNS)
31/148
20.94
(with or without Gl/CNS)
32/148
21.62
CNS (with or without GI/Eye)
2'3/148
15.54
Symptom Groups
3ye
r
I 5
■
■ x’
i.
J-
■
"'' \ s■
t,
V*
. >y
,
x-
■.
n.
•/ •
z;
4 V Zi ■'
[
‘
*
-f ..
k,
<•!
• : •t’
/
1
‘ ’■ v
i•'/
'y'
•
:
•
i4
i '/
■\
■'
I
' V.u
y
All
A* - ■ in
'X' / J / 'X.Xur v
;
■
V ''J' .
V
'<* S/A J
r
i
■
■■
•
: I
\
■
••
yv,
P ' 7.' ’..V :7 'W/ '<7
• < • :R ;!
■
■.>■■
■•v A
;I
■ .
■
-
f'M'. r ■ l- rl
:
/
if
4
-/
77 iUM/' / ■;
;:w\7 ■//■:'■■' i
■!
tk- v-.
r -
• *
I
/•
. .
11 ’
Table : 4
Patterns, of disturbance of vision in 10 — 45 yrs.
of population in J.P. Nagar and A. N-agar. (Figures
in bracket indicate actual numbers.)
Blurring of vision
\
(1)
(2)
Ahxormal distant vision
I
(3)
Abnormal near vision
J.P. NAGAR %
ANNA NAGAR
74.24 (98/132)
(a) •
28.57 (34/117)
(65/141)
(a)
21.88 (21/96 )
17.55 (20/114)
(b)
8.74 (9 /103J
42.k*
(4)
Corneal Opacity
NOTEs-
4.7
( 7/148)
(b)
2.8
%
(4 /138)
2.
Includes Photophobia.
Normal vision 6/9 - Distant Vision tested
by means of Snell^'s chart
3.
4^
By means of near vision chart
In J.P. Nagar and Anna Nagar each there
are two central opacities.
1.
2
(a) tested by X d.f.l
xr2- - (b) tested by X d.f.l
p
0.001
p - Non-signifleant.
Table s 5 A
Mean pulse rate/minute (S.D.)in males &
females of J.P. Nagar and Anna Nagar.*
J.P. NAGAR
*
ANNA NAGAR
Male
77.13 (11.28)
n = 67.
77.94 (10.68)
n
73
Female
85.73 (13.21)
n = 78.
85o05 (11.20)
n
59
Total
81.70 (13.20)
n = 145.
80.4 (13.0)
132.
n
All the differences in mean pulse rates
were tested stastically by 1t1 test and
found to be non-signifleant.
Table
5B
Mean Respiration Rate/minutn (S.D.) in
males & females of u',9. Nagar and Anna Nagar. *
JoPo
AxilA NAGAR
21.73 (3.98)
n = €9
21.21 (3.84)
Female
21.84 (1.92/
n = r. 0
20.92 ( i,70)
n = 56
Total
21.87 (4.51)
n = 139
21.09 (:«77)
r = 130
Male
*
NAG. \R
lx ■-= 74
All the differences j
mean respiration rates
were tested stastica'.j.y ' t‘ tesJi and found to
be non-significant.
Table s 5 C
Mean blood Haemoglobin in gm.% in J.P.Nagar &
Anna Hagar, (The figures in bracket are S.Ds
of means.) n -■ sample size.
Ma?
J.P. NAGAR
ANNA NAGAR
14.68 (1.79)
12.70 (1.35)
n - 17.
n - 11 o
(a)
10.79 (1.34)
n ~ 18.
12,7 (I.46)
n
20o
(b)
Female
(a)
^d.f26
(b)
^d.f36
18
p
OCO1
4.20
TD
<0.001.
Table s 6 A
Mean Menstrual cycla length in days in
J.P. Nagar and Anna Nagar after and before
gas exposure - ( Figures in bracket indicate
S.D. in days.)
N A G A R
Before
N A G A R
Alter
A N N A
■ eford
32.32
25.59
(13.51)
(12.04)
35.41
(20.09)
(19.89)
n
n
Po
Jo
n
31
ii
31.
36.10
29.
t
P <0.05
P > 0.8
a.
29 o
0o131
2o06
t.
J
d.fo6 0
s-
After
d. f o
56
differe n.e 3 3 in means menstrual cycles
length - -r i days between J.P.Nagar, and
Anna Na y.r after the gas exposure.
t. a
J O'
2 <,46
d. f.
58
P
C f05
Table, s 6 B
Percentage distribution of Flow in J.P. Nagar &
Anna Nagar before and after the gas exposure.
( Figures in bracket are number of cases )
ANNA
N A G A R
Scanty
Excess
Total
2o6
(1)
18 n 4
(7)
100
(38)
5.8
(2)
20u7
(7)
100
(34)
N A GAR
Jo Po
Scanty
Excess Total
Before
5o5
(2)
11
(4)
100
(36)
After
25.7
(9)
31.4
(11)
100
(35)
.
\
x2 < 1
X2 =
11.96
2.
d.f.
P < 0.01
d.f. - 2O
P
0.50
After the gas exposure
J.Po
& A.N.
X2
7.82
d.f. = 2O
P<< 0.025
Table s 6 C
Percentage distribution of colour of menstrual
flow in JoP.Nagar and Anna Nagar be£pre and after
the gas exposure. (Figures in brecket are No 6of-cases/
N A G A R
A N N A
N A G A R
Black
Total
Black
‘J otal
5.8
100
0
i 00
J oPa
Before
After
(2)
(34)
(0)
(3 7)
46.8
(15)
100
(32)
8o8
(3)
100
(34
x2
X2 =
3O41'
dof. = 1
P - N.So
14o46
d.f. = 1
P zl 0o001
After the gas exposure
2
X = 12.03
d.f. = 1
P -
J. Po and A.No
0o001
= JP Nagar s AN = Anna Nags*
Table s b D
Percentage distribution of Dysmenorrhoea
in J.P.Nagar and Anna Nagar, before and
after the gas exposure. (Figures in bra
cket are number of cases.)
t
J.P. N A G A R
ANNA
N A G A R
J.-ve
Total
+ve
Total
Before
28.5
(10)
100
(35)
48.7
(19)
100
(39)
After
65.6
(21)
100
(32)
39
(14)
100
(36)
x2
X2
9.21
d.f. = 1
P
0.71
d.f. = 1
0.01
P
N.S.
After the gas exposure
J.P. and A.N.
X2 = 4.89
d.f. = 1
P
0.05
Table s 6 E
Percentage distribution of Leucorrhoea in
J.P. Nagar and Anna Nagar - before and
after the gas exposure. (Figures in bra
cket are number of cases)
P.
N A G A R
NonSpecific Speci
fic Leu. Total
Leu.
Non
Specific
Leu.
Before
15.5
(7)
0
(0)
100
(45)
After
22.2
(10)
35.5
(16)
100
(45)
J.
^2
X = 22.5
d.» f. * 2.
ANNA
Specific
Leu.
Total
16.6
(7)
14.3
(6)
100
(42)
14.6
(6)
14.6
(6)
100
(41)
X2
1
d.f. = 2
After the gas exposure
J.P. & A.No
X2 = 7.455
d.f. = 2.
P
0.025.
J P = JP Nagar
s
A N = Anna Nagar
’ N A G A R
P N.S
Table
K.l
2
Distribution of Mortu values.of Body Surface Area (M )z
FEV, (Litre.), FVC (Lit..), FEV/FVC % in different age
sex gpo in J.P. Nagar and Anna Nagar.(a)*
(Figures in
bracket are S.Ds) n = number of persons in each cell.
P = P value.
-----------■BSA (M )
FVC (Lit.)
FEV,/FVC
%
A.Nt
J.P.
J.P.
A0No
1.23
1.22 1.59
1.93
(0.14)(0.19)(0.74) (0.48)
n=4
n=4 P=NS
1.72
(0.77)
P=N.S.
2.20
87.05
(0.51)
87.8
le22- 1.15 1.76
1.77
(0.12) (0.13)(0.84) (0.33)
n~3 • n=6
P=NS
2.07
(0.88)
P=N.S_.
2.10
84.3
(0.40)
84.2
1.49
1.51 2.04
2.66
(0.09) (0.12)(0.47) (0.51)
n=45 n=55 P40.031
2.99
2.39
(0.55)
(0.47)
P<0.001
79.1
88.9
M
2.54
76.3
1.97
(0.38)
(0.43)
P40.001
88.6
1'
1.37 1.35 1.64
2.25
(0.11) (0.12)(0.44) (0.42)
n—56 n=52 p^O.OOl
1,50 1.53 1.88
2.26 ’
(0.14) (0.09)(0.53) (0.19)
n=12 n-6
P<0.05
2.20
(0.43)
P<0.05
2.54
85.3
(0.24)
88.9
1.37 1.41" 1.51
2.13
(0.09) (0.22)(0.48) (0.18)
n=ll n-7
P4.0.01
1.86
(0.58)
P40.01
79.8
2.48
(0.21)
85.9
1.35 1.38 0.94
1.91
(0.04) (0.15)(0.39) (0.15)
n-2
n--4
P4.0.02
1.83
(0.35)
P=N.S o
2.17
(0.16)
51.8
88.0
1.32 1.28 1.39
1.90
(0.06) (0.05) (0.3,1) (0.07)
n=3
n=3
P<0.05
1.96
(0.31)
P=N.S.
2.13
(0.15)
63.4
86.2
~Age-Sex
J.P
in yrso
1C--14
M
15-44-
46-60
' M
61 •<*
M
F
(a)*
A.N
FEV,(Lit.)
.T.P_o .
A.N.
All the differences in Mean Values between J.P. Nagar &
Anna Nagar in each age-sex category were tested by
’t’
test.
Table 8
Exposure History_and_Safety^Measures
Anna Nagar
J P Nagar
Where at
the
Ran
Wet
time of leak towel Blanket out
In the Basti.
5
Out c f home
(in Bhopal)
1
7
Nil
Wet
Blanket
towel
124
8
9
1
2
6
Ran Nil
out
64
52
2
5
11
10
Out of Bhopal
Total Noo148
Total No. 158
Notes Nil means remained in the house without safety measure.
Table 9
Number of attacks (respiratory infections)
in the one month preceding the study
Anna Nagar
J P Nagar
Age
One attack
often
Nil
One attack
Often
Nil
10-15 yrs
3
13
15
4
1
16
16-45
15
46
35
24
7
68
46 t
3
14
4
4
4
11
_3 2 _
_12
95
_21 _
_.73 „ 54__
ir
Bp - 1
■
medico friend
circle
bulletin
JANUARY
wo®
1985
ditorial
The Bhopal Disaster
We live in a world in which violence, waste and manipulation have not only become central elements
in our lives but which have become profitable for the merchants of death, the rapists of the earth
and those who manipulate our behaviour, our fears and desires.
—Anwar Fazal
International Organisation of Consumer Unions
The world’s worst ever man made industrial and
ecological tragedy took pace on the 3rd of December
1984 at Bhopal. 30 tonnes of stored methyl iso cyanate
escaped into the atmosphere killing over three thou
sand people and over 3000 cattle and affecting over a
lakh people (official estimates!) . Even these shocking
statistics hide the actual enormity of the human
tragedy — of'the lives lost, the families affected, the
people blinded and ill and the thousands impoveri
shed .
Public and government reaction to thL catas
trophe had resulted in relief efforts. Wide media pub
licity has led to the spontaneous formation of citizens
groups and collectives to look into not only .the
deeper issues of this event but also to prevent such
events in the future. Zahreeli Gas Kand Sangarsh
Samiti (Bhopal), PARIS AR A — Movement lor Envi
ronmental Protection (Bangalore), Movement for a
Safe Environment (Bombay) and Movement for Envi
ronmental Protection (Madras) are some examples
of this upsurge.
Notwithstanding the phenomenal human tragedy
and suffering caused by this event which need relief,
rehabilitation and compensation efforts, all concerned
citizens should not miss the opportunity to analyse/
understand the deeper socio-political and technolo
gical crisis of which this disaster is only a symptom.
This is the time to question —
—
—
the role of multinational corporations and the
double standards in their functioning in the
developing world;
the governments role and complicity in impro
per siting, continued licensing, improper moni
toring of dangerous industries and in the
continued flouting of its own rules and regula
tions;
—
the national industrial and development policy
in the light of people’s health and ecological
issues;
the political exploitation of the poor especially
the slum dwellers and workers;
the lack of awareness among people, citizens
groups, consumer groups, workers unions,
voluntary organisations and action groups on.
health, safety apd environment issues;
the whole question of the right to information
at all levels and the existing control/monopoly 1
of information at multinational and govern-i
ment and professional levels;
the basic question of the relevance of pesti- :
cides to our agricultural economy in the light
of available scientific and social knowledge
regarding the disruption of eco-systems and the
long term effects on land and agriculture
This bulletin issue is a start in that direction and
includes a n'jemorandum from Bombay of which mfc
was a signatory, first hand report from one of our
members of the dynamics of relief work in Bhopal,
and an overview of the efforts of unions and workers
in occupational health action in the U.S.
INSIDE
No more Bhopals
2
Learning from the relief work in Bhopal
3
Bangalore Meetings
5
Health and Safety Movement in the U .S.
6
I
No more Bhopals
FIGHT FOR THE RIGHT TO LIVE*
We h;ave witnessed the worst ever industrial and
erjiyironmehtal disaster in the history of humankind,
id Bhopali recently. This horrendous tragedy has
forced people from all walks of life to react strongly
and actively.
provide health care facilities for those who will suffer
from long term effects of the poisoning, years from
now.
4. Right to information: All the information with
Union Carbide especially with reference to details of
the manufacturing process, immediate, long term,
carcinogenic and genetic effects of MIC and phos
gene must be made available to the public. The gov
ernment must intervene to obtain this informa
tion immediately. All hospital records of victims,
and post-mortem reports of the dead must be made
public. All information — process details and toxi
cological data of products — of all hazardous plants
should be made available to people in neighbouring
areas in a language that they understand. All studies
undertaken by institutions such as NIOH, CDI, ITRC,
NEERI etc. must be made accessible to the’public.’
5. Review of Existing laws: Existing laws con
cerning industrial zoning, industrial health and safety,
and environment should be implemented uniformally
all over the country. A re-examination and thorough
review of these laws must be undertaken immediate"ly
and it must be made public. AH such laws must be
periodically reviewed.
Industrialisation in India has taken little account
oli Either the appropriateness of technology or work
reflated health issues, safety measures or health hazards
fcjr'people at large. Hazards and accidents in indus
tries — whether in textiles, chemicals, mines, petro
chemicals.; railways, docks, cements or fertilizers are
ciiher hushed up, underreported or are totally ignored.
Ajhd even iwheh they are known, neither the njanagemeint nor the government, nor workers* organizations
or voluntary groups have paid much attention to it.
The time for passive acceptance of industrial hazards
is' forever past.
What happened in Bhopal is not merely a tragedy
it is a crime against people. We mourn the dead.
And strongly condemn those who were responsible
fc|r it.
This incident proves to us over again that we
cannot depend on industrialists or governments to
ehsure our health and safety. We appeal to the citi
zens — professional bodies, civil liberties organiza
tions, workers unions, women’s groups and indivi, djials — to press for the following demands through
demonstration, rrjass education, signature campaign,
letters to the editor in the press, legal action and "by
sending petitions to Assemblies and to the Parliament.
Citizens’ Committees: Citizens’ vigilance groups
which can: co-opt legal, medical and technical experts
irj the field should.be constituted for supervision and
effective, implementation of the measures recommendid here.'
I 2
Pimishrnent to the guilty: All persons, organi7 'ions arid agencies responsible for the tragedy __
union Caj-bide management, state and centrargovernn^ent which sanctioned the plant, supervisory and
monitoring agencies including factory and explosives
iijspectors.— must be severely punished.
3. RdhabilHation^ compensation and other aid to
victims: Victims should be paid a compensation that
is at least equivalent to that legally available in the
parent country of Union Carbide", ie., in USA. Those
Who have been disabled should be rehabilitated and
provided 'employment. Union Carbide should be
charged with the financing of the setting up of reha
bilitation ‘centres. A Special court must"be constitu
ted for the speedy processing of Bhopal eases Long
t|r.m noriitoring of health conditions of victimepidemiological and environmental studies must be
ihstitiilc-d immediately, paying special attention to the
fact iluit won.cn might have been more susceptible.
The results of these studies should be published in
dtie mass pedra. All arrangements must be made to
Cunent compensation laws do not adequately
protect the health and safety of all sections of the
population. A comprehensive law covering all coir*pen?.at!°r J^.ues’ making payment of compensation
a stiict liability on the company must be brought into
existence.
6
Environmental and Health Studies around
existing emd proposed industries: The government
should finance citizen’s committies or other indepen
dent authorities to undertake environmental and health
studies around existing hazardous plants and indusiial areas. These should be made accessible to the
public Periodic surveys should be carried out to
assess ill effects. It should be made mandatory to
issue public notice adequately in advance of the setting
up of any new potentially hazardous plant. Health and
en\nonmental studies must be undertaken around
the sites and made public.
7. Rights to workers, unions and citizens com^
mittees: Independent committees of workers and their
i epi esentatiyes should be given, the right , to investi
gate work conditions and to make direct complaint
to the court where necessary. All workers in such
P ? SAhHU d be Provided with relevant safety equip
ment. All workers — whether temporary, permanent,
badli or contract — should have the right to stop
working with full payment until the hazardous condi
tions are remedied.
(Continued on page 8)
- —.TJ .......
2
1
hh
LEARNING FROM THE RELIEF
ORK IN BHOPAL
••• abhay bang
An article in mfc bulletin on Bhopal disaster is expected, by
tr dition, to focus on the? political and economic reasons behind the
*he tragedy* For such analysis the readers are recommended to read
two excellent papers of Barry Castleman which appeared in
International Journal of Health Services some time ago (The export
of hazardous factories to Developing Nations1, Vol.9, No.4, 1979
and •The double standard in industrial hazards’. Vol.13, No.l, 1983).
I shall also not attempt to investigate and describe the chronology
of the events. Newspapers have published lot of information on
that and I am no wiser than the journalists. As the title suggests
I shall restrict to the relief aspect, that too mostly in relation
to public health, for there were ample t ings to learn from that
alone*
When the Gas Struck
When the gas struck at about 1.00 am on 3rd December, people
woke up with severe sense of suffocation, cough and
irritation in the eyes. Most of the deaths were inst nt due to
suffocation or pulmonary edema* The worst hit were children. many
of whom died in the beds* The result of this cruel preference
of the gas was that very fev/ chileren remained orphan, because
usually chil ren died before their parents*
2
» l
2
It is almost an universal law that the poorest live in
the dangerous areas. When the flood strikes, the people who live
on low land and are the most affected are always the poor.
Bhopal was no exception. People living in the immediate vicinity
of this chemical volcano, were mostly the slum dwellers. But
besides this fact, two other disturbing pieces of information
explain the very striking class distribution of the victims.
The residents of the Jayaprakash Nagar slum which is the
closest and the worst affected ar a, categorically state that
at about 12 □•Clock in the midnight, all the workers in the
Union Carbide plant fled away in the factory buses but no siren
was blown. It means factory staff came to kno
about
the
impending danger at 12 and safely escaped ’without warning
people or the police. This may e plain the strange fact that
only one worker of the factory was injured by the gas when
hundreds were working in the night shift.
Similarly, it is alleged that on coming to know of the
danger, most of the police and other government officers and the
ministers escaped out of Bhopal by the government vehicles at their
disposal, instead of tryin
to warn or help the people. Rich
also fled in their private vehicles. Those who did not have
any vehicles, obviously the poor, had to
ace the gas.
The immediate effect of the gas on the survivors was
irritation of the mucus membranes of eyet and the respiratory
3
3
tract, leading to severe and widespread conjunctivitis.
sometime keratitis, and large number of people with respiratory
symptoms. Many also had vomiting. The medical persons were in
dark about the harmful effects of methyl iso cyanate (MIC)•
They were even not certain whether it was MIC or phosgene gas:
so the fear of the coming unknown effects was looming on everybody.
19 cases of CNS involvement were reported in the Hamidiya Hospital.
This gives credit to the rumour that on autopsy, cerebral oedema and
haemorrhage were often found.
The Ongoing Relief and its Criticism
When we reached Bhopal on the morning of 5th December,
the administration had overcome the initial shock and the
relief operations had begun. Hospital staff, interns, and
medical students; various social and religious organisations
*
had responded quickly. Food and blankets were being distributed
freely. Dead bodies were being removed.
The first instinct of the medical profession naturally
was to offer symptomatic relief to the sufferers. As the
hospital was full
ith the dead or very serious, most of the relief
work was done from the temporary tents. About 100 such medical
relief clinics were opened in the premises of the hospital
or on the roads near the affected areas. Doctors were treating
long queues o
patients. The method was typically uniform
everywhere, with some obvious shortcomings.
4
4
I4o case papers were ma e. Henc
the identity of the
patients, physical signs and the treatment given - nothing
was being recorded. The reason offered was that the doctors
were too busy in treating and the records were not the priority
in such situation. The recult of course was that the medicines
were distributed like toffees. One of us saw a child t king
an injection and then running to his friends to boast that it
was his sixth shot that day.
People were the first to recognise this deficiency and
started losing faith in such totally adhoc and symptomatic
treatment.
Interns and doctors running these clinics were not given
any guidelines for treatment by the senior doctors. Hencethey
were using medicines in the most bizarre way.
No attempt was made to train or involve non-medical
volunteers or family members. Thus for conjunctivitis, even
the eye drops were put in the eyes by the doctors alone. This
resulted in an unending burden on the doctors; and the patients
were able to get eye drops in their eyes once in a day when
they could reach the doctor through the long queue.
No certificates of death or disease were bein
issued.
There did not even exist a reliable method of recording and
counting deaths, which resulted in widely varying estimates of death
from 2000 to 6000. This neglect may become a tremendous handicap
to the poor to get compensations whenever that comes.
5
5
Besides the sheer magnitude of the problem, another reason for
such erratic medical relief wan that it was put in the hands of
clinicians. When about 200,000 people were affected, it was absurd
to control the medical relief operation from the hospital by the
medical superintendent. Though a very decent man, he thought the
respirators as the most important need of the hour. The whole
operation was carried out through clinician’s point of view. This
resulted in such decisions as offering treatment in clinics expecting
victims to come there. Clinicians can only set those who come to
them and never know about those who don’t come. This deprives
them of the total view of the situation. We found that a large
number of victims were not going to the clinics due to reasons
like despondency, inability to walk because of severe eye problem
or loss of faith in the quality of the relief offered.
This also m ant that the real number of the people affected
would never be known. The estimates of number of patients treated
varied from 650C0 to 1,50,000 and each estimate may have counted
same patient many times and totally missed those who did not attend
the clinics.
A quick and crude survey of the remaining residents of JP colony
showed us that about 50% had eye problems and about 25% had respiratory
symptoms. Surprisingly large number of people, even those with
minimum respiratory symptoms, had rhonchi and coarse crepitations in
the chest. It seems that the irritation by the gas had produced
chemical bronchitis and bronchopneumonia on a large scale. As many
«
6
6
of such •mild coses1 were not being examined, clinicians
in the OPD could fail to appreciate the widespread nature of
the respiratory involvement. Unfortunately all these facts were
not documented and hence, it seems, the real epidemiology of
morbidity may never be known.
Alternative Plan
We planned a relief program to be run by SEWA, a local
Women^s organisation for a small but defined population. The
main features were : —
(A) Female social workers from SEWA visiting all the houses
in a slum of 1000 families for
1, population enumeration
2. identifying dead, lost or moved out persons for
compensation and economic rehabilitation of the family
3, screening of all persons for the presence of symptoms
which started with the gas exposure and recording these
4. uncomplicated conjunctivitis and gastritis to be treated
by the social workers, involving and training the family
members in eye care and handing over a tube of eye ointment
to them
5. identifying patients with suspected keratitis and patients
with respiratory symptoms to be examined by doctor
(B) Doctor visiting all the houses, examining those with
respiratory symptoms ’and suspected keratitis (identified by
social worker), recording physical signs and treatment given
7
We thought that all the persons with rhonchi and/or crepitations
should be given antibiotic cover (preferably inj. benzathene
penicillin) as they carried a great risk of catching secondary
infection. similar to one after an attack of measles or
influenza*
We thought that the treatment should be provided at home
so that all the population will be identified, examined and
tr- ated, which can not happen in an OPD set up* This was
specially important for the documentation of the morbidity
as many victims did not go to OPD.
(C) All the population to be followed up for coming few
eeks
to provide continuous care and recording complete impact of
the tragedy.
Two doctors, three interns, four nurses and about ten
female social workers could be mobilized and were explained
the deficiencies of the ongoing relief operations; and the
concepts and methods involved in the one planned by us. forms
for population enumeration and case records, and guidelines
for survey and treatment were prepared and explained. Unfortu
nately I could not stay longer but felt that the plan was
well explained an
agreed upon by the team.
The experience
The experience of the next 10 days work, as reported by the
social worker in charge of the operation was as followsi
- On the first day when the team went- to the slum and
started home visiting, doctors protested that it was
not their job and they set up an OPD. At least half of the
8
8
doctors could be pursued to continue home visiting
- Doctors could not swallow the idea of social workers
treating conjunctivitis and kept all the clinical
work to themselves
- The doctor
in OPD refused to write physical signs
and diagnosis in the case papers on the ground that it
would take time and the fact that the diagnosis could
be guessed from their treatment
- The typical treatment given wass
8 eye drops put once in a day by doctor or nurse;
8 cap tetracycline ITDS for one day;
8 tab B Complex;
8 tab multivitamin;
s corticosteroid injection
- All the time saving devices in the plan like training and
delegating easy tasks to social .orkens;
using
eye ointment which has longer duration of action than
eye drops; using benzathene penicillin to ensure week long
antibiotic cover, were stubbornly refused by the doctors.
It was not possible for the social worker to over rule
the medical supremacy.
The physical signs recorded by the doctors by home visit ng
were usually of poor quality. Some examples are8— chest clear, crepts present
- mild crepts found (there is nothing like ’mild crepts*)
- slight coarse crepts +ve
Each doctor used his pet expression and the recorded signs were
• ...9
9
monotonously the same in all the patients examined by the
same doctor. Obviously the doctors did not examine sincerely
or they were not at all sure of their findings of physical
examination.
In spite of these short comings^ this relief approach
gained instant popularity mainly because it was the only
place in Bhopal where case papers were being prepared and
record maintained. People quickly realized its importance
and even asked for records to be gi en to them. The relief
authorities in Lhe city brought foreigners to proudly show
this operation.
Surprisingly and fortunately the tide of secondary infection
did not occur anywhere and hence death toll did not continue to
rise after initial 3-4 days. The reasons for this reluctance
on the part of micro organisms to invade damaged respiratory
tracts are not understood. Antibiotic cover was either
not vien or was very inadequate for most of the affected
persons; and hence, cannot explain the phenomenon.
After 10 days of working when the operation neutralization
of the stored MIC started most ofthe relief work was wound
up as the people fledaway. At that time, eye problems had
considerably reduced but the respiratory one had continued.
though at the reduced level.
I recently learnt that the ICMR has declared a decision to
devlope a plan of long term surveillance to find out the
effects of gas exposure. That would be a stupendous but very
....10
>
10
valuable task, specially because industrial toxicologists in
the West are predicting that 5 to 10 percent of the affected
will have chronic respiratory diseases.
The compensation for the death and the disease may not
be fully available to all due to lack of record or evidenc- •
Lessons
1. Organising mass medical relief in the disaster situation
should be done not with a clinical approach but a
population approach;
2. Persons in the responsible positions shouldbe trained
for disaster management in anticipation;
3. There should be continuity in the planning and
implementation of any program, the lack of which was
responsible for proper implementation of our plan;
4. Record keeping and documentation is vital in all such
operations;
5. Besides their well known biases against delegation.
even the clinical performanr of the doctors was a sad
commentary on the outcome of medical education and the
standard of the profession. One tends to question the
right of objection by the medical profession to the use
of auxiliaries or village health workers on the ground
of the lack of professional training to them.
....11
/
11
6* The Bhopal tragedy acts as a warning signal to all
the socially conscious persons that the industrial
hazards and pollution are no longer a remote problem
restricted to the developed countries. As Barry Castleman points
-
/>
out in his earlier mentioned papers, developed countries
are rapidly expopting their technology, production processes
and the products to the third /world without proper safety
measures or information Znd education to the people.
7• Bhopal tragedy cfe-n be a powerful tool in the hands of
environmentalists and consumer and citizens rights groups.
A careful documentation of the ill effects - medical.
social, economic and ecological - will go a long way to
support the efforts of such groups•
m ? .'tco friend circ’o
F j,c , zation
utillefin office]
323 V M :
ist Block
Koram-^gala, Banfiaiore-560C34
PROJECT
To evolve a strategy of medical relief
and rehabilitation which best meets the
people*s medico-social needs and expectations.
An approach document !■ the study/
intervention by the team from the
medico friend circle to be conducted
in Bhopal 17-25th March 1985.
•••
Objectiveswnethodology-plan of action
outcome.
(Finalised in Bombay on 10th March* *85.)
These are not our objectives.
1.
To organise a parallel study by a
non-governmental voluntary agency.
Jin addition to the numerous studies
being undertaken by ICMR in collabo
ration with local departments of the
Gandhi Medical College and other
research institutes in the country.
2.
To organise studies to identify long term
sequelae of MIC exposure including
carcinogenedty or mutagenicity or to
obtain basic understanding of the
biological alterations associated with
exposure to MIC.
MFC does not have the resources* the organi
sation* the expertise or for that matter the
mandate for such studies.
.f
We believe that the primary role of relief.
Service* research is that of local and
national institutions and delivery services
specifically established for this purpose.
... 2.
1 2 1
Our role is to catalyse, evolve, stimulate, suggest
and enable a greater people orientation in the
efforts.
OBJECTIVES
A - To evolve a strategy of medical relief and
rehabilitation which most effectively meets
the medico-social needs of the gas disaster
victims and their expectations
1)
Assessing the current health status and
medico-social problems of the people and
quantlfy/Qualify them within the available
technical resources of the team.
ID
By priontising these problems in terms
of magnitude and implications for relief
and rehabilitation.
111)
By Identifying health problems and issues
which urgently require health education
input and to clarify the content and
context of this education.
1V)
By studying the existing plan of medical
relief and rehabilitation services
available to the people.
V)
By studying the peoples perceptions of
these services.
■<
B - To evolve a strategy to operationalise the
strategy outcome of A by working towards
its adoption by the local government health
service organisations
1)
Assessing the perceptions of government
doctors in dispensaries and polyclinics
to the medical problems and relief efforts
and eliciting suggestions from them for
its improvement.
11)
Studying the local dynamics of decision
making, organisation, coordination and
communication for relief and rehabilitation.
... 3.
I 3 t
METHODOLOGY
The MFC team will be arriving in the selected Fastis
of Bhopal three months after the tragedy. Numerous
teams of investigators and relief workers both
governmental and non-governmental have visited the
people, made enquiries, offered or promised relief,
raised expectations about compensation and assistance
and have carried out various tests. These teams have
not often been complementary and quite often worked at
cross purposes.
For the MFC team to ensure that it is able to get
reliable/ authentic/ relevant information from the
subjects of the enquiry it has to apply an approach
that will counter this pre-conditioning of the bastl
dwellers and establish a meaningful rapport. This
rapport must be free of suspicion* dependency or
false expectations.
We have therefore decided to employ the following
strategy.
1. Preparation of the qammuultY
a) A series of informal group discussions will
be held in the bastis during which members
of the visiting team will explain the
objectives of the study, the methodology and
the possible outcomes.
The approach in these group meetings will be
frank, open and participatrwy. It will
clarify the nature of the enquiry, the
absence of concurrent terminal medical
relief, the free availability of data
to individuals and the community, the method and
for a sample. It will encourage participation
by the community in operationalising the
proposed plans*
b) To supplement this effort a small pamphlet
in Hindi which clarifies and emphasises
the salient features of the study - the
j approach and components prepared and distributed.
c) To respond to requests for consultation,
examinations, dialogue, reassurance and
counselling by families not included
in sample a small team will be kept
available specifically to undertake this
task.
• •• 4.
I 4 »
d)
A referral link will be established with the
government dispensary and polyclinics and the
NGO clinics so that the inevitable expectation
of medical relief may be suitably channelised*
The doctors and health workers in these clinics
will be contacted earlier and Informed about
the study and procedure of referrals*
•)
In the last two days of the stay informal group
discussions will bo held in the bastis to share
the main findings* explain some of the implicat
ions* demystify the situation and respond to the
peoples queries about their problems*
a)
Three bastis with reported differential
exposure to gas have been selected*
Approximately 250-300 families will be
covered in these three bastis by a systematic
sampling*
The number plates Issued by ICMR for enumerating
the households will be used to identify/ select
households*
2*
b)
c)
3.
The survey will be recorded on proformas which have
both a family contponent and an individual sheet*
a)
b)
e)
d)
f)
Identification data
History of complaints after disaster asp.
presenting*
Clinical examination
Tests for visual acuity* lung function etc*
Interview regarding perceptions of relief
available and expectations*
Other relevant investigations (resources for
which are mobilised by 14th March)
(Seprate proforma for survey has been prepared and la
being converted into a standarised key of questions
in Hindi for the investigators)*
• •• 5*
1 5 l
4* Additional components
g)
Interview with senior government officials
and decision makers to identify content/
ratlonale/components of medical relief
and rehabilitation services (actual plan)*
h)
Interview with doctors in government dispen
saries* polyclinics as well as GPts in
affected areas to assess perceptions of
problems* awareness of guidelines* available
services and suggestions for Improvement*
1)
Perusal of all available data/records/
information/survey reports available and
accessible locally with voluntary groups
and governmental organisations*
PLAN Of ACTION
Till 16th March
Identifying team
Mobilising resources/equipment
Reviewing available literature
reports on the problem*
Clarifying issues for study*
Finalising objectives (10th
March* Bombay)
Finalising family/individual
proforma*
Finalising format for group
discussions*
Finalising organisational details*
Finalising local arrangements*
Finalising of bastis and families
in sample*
Group discussions in Bastis*
Orientation of investigation team.
Preliminary round of survey and
finalisation of daily plan*
Survey of families*
Interviews with local doctors andM
decision makers*
Terminal meetings with best!
dwellers on findings*
Perliminary tabulation*
.*•6.
*
» 6 «
Outcomes
1.
Evolution of a medical relief and rehabilitation
strategy geared to the medico-social needs of the
disaster victims and their expectations^
2.
Identification of a priority list of medico-social
problems for which rational management guidelines need
to be evolved and disseminated.
3.
Identification of Health problems and situations for
ehich health education materlals/media/methods need
to be evolved for patient education, preparation,
reassurance, f(also some preliminary content guidelines
for these),
Follow up Action
1.
Forward report/plans/suggestions to
MP Govt, health Services
Bhopal Medical College Faculty
Doctors of Bhopal including local IMA
ICMR and associated institutions.
2.
Evolve health education materials and methodologies
along with other voluntary and government agencies
for the problems identified in survey.
3.
Evolve guidelines for medical professionals in Bhopal
who are providing relief services to disaster victims,
(requesting IMA to organise meetings to discuss these
and disseminate theml)
This approach document has evolved out of a review
of available news and research reports on Bhopal,
report of a fact-finding team from Mfc presented
at the Bhopal convention, interviews with doctors,
experts, relief and action groups who are concerned
about Bhopal and/or have visited it in recent weeks
and finally out of a one-day consultation of some
members of the proposed mfc team at Bombay on
10th March,1985,
****
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medico friend circle
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Organisation
326, VMain, 1 Block
Koramangala
Bangalore - 560 034
India
&
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Ref. No. B :
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and under The Bombay Public Trust Act, 1950 with No. F-1996 (Pune)
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Registered Office : 50, LIC Quarters, University Road, Punc-4p016
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An Appeal
Dei-r friends.
This report of a study undertaken by a team of
members of the medico friend circle (mfc) has been
sent to the Government of Madhya Pradesh, the Relief and
Rehabilitation Commissioner, Bhopal, the decision makers
in the Health and Social Welfare Services of the
Government of Madhya Pradesh, the senior medical faculty
of Gandhi Medical College, the Indian Council of Medical
Research, with the full confidence that a meaningful
rehabilitation strategy is possible in Bhopal, if bold.
imaginative and committed steps can be taken by the
planners and decision makers.
2.
To you all—voluntary agencies, citizens
committees and action groups, representatives of the
medical and scientific community in India including
professional associations, journalists, media men.
donors, members, supporters and friends—. We need
r
your help in bringing a more meaningful strategy of relief
and rehabilitation in Bhopal. You can help by doing one
or more of the following:
*
(a) disseminate this information to others to
generate pressure of public opinion on
government, ICMR and others for more
effective action?
(b) share this report with medical experts and
scientists and send us their reactions/
responses/sug estions. Open scientific
debate is the need of the hour;
(c) Write or lobby about these issues and keep
us and all other organisations involved on
the Bhopal front informed about your efforts•
Looking forward to your committed support and
involvement.
Yours sincerely,,
Ravi Narayan
Convenor: mfc
September 1985
/
(2)
Also available from mfc office
326 V Main I Block
Koramisngala, Bangalore 560034
1. Medical Relief and Research in Bhopal—
the realities and r. commendations (Feb 1985)
Rs.2.00
2. An Epidemic of gynaecolo*leal diseases* effects
of Bhopal disaster on Vsomen*s Health
Rani Bang
Rs.2.00
3. Review of available literature on MIC
and details of ICMR and other studies
Rs.2.00
4. Rationale for the use of sodium thiosulphate
as an antidote in the treatment of the victims of
the
Bhopal disaster—a review
5. The Bhopi?l Disaster—mfc bulletin 109
Rs.2.00
Rs.2.00
6. Medical Resea ch ln Bhopal—are we forgetting
the peopled bulletin 112
7. rihe
8. The
Challen-e
Bhopal—mfc bulletin 114
peed for a co.Tunication strategy
Rs.2.00
Rs.2.00
Rs.2.00
FL
^^5
medico friend circle
The medico friend circle (mfc) is a circle of friends
with medical/non-medicaJ backgrounds who sharethe
common
conviction that the present system of health services
and
medical education is lopsided in the interest of the
privileged few and must/changed to serve the interests of
the large majority, the poor, mfc fosters
a •thought
current* upholding human values # people and community
orientation of health care and medical cducat on*
demystification of medical science
and a commitment to
the guidance of medical interventions by peoples*
needs and
not comme cial interests.
mfc offers a forum for di logue/debate, sharing of
experienc and experiments with the aim of
realising the
goals outlined above, and for takingup issues of
common concern for action.
For further details regarding mfc BHOPAL STUDY,
Ashvin Patel
Anil Patel
ARCH
21 Nirman Society
Alkapuri
contact—
AxRCH
OR
Mangrol At & po
Via Rajpipla
Vadodara 390005
Dist Bharuch
Guj arat
Gujarat 393 150
mK k>-' z
I „£SS RELEASE
The MFC Bhopal Study
sodium thiosulphate so that their suffering is reduced
and they may go back to work. This service and
other medical facilities should be urgently provided
in a decentralised way, close to the bastis in affected
areas.
The insight that sodium thiosulphate may well
be effective was known even in the first week after the
disaster. It is extremely disturbing and deplorable
that decisions on vital issues like this which affect the
lives of thousands of people should have been so long
delayed. Even more shocking is the fact that even
now, a month after the recommendation was publici
sed, mass detoxification of MIC victims has not
begun.
The Medico Friend Circle, an all-India group of
s .ally conscious doctors and health workers has
just completed a systematic study of the continued
e :ts of toxic gas in two bastis in Bhopal. The obser
vations of the study conducted between March 18-25
ir he highly affected Jayaprakash Nagar and the less
auveted Anna Nagar are yet to be fully analysed.
However, the initial findings definitely indicate that
(v the affected population is already showing signs of
reduced breathing and working capacity which is
1: ly to be permanent unless remedial measures are
urgently introduced; (ii) pregnant women who had
t n exposed to the gas in the first three months of
pivgnancy or have become pregnant since the disaster
b"”e still not been informed about the possible
d-aigers to the foetus.
Moreover, detoxification
rr°^sures recommended by ICMR over a month ago—
t administration of sodium thiosulphate has not
been implemented. The Medico Friend Circle is
c? fly concerned and agitated about the situation.
Possible risks to the foetus
Another disturbing feature is that pregnant
women who have been exposed to MIC have not been
given any advice regarding the possible risks to the
foetus. Given the fact that the first three months of
pregnancy is the most sensitive period, it is likely that
these women as well those who became pregnant
immediately after the disaster are likely to give birth
to deformed babies, since MIC or its breakdown
products are very reactive chemicals. Moreover many
of these women have received several types of drugs
when as a rule no drug should be given in the first three
months for fear of drug induced deformations. Some
of these drugs, especially steroids are known to cause
deformities.
There is an urgent need to inform people,
especially women about these dangers and to allow
them the option of medical termination of pregnancy.
Adequate and free facilities should be made available
to those women who opt for it without coercing them
to undergo sterilization. Further, those couples who
have lost children and want reversal of sterilization
must be offered these facilities free of charge.
Policed breathing and working capacity among the
ii cted population
The Medico Friend Circle’s study team has
o^erved that men are not able to go back to work
b^ause of breathlessness on accustomed exertion
( ;rtional dyspnoea). Those who have returned to
work report definitely reduced working capacities.
I st women find it difficult to carry on their usual
household chores. The team has noted with particu1 concern that very few of the children can even
p!ay or participate in normal physical activity in the
a°’'cted bastis.
It is well known that a large proportion of the
T ? affected population is likely to develop fibrosis
oi the lungs (development of scars) following inflamr *ion of the lungs due to irritation. This condition
permanently affects breathing and hence working
c?,r»acity. Such a condition is already in evidence in
t population covered by the MFC study.
Doctors belonging to MFC had pointed out
these dangers in a earlier note sent to the concerned
authorities a month ago. But to date nothing seems
to have been done.
Many of these women have by now crossed the
five-month limit of pregnancy beyond which MTP is
unsafe. But there are some who can still terminate
their pregnancy although the risks are greater than in
the first weeks. Facilities for ultrasonographic exami
nation should be made available to these women
immediately to detect gross abnormalities in their
foetuses.
Simple breathing exercises are known to help
tv reduce this disability. Information about these
e'^rcises must be made widely known and their
L ^ortance stressed.
ss detoxification by sodium thiosulphate
More than a month ago the ICMR had recomj ided the administration of sodium thiosulphate
for detoxification of all patients suffering from symf ms of MIC poisoning. This recommendation was
b.taed on conclusions drawn from a double-blind cliniC"1 study. But as yet, there appears to be no strategy
l action with regard to administration of sodium
thiosulphate to the vast majority of affected people.
ly a tiny fraction consisting of the seriously ill are
receiving the injection.
f
That this is not being done is a reflection of
the indifference of health authorities towards the
health problems of poor women. Moreover MFC
feels that the ICMR study designed to follow up these
women on a long term to assess the percentage of
deformities without informing women about the
MFC emphatically feels that as suggested by
the ICMR, all patients suffering from symptoms of
C poisoning should be urgently administered
(Continued on page 8)
5
Scientific Medicine
^Dear friend. . .
*
A lot of Medical Representatives visit me in
my small hospital. Brimming with enthusiasm, they
let loose a torrent of words, a mixture of sales-talk
and pharmacology — mostly sincere, not usually
accurate.
One enthusiastic fellow tried to sell me a
new antibiotic ointment containing Fusidic acid. He
showed me pictures of a patient with eczema on the
face, before and after treatment.-The “before'’ pic
ture shows the lips and chin of “a 14-year-old girl
with extensive eczema” The “after” picture shows
the lips and chin of a shaven male^ Either the ad
vertisement is a fraud or Fusidic acid has stronr
androgenic properties.
Another poor Medical Representative gave
me the usual lecture, then left behind a lot of san>
pes. Unfortunately the B-Complex capsules, thorn h
manufactured only a month ago, were spoilt.
Now all drugs are bought only after consult
ation between the Pharmacist, the Administrator
and myself. The B—Complex capsules were discar
ded. The other samples are given freely to deserv
ing patients. I have removed all drug advertisemients
from our hospital, including calendars. But in a pro
minent spot in the Pharmacy, you will find the
advertisement on Fusidic acid—a constant reminder,
to the Pharmacist and myself, of the treachery of
drug advertising.
Newton Luiz, Kerala.
I
I
_*
It was heartening to see such a large number
of people who believe in the social cause at the
Jmfc ■'meeting in Bangalore.
I shall like to contribute in mfe’s programmies.
Now a few opinions. During the discussions
on national tuberculosis programme, it became evi
dent that the homie work was not done pnoperiy and
the active members were not prepared sufficiently.
This is a sad thing because I am sure that many of
the participants had come to the meet for getting a
.' uideline on which they could work after returning to
their field. However, this promise was not fulfilled.
Secondly, the sessions were too long to be
comfortable. Not only it obstructed the enthusiasm
of participants but also did not allow for a purpose
ful acquaintance with each other. I feel that for such
an activity as mfc has undertaken, development of
personal communication among various groups are
vital for effective working and spreading the movemient. It should be seen that the sessions are not
extended beyond 2—3 pm and remaining time be
left for group interactions. I have learnt a lot during
my talk with groups of participants. Though there
was not much time for this, I can say that they
were more informative than the lengthy sessions of
the mfc on NTP critique. I am sure that participants
would learn m'qre by informal interaction with each
other and provisions should be made to encourage
such activities.
—ArMind Jha, Bombay.
6
I
Whenever there is a discussion on the diff
erent pathies, I am confused by the profusion of
terms to describe the system of medicine that I us*
in my practice. Allopathy, western medicine, mod
ern medicine, and scientific medicine are all termr
used to distinguish our system* of medicine fron.
the others — ayurveda, siddha, unani, shamanism
and homeopathy. Perhaps this confusion and pro
fusion of term's comes from muddled thinking.
The word ‘allopathy’ is outdated and shoulo
never be used by us; we should not define our system
of medicine in terms of someone else’s incorrem
perception of our system. Several mfc members
have pointed out that allopathy is a misnomer. Tin
aim' of most of our treatments is not to produce an
opposite effect to the disease at all. If homeopaths
want to continue to use the word to distinguish their
system from ours, let them do so.
Western medicine is another popular term',
but it is a bit limiting. It fails to distinguish oui
medicine from' the 19th century pseudoscience
homeopathy. The practice of unani also originated
in the west. Besides lending an unnecessary foreign
name to our medical system-, it no longer describes
the practice as it exists in India.
The term modem medicihe ' is also used.
Although most of the knowledge used by us is new,
it is not the distinguishing characteristic of this
knowledge. Two hundred years have passed since
digitalis wag first used for dropsy. Modern is a
better emotive term* than a descriptive one.
_
The best term to use is scientific medicine.
This contrasts our practice with the traditional sy&terns of ayurveda, siddha, unani, sham'anism; and
even homeopathy.
Scientific medicine includes all aspects of
healing that are proven (by scientific method) to
do more good than harm. Thi's scientific method in
cludes the powerful experimental tool of the clinical
t-ial.
The use of steamed, sterile- banana leaves
as dressings for bums is not western, modern, nor
allopathic.. It is scientific medicine employing the
scientific principle of antisepsis and proven by clini
cal trial to do more good than harm. The use of
Rauwcifia serpentina for high blood pressure is
also described in ayurvedic practice, but has become
part of our present practice of scientific medicine
only as reserpine has been proven to lower blood
pressure, and treating high blood pressure has been
shown to do more good than harm. Openminded
practitiojners of scientific medicine wij) have no
diffculty integrating proven methods from th3 tradi
tional system's into scientific practice.
If we think clearly, perhaps we will begin to
talk more clearly. We will begin to hear less of the
other pathies and will begin to hear more of the most
important pathy in the healing arts — empathy.
Jamie Uhrig — Mitraniketan
I
? Introducing the Third Anthology
Under the Lens — Health and Medicine
Policy), clearfy bring into focus the growing concern
of all genuine thinkers regarding the dangerous and
erroneous drug policies in the Third World.
An orthodox reader may wonder how a Caste
War Among Medicos or Minimum Wages for Agri
cultural Labourers could ever find a place in a de
bate on health. This only helps to emphasize MFC’s
main refrain that health is not a medical subject but
a socio-economic topic, and that no true health
worker can isolate himself (or herself) from the
current
socio-cultural
and
politico-economic
•forces. This understanding reveals the other side ot
the coin too—finances are not the main constraint
in achieving Health care for All (Family Planning
& Problem of Resources; Kerala, A Yardstick for
India).
This book is an attempt to bring under focus
issues which have hitherto been missed or ignored
and t£ adequately magnify them to put them under
proper perspective. We hope you will welcome it as
enthusiastically as you did its predecessors.
Kamala S. JayaRao.
Within ten years of its inception, the Medico
Friend Circle (MFC) has become a familiar name
in various circles of development workers. It is in
response to this growing interest in MFC’s analyses of health care, that we venture out to offer yet
another anthology of articles selected from our
monthly Bulletin.
This book does not carry the same degree of
perplexity, which its two predecessors did. For,
amidst the intricate scenario of problems, solutions
and problems arising out of solutions, one discerns
certain well-defined and definite areas of focus.
The focus is at times a bit unsteady and not so
definite as to generate dogma,- not yeit, we ar© still
sc arching for solutions, and have become wise enough
to admit, not the solution.
After the mad rush of critiques, arguments
and counter-arguments, which characterised the ear
lier two books, particularly the first one, we pau
sed to take a deep breath. A stage had arrived for
some calm thinking. This was, in a way, reflected in
the narrowing down of areas of focus, and the
near total absence of debate in issues Nos. 56—95
of the MFC Bulletin, which fonned the source for
this anthology. This was a period for, reflection, re
assessment and re-structuring of ideas.
Thus, definite areas started to come under
focus. What one sees Under The Lens is not the
total picture, but a few definite foci in it. Moreover,
is not what one sees under the lens, only an image?
But the image helps in understanding the situation,
in arriving at a diagnosis and thus in finding solu
i
1
DRUGS
Consumer Alert - Action
- Welcome
9th April 1983
“Although Clioquinol can severely damage
the nervous system and has injured more people than
any other drug, it is still being sold in about 100
countries around the world.
Ciba-Geigy the biggest producer of Clioquinol
has at last decided to phase it out from the world
market within 3 to 5 years. But this exposes large
populations to unacceptable risks for yet another,3
to 5 years and offers no benefits. We urge all nati
onal drug regulatory authorities and the World
Health Organisation to ensure that, the production
and sale of oral preparations containing Clioquinol
or any Hydroxyquinol ne is stopped now.”
—1OCU seminar on Health, Safety and the
Consumer, Ranzan, Japan.
tions.
We show you in Under The Lens, some of the
pathogens and the pathology: the wrong paths in
health care, traps on seemingly right paths and a
frightening pattern of “no health”. The book con
tains admissions of self-made mistakes (The other
side of Health Education, Role of the V H W); the
myths in community health (People’s participation,
community participation in Health Care; Health
For All by 2000 A.D); the wrong directions on the
national highway of health
(Health Care vs The
Struggle for life; Misuse of Antibiotics; Is BCG
vaccination useful? How successful are supplemen
tary Feeding Programmes?); the subtle and not so
subtle, pressures of international politics on health
(Research A Method of Colonisation; Multination
als in Drug Industry).
In line with the earlier two books, the present
one is also a potpourri of different aspects of health
and health care, a reflection of the wide and varied
interests (but always deep) of MFC. It covers com
munity health (questioning on the way, whether
there is a homogenous community, what is meant
by people and by Health for All), drug policies, clini
cal medicine, nutrition, contraception and much
more. There is a heavy emphasis on various aspects
of drug policy and therapeutics. The analyses by
Anant Phadke (Multinationals in Indian Drug
26th November, 1984
In October 1982, CIBA-GEIGY had publi
shed a new policy on control of diarrhoeal diseases.
This policy included the announcement of the world
wide gradual phasing out in three to five years of
Ehterovioform,
Mexaform
and others., drugs
which have been used for the controdi of diarrhoeal
disease for decades. However, in connection with a
series of SMON- cases in Japan, these drugs
became the object of a public, controversial discu
ssion concerning drug benefit/risk.
Within keeping of the announced policy,
■ (Continued on page 8)
'"T
I
mfc bulletin: APRIL 1985
RN.27565/76
(Continued from page 7)
r'|
sales of the products concerned have been discontin
ued since October 1982 in some 90 countries. The
gradual phasing out of these drugs has taken place
with the approval of the National Health Authorities.
The World Health Organization in Geneva was
regularly informed of the present state of develop
ments.
Today, the method of Oral Rehydration
offers a significant alternative therapy in the con
trol of Diarrhoeal Diseases—particuMy in the field
of Infant Diarrhoeal Diseases. Ciba-Geigy has deci
ded to account the present concepts and develop
ments in this field into a new pojicy, . thereby
abandoning the use of Clioquinol—containing and
related drugs. Consequently, Ciba-Geigy will accele
rate it original policy on controlling diarrhoeal
diseases, whereby the supply of the Anti-Diarrhoal
products vill be stopped by the end of the first
quarter of 1985.
Press release by Ciba-Gcigy.
30th November 1984.
The Presidont of IOCU, Anwar Fazal, today
welcomed the news that Ciba-Geigy is abandoning
the worldwide supply of its clioquinol containing
and related drugs by the end of March next year.
Clioquinol and related’ drugs—the group of
hydroxiquinolines — have been proven responsible
for a serious nerve disease “SMON” (subacute—
myelo-optic-neuropathy) which often leaves people
severd’y crippldd, blind or both. There have been
more than 10,000 “SMON” victims in Japan alone
in the late 1960s.
“Wc hope that this marks the beginning of
a new assertiveness on the part of Ciba-Geigy to
have nothing but the highest ethical standards in the
marketing of its products,” says Anwar Fazal.
The IOCU President added that there is a
clear moral responsibility on all manufacturers of
oral Clioquinol and other hydroxiquinoline contain
ing drugs to follow Ciba-Geigy’s example and stop
the production and sale of these products without
any further hesitation. “We will insist on thei recall
of such drugs already distributed to retailers and
there is no excuse whatsoever for governments to
allow this drug to be in circulation”.
— Press release by IOCU
!
NOTE:— Malaysia has banned this drug. It is how
ever widely available and used in Indonesia, Thai
land and India. The two commonest preparations
are Mexaform and Enteroviofonm.
j
Editorial Committee :
kamala jayarao
anant phadfce
padma prakash
ulhas jaju
dhruv mankad
abhay bang
editor: ravi narayan
Rcgd. No. L/NP/KRNU/2e2
-----------------------------—-----
mfcf ollow-up in Bhopal
Wanted volunteers for follow-pp
action in Bhopal in the month of May.
This will include study of pregnancy
outcome, health education and a com
munication strategy for doctors and
voluntary agencies. Anybody who
would like to participate/support—con
tact mfc office immediately.
4
Placement Available
Required a doctor to serve the rural community
around Madurai in Tamil Nadu. Persons oriented
in community health and preventive health care
activities will be preferred. Monthly emoluments
Rs. 1200.00 (all inclusive) plus free housing.
Interested persons may apply to : The Director
Rural Theological Institute PTC Post Madurai 625022
(Continued from page 5)
possible risks or the advisability of MTP is unethical.
The dangers to pregnancy are well known and poor
women should not be used as guinea pigs in medical
research.
Contraceptive advice to affected couples
Most of the MIC-affected population is still
suffering from symptoms of cyanide—like poisoning
indicating therefore the persistence of the biochemical
changes which have occurred due to MIC poisoning.
It is safer to avoid pregnancies till complete detoxifi
cation has’taken place. Since a large proportion of
the women are suffering from menstrual disorders and
other gynaecological problems, male contraceptives
(Nirodh) should be recommended rather than Copper
T or oral contraceptive pills by the women.
We demand that the health authorities should
give serious and urgent consideration to the issues
raised here.
Views and opinions expressed in the bulletin are those of the authors and not necessarily
of the organisation.
Annual subscription — Inland Rs. 15-00
Foreign ; Sea Mail — US S 4 for all countries
Air Mail : Asia — US $ 6; Africa Europe — US $ 9; Canada & USA — US $ 11
Edited by Ravi Narayan, 326, Vth Main, 1st Block, Koramangala, Bangalore-560034
Printed by Thelma Narayan at Pauline Printing Press, 44, Ulsoor Road, Bangalore-560042
Published by Thelma Narayan for medico friend circle, 326, Vth Main, 1st Block,
Koramangala, Bangalore-560034
113
medico friend
circle
bulletin
MAY
INJECTABLE
1985
CONTRACEPTIVES
Injectable contraceptives (ICs) have been on
the pharmaceutical map of the world since the ear
ly ‘sixties. Ever since then they have been at the
storm centre of a controversy that may well be the
longest ever on a medical issue. Two countries,
USA and UK have appointed public enquiry com
mittees on the matter.
In India, the ICs controversy was of largely
academic debate until about six months ago when
the government issued a directive permitting the
import of NET-EN, one of the ICs. Around the
same time it was also decided to introduce the IC
as one of the cafeteria methods offered in the government Family Planning Clinics.
The ICs controversy has raised some fundamen
tal issues — the manner in which decisions which
affect thousands of people are taken; the ethics of
medical research and control and the more funda
mental problem of appropriate animal models for
the testing of drugs. It also brings into focus once
again, the role of the multinational drug companies
in pushing potentially harmful drugs in the third
world with the active participation of the con
cerned governments.
ICs are hormonal contraceptives which may be
administered in the form of once in 60 or 84 day
injections. They are synthetic progestogens. The
two currently available ICs are Depot medroxyprogestogen acetate (brand name Depot Provera)
and Norethisterone enanthate or NET-EN (brand)
name Norigest) While they are both synthetic pro
gestogens they belong to
different
groups
of
steriods.
These synthetic progestagens
inhibit the production of gonadotropin which
in turn prevents ovulation. The endometrium
and the fallopian tubes are also perhaps affected
contributing to a reduction in fertility.
Depo Provera has currently been approved for
use in 84 countries whilst NET-EN is ‘registered’
for use in 25 countries but approved for use in 40.
It is neither registered nor used in UK or the US
(War on Want, 1984).
The Depo Provera Board of Inquiry in the US
has strongly recommended to the FDA that the
drug sould not be licensed as a contraceptive. In
UK however, the Board of Inquiry has cautiously
permitted the use of ICs in cases where other
methods are unsuitable. In India Depo Provera is
not allowed to be imported. However, it is not
banned dither.
Since Depo Provera has been in use much
longer, much more research material is available
on this than on NET-EN. Although they are diff
erent steriods, it is possible to examine some of
these findings with reference to
NET-EN.
Toxicological
studies
have been
carried
out in accordance with the requirements of
th© US FDA. These results have been monitored by
the WHO Toxicological Review Panel periodically .
The drugs have been tested on rodents, beag e
dogs and rhesus monkeys. The Depo Provera ani
mal studies have come in for a lot of criticism. Ste
phen Minkin a former Nutrition Chief of the UNI
CEF project in Bangladesh
first
revealed
that Upjohn, Depo Provera’s manufacturer had not
in fact reported all the findings of their trial on
beagle dogs. The 7-year studies on beagle dogs had
INSIDE
Bhopal-Citizen’s responses
4
Dear Friend
5
Garibi Hatao
6
Irrational Painkillers
6
Book Review
7
Keeping Track
7
Drugs Alert
8
•4
Depo Provera has been tried out in India, by
the ICMR, but reports have never been available.
There are two' major NET-EN studies — both coordi
nated by the WHO. The first was a two-year multi
national comparative trial of three regimens of DP
given at 90 days interval, NET-EN at 60 d!a.y inter
vals, and 84 days interval. Over 3000 women parti
cipated in the trials which began with recruitments
in 1977 and the final follow-up in 1982 (WHO,
1983). The other multicentre trial was conducted
in India by the ICMR in 16 Human Reproduction
Research Centres. This study compared two regi
mens of NET-EN of one 200 mg injection at 60
days and 90 days. Over 2000 women participated in
this study which ended its first phase in October
1983. (ICMR, undated).
shown that mammary gland nodules developed in
ad tnose animals which survived beyond the first
few years and some of these were malignant.
Another finding was acromegaly or an abnormal
growth process. Ten-year monkey studies have also
been conducted using DP. Again mammary nodules
developed in the low-dose groups.
Endometrial
carcinoma was also observed in some of the mon
keys. (WHO, 1982). Minkin further reports that
curvature of the spine was also found in experi
mental animals, which is a possible indicator that
Depo Provera inhibits growth hormones .
The NET-EN studies have not however shown
the same results. The beagle dog studies have
shown that the drug may be inhibiting or affecting
carbohydrate metabolism. One case of endometrial
cancer was reported in the monkey studies. The
WHO Toxicology Review Panel, after a thorough ex
amination of the results came to the following
conclusions — (i) that beagle dogs were considered
an unsuitable toxicological model for the study of
progestogens; (ii) that the tumours in DP admini
stered monkeys arose from a cell type not found in
women and so could not be considered to indicate
increased risk for cancer. (WHO, 1982).
A common feature of both the studies is the
very high drop out rates, most of which were due to
menstrual irregulaities. In the 1977 WHO trial the
drop out rate per 100 women ranges from 59 to 89
and in the Indian study about 50 per 100. Menstrual
irregularities included amenorrhoea, excessive bleed
ing, and spotting. In the WHO study 40 percent of
the women suffered from! amenorrhoea of more than
90 days.
Late last year the USFDA’s Board of Inquiry
has categorically countered both these contentions
of the WHO Panel. It has stated that “Data from
the studies on the rhesus monkey and -beagle dogs
cannot be dismissed as irrelevant to the human with
out conclusive evidence to the contrary. Such evi
dence is not available at this time. Therefore, the
fact that malignant neoplasias developed in two
species in target organs of sex steriods must be con
sidered as an indication of the potential of proges
togen s, including DMPA, to promote the develop
ment of malignancies in target organs.” (Report of
Public Board of Inquiry, (1984).
The 1982 WHO document has specifically
noted that menstrual irregularities are not likely
to be a major health problem. There is really no
scientific evidence to back this up! Very little is
known about the mechanism of bleeding disturbance
especially those related to steroid contraceptives
(WHO 1982). This being so, it is ratheir curious
(that the Indian decision to introduce the IC into
the family planning programme should have come
after the study results were known. One apparently
facetious argument that is being used is that since
Indian women are in any case anaemic, amenorr
hoea would in fact help them in the long run . A
similar argument is forwarded for another of the
side effects, weight gain. In the light of how
little i-s known about menstrual irregularities, such
If one were to accept the WHO conclusions on
cn
the unsuitability of beagle dogis as toxicological
models for progestogens, then obviously the animal
studies data becomes invalid. If this is so, on what
basis are human trials, which can only follow •upon
animal trials, being conducted?.
mfc Anthologies
Human Trials
There
are
volumes of
literature
on
the Depo Provera human trials. One of the ‘pio
neers’ in the use of Depo- Provera was E. MacDaniel
who tried out the drug on thousands of Thai women.
These studies have come in for a lot of criticism.
The US Board of Inquiry has stated that the data
on humans is insufficient and inadequate to either
confirm or refute the animal study results (Report
of Board of Inquiry. 1984.) It has pointed out that
in a majority of the studies there were no controls,
nor is there sufficient background inforirJation on
which one may decide on the possible carcinogenic
risk. Moreover the Thai trials have also been critici
sed on ethidal rrounds—‘informed consent’ was no
where practiced1.
We are sorry to inform our readers about
the unavoidable delay in the Printing of the
Hird anthology and the reprinting of the I
and II anthology. Those who have sent us
pre-publication payment are requested to bear
with us. The pre-publication offer of Rs. 35/for the set of three anothologes is also being
extended till 30th of May 1985.
2
arguments coming from ‘experts’ in the field must
be roundly condemned as being thoroughly unscienti
fic.
It is also rather disturbing to note that a 24month study should be deemed sufficient to prove
the drug’s safety when it is known to be a possible
carcinogen. Another area which has been ignored is
the possible teratogenic effects of ICs. The child
may be exposed to the drug if the mother’s pregn
ancy is undiagnosed when the contraceptive is ad'ministered.
Experts have stated that there is a positive
and significant association between progestins and
birth defects (War on Want, 1984). There have
been hardly any well-designed follow-up
of
children who might have been exposed to the drug.
Contraception failure may also lead to exposure of
the foetus to progestogens. In the two studies cit
ed contraception failure occured in 0.4 to 1.4 wo
men per 100 women (WHO, 1983). While this
seems like a small proportion, the total numbers are
likely to be large when ICs are 'being given through
the family planning clinics. Another factor to be
considered 'here is the effect of progestogen’s on
breast fed infants. According to the WHO report
a breast fed infant of a mother on NET-EN would
receive about 0.05 per cent of the maternal dose
over a two-rrJonth interval. (WHO, 1982). It has
been reported that even this small amount may
prove harmful because (i) the brain is not fully
developed and is sensitive to hormones and (ii) the
immature liver and the consequent slower elimina
tion may lead to a high accumulation of the hor
mone in the blood. (War on Want, 1984). When
.so ‘little is known in this area, is it ethical to
introduce this contraceptive in the national family
planning programme .
IC’s become part of the ‘cafeteria’ approach, in
formation will be at a greater premium because then
there will be no need to ‘persuade’ the subject so
as to get a adequate sample for research. The
manner in which ICs have been introduced smacks
of indecent haste. For one thing, although the ICMR study was completed by October ‘83, no report
was forthcoming until recently. In fact the first
published article seems to have appeared not in an
ICMR publication but as an article in a specialised
journal to which few non-research oriented institu
tions have access—Contraception. It may of course
be argued that Since there has never been a tradi
tion of debate on .scientific and medical issues in
the country, why should ICMR have acted any
differently. And that is in fact the major issue
here. — that people have a right 'to decide whether
or not they would like to take the risks that are
today being thrust upon them.
PadirJa Prakash, Bombay.
REFERENCES:
1.
2.
4.
The ICMR has outlined a set of guidelines for
family planning clinics regarding the use of ICs
(GOI, undated). These are very similar to the WHO
guidelines and include criteria for .selection, pre
examinations to exclude cancer of the breasts and
genital cancers, undiagnosed abnormal uterine bleed
ing and so on. Given the overcrowded understaffed
family planning clinics how much time would the
doctor be able to devote to the potential IC user.?
5.
6.
7.
As reported earlier the government has now
allowed the import of NET-EN by private practi
tioners, nursing ‘homes etc. And yet there is no
mechanism to ensure that the guidelines are follo
wed. Moreover, ICs have a great potential for
misuse. For instance, in UK, women in some hos
pitals were refused rubella vaccine unless they ac
cepted DP (Campaign against Depo Provera).
Closer home in Bhopal, women are not being allow
ed to have MTPs unless they accept copper T s.
This perhaps is the most frightening aspect of the
whole situation. Women will loose whatever
little control they had over contraception. There
is plenty of evidence that even during the trial
phase., ‘informed consent’ was only a myth. When
War on Want, Norethisterone enanthate, Dec.
1984. UK.
WHO, Multinational comparative clinical Tri
als on Long-Acting Injectable Contraceptives:
NET-EN given in two dosage regimens and
Depot MedroXy Pro "esterone Acetate. Final
Report Contraception, July 1983.
WHO, Facts about Injectable Contraceptives,
Memorandum from a WHO meeting, Bulletin
of the WHO 60 (2) : 199-210 (1982).
GOI. Guidelines for use of NET-EN, an Inje
ctable contraceptive for its use in Govt and nonGovt FP. Clinics, Undated 1984.
Report of the Public Board of Enquiry on Depo
Provera, Weisz Chairperson, Ross GT and
Stolley PD. 1984 Oct.
ICMR, Comparative Evaluation of contracep
tive efficacy of NET-EN (200 mg) injectable
contraceptive given every two or three months.
Mimeo, undated.
Campaign against Depo Provera UK, 1984.
Placement Available
We are looking for h Hindi speaking doctor to
help run a small rural health project in Santhal
Parganas; Salary negotiable. Applicant please write
with details of qualification and experience to: M.
Ganfftili, PO Jagdishpur, Via Madhupur; Dist Deoghar; Bahar 815353.
3
113
Bhopal — Citizens Responses
(a) A National Convention on ‘Lessons from Bhopal:
Environment, Science and Democratic Rights
in the context of the Role of Foreign Capital and
the Indian State” w'as held on Feb 17-18 at Gandhi
Bhavan, Bhopal. It was attended by more than 150
delegates belonging to about 65 organisations from
13 different states of the country and also by delegates from Afganistan and Nepal. Copies of the
declaration made by the Convention are available
from: Rashtriya Abhiyan Samiti, Zahreeli Gas
Kland Sangharsh Morcha C/o Vibhuti Jha, Advocate
49 Shyamala Road, Bhopal 462002.
rhe mfc Bhopal intervention
(a) the mfc study report :
The report of the study undertaken by the
mfc team from 17-26 March 1985 hlas just been
consolidated at Baroda on 27-28 April and will be
ready for circulation by the end of May. The report
which probably will be among the finst community
based epidemiological and socio-medical surveys to
be rdleased to the scientific community, press and
public will highlight the grave findings of the state
of health of the Bhopal gas victimsi three months
after the disaster. It will also contain a report on
peoples perception of health services, case studies
and bibliogriaphy. For further information, write
to mfc office, Bangalore.
(b) A National Campaign Committee (Rashtriya Abhiyan Samiti) was formed at the above con
vention and had its first meeting on April 6-7, 1985
•at Bhopal. It decided to organize a mass rally
(hold a public meeting and present a memorandum
to the Prime Minister with signatures—target be
ing ten lakhs) at Delhi on June 5, 1985 which is
observed as world Environment Day. For a copy of
the memorandum, and further details of the national
committees, plan and suggestions for action, write
to the above address , (a)
(b) Communication strategy on Health Issues
A note on th© need to evolve a communication
strategy on health issues following the Bhopal gas
tragedy hUs been prepared and circulated to volun
tary agencies and citizens groups working in Bhopal
and the MP Government health authorities. This
note is available on request from th© mfc office.
Bangalore. Thelma Narayan of mfc will be based
m Bhopal from 12 to 28 May 1985 to heOp evolve
such la communication strategy. Please send com
ments on the note, ideas suggestions to her C/o
Gandhi Bhavan, Shyamala Hills Near Polytechnic;
Bhopal 462002.
(c) Bharat Vignan Kala Morelia
The Kerala Sastra Sahitya Paris-had has organi
zed ian All India Science through Art campaign,
covering 8000 kilometres in the month of May thro
ugh 100 places spread over Karnataka, Andhra
Pradesh, Madhya Pradesh, Maharashtra; Rajasthan
Uttar Pradesh and Delhi. This moroha is dedicated
to the memory of the brothers and sisters who lost
their life in the Bhopal genocide with a promise
to avenge their death. The route/dates in May 1985
of the Yatra are as follows: Bangalore (l-3){ Harihar
(4); Hubli (5-6); Shol'apur (7); Pune (8-10); Secun
derabad (11-14). Bhopal (14-18); Indore (18-19)
Ajmer’(20-21); Jaipur (21-22); Delhi (22-29).
(c) Study on Pregnancy outcome
A tentative plan for a study on ‘Pregnancy
Outcome’ to be undertaken in Bhopal in the second
week of June has been drawn up and preprations
are on th© anvil. Volunteers interested in participa
ting and readers/members interested in supporting
this study with ideas, suggestions and technical
information, please write to: S'atyamala, C-152;
MIG Flats, Saket, New Delhi- 110017.
(d) Eklavya has brought out a Bhopal—The
State of the Environment report on the 100th dav
of the gas tragedy (March 12, 1985), in English and
Bhopal Gas Tragedy—Jan Vigyan Ka Saval — a
brochure in Hindi on their exhibition held in the
bastis. For further details/copies write to:
Eklavya, El/208, Arera Colony; Bhopal 462016
The J N U Study
An epidemiological 'and sociological study of
the Bhopal tragedy focussing on the size, distribu
tion and causes of the various health conditions
produced by the tragedy, and social and economic
profile of the victims was undertaken by the Centre
for Social Medicine and Community Health of JNU
in December- January 1984-85 and has been reported
in JNU News in April 1985
(e) “No More Bhopals”—an exhibition
The Centre for Education and Documentation,
Bombay, along with a few friends has put together
a large exhibition to highlight the world’s worst
‘industrial Occident in Bhopal. Two sets of 35
posters mounted on flat hard board are available:
one in Hindi and one in English. These two sets
are now circulating in India". All groups interested
in showing it may contact: CED 3 Suleman Chamber,
4 Battery Street, Behind Regal Cinema Bombay
400039 (telephone 2020019).
For further details and copies of the report,
write to:
D Banerji, Professor of the above
Centre, JNU New Delhi 110067.
4
Drug Action Focus
tyear friend. . .
4.
Annual Meet 1985 — Some reflections
1.
■
This was the first mfc meet I attended. I am
very happy to have come. I am impressed and
encouraged to meet such a variety of people
who are committed to people especially the op
pressed and who are concerned about a change
in values — a change of society.
The meet was interesting, but a little too
packed; there was not enough time to meet
people individually (But in only 2 dlays it is
almost impossible)
Hilda Sina, Vagamon, Kerala.
2. First let us say that the qualities, backgrounds,
achievements, activities, and aspirations of the
group in general were varied and exciting. It
is good that such different people can come to
gether with some hopes and interests in com
mon, and share and develop their ideas. The
‘old’ group did not dominate the ‘new’ nor did
they show impatience nor intolerance with
the ‘new’. Even the long term mfc members
did not criticise each other in harsh terms
and showed mutual respect even in disagree
ment. This is amazing and highly commend
able .
Everyone seemed welcome to attend and parti
cipate. The attitude seemed to be that we
could all learn from each other.
Smail group discussion followed by plenary
sessions were very good. A little more time
for informal meetings would have been nice .
It would have been nice to have all the back
ground papers before the meet because read
ing time was short once we arrived..
The meet served its main purpose for us in
meeting like minded medicos and non-medicos
alike from various parts of India.
Penny Dawson, Jamie Uhrig,
Mitraniketan, Kerala.
3.
I got to know quite a number of people with
whom I would never have come in contact otherwise.
It was quite informative except where people were
getting into unavoidable technicalities, which of
course were difficult to follow.
The time limitation was an inhibiting factor.
We had to skip quite a lot of things.
I was in the group discussing how to raise pub
lic awareness about TB. The ways that were dis
cussed were the ones that we had already discussed
in our SPACE meetings. Participants were trying
to express with their experiences why they came to
such conclusions. They were not allowed to tell their
experiences but what they had inferred from it—
of course due to lack of time.
Then some participants had a set of opinions
formed and they refused to come out their circle.
This led to heated arguments now and then.
On the whole it was nice.
—Malarvizhi, Madras.
Instead of choosing new topics each time can
we have a meet where we reanalyse some cast
issues and topics. There is a general feeling
amongst people that after discussions we do
not follow up on the topics anymore. Drugs
topic for example.
I think although the Drug Action Network is
working full time some of us in mtfc feel side
lined now and find little or nothing to con
tribute Raising the issue in an annual meet
may turn out newer aspects of the problem.
I think that DAN is directing its efforts in the
wrong direction. Instead of pressing the drug
controller of India for action all of us should
conscientize undergraduates and upcoming do
ctors. Our fight should be at a lower level
rather than at the level of government policy.
This is my disillusionment with the DAN and
I hope we can correct its course by ano her
discussion on the topic of drugs.
Vineet Nayar, Vellore.
Whither Company Doctor?
5.
5
The purpose of this letter is to motivate a
social scientist or a researcher to conduct a
study on the interaction between a worker and
the so called “company Doctor” I am sure that
the finding^ of such a study will be revealing.
Both public and private sector Industries em
ploy doctors on parttime or full time basis to
man their first aid centres, (ambulance rooms,
dispensaries and hospitals, and these doctors
’are called “company Doctors”.
An observation made by me (over a period of
three decades) is that the workers look at the
company doctor with askance. He is consider
ed as a “management Agent” having no sym
pathy for the workers. The workers attribute
the following characteristics to the company
doctor.
1) He lacks human touch. He thinks that
workers FEIGN sickness.
2) His medical opinion and diagnosis are de
pendant on the instruction of the com
pany/management.
c) At th© behest of the mantagement, he goes
to the extent of certifying as “medically
unfit” even physically fit persons.
4) He asserts that working environment and
sanitation are the best available any
where.
In most cases where his opinion is contested
and referred to outside doctors and specialism's,
he is proved wrong. In1 most of the court
oases, he is disbelieved and held to be biased.
I wish that there is a healthy debate and any
company doctor comes forward to assuage these
feelings of workers It is observed that public
sector employees have better opinion about
their company doctors.
Yours
U.S. Venfcatraman,
Bangalore
GARIBI
Rational Drug Policy cell mfc
HATAO 1
PRESS RELEASE
A move is on in India’s Planning Commis
sion to determine anew the parameters for defin
ing poverty.
The action was undertaken, reportedly,
after Prime Minister Indira Gandhi observed that
’she found a lot of bright faces in niral India,
which Was not reflected in current official statistics
showing that poverty in India is actually increas
ing.
The controversy actually started last year
after a cross-country walk-athon. by Janata
Party President Chandra Shekhar, who said that
he was appalled to find the dehumanizing poverty
in which India’s masses were living 36 years after
independence.
Irrational Pain-Killers
Only 14 out of 59 analgesic preparations found
scientifically justified !
Dr Jamie Uhrig and Dr. Penny Dawson of
Medico Friend Circle have analysed 59 preparations
listed as analgesics and antipyretics in the July’ 84
issue of MIMS, India and found 45 of these 50 pre
parations to be irrational on some ground or the
either.
Basing themselves on the latest authentic
text-books., Dr. Uhrig and Dr. Dawson rigorously
studied each of these preparations and graded
them into the following categories :
A: Use of the product is justified-14 preparations
for example: Phain paracetamol, Aspirin etc..
B: The combination is not proven to be superior
to single ingredient preparation and hence
not recommended . ...........17 preparations.
For example — Equagesic, Malidens, Micro
pyrin, Optalindon .... etc
C: The combination has been proven to be in
ferior to single ingredient preparation and
should be withdrawn.... 11 preparations.
For example—Apidin, Carbutyl, Dolopar
Plus, Norgesic, Parvon—-N, Parvon—P, Proxivon, Spasmo—proxivon, Sudhinol—N C....
etc.
D: The preparation contains analgin and should
be banned ..................... 17 preparations.
For example------ Codosic, Dolopar, Novalgin,
Ultragin, Sedyn—A forte, Spasmizol.
etc.
Drinking Water Data
Half of the country’s 576,000 villages still did
not have any drinking water facilities, Shekar said
after his 2,500-mile trek that took him through six
of India’s 22 states in six months.
According to official statistics, 339 million
of the total population of about 700 million were
below the poverty line defined as !a daily 'mini
mum calorie intake of 2,400 per person in the ru
ral areas and 2,100 in the urban areas, or a $6.50
per capita income a month in the rural areas and
$7.50 per capita income a month in the urban
areas
This means that 45 percent of the people still live
on a less than subsistence level. Of them, 272 mil
lion were in the rural areas and 67 million in the
urban ‘areas, showing that large-scale poverty con
tinued in the villages.
We conratulate Dr. Uhrig/Dr. Dawson for
their spontaneous initiative
in conducting this
study. This study is (available with the Rational
Dru^ Policv Cell of M.F.C. at a cositHprice of
Rs. 3/. Please write to:—Anant Phadke, 50, LIC
Quarters, University Road, PUNE—411 016.
Also available with mfc office, Bangalore.
Officials Are Upset
These statistics and comments by Shekar
were not appreciated by the powers that be. They
felt, and some economists backed them that the
extent of poverty in the country was being exag
gerated and that undue publicity might hamper
foreign investment.
So a group in the Planning Commission ad
vocated a lowering of the cut-off point, thereby lift
ing a large segment of the people above the poverty
line.
According to views
expressed by some
members of this group, the (actual calorie intake
for
Survival
was
actually
much
lower
One of them, Prof. P. V Sukhatme, contended that
the present cutoff point was the average require
ment of a healthy and active population and not
the minimum below which a person should be con
sidered undernourished. He suggested that a defined
lower end of the range of the energy intake of a
healthy individual be used as the cutoff point for
determining undemutrition and the poverty line.
from 339 million to 215 million and the miditerm
appraisal contends that that the number has already
been cut to 282 million in the first twio years of
the plan.
If these claims are indicative, all 339 million
can be expected to be lifted above the poverty line
by 1990 some economists said. And if the line it-sefff
was amended, poverty itself could be expected to
be eradicated in India very soon.
. .
Prof. C. Gopalan Director Generali of the
Council of Medical Research, has disputed Prof.
Sukhatme’s claim and said that mean calorie
intake of a community should continue to be the
dividing line of poverty. He hoped that the com
mission would not undertake such a deceptive short
cut to national prosperity considering the magni
tude of the problems of poverty.
Source:
INDIA ABROAD.
April 6, 1984.
Targets of Sixth Plan
The Sixth five year development plan (1980
85) target is to reduce those below the poverty line
6
Book Review
JCteping
BEHIND POVERTY, Djurfeldt and Lindberg,
Oxford & IBH Publishing Co., 1976 — Books 22 &
23 in Scandinavian Institute of Asian Studies Mono
graph Series.
(mfc Sources)
When the Searh Began — Ulhas Jajoo
The story of a team of friends and their ex
periences in organising a Novel Health Insurance
Scheme among villagers in Maharashtra — the
lessons learnt, the failures*, the perspectives
gained.
Mahatma Gandhi Institute of Medical' Sciences
Sevagram — 442 102, Maharashtra (Rs. 5|—) ,
2. Health Education Posters on Malnutrition
—Ulhas Jajoo
A set of xeroxed posters developed from the
experiences gained in the above project (1)
Mahatma Gandhi Institute of Medical Sciences
Sevagram — 442 102, Maharashtra (Rs35|- for
a set)
3. Minimum Wages — need for fair reward to labour
in Agriculture and Employment Guarantee
Scheme — Abhay Bang.
— An examination of the cost of production
of labour and new recomendation of what should
be appropriate minimum wages based on Calorie
and Protein requirements.
—Acadamly of Gandhian Studies, 2-2-11334/5,
New
Nafllaikunta,
Hyderabad •— 500 004
(Rs. 2|-)
4. Diarrhoea and ORT — Lal it Khanra
A discussion of the issues involved in the manage
and the rationale of
ment of diarrhoea
oral-rehydration therapy for pro-fessional and
and community education (in Bengali)
Chandabnati, Tamluk Dist, Midnapore; West
Bengal — (Rs. 1|-)
5. Diseases of Children (in Marathi)
— Bipin K. Parekh
A book for educating para-medical staff and
for child health education with 64 pages of line dra
wings from a total of 175 pages.
Mamata, Mamfledar Malenaon — 423203 Dist
Nasik. (Rs.20/-)
1.
Health Care io India seems to have few hard
cut opinions: this makes it easier to digest (but
far more boring) than Rakku’s Story. The latter
is a hard hitting (ie., unpleasant) view of the medi
cal system. It rejects the alternative approaches
usually suggested and so rejects their creators
(after all it is these people who might have pro
fited from reading Rakku’s Story).
Futher, Rakku’s Story is too local in place as
well ’as in time; it does not explore the broader
Tamil Nadu or Indian situation at all; no effort is
made to refer to the history of the area.
I agree that the people represented in the
book do not know (history or a geography — politi
cal, economic or social. But changing the world
begins at this point, at this question: How do we
in this historical and geographical situation relate
to other situations? For this is the beginning of the
next question: How can we change the present
situation?
Here one points to Djurfeldt & Lindberg's
book Behind Poverty. The first section of this
tftudy is devoted to filling in such background
material and, it is both specific to the area dis
cussed (Chingleput in 1969-70) and also related
to relevant parts of the broader situation' unlike
Health Care in India which has a vague “wide”
background or Rakku’s Story, which has a super
“narrow” outlook.
Studies like Behind Poverty (the social for
mation of a Tamil village) might be done for
other areas — North Arcot, Larkana, anywhere.
This study is useful to its immediate neighbours
and as a model for other areas to imitate. But
ready made analysis of fall India (without speci
fying how different various areas are) like Health
Care in India are prone to 'become “Bibles’.
Why don’t more people read their State Ga
zettes, State Histories and study local languages
as a background to NGO work in communities?
ANNOUNCEMENT
If you are prepared to launch a public ser
vice or development project, working full time and
develop this into a self sustaining, independent
innovative effort — contact Kishore Saint, Exe
cutive Director, The Ashoka Foundation 11—A,
Old Fatehpura, Udaipur. — 313 001 with ini'roductory note, plans and brief biodata The founda
tion wishes to support young enterprising persons
with strong social commitment in efforts express
ing creativity and initiative so thalt new solutions
to the myriad problems in our society may
emerge.
Pills Against Poverty — companion volume to
Behind Poverty — is*a book by two Scandinavian
University Sociologists on the introduction of
Western Medicine in a Tamil village.
The name gives away the authors’ views but
one hopes doctors will read Behind Poverty first,
however tempting the medical topic is.
Prabir, CMC, Vellore
(
Jrack
7
mfc bulletin: MAY 1985
RN.27565/76
Regd. No. L/NP/KRNU/202
Drugs in Diarrhoea—A Question of Life & Death
Clioquinol & Antimotility Drugs—are they safe?
CLIOQUINOL
Medicines like Enteroquinol, Mexaform and
Enterovioform contain Clioquinol — the drug that
has resulted in thousands of cases of paralysis 'and
blindness due to Subacute Myelo Optic Neuropathy
(SMON).
SOME FACTS
1. In the thirties, when Ciba-Geigy intro
duced Clioquinol, the animal experiments had
shown the occurance of the same disorder of the
nervous system as was found later on in human
beings. The company, in fact had warned the ve
terinarians not to use the drug in animals. But
this information was not passed to others.
2... Even cases of SMON studied by doctors
on behalf of Ciba-Giegy have shown that the disease
is found all over the world and was not confined to
Japan Seven cases were reported from Bombay.
3. Clioquinol can also produce Optic atro
phy. The Indian Opthalmogists do see cases of
Optic atrophy for which they fail to assign any
cause. When asked, if they took the history of
prolonged or repeated courses of Clioquinol taken
by these subjects, the answer was in negative.
4. Now that Clioquinol is shown to 'be harm
ful to animals as well as human beings, why should
this drug be used when we have comparatively sa
fer alternatives like Metronidazole? Dr. Andrew
Herxheimer, editor of the reputed ‘Drug and The
rapeutics Bulletin’ told me that considering all the
factors like efficacy, safety and .price; Metroni
dazole was definitely to be preferred and with the
present available evidence, Clioquinol should not
be marketed. (Incidentally he is aware of the sus
pected carcinogihacity of
Metronidazole
in
mice)
5 After all the scientific evidence was pre
sented in the Japanese Courts, Ciba-Geigy render
ed an unqualified apology for the suffering that
Clioquinol caused and then decided to withdraw the
drug world-wide.
6 When Clioquinol is readily available,
even cases of watery diorrhoeas (which /are mostly
due
to viruses) are treated by Clioquinol group
Editorial Committee :
kamala jayarao
anant phadKe
padma prakash
ulhas jaju
dhruv mankad
abhay bang
editor: ravi narayan
of drugs. So it is 'better not to have such a drug
for which a safer alternative was available.
7. Myself, a pediatric Colleague and two very
busy general practitioners of Bombay have not used
Clioquinol for years and we are' all quite happy
about it.
With my most sincere regards,
Yours sincerely,
Sd/—
Chairman, Medical Committee,
Consumer Guidance Society of India,
Ciba — Geigy Withdraws Tanderil
The multinational pharmaceutical firm CibaGeigy Pharma has announced the withdrawal of the
drug Tanderil world-wide and restricted use of the
drug Butazolidin, the Voluntary Health AssocilaTion of India said here today.
Tanderil was commonly prescribed for joint
pains While its sales will be' discontinued by the
firm, it has announced that Butazolidin will be
restricted to the treatment of only four classical
forms of rheumatic diseases: 'active ankylosing spom
dylitis, acute gouty arthritis, active rheumatoid
arthritis and /acute attacks of osteo arthritis. It is
to be recommended only for cases where other 'the
rapeutic measures have been tried and found un
satisfactory .
Dr. Mira Shiva, Coordinator, Low cost drugs
and Rational Therapeutics attached to the VolunHealth Association, said the demand for sceeening
all the drugs in the market, with immediate with
drawal of the hazardous drugs cannot be emphasis
ed more. The basic expectations from the national
Drug Policy in’ the offing were: (A) The withdra
wal of hazardous and irrational drugs: (B) Adequate
production, distribution, and availablity of essen
tial and life-saving drugs; (C) Availability of un
biased drug information for health personnel and
public and (D) Effective quality control and drug
control.
DECCAN HERALD
13th April 1985
Views and opinions expressed in the bulletin are those of the authors and not necessarily
___ —_
•
of the organisation.
Annual subscription — Inland Rs. 15-00
Foreign ; Sea Mail — US $ 4 for all countries
Air Mail : Asia — US $ 6; Africa & Europe — US $ 9; Canada & USA — US $ 11
Edited by Ravi Narayan, 326, Vth Main, 1st Block, Koramangala, Bangalore-560034
Printed by Thelma Narayan at Pauline Printing Press, 44, Ulsoor Road. Bangalore-560042
Published by Thelma Narayan for medico friend circle, 326, Vth Main, 1st Block,
Koramangala, Bangalore-560 034
Post - Script
Most of this report relates to events, information and issues in
Bhopal till end of March 1985. Two months have passed since our
survey. Much has happened in the last two months. April - May
in Bhopal.
Much still remain to be done.
1) I.C.M.R, has reiterated its guidelines on the use of Sodium
Thiosulphate as a detoxification agent, Guidelines were released to the press on the 4th of April, At the 3rd meeting of the
working group on thiosulphate therapy
held at IOMR’ head quarters
on 4th April all aspects of the problemz interpretation of research findings and points of controversy were considered and
the guidelines released earlier have been re-endorsed.
11) Locally in Bhopal, sodium thiosulphate injection is now
available in a few government clinics and dispensaries and is
gradually being made available to voluntary agencies and general
practitioners. However the implementation of this scheme is still
very tardy and reflects the apathy of the local medical servioes.
Many voluntary agencies are in the process of starting detoxi
fication clinics. A dip-stick method of estimation of urinary
thiocyanate level has been evolved by Regional research labora
tory in Bhopal and refined by Christian Medical College, Ludhiana.
This will take care of the problem of logistics of estimation by
the more sophisticated methods.
Ill) Levimasole (an ascaricide) has been used by some investigators
as an immunomodulator agent for ameliorating the symptoms attri
butable to the respiratory system.
The rationale is not yet
clear and the results of trials not yet communicated. Respiratory
physiotherapy has been accepted as having a definite place in
treatment. This was pioneered by the Union Research group but
will now become part of the general treatment schedule in all
centres. Some interest has been generated in the possible role
of treatment with hydroxycobalmin.
iv) A meeting of citizens groups and voluntary agencies on 4th &
Sth April has resulted in th$ fromation of a national campaign
committee with the Zahreeli Gas Kand Sangarsh Morcha as coordinator♦
The committee will bring pressure to bear on the government decis
ion makers and the medical and scientific community for a speedy,
just and relevant relief and rehabilitation strategy. Public
meeting, coffimunity education programmes, signature campaigns,
memoranda and other forms of Gollective action are planned.
v) A communication strategy evolved on the overall perspectives of
the mfc sujrvey team was circulcjted to voluntary agencies, decision
makers in Madhya Pradesh healtlii services. Professors of the
\
...2.
s 2 s
medical college in Bhopal and the ICI4R.
The ICMR director
general has written to say he‘considers it a significant and
constructive contribution which should certainly be circulated
to all concerned in. the government and in the voluntary and
private sector, and has offered to provide research results and
support with research and development activities,, The note has
been welcomed by the voluntary agencies in Bhopal but generally
ignored by the decision makers in the government and the local
medical college.
vi) The voluntary agencies have been active and increasing
their collaboration and joint action.
There have been two meet
ings to share experiences and there may be joint action on che
detoxification front.
One group the Trade Union Research Group
have started nutrition supplement programme with a soya/wheal
mix. Some doctors scientists and others have started the Madhya
Pradesh Vigyan Sabha which has opened a clinic, initiated a
Survey of 6000 families to build up data base to provide lc- .al
aid and plan rehabilitation programmes. They will also be
undertaking an a wareness building programme among the people.
The Indian Red Cross Society have also initiated services in Bhopal.
vii) The Bhopal Eye hospital organised a meeting sponsored 1-
the
Royal Commonwealth Institute for the blind on the Eye problems.
Many ophthalmologists have felt that all the eye symptoms are
attributable to trachoma, vitamin A defficiency and the expect
ed number of refractive errors in such a population. There is
evidence however that refractive errors corrected in OctoberNovember 1984 has deteriorated. They have eyes but cannot sea’
viii) Overdrugging has become a problem and some doctors am
beginning to recognise it finally.
There have been reports of
fungal ulcer of the cornea due to excessive doses of antibiotic
ophthalmic preparations, a case : of hyperglycemia diagnosed us
diabetes after high doses of steriod.
There are indications that
tuberculosis would have flared up due to indiscriminate steroid
therapy.
ix) The LCoM.R
organised a two day meeting May 3rd/4th 19‘3 5
attended by over eighty eminent scientists to review the current
status of research, The press release about the meeting gives some
information s carbamylation of hemoglobin may prove to be an important
marker to identify those exposed to the gas. detailed epidc'vologieal study covering 85,000 persons in the affected area on- 20000
in a non affected area have been Initiated and will include periodic
visits to monitor health problems as well as lune functions
... 3.
s 3 s
blood gas analysis, occular studies, mental health, growth and
development, neurological problems, immunological and genetic
parameters on’ a cohort of these, no rase of total blindness
identified, a survey of cognitive function in school children
is planned; the treatment schedule continues to include broncho
dilators, steroids, sodium thiosulphate and psychosocial therapy;
ICMR expert committee has recommended well designed and properly
monitored clinical trials using double blind method on the effi
cacy of bronchodilators, aminophylline, sodium thiosulphate and
levimasole.
x) Psychological stress and mental health problems have been
. established as being of grave importance by visiting psychiatrists.
A mental health team from Lucknow comprising psychiatrists. Psycho
logistsand psychiatric social workers have been conducting regular
out patient services in one of the polyclinics, and visiting 10
government dispensaries in rotation.
Surveys of mental health
problems in adults, adolescents and children are planned.
A team of psychiatrists from National Institute of Mental Health
and Neurological Sciences have conducted training programmes for
medical officers of the state health services posted in gas affect
ed areas.
The training provides necessary skill to diagnose and
manage the common mental problems seen in the victims of gas
exposure.
xi) Pregnancy outcome and effects on the foetus continues to
remain a point of serious controversy with government reports,
ICMR report, news items in local media and voluntary agency assess
ment being in constant conflict. There is growing evidence that
abortions, still births, deformities and low birth babies are on
the increase.
The controversy will hopefully be settled in June-
July when most of the mothers who were in the first trimester at
the time of exposure will deliver.
community
This calls for well planned
based investigation ICMR and other agencies including
mfc are gearing up for this.
©
0 °
The JNU study
An Epidemiological and Sociological
Study of the Bhopal Tragedy
— A Preliminary Communication, (Feb 1985) Debabar Benerji
Study of the immediate sequence of events
which culminated in the Bhopal Tragedy should
cover a very wide range of scientific investigation.
It becomes still more extensive when the immedi
ate causes are analysed against the background of
the wider issues of concern for protecion of people
against industrial hazards in India.
Non-availability of certain critical informa
tion concerning the poisoning and several other
hurdles created further problems. Quantity and the
rate of discharge of the “gas”, its chemical compo
sition, direction, and velocity of the wind and the
influence of physical behaviour of the discharged
‘‘gas” on incidence, spread and virulence, are ex
amples of such critical information.
Clamping of virtual embargo on information
on these activities, mass exodus of the victims
before “Operation Faith”, invasion by lawyers and
touts and (an understandable) deep distrust of
the victims, have been other hurdles which came in
the way of conducting the study.
Demarcation of the affected population, their
stratification into most intensely affected (hi h
mortality), moderately affected (low mortality)
and others (no mortality) and their sub-stratification interms of mohallas was the first phase of
the study design. Each mohalla was taken as a
unit for applying the field work (observation) tech
nique to obtain data on the sequence of events.
With the observational data forming the back-drop,
quantitative data were obtained by administering a
semi-structured interview schedule to a random
sample of 6.66% (1 in 15) households in each
mohalla of the most intensely and the moderately
affected population. A study population of 68,000.
covering 29 moballs (yeilding 700 households for
administering the schedule), was taken up.
Data from field work made it possible to
reconstruct the social, psychological 'atmosphere
among the population which had to take the brunt
of the 'poison gas. They were mostly very poor peo
ple sleeping huddled together in their ramshackle
shanties in the winter night of December 2-3, 1984.
They were not told of the potential dancer from the
Union Carbide Plant. They all insisted that they
were never told of the preventive measures to be
taken against any possible gas leakage. They did
not hear any alarm sinnal.
The immediate task before scientists in
India was to have an integrated approach to collec
tion of data. At the Centre of Social Medicine and
Community Health of Jawaharlal Nehru University
(CSMCH), we were particularly anxious to syn
chronise our own actions with other units within
wider organisations under the leadership of the
CSIR. CSMCH had immediately got in touch with
TCMR to develop a joint approach to study the
problem. However, as time passed it was felt at
CSMCH that there were still considerable uncertain
ties about obtaining the vitally needed epidemiologi
cal and social science date through a joint study
with ICMR. As it was feared that valuable informatwill be lost if there was any further delay,
CSMCH took upon itself the task of collecting at
least some basic data. These included: (1) size and
ddstiribution of the cases: ('a) who were cured? (b)
who continue to suffer? (c) who- have developed
complications? and, (d) who have died because of
the poisoning?
background
of
the
(2) social-economic
victims;
(3) ecological setting of the affected areas;
community organisation and power struc
(4)
ture;
(5) pre-existing community perception and
knowledge about the hazards; and (6) com
munity response to the disaster
It was quite a challenging task to design and
conduct in a short time such a complex study.
(Continued on page 2)
bilition services being organised; and a study on
the peoples perception of these: the scientific con
troversy about the cyanogen pool and thiosulphate
treatment and our recommendations for relief, reha
bilitation, communication, research and Govt-NGO
collaboration. The report also features a reference
list of over 80 articles relevant to the Bhopal disa
ster. We release this report with the sincere hope
that it will support the affected people in their
demand for justice and meaningful relief and rehabi
litation.
Copies will be available on request from
mfc office in Bangalore & Pune; CEDS—Bombay:
K.S.S.P. Trivandrum; VHAI, New Delhi; Gandhi
Bhavan, ZGKS Morcha office; Eklavya in Bhopal;
and S.H.R. Office, Bombay after 25th of June.
They were woken up with a sense of increa
singly intense feeling of irritation of the eyes and ac
companied with a most horrifying sense of suffo
cation The suddenness of the onslaught affecting
every person in the middle of the ni ht, violent
cough and vomiting and purging and the a ,ony of
suffocation and the psycholo' leal and physical im
pact of sudden blindness generated an atmosphere
of extreme panic. Even at a time when the very
survival of an individual was at stake, there were
numerous instances of efforts to come to the help
of the near and dear ones. But in the depth
that winter night, when a virtual panicky stampede
had already started in the neighbourhood, individ
uals were struck with a dreadful feeling of help-
3 •
with large holes? proportion of kuccha houses was
higher; proportions having a tap or an electrical
IconnectSon was significahtly lower While the
proportion of muslimis among the dead was simi
lar to that in the overall population, the propor
tion of those belonging to the lower and backward
castes was significantly higher.
In all, 82 dead people and 5 lost cases, prcisumed dead, were identified in the course of data
collection through the schedule. This amounts to
1305 dead in the population of 68,000. Amongst
87 dead or lost cases, males predaminate, accounting
for 52 (60 per cent) of them.
A very significant findin'■ in the analysis
was that this male predominance was almost ex
clusively accounted for by those falling within the
age rame of 2 to 20. Why is it that in all the
age groups within 2-20 years, the males predominate
to such an extent? This needs very careful study.
In 49 households there was only one death per
household. There were two deaths in 11 house
holds, three deaths took place in four households
and only one household had four deaths
Even at the time of collection of the date
(January 6-15, 1985), 57 per cent of the victims
still complained of beinr ill.
21 per cent had decided not to run out. of
their houses and the percentage of the dead who
did not run is 25.42% 73 pet cent came out 'and ran
on foot: 6.3 per cent used some vehicle in trying
to get away. None of those who used a vehicle had
died, while 75 per cent of the dead were among
those who ran
foot.
40.2 per cent of the affected population
have been treated in hospitals,2.5 per cent in dis
pensaries, 25 per cent by reneral practitioners; 2v5
per cent by registered medical practioners (RMPs);
46 per cent in camps and 9.1 per cent in institu
tions outside Bhopal.
NOTE: The quantitative date presented above are
only tentative, based on hand tabulation of some
data. Furthur analysis is awaited.
lessness when they were themselves unable to see
anything, coughing and vomiting violently and,
above all, gasping just to keep alive.
At a macro level it 'has been possible to
reconstruct the terror inspiring spectacle of the
Union Carbide Plant taking the form of a real life
Frankensteinian Monster in the middle of the night
and literally fumigating tens of thousands of in
nocent human beings like rats and pests. It is a
devastating indictment of those who blindly wor
ship technology and industry and consider them
selves as liberators of mankind.
Following the now well established pattern
of tyranny of industry on the toiling masses, even
among the shanty dwellers, the weakest sections
suffered more because many were already handi
capped with pulmonary insufficiency (due to various
conditions) and poor oxygen capacity (due to anae^
mia). They had also to pay a heavier price because
the patched up pl'anks, pieces of tin, elastic sheets
and thatch which formed the walls and roofs of
their pathetic hutments, left gaping holes for the
deadly gas to come within the grossly overcrowded
single “room”. When they found themselves getting
increasingly suffocated within their hutments, they
tried to run away in the open, often in the direction .
of the wind carrying the gas. Men, women, children
ran till they fell down unconscious. Many were
trampled on in the stampede. There were no rescue
efforts till the day break.
As in any other city in the country, a large
“number of homeless people lived in and around
the Bhopal Railway Station — transit passengers,
vagrants, destitutes and beggars. As they were
more exposed, the impact of the poison on them
was much greater — the deaths must have been
proportionately larger in their case. But there is no
record or estimates, of this.
As expected, the few rich, who came within
the central sweep of the fumigation, did not “suffer
as much damage. They had the protection of their
well-built houses and healthier bodies and many
of them could escape the gas by using bicycles,
scooters, cars, jeeps, tempos or trucks.
More than half of the affected population
belong to a category which did not ge*t two full
Imeals everyday all around the year. Only 10 per
cent of them could be considered well-off in the
sense that they do not have any problem in getting
two-full meals and have an income of, say, Rs 150
per head per month or more. Half of the houses
had holes in them which allowed in air from out
side in the winter. 70 per cent of the houses were
kucchia houses. Only 38 per cent had a tap and 6Q
per cent had an
electrical connection, 30 per
cent of them were muslims, 20 per cent belonged
to lower castes and 18 per cent to the backward
castes.
A remarkable feature of the socio-econo
profile of the dead is that in terms of every crite
ria, this group was even more disadvantaged than
the affected population. There , were more poor
among the dead. 56 per cent of them lived in houses
MID-ANNUAL MEETING
The mid-annual EC/Core group meeting of
mfc will be held at Sainik Rest House, Patiala from
26th to 29th July 1985. At this meeting we will be
discussing the following:
1) The role of mfc — Discussions will be based on
articles of Ashvin Patel and Anant Phadke fea
tured in mfc bulletin 100-1 in April — May 1984.
2) The me intervention in Bhopal — an assess
ment and future strategy.
3) Some case studies will also be presented to
try and identify the focus of ’he next annual meet
on the theme. Occupational and Environment
health.
Detailed information and further background
is being sent to all invitess separately. In lieu of
the uncertainties of Punjab, alternative venues are
'also being explored. Delhi is a likely alternative.
4
4
The 'Nagrik' Study
The Bhopal Disaster:
Effects on Mental Health
(Highlights of the survey conducted by the
Citizens Committee for Relief and Rehabilitation,
Bhopal, the Voluntary Health Association of India;
New Delhi and the Bhopal Relief Trust, Bombay).
'Things can be so bad that to be sane is insane’
Nietzsche
The Bhopal disaser has once again brought
to the fore the phenomenonal psycho-social collec
tive stress that people can be subjected to by manjmade or natural interventions in history. “The
psychological phenomena of disasters are the con
sequences of the combined individual stress reac
tions and of reactions to changes in the social
milieu1. Hence the psychic distress and behavioural
disturbances of 'an indivdual cannot be fully under
stood or managed unless they are analysed as
—^elements in the disruption of the equilibrium of
a social system”. (1) The fourth Advisory meleting
on Mental Health (ICMR) December 12^14, 1984.
viewed the mental health needs of the affected popu^lation as follows: (3)
The acute needs are the understanding and
provision of care for confusional states, reactive
psychoses, anxiety-depression reactions and grief
reactions.
Longterm needs arise from the following
areas, namely (1) Psychological reactions to acute
and chronic disabilities, (II) Psychological prob
lems of the exposed sub jects (currently not affected)
to uncertainities of the future, (III) effects of
the broken social units on children and adults, and
(iv) Psychological problems related to rehabilita
tion”.
A mental health team from Lucknow com
prising psychi'atristsi, psychologists and psychiatric
social workers have been conducting regular out
patient services at a Government Polyclinic in
Bhopal and visiting 10 Government dispensaries in
rot'ation. The mental disorders seen are neurotic
depression, anxiety neurosis and hysteria. Psychotic
disorders are rare. There are plans to survey the
affected population for detecting and providing
(Continued on page 8)
Salient Findings
* People living as far as 8 Km away from the
carbide factory have been affected by the MIC
gas.
* Of the 741 patients examined by the Survey
team, (104 to 109 days after disaster) it was
found that injury persisted in almost all the cases
in spite of the treatment that the victims had
received so far.
* There was a high level of thiocyanate in the
iSub-soil lakes and filtered water of Bhopal, even
more than 100 days after gas disaster
* The blood of ’affected population showed that
their average thiocyanate level was three times
that of the average found in Bombay.
An unusually high number of women had abor
ted and were also complaining of unexpected
white discharge.
* Clinical examination of expectant mother re
vealed that the development of the foetus has
been adversely affected
# The vision of a large percentage of children* had
been affected by MIC and a sizable num
ber of the affected people m'ay develop cataract
irrespective of their age. A large number of
people have refractive errors.
* A good number of patients wete found to be
having stomach and abdominal complaints.
* The affected population mainfested neuro muscuweakness of an unknown nature.
* The tragedy has also created excessive psycho
logical stress
Important Recommendations
* Systematic follow up and monitoring of all affepeople for a minimum of three yeans.
* .Every person in affected area to be X-rayed at
six monthly intervals for three years, to ensure
that further complications did not arise.
*
All women who were pregnant at the time of
the gas disaster and those who conceived sub
sequently should be carefully monitored. Modern
monitoring techniques like Ultra-Sonography
and aminocentesis should be used for the pur
pose. The parents must be 'advised about the
possibilities of abnormal babies, and should
be suitably coniselled for continuation or termi
nation of pregnancy.
* Ophthalmic camps should be set up immediately
in the city for testing of vision and providing
spectacles.
Affected people should be made to undergo
investigations like the electromyography (EMG)
before and after exercise for both limb and
eye muscles.
All babies born since December ‘84 have to be
monitured carefully for the growth and latent
abnormalities.
Rehabilitation programmes will have to be
worked out after assessing the datmage for
helping the victims to take up new jobs and
occupations in conformity with their disability.
* Potable water in Bhopal needs to be made
safe and there is urgent need to decontaminate
the water if the level of thiocyanate was found
persisting.
Source: Report of “Medical Survey on Bhopal Gas
Victims” released on May 2, 1985. Copies
available with Nagrik Rabat Aur Punarvas
Committee, 34 Ashiana Complex, Kohefiza,
Bhopal-462 001.
5
Nuclear Reactors
environs of the present NFC site, since daily one
drum of waste is produced and the quantity is
likely to double. This hazard is particularly dange
rous since -it gets carried through generations.
Nuclear reactors and fuel complexes are
increasingly becoming status symbols of moderni
sation. As an energy resource the government is
fast promoting their development all over the
country. In many countries their continued use
is beginning to be questioned in lieu of the potential
environmental hazards. We present here a letter to
the 'Prime Minister which was sent by the Joint
Forum for Protection of the Environment, Hydera
bad in May 1982. This forum consists of the Hydera
bad branches of the Indian Women Scientists Asso
ciation, Forum for Science, Technology and Society
and the Society of Biolo ical chemists of India.
The letter brings out in graphic detail a real-life
case study of the potential hazard of such com
plexes.
3) Disposal of non-radioactive wastes: Despite
the NFC’s claim that only non-pyretic materials
like magnesium chloride are dumped out, the
presence of inflammable materials like magnesium
and zirconium in these dumps appears to be true;
and the recent deaths due to burns in the area that
have been repored in the national press need no
reiteration here.
In view of the ignorance and
poverty of the masses in India, extra precautions
and security in disposal of such wastes is
essential. The disposal of extremely toxic metals
like arsenic and selenium produced in the special
materials-plant of the NFC is also not safely done.
“This letter is to share with you our serious
concern about what we have read, heard and seen
regarding the safety measures and methods of
disposing wastes at the Nuclear Fuel Complex
(NFC) in Hyderabad. The information contained in
this letter is based on a) recent visits by the mem
bers of our 'Forum to NFC, and the discussions held
with some senior officials of NFC regarding waste
disposal facilities, and (b) feed-back from some
of the past and present employees of NFC, re arding in-house safety measures. We are convinced
that the situation as it stands is alarming, and
likely to become disastrous if NFC goes ahead with
its plans to double the production under the exist
ing conditions. NFC is a high technology enterprise,
which handles vast amounts of toxic, mutagenic,
inflammable and radioactive materials. Thus it has
to be especially responsible in its material handl
ing and disposal, and in educating the workers re! arding the hazards involved and the care needed.
As a public sector enterprise, it should be a trend
setter in such matters.
Some of our findings
are as follows:
An Alert
4) Effluent treatment facilities: The sedimenta
tion tanks and evaporation ponds are poorly cons
tructed and lead to contamination due to spillage,
particularly in the monsoon season. The effluent
treatment facilities at the NFC appear t0 us
to be primitive and inefficient, considering the fact
that the NFC is a high-technology enterprise.
5) Hazards to school children in the area: Besides
the hazards mentioned above, we are also informed
that three children of the DAE Central School have
died in recent years of malignacies. It is impera
tive that routine screening and health checking of
children be done by an independent body such as
the school health board doctors.
6) Workers’ safety: Apart from the environmental
hazards listed above, there seem to be inadequacies
in the safety measures in the in-house working of
the NFC, posing health hazards t0 the workers
there. A few examples are: chlorine leakage in the
zirconium sponge plant; bursting of boiler pipes
\Such as what happened on 26/3/82); exposure to
"Jth temperatures near the chlorinating plant
(which might lead to conditions of “sub-fertility”
in men as suggested by the high rate of abortion
among their wives); high levels of alkali dust and
sulphur dioxide in the atmosphere around the zir
conium oxidation plant causing allergy and bron
chial problems; respiratory problems due to fumes
of oxides of nitrogen in the uranium oxide plant
where exhaust facilities are poor, provision of
poorly designed masks to workers in the rrinding,
blending and ammonium diurariate cake oven areas;
no masks in the wet areas where there are fumes of
nitrogen oxides. Rubber gloves are provided twice
a year only, and as a result the workers often have
to handle dangerous material with tom gloves or
even bare hands. An instance was reported to us
where an officer allegedly handled uranium powder
with bare hands as an act of bravado, presumably
to convince the workers that the material they were
handling was not all that hazardous. This report, if
of particular concern
Contamination of drinking water wells in the
area with nitrates and
radioactive
—- —
-1----- ..e materials: This
is a problem that the NFC is aware of(> the trend
already is alarming, and is bound to reach serious
proportions in the near future if no corrective mea
sures are taken. Also, the firm that buys the nit
rate-rich effluents from NFC, M/s. Deccan Nit
rates, does not handle them with the required care,
resulting in ground water pollution.
2) Burial of radioactive waste — Uranium: The
present containers used for the packing and burial
of the waste uranium are dangerous, since they
cannot withstand the environmental wear and tear.
There is every chance of the waste seeping into
the ground and entering the food chain. Though, al
pha rays are poor penetrators, they are extre*mely
dangerous when ingested.
There also appears to be the eventual danger
of spreading this hazard to areas other than the
(Continued on page 8)
6
1
I
Food in the Hands of Big Industry
Iodine — deficiency goitre is one of the
nutritional prolems that can be very easily con
trolled and prevented. This has been successfully
done in many European countries. In India, the
entire Sub-Himalayan belt comprising of Jammu
& Kashmir, Punjab, Haryana, H P; northern parts
of UP, Bihar and Bengal, the far-eastern States
and isolated pockets in Maharashtra and M P. are
endemic for goitre. In 1959, the government with
UNICEF aid set up 12 iodisation plants to produce
iodised
salt
(Potassium
iodate
added
to
common
salt).
The salt
produced
was to
meat about 50% of the estimated needs and also
some of the needs of Nepal. However, and not sur
prisingly, even this simple programme of manufa
cture and distribution of the salt, suffered from
various defects. These were reviewed by Dr. Gopalian
under the title ‘The National ooitre Control Pro
gramme — A sad story’ (NFI Bull. July 1981).
About four years ago, at a seminar at the
NIN, we were informed that the government
was
contemplating handing over the iodisation pro
gramme to the Tatas. In this matter, obviously the
govt, did not drag its feet and on my recent visit
to Delhi, 1 saw iodised salt in the mlirket. Whether
handing over the production to the Tatas will solve
the goitre problem, is an entirely different matter.
I do not know whether Tatas will also handle the
distribution One of the reasons for the failure of
the National Programme was nonavailability of the
required number of railway wagons for the trans
portation of salt, and that the railways did not
provide covered wagons durin? the rains. How
will the Tatas solve this problem, and if distribu
tion is still in the hands of the government, then
what matters who produces the salt?
The Control Programme involved manufa
cture and distribution of the iodised salt. Plants
for iodisation were set up with UNICEF aid and
we had all the technical know-how. Since it was
fortified common salt, the house wife would use it
in cooking and there was not much nutrition educa
tion involved. The salt was to be sold in place of
ordinary cooking salt, therefore sale of ordinary
salt was to be banned The extra cost of iodisation
was not to be borne by the people but by the govt.
There the salt was to be sold at subsidised
cost. Perhaps, Tatas are now receiving the subsidy.
Whether administrative inefficiency^ alone wais
responsible for handing over the production to the
Tatas or whether other factors weighed equally or
more, one will never know.
As Dr. Gopalan said
“administrative incompetence,
lack of co-ordina
tion between various agencies involved, and Com
mercial and vested interests (emphasis mine) have
apparently combined to wreck the Programme.”
Although termed a National Programme it was natu
rally restricted to certain contiguous geographical
areas. Of couse, in a country of India’s dimensions,
even this area is sufficiently large. Nevertheless,
the Programme was a comparatively simple one.
But it failed and that too, in the hands of a govern-
ment which claims to improve the health and nutrition of millions of children through a nation-wide
network of ICDS Programmes.
I do not know whether the Tatas are using
the national iodisation plants or whether their salt
production is in addition to that produced by the
public sector or whether those plants are now let to
lie idle. The point is, that a health programme, not
dependent on ‘drugs’, has passed into the private
sector.
That, however is not the end of my story.
Of the total common salt, or sodium chloride manu
factured, only a small amount goes for human
consumption. Much of it is used for industrial
purposes.- The Tata chemicals were perhaps already
manufacturing common salt, and production of
iodised salt will be a very small part of this ven
ture. However, for producing edible salt for iodisa
tion, they apparantly produce more salt than
needed for fortification. The Tatas are therefore
now marketing table salt, at least in the cities
where table salt (powdered common salt) is mostly
-used.
Hitherto, table salt was marketed by small
entrepreneurs. It w’as
mostly pulverised crude
salt. Tatas salt may be more refined. However, the
small industries will never be able to compete with
a big industrial house. By taking the lead from the
Tatas, if other chemical manufacturers also market
table salt, the small or cottage industries will have
to close their business. A year or two ago, Brooke
Bond, the famous Tea and Coffee House Started
marketing powdered spices like chilli, turmeric,
dhania etc. Once again, entry of a big industrial
house into the domain of cottage industries. Very
recently, in the South, another big company has
started marketing vadams (badis) and papads, in
fancy shapes and under very fancy names
This then is a slow but steady entry of big
industry into that part of the processed food market,
which uptil now was entirely under cottage indus
tries. Although such cottage industries were in the
hands of middle classes, driving them out of busi(Continued on page 8)
mfc needs you in Bhopal
Your support,
donations,
involvement;
volunteered presence and participation continue to
be required in Bhopal.
Ths tasks ahead.
— Organisation of Detoxification
clines and
trials through voluntary agencies.
— Pregnancy outcome study
— Developing content for Health education and
aw'areness building postsrs, pamphlets etc.,
'— and many other areas of action.
For further details write to mfc, Gandhi Bhavan,
(ne’ar polytechnic), Shyamala Hills, Bhopal —
462 002 or to mfc, Bangalore office.
7
1
I
4
r
mfc bulletin: JUNE 1985
RN.27565/76
Effects on Mental Health
(Continued from page 5)
supportive follow up for mental health problems in
adults, adolescents and children (2).
A team of psychiatrists from NIMHANS,
Bangalore Wave conducted training programmes in
mental health for the medical officers of the state
health services, posted in ths gas affected areas.
Tht training provides the necessary skill to diag
nose and manage the common mental problems seen
in the victims of the gas exposure (2).
A mental health care manual has also been
prepared by the Bangalore team (3).
The mental helalth dimension is a much
neglected dimension of health inspite of the much
publicised WHO definition of health. Doctors in
Bhopal were disregarding or misinterpreting the
symptoms of
stress
and
passing
it off
as malin ering or compensation, neurosis,
Thiis
mis-diagnosis was sadly reflective of our medical
training which plays only lip service to mental
hefalth inspite of its grave importance in health'
care and the doctor patient relation-ship.
We salute our community oriented Psychia
tric colleagues for bringing to the fore this much
neglected dimension through practical interventions
in supportive care, communication and training in
Bhopal and not exploiting the situation only for
its research potential.
1. Kinston, W and Rosser, R. (1974)
Disaster: Effects on Mental and Physical state, Journal of
Psychosom. Research 18, 437
2. Directorate of Information and Publicity, M.P. Govt (1985)
Review meeting of ICMR Projects at Bhopal, Khabar.
5th May 1985.
3. Mental Health Care Manual for Medical Officers.
by R. Srinivas Murthy et al., National Institute of Mental
Health and Neuro Sciences, P.O. Box. 2900, Bangalore 560 029. (For copies of the manual write to Dr. R. Srinivas
Murth} at the above address)
4. Also available with mfc office a list of references on mental
health aspects of disasters.
The Challenge of Bhopal
(Continued from page 1)
ght provoking example showing
to, we can.
that if we
want
Bhopal too is a challenge? So are many other
more insidous developments in our country. The
growing investment in- nuclear 1— energy now dis
credited as an energy resource in the West, or the
gradual take over of the cottage industry in food
by big
business, — each of
this
though
different from th© other has a growing similarity
representing either a subservience to the profit
motive or an insensitivity to health hazards or
Editorial Committee :
kamala jayarao
anant phadke
padma prakash
ulhas jaju
dhruv mankad
abhay bang
editor: ravi narayan
\
Regd. No. L/NP/KRNU/202
both. We feature some of these aspects in this
bulletin. We also feature investigations in Bhopal
which raise some of these issues for our readership.
Minimata, Seveso, Long island were too1
distant to make any impact. Amlai, Chemibur, Handigodu, Harihar, Zuari, Nagda, Mavoor, Silent vally,
Thai vaishet hare not stimulated us either. Will
Bhopal dp so?
Nuclear Hazards
(Continued from page 6)
true, is truly shocking.
7) Functioning of the health physics unit: The
health physics unit that monitors radioactivity and
oher environmental pollution in the NFC should be
under an independent agency not answer able to NFC
or the BARC. The alleged victimisation of a scien
tist of the health physics unit who did try to raise
his voice about some of the environmental issues,
(if correct) is a matter of deep concern.
In conclusion we suggest that an independent
panel of experts and concerned ctizens be invited
to make an indepth, impartial inquiry, and review
the situation in its totality (rather than isola
ted accidents) and suggest immediate remedial
measures. In this regard our Forum will be willing
to offer Whatever help it can.”
(Some action towards improvement has taken
place in response to this letter. For instance the
Nuclear Fuel Complex has been brought under the
Pollution
Control
Board
and
they
have
to
obtain
consent
from
the
Pollution
Control Board before discharge of the efflu
ents. They
have
built a compound
wall to
improve security. Their sedimentation ponds have
been lined with some kind of plastic material to
prevent seepage. Several shortcomings still need to
be reexamined.)
Will citizen’s groups keep- up the pressure
please! This is particularly urgent since a recent
government decision will promote their installation
all over the country in our attempt to prepare our
selves for the
‘quantum
jump*
into
the
31s Century. The movement against the prevention
of Nuclear War is not enough!!
J !
(see mfeb 102)
(Continued from page 7)
ness in this manner, will not help the poor but only
expand the ranks of the poor. I am not an econo
mist. I do not understand the full implications
and the reasons for big industry entering into the
small-chain food market, but to me the consequen
ces appear alarming.
— K. S. Jayarao, Hyderabad
Views and opinions expressed in the bulletin are those of the authors and not necessarily
of the organisation.
Annual subscription — Inland Rs. 15-00
Foreign ; Sea Mail — US $ 4 for all countries
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Edited by Ravi Narayan, 326, Vth Main, 1st Block, Koramangala, Bangalore-560034
Printed by Thelma Narayan at Pauline Printing Press, 44, Ulsoor Road, Bangalore-560042
Published by Thelma Narayan for medico friend circle, 326, Vth Main, 1st Block,
Koramangala, Bangalore-560 034
114
medico friend
circle
bulletin
JUNE
1985
EDITORIAL
THE
OF
CHALLENGE
BHOPAL
“The growing multinational culture must be destroyed because it leads to economic chaos, increased
social disparities, mass poverty andfilthy affluence in coexistence, environmental degradation, and ultimately
civil strife and war.
To get a balanced, rational development and to preserve the environment, a new development process is
needed. The biggest intellectual and political challenge of our times is to articulate and demonstrate this
new kind of development.”
— A statement of shared concern
Citizens report on state of India’s Environment. 1982.
I
Its six months since the worst industrial and
environmental disaster in recorded history. Bhopal
has not only been a nightmare for those who were
there on the night of 2/3 December, 1984. It is
also a portent of events to come.
World Environment Day (5th June) has
come and gone. There have been the usual meetings,
seminars and lectures, the usual lip-service to eco
logical sensitivity, the usual narrations of the
health and social hazards of environmental pollu
tion and the usual pious recommendations of what
clan and should be done.How many more Bhopals will we need in this
country before we are shaken from our apathy?
—from our callousness to our disadvantaged
tend exploited fellow human beings who are
always the worst hit in such disasters.
•—from our insensitivity to nature, our forests.
our rivers and our land.
—from our insensate rush for chemicalising and
technologising our lifestyles.
—from our race for profits even tet the cost of
the health of our workers, our people.
The medical community in India will be
increasingly called upon to respond to the medical
aind health problems caused by more ecological
disasters. What will our response be?
Will we see every disaster as a chance to
refine our clinictel skills, satisfy our charity and
welfare urges, exploit the research potentate! for
career development and use the opportunity to ask
for more and more sophisticated gadgetry for our
institutions?
Or will we be challenged by these disasters
to riaise our voice collectively to oppose the unheal
thy trends in our society to use our knowledge
and social potential to support the growing aware
ness for a healthier and more egalitarian social
system; to use our research skills to strengthen and
concientise our fellow human beings to an increas
ing health 'and ecological awareness.
The dilemma of a man who enters a room
to find a tap running and a wash basin overflow imp
faces us today. Will we choose 'to be floor mowpers
or tap turners off?
\
Overpowered, compromised and hypnotised
by the products and high pressure steles tactics^ of
the multinational pharmaceutical industry, our Sen
sitivities have been so dullened that we are, quite
content to be merely ‘floor moppem’. Can we ever
be tap-turners off? The International movement of
physicians for prevention of Nuclear war ife a thou(Continued on
page 8)
INSIDE
i
Bhopal
The mfc study
2
The JNU study
3
The ‘Nagrik’ study
5
Mental Health?
5
Also
Nuclear reactor-an alert
6
Food in the hands of Big business
7
The mfc study
The Bhopal disaster aftermath
— an epidemiological and medicosocial investigation.
The medico friend circle survey team
which undertook an epidemiolo. ical and medico
social survey in Bhopal, of a randomly selected
community based sample of 60 families each of
J.P. N'agar (severely affected) and Anna Nagar
(minimally affected) from 19th to 25th March 1985
has found that more than 100 days after the disa
ster the people affected by the toxic gas exposure
which included MIC suffer from a multisystemic
manifestations of physical
and
mental, ill
health further compounded by psycho-social and
socio-economic family and community crisis.
Medical Monitoring of affected people
Community he'd 1th orientation of medical
relief centres.
vii) Family based records.
— only this will meet the peoples needs and expec
tations.
v)
vi)
2. A communication strategy which will include
a) A continuing education strategy for all he'alth
personnel working in gas-affected areas in go^vemment or voluntary agency clinics.
b) A creative non-formal health education of the
affected people in which available knowledge
of the disaster and its effects on health must
be translated into supportive interventions in
lives of the people.
Salient Findings
* A multidimensional symptomatolo y reflective of pulmonary, gastrointestinal, neuro mus
cular and visual dysfunction
* Disturbances in vision particularly distant/near
vision problems
* Disturbance in menstrual function in women with
an increase in certain types of gynaecological
problems, as well as a disturbance in sexual
functions in male.
* An established effect
on Lactation in nursing
mothers.
* A highly probable risk to the child in dtero.
* A large magnitude of psychic impairment
This strategy must be dynamic, responding
to new developments in the peoples health status as
well as to research findings as they become known.
3. An integrated, community based, epidemiologically
sound, research endeavour.
This must shift focus from hospital or dis
pensary based samples to population based samples.
Epidemiological profiles of ill health and disabi
lity need to be built up using sodium thiosulphate and
other treatment not only as thefapy but also
potent epidemiological tools through well designed
community based trials.
All the above ill health is within the
social context of a highly disadvantaged, low income
Trooto of Fasti-dwellers, whose earning capacity
has Theen further compromised due to loss of
wage’s; physical disability and mental stress affec
ting/work performance; and who have escalated
into Ian acute socio-economic crisis due to inadequate
compensation and greater indebtedness due to in
creased lo»an taking ,to avoid penury. Unless the
health of Bhopal victims is seen in this totality, one
cannot even begin to appreciate the true magnitude
of the huhian problem.
Urgent issues needing focus are risk to the
unborn foetus and risk to the reproductive system
of affected individuals. There is also urgeht need
for informed consent 'as a minimum medical ethic.
Government — voluntary agency
collaboration
Closer coordination and encouragement
of active collaboration by government, ICMR and
local decision mlakers with voluntary agencies, citi
zens committes, action groups and socially sensi
tive sedtions of the medical and scientific commu
nity.
This coordination must be dynamic, open to
dialogue and debate, mutually supportive and free
of suspicion.
4.
Recommendations
The relief and rehabilitation of the affected
population must therefore be through an integrated
community health and development plan which is
evolved by multidisciplinary interaction 'and close
collaboration between the'government and non
government voluntary agencies and citizens groups
fully involving the affected community in planning,
decision m'aking, organising and maintenance of the
services.
The welfare and rehabilitation of the disaster
victims must be our primary concern.
(NOTE:— The above is ’a synopsis of our
conclusions and recommendations which will be
available as a printed report of the mfc study by
the middle of the month (cost Rs. 5/-). The report
includes the detailed findings of the team; includ
ing tables; review of available literature on MIC
and details of ICMR and other studies in Bhopal,
some observations on the psycho-social dimensions
of health; a review of the medical relief and reha-
We recomend,
1, A community oriented relief and rehabilitation strat
egy which must include
(i) Occupation/economic rehabilitation
(ii) Basic supplies till (i) is over
(iii) Psychosocial support
iv) Medical relief including detoxification
(Continued on page 3)
2
I
I
medico friend
circle
bulletin
JULY
1985
Blessed are the small in size — if they are Indians
Kamala S. Jaya Rao
(A debate has been going on over the past 4—5
years regarding the meaning of malnutrition and
the significance of small body size. The debate is
published mainly in Economic and Political Weekly,
land to some extent, elsewhere also.. The debate was
sparked off by a study by V. M. Dandekar and N.
Rath on the measurement of poverty in India. Since
the whole debate is of topical interest land concern
to mfc. Anil Patel 'has been coaxing me to write
about it in the Bulletin. I have been hesitating
because,
being
a debate
mainly
between
economists and statisticians, 1 felt I cannot do am
ple justice to it. However, I agree with Anil about
the importance of the subject to mfc and Abhay
Biang assured me it is not too late even now to
write about it. I have, for obvious reasons, kept
absolutely clear of all complicated statistical
definitions and Arguments. Yet, I hope, I have bro
ught out the essence of the debate, and more import
antly, the implications of it.)
In 1971, Dandekar and Rath published the
results of their study on measurement of poverty
in Indila. The definition of poverty is relative, and
varies from place to place and, from time to time.
Any criterion chosen to, measure the incidence of
poverty has, therefore, to be necessarily arbitrary.
However, there has to be strong logic in using thlat
particular criterion. Dandekar and Rath used the
mean per capita energy requirement of la household
as the cut-off point; percentage of households con
suming less energy than this value should be con
sidered a percentage of population thlat is poor.
The argument being that the income of the house
hold was so low that it did not permit them to buy
adequate food to meet the specified energy. There
fore households with such low energy intakes may
be considered poor and therefore income levels of
such households be considered as being below the
poverty line. This argument sounds logical It 'is
well-known that in countries where malnutrition is
a sizeable problem, the major cause is poverty. It
is also known that in poor households, a major part
— 80% or more — of the total ingome is spent on
purchase of food. Dfandekar and Rath therefore
considered income levels which did not meet with
the mean per capita energy intake of a household, as being below the poverty line. Thus esti
mated, the incidence of poverty, in the seventies,
was 40%. It is necessary to point out one thing
here: this does not mean thlat a household with low
energy consumption (less than 2^250 Kcals) is
necessarily poor or that one consuming more than
2,250 Kcals is necessarily not poor. The figure
only indicates that by the chosen ylard-stick the
incidence of poverty in India was 40%.
Dr. Sukhatme objected to the use of the mean
energy intake as the cut-off point. Perhaps Dr.
Sukhatme would not Wave objected if the figure was
higher, but strangely
and unfortunately the
figure was 40%. Let me explain this. In a large
population, if the values follow a normal distribu
tion (statistical normal) the mean and the median
values will be similar, so, hlalf the population
will have values above the mean, and half below the
mean. Dr. Sukhatme largued that if nearly half the
population is to be considered undernourished, the
other half must be overnourished. Hence, there will
be no one with normal nutrition! Therefore, the
use of the mean figure as a cut-off point was wrong.
If you notice, the focus took a strtange turn. While
Dandekar and Rath said that about 40% of the
households were poor, Sukhlatme said that 40% of
the population was not undernourished
Dandekar (EPW 16 (30) 1241, 1981) pointed
out this anomaly. He said, T wish to emphasise
that, all through our little study on Poverty in
INSIDE
Emerging Medical Culture
5
On Calling the Laboratory
6
Dear Friend
7
News from Bhopal
8
Indila, Rath and myself have been discussing pover
ty and not underQutrition’.
control of body weight is exercised through
llary co-faictors’.
When a population is classified on the basis
of a certain income or expenditure, howsoever deter
mined, .... we are defining poverty
, on the
the other hand, if we classify la population by its
energy intake, we are trying to identify undernutri
tion
The two are related,
But the
two are not identical’.
‘The only inference I dan draw is that energy
intake is used with variable efficiency by means of
some homeostatic mechanism working for the good
of the whole body and controlling body weight in
the process
The real controlling variable of
the homeostatic process is not energy balance,
but fluxes, pressures, electric potentials, concentra
and body
temperature,
environment,
tions
etc.’
‘However, 'a point is reached in the
intake; below which the body is not able to
maintain body temperature andI is forced to part
,
-xi
..
p .
.
•
x .
•
. .
with
its
fat
to
maintain
weight.
That is the point
of undernutrition, also alternatively called the
lower threshold value of the homeostatic tatage,
for maintaining nutrition state of the body. In . . .
Kerala, external temperatures are close to body
temperature, heat dissipation is negligible
and
body weight can be maintained at relatively low
intakes’.
I will explain in a little more deWil why
Sukhatme is not willing to accept the mean figure
as the cut-bff point. However, it is necessary to point
out that while Dandekar Was considering energy
intake of households, Sukhatme was talking of '
energy intake of individuals.
The rlange of values for any parameter indicates
that the value for that parameter is not the same
for every individual studied. Different indivi
duals have different values, and the whole forms
the range. Thus there are variations in values of
individuals, that is, there is inter-individual Varia
tion. Apart from this, there is an intra-individual
variation. For example, if my fasting blood sugar
is 80 mg% one day, it may be 75 on another day
85 on another day—but all within the normal range.
anci
I will not comment on Sukhfatme’s knowledge
of human physiology. Perhaps, he should have stuck
to his own field of statistics and not strayed into
nutrition and physiology. He calls the ‘-2 S. D
level’, a threshold value. Thus, wittingly or unwit
tingly, he Was invested this statistical cut-off point
with physiological significance. It is important to
remember th^t this so-called ‘threshold’ is a stati
stically derived value for a set of energy intakes. If
nutritionists were to discover at any later date,
that what they hitherto considered the meain energy
requirement w|as an error, and that the mean is
actually higher or lower than the presently consi
dered value, the 2< S.D. value may also change.
Then, will the body also change the level lat which
it is ‘able to maintain body temperature’?
According to Sukhatme, the inter- and intraindividu'al variation in energy intake of individuals
of a given physiological group, are similar. Thus,
if the energy intakes of females of my tige and body
size were to range from 1900-2500 Kcals, my
energy intake on different days may also vary from
1900-2500 Kdals. Sukhatme derived this by analy
sing data published by other workers. His conten
tion may be true, or may not be true. The reason
for my doubt is not on statistical grounds; but
from a purely common sense point of view, it seems
incredible that the Variation can be so large.
Nevertheless, we shall accept it in the absence of
any contrary data. This being the case, Sukhatme
slays that one should consider only values below—2
S.D. of Mean as low intakes. Thus estimated, and
according to Sukhatme, the incidence of under
nutrition in the country is only about 2,0%, or half
of the figure derived by Dandekar. Dandekar, in
turn, analysed data published by the NNMB, using
the criterion suggested by Sukhatme and found
that 40 — 45 % of the households had energy inadequlacy. Dr. Sukhatme prompty rejected this on
grounds that NNMB data were not reliable.
Now Sukhatme’s argument Was that since in a
healthy, active population half of them are expected
to have energy intakes less than the mean, if we
accept Dandekar’s figure of 40%; it shows that the
population is healthy, active and normal! We
must remember that energy intakes of half a nor
mal population will indeed be below the mean but
but if their requirements were higher, they c’an af
ford to buy the extra food Dandekar was saying
that 40% of the households had incomes which did
not permit expenditure on food to meet the mean
requirement. He therefore Sarcastically asked whe
ther in a healthy, active population half of them
should have such low incomes too! He said Sukhatme Was unable to clearly see the distinction bet
ween poverty and, undernutritionthe two are re
lated; but not identical, phenomena. He then said,
‘Sukhatme is confused’. I do not 'ag*ree with Dandekar. Sukhatme was. not confused. Sukhatme sim
ply tried and succeeded in confusing nutritionists as
v^pll as 'administrators, by neatly exploiting the
fact that Dandekar used energy requirement as a
yard-stick to measure poverty. Sukhatme’s argu
ment that undernutrition is far less than 40%, and
his use of terms like ‘threshold value’ — have come
in handy in many quarters. Dr. Gopalan put it mild-
Two questions arise here. If a normal indivi
dual’s energy were to vary between — 21 S.D. to
+ 2 S. D. of mean, why can it not on occasion fall
below — 2 S.D. too. Why should he be classified
as undernourished if on one day his value is this
low; in the riext few days he may go back to the
above—2 S.D. level, since his intake is highly vari
able. Secoridly, how does the body deal with such
large variation in energy intake? Sukhatme gave
his answer (EPW 17 (50) 2000, 1982): Tf the con
trol system in the body were to tolerate energy
balance of this order and yet maintain body weight
within narrow limits
(it) means that the
2
ly when he said that this has ‘generated the unfortu
nate impression among policy-makers that under
nutrition is not a serious problem in the country
any more’ (EPW 18 (15) 591, 1983). Sukhatme
himself proudly proclaimed (EPW 16 (32.) 1318,
1981): ‘Already the term mild malnutrition has
disappeared, .the principle that an individual eating
below the recommended intake is at risk and that as
the intake decreases the risk of deficiency increases,
is being reformulated’. Whoever has helped Sukhatme
in performing this hat trick, I am certain it is not
the sensible among the nutritionists.
eager to know what this wonderful biochemical
measure is, but would have been immensely gr'ateful to Sukhatme had he declared its nature.
Whether it is warranted or unwarranted to
label them as. undernourished, the fact remains that
a large number have a small body size. In Nepal
and Sri. Lanka which are our neighbouring coun
tries, and whose data Sukhatme has published
(EPW 17 (50) 2000, 1982), ignoring India, only
40—60% have normal body size. So at le’ast 40%
have small size (height or low body weight or both).
Strange, but we have come back to the figure of
40% 1 What about this? Tell them, tell the policy
makers and planners they are ‘small but heialthy’
says Sukhatme. They can work hard, they do not
die; in other words, they have ‘adapted’ to .this
and they are in no- danger.
In assessing nutritional status, energy intake
cannot be the sole measure. In fact, a single ass
essment by itself is not a reliable indicator. It has
to be taken in conjunction with anthropometric
measurements, at least, height and weight. Irres
pective of whether values below mean energy require
ment or below—2S.D. of mean, should be consi
dered as undernutrition, if 'a large portion of the
population is underweight or underheight or both,
this needs to be taken note of. Since undernutrition
is a major cause of growth retardation in a country
like ours, this should also indicate the incidence
of undernutrition in a population. If Sukhatme’s
argument w’as correct, then a large proportion of
the population should have normal body size, which
we know is not true. Sukhatme was quick to rea
lize that
this
argument
would
crop up.
In fact, he was quicker than the nutritioni
sts, who for some reason kept quiet for a long time.
Either we were overwhelmed by the statistical lan
guage, or the whole debate was considered to per
tain only to statistics. Or, Sukhatme succeeded and
he totally confused the nutritionists. It w?as an
opportunity lost for the nutritionists and a tacti
cal gam for Sukhatme. To forestall the above argu
ment, Sukhatme advanced two more hypotheses
leading the issue into 'a very disturbing and danger
ous situation.
It is indeed true that the small body size is an
end-result of
adaptation.
But whiat is this
adaptation? A growing child cannot grow norm-ally
if the building m-aterial, namely nutrients, are lack
ing That is, there is growth retardation. The orga
nism in order to survive physically, has cut down
its growth rate to conform to the energy available.
Here.;, instead of food being sufficient for normal
growth, growth has suffered due to tack of food.
This
‘adaptation’
cannot be
considered
a
normal
state
but
as a
compromised
state,, and at what physiological cost it has occured
we do not know Gopalan said (EPW 18 (15) 591
1983): ‘Adaptation, in the current context, repre
sents not a stage of normalcy but one of “strategic
metabolic and functional retreat”
‘The assum
ption that these stunted children are perfectly
healthy and functionally as effective and productive
as children with normal growth and development,
is a sweeping one
The new low levels pro
posed as the limits of calorie adequacy (mean —2
S.D.) may be a good prescription for a “survival
ration” which will permit mere existence. Those
interested in building a strong vigorous nation, of
healthy productive adults, and of Active children
who can run, play and bounce about.... may how
ever not be prepared to buy such a prescription’.
However, it is not hard to see that there are many
who actively welcome such prescriptions.
First, was the postulate of a threshold value
He said (EPW 13:1373 1978) “fortunately for most
of us, unless the intake is too low; the efficiency
of utilisfation of energy is improved. Therefore, ar
intake lower than the average may not cause any
hardship unless this was so low that the power of
regulatory mechanism is diminished’. Although he
argues that Values above 2 S.D. are all normal
(which m'ay be true), implicit in the words ‘too
low’ and ‘so low’ in the above passage, is the ack
nowledgement that values below the mean may be
low. Then he acknowledges that in their ‘own sur
veys in Uruli — Kanchan and in villages around
Pune. . . .the body build of children living on in
takes, smaller than the -average was certain!v
small’, and adds a strange comment that ‘the infer
ence that they were
undernourished . . . .was
found to be unwarranted on biochemical examina
tion of blood ! And, I was under the impression that
nutritionists were yet-to find a biochemical index
more sensitive th’an body size to assess undernutri
tion. If food intake and body size are not good indi
cators of undernutrition, not only would one be
Sukhatme’s argument is two-fold. Since the
mild and moderate degrees of malnutrition can take
care of themselves we need to bother only about
the severe cases and their number is small. Even if
this be true, Gopalan pointed out a fallacy (NFI
Bull. Oct. 1983 and Apr. 1984). The so-called
mild, moderate and severe forms of malnutrition is
an arbitrary classification. More importantly, they
are not static conditions. The mild and moderate
cases can and do slide into severe degrees of mal
nutrition. Therefore to think of extending help only
to severe dases is extremely unwise. This would in
effect mean that we wait till a mild case becomes
severe and then extend help to it. This is like the
Sanskrit saying that one starts digging a well after
the house has caught fire.
3
ough looking small in stature for their age, c’annot
be considered to be under risk of developing mal
nutrition'’.
This argument about small individuals being
‘adapted’ individuals who are at no risk unless they
go below a ‘threshold’ level is a very harmful
theory. This is relegating a large part of the popula
tion not merely to remain small in size but to suffer
all ills of which the small size is a consequence.
Therefore Asok Mitra, formerly of the Planning
Commission, said, “the turn the controversy has
taken in recent years has not helped in reducing
malnutrition. . . . (but) has sought to bring about
what I once called instant revolution .... Intellec
tuals and scientists responsible for introducing
this line, must be held cle'arly accountable. I would
not hesitate to call it harmful, witting or un
witting
sophistry because in
other forums
of debate, we
grade the progress^ of
< people
.
.by
the
average
and countries for instance
For our own childnational weight and height,
ren we do not consider small bones, low height,
small weight, low physical perform’ance and low
energy level “beautiful” or “good nourishment1’
at all’. (Future 11:12).
If you have not read the above passage carefully,
please do so. We are told we have a problem of
poverty. As a consequence our children are small
in size. But that will improve, when economic
conditions improve. However, do not be anxious
about the economic conditions. They take a very,
very long time to improve. But even otherwise, the
children have adapted to the low food intake ’and
will continue to survive. God bless them.
In case you are the type who will not believe
what an Indian tells you and want tO‘ hear it from
a white-skinned ‘expert’, here is David Seckier
endorsing the Indian’s view (Seckier in Newer
Concepts in Nutrition — Maharashtra Assn. for
Cultivation of Science, Pune. ED. P.V. Sukhatme
pp 127-137). Seckier says there are two types of
smallness, one ‘due to poverty, to poor physical and
socio-economic environment’. Second is due to
malnutrition. He says in the first instance the envi
ronment should be improved; and, Sukhatme has
already told us that this is a slow process, but the
children though small in size are under no risk.
Now, any ‘sensible’ person would ask sooner or
later, that if the population is not under risk, if it
is ‘small but healthy’, why should even the environ
ment be improved? That will automatically solve
so many other problems, will it not?
Sukhatme’s second argument is that the small
body size is not a consequence of undernutrition
but is due to poor environmental sanitation and
diarrhbeas. That these two have a role to pl’ay, no
one would deny. But to say, undernutrition has no
role to; play whatsoever, without supporting evi
dence, is most unscientific. On the other h'and,
there are any nti-mber of animal experiments, where
environment has been maintained evenly and the
anim’als showed growth retardation when food was
restricted.
Regarding the second one, Seckier s'ays inter
vention should be addressed towards individuals.
What sort of intervention? In Seckier’s own words.
‘The great challenge to nutritional science is
to
devise anthropometric indexes based on safe mini
mum standards rather than maximum genetic
potential’.
When Dandekar and Rath spoke of the incidence of poverty, Sukhatme diverted it towards
undernutrition, and says undernutritiota is no big
problem in the country. The statistical jargon and
formulae were enough to totally confuse the nutri
tionists. Then he talked of “adaptation to low
energy intakes” and made many off the cuff state
ments regarding energy balance, BMR, genetics etc.
The message is clear. Sukhatme says wc need
not eat as much as the nutritionists ask us to eat,
and which the Americans, Europeans and many
others are eating. We do not die even if we eat less.
We are doing all the necessary work. Your pro
blem is you are shorter 'and lighter than the
Americans. So what, but you are ‘healthy’.
The papers were published in the EPW which
most biologists do not read anyway. The arguments,
on the other hand, being outside the field of econo
mics, the economists kept quiet. Having however
acknowledged that body size is small, he has ad
vanced the ’‘small but be'autiful” hypothesis. And
now, ultimately this body size restriction is said
not be due to undernutrition but poverty. But, what
is the extent of poverty he does not mention. He
says (EPW 17: 2000, 1982) : ‘The second problem
we are confronted with is the problem of poverty,
small stature in
children
is
the
direct
result of this poverty ’and low socio-economic sta
tus, expressing itself in miserable conditions of
Jiving. Intervention to deal with this problem need
not be focused on food and water ............................
As overall economic growth increases environmen
tal conditions may be expected to improve. This
will necessarily be ’a slow process, but this aspect
need not disturb us unduly because these people
will normally be in energy homeostasis and alth-
Seckier says, who told you, you are small. You
are aiming too high. Why should you be so tall and
so heavy. What if your own nutritionists have
shown that when nutrition, environment and health
care are good, your children grow up like the
Americans. You need not reach the Standard. Bring
down your Standards. So, eat food bare enough to
keep you living and bring down your anthropome
tric standards. See, there is no problem of either
undernutrition or small body size.
By equating sheer ability to survive, with
health, Sukhatme and Seckier have declared that
there is no problem of under nutrition. The exis
tence of poverty is acknowledged butt implied is
not- be ----much exercised
the meaning that we ineed
---- 1 —
(Condnaed ©■
4
page 6)
I
Emerging Medical Culture — I
Too Many Investigations:
I
r
pared to sputum acid fast tubercular bacillus, X-ray
chest gets a positive nod for investigating tubercu
losis of lungs; blood sugar estimation is considered
more sophisticated than simple urine sugar exami
nation; blood urea gets an upper hand for diagno
sis of kidney disorders when compared with urine
albumin and microscopy and urine bilirubin and
urobilinogen are seldom considered important when
compared to a battery of biochmical liver function
tests.
Too often investigations are advised with
out close scrutiny of the outcome that one expects
out of them. For a case of head injury X-ray skull
is quite often advised to judge brain injury, while
scientific data suggests that bedside examination
is a better guide and contribution offered by an
observable fracture of the skull in management of
a patient is nil. X-ray cervical spine is invariably
advised for suspected case of cervical spondylo
sis, while it is the clinical examination which alone
dictates the mode of treatment. And so on.
Out of a battery of tests available for pro
per diagnosis in a’given patient, the clinician has
to select the accurate, safe and cheap procedure.
He must be aware of the inherent limitations of
each test i.e., the sensitivity of an investigative
procedure to pick up the disease and specificity
of the procedure for a definitive diagnosis of the
same disease.
Patholgical investigations, like planned ad
vertising campaigns, often create wasteful wants.
A doctor can earn much more from them than what
he can earn through a simple consultation. Ring
practice-in the current commercial medical jargonis acquiring new significance it had never assumed
before. A patient in the ring is just a defenceless
pawn—too meek to make a move — ’as he passes
through the check-posts of specialists, each squeez
ing his hardearned money.
The human body is treated like a machine.
The human element in treatment of the patient is
fast vanishing. We 'have learned to look at the
heart, kidney, liver......... and have forgotten the
human being who harbours all of them.
How relevant are those immortal words of
Sir Robert Hutchinson in this context:
From inability to let well alone;
From too much zeal for what is new
And contempt for what is old.
From putting knowledge before wisdom
Science before an art, and cleverness before
common sense;
From treating patients as cases;
and from making the cure of the disease
more grievous than its endurance
Good Lord deliver us!
Ulhas Jajoo
Open up any text book of modern medi
cine, and you find a growing, rapidly enlarging,
list of investigations. Take any disease from com
mon cold to cancer and you see a physician order
ing a battery of investigations. Being trained in
the traditional western style of medical education,
a young medico lends a deaf ear to the patient’s
history, turns a blind eye to the vital examination
and relies entirely on complex investigations as
if they would, like Aladdin’s lamp, always solve the
clinical problems, With computers having already
made a significant dent in medical technology a
day is not far off when blue chips would replace
human grey matter. Let us start with a simple in
vestigation—an electrocardiogram. A basic investi
gation for recognising various heart diseases. ‘We
must not forget however, that an electro-cardiogram
does not solve all the problem’, writes J. Willis
Hurst in his magnum opus of cardiology.’ and
Jiiat many problems may be created by its use’,
(emphasis my own). Nothing can be more of an eyeopener than the view of Frank Wilson, father of
modern electrocardiogaphy who writing the preface
of his son-in-law’s book in 1951 warns:
Tn the last two decades, there has been a
tremendous growth of interest in the BCG diagno
sis and the number and varieties of ECG in use.
In 1914, there was1 only one instrument of this
kind in the state of Michigan and this was not in
operation;, there were no more than a dozen ECG
machines in the whole United States. Now there is
one or more in about every village of any size, and
there are comparatively fewer people who are not
in danger of having their peace and happiness
destroyed by an erroneous diagnosis of cardiac ab
normality based on faulty interpretation of an
EGG than of being injured or killed by an atomic
bomb.’
Frank Wilson’s prophecy is certainly sound
ing true in 1984. An ECG strip, innocent and im
pressive though it appears, is capable of stripping
the poor man’s money, happiness and tranquility.
Roentgen rays are no longer the rays of hope to 'a
diseased patient. The indiscriminate use of Roent
genology may offset the very advantages it offers.
Come what may, an X-ray occupies the numero uno
position in diagnostic work up of a busy practitioner,
who believes more in Roentgen’s tubes' than on
Laennec’s stethoscope.
‘Look before you leap to a lab’ should be
the most candid advise to a busy practitioner.
The phenomenal rise in laboratory ihveistigatioms
in the last decade reflects the blind faith of doc
tors, in’ the numbers game. ’ The sufferer is the
ordinary man. In his vain hope to get rid of suff
erings, he spends his hard-earned money over un
necessary investigations which do not have a bearing
on his treatment. Simple investigations which pro
vide important clues to the diagnosis are ignored
while costly investigations are advised. Thus com
Dept, of Medicine, MGIMS, Sevagram.
(Extracted from an article written by the
author for creating awareness in the lay media. The
article is entitled— The Emerging Medical Culture).
5
Announcing A.R.l. News
On Calling the Laboratory
—A forum for the exchange of news and views
on acute respiratory infections.
The challenge to health services in develop
ing countries to introduce effective control pro
grammes for acute respiratory infections (AIR)
remains largely unmet. A major reason for this is
the lack of available information about the causes
of ARI and possible approaches to the problem.
Since 1976 WHO has initiated ARI control pro
grammes and research studies, but lack of informa
tion to complement these programmes is still a
major problem.
ARI News is intended to provide an infor
mation channel for disseminating new research
ideas and a focus for discussion by readers of the
practical issues involved in ARI control.
The newsletter will be available free of
charge in developing countries
If you would like to be placed on the ARI
News mailing list please write to:
AHRTAG, 85 Marylebone High Street,
London, WIM 3 DE, U.K.
Please contemplate! It would be a good idea
to have a space in every 1'aboratory /X-ray/ECG
fdrm in which the doctor has to state exactly why
he had ordered a test. I believe if answers were
honestly filled in, we might get this sort of thing:
i. I order this test because if it agrees with my
opinion I will believe it, and if not 1 shall dis
believe it.
I do not understand this test and I 'am uncer
tain of normal values, but it is the fashion to
order it
3. When my chief asks if I have done this or that
test I like to say yes, and so I order as many
tests as I can to avoid being caught out.
,4. I have no clear idea what I am looking for,
but in ordering this test I feel in (a vague way
(like Mr. Micawber of David Copperfield) that
something may turn up.
5. I order this test because I want to convince
the patient there is nothing wrong and I don’t
think that he will believe me without a test.
6. Lastly—(the cynic would sa?) — it is remune
rative to the institution or to my pathology
friend (!) —what does it matter if the patient
or his relatives are exanguinated!
(Continued from page 4)
(about it, since the people are ‘healthy’ and survi
ving. It is obvious that this will- be most welcome
to a government, which hitherto did not know how
tO' deal with this problem of poverty and under
nutrition. We can now, not make even a show
of socialism and Can, as is being done nbw, talk
more openly of computers, colour TVs, delux cars
and what not. It is, therefore, important that
this issue is again taken
up freshly — the
issue of poverty and under nutrition. Previously
we were told we were small in size because of
racial and genetic factors. When this was disproved,
we 'are now told being small is no handicap. Suk’hatme’s arguments have led the country into a
dangerous situation, and created a happy situation
for those who want to see us always small, poor
'and undernourished. We must realise that the three
go together and cannot be artifically separated as
Seckier has tried to do. It is time some economists,
nutritionists and other scientists write strongly
'and clearly about this issue. This is not just a
statistical exercise, as the nutritionists hitherto
thought. Nor is it a question of mere nutritional
physiology as perhaps the economists are thinkking. It is a very important issue of whether the
Source:
SURG VICE ADMIRAL G KUPPUSWAMY,
PVSM VSM PHS., Doctor. Nurse & Patient, Golden Jubilee
Souvenir, St Martha’s School of Nursing. 1983, p. 51
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development programme of village development
project (registered charitable society) in rural
Tamil Nadu. Prefer INSA/RUHS A/Deenabandu
trained applicants for responsible and demanding
work. Salary negotiable.
nation
mfc study report
Due to unavoidable reasons, the printing of
the mfc study report — The Bhopal Disaster
Aftermath an epidemiological and medico social
investigation — has been delayed. It will be relea
sed next month. Send your order for copy/copies
immediately at Rs. 5.00 per copy.
Apply to the Director, Reaching the Unreached of
Village India, Ganguvarpatti PO., Madurai 624203
6
Dear Jrimd
To be fair to ‘‘Rakku’s Story”
I was quite surprised to read in. MFC bulletin
(May’85) a very casual treatment of four important
books in a single column (!) under the title “book
review.” I do not know whether Prabir, the author
of this “review” had sent these jottings as “review”
for publication. If not, even then it is quite unfair
to pass casual remarks on such important books.
In the recent past, I have read one of these books
(“Rakku’s Btory”) “reviewed”
by Prabir and I
would like to point out that none of the remarks
made by the reviewer are fair. He says that “Health
Care in India’ is far more boring than “Rakku’s
Story”; meaning thereby that “Rakku’s Story” is
somewhat boring. But on the contrary, I found
that Sheila Zubrigg, the author, lends this book an
unusual character which is exactly opposite of
boredom by starting the book with 'a chapter cont
aining Rakku’s Story—the tragic, poignant tale
(based on real events) of a poor mother who un
successfully tries very hard against all odds to
save her son from the clutches of death in an attack
of diarrhoea. Her narration hag a literary quality
not usually found in books in the medical world. . .
“After their father had finished, Ponnu and
her brother took their places on the mat and plung
ed into the tasteless porridge with an enthusiasm
imagined for the festival meal. Rakku scooped out
the remaining porridge. Lifting up the plate with
her right hand, and with the baby in her other arm,
she sat down opposite the children. She loosened her
blouse to let the child nurse in her lap while she
quickly ate. She left a small portion on one side
of the plate and told Ponnu to feed it to the baby
at mid-day. And shaking her head she added, “For
the baby, defar child, not for you.” The small girl
nodded, but her lips tightened as she turned away
from her mother’s look.”
The reviewer finds fault with “Rakku’s Story”
because it is “local in place 'as well as in time; it
does not explore the broader Tamil Nadu or Indian
situation at fall. ...” This is quite an irresponsible
statement to make, to say the least. The book very
much explores the “broader” situation. I can do no
better than quote from the author’s introduction.
“Rakku’s story is then used as a base and
stepping-stone for a deeper understanding of the
causes of ill-health and unnecessary mortality. And
so the second part of this book is a closer look at
this woman’s life in relation to the rest of society,
seeing how her life differs from that of women in
India whose children do not die. The questions
which her story r'aises lead the analysis step by
step out from her thatched mud home, beyond her
village, beyond even the hospital where she takes
her dying child, to the very structures and nature
of Indian society as a whole........ Part three of the study looks at the structure
and assumptions of the existing Indian health care
system, and its historical roots in the Western medi
cal and social model. It examines the forces, eco
nomic and political,
national and interna
tional, which continue to shape 'and legitimize a
health system which is clearly inadequate and
often inappropriate to the needs of the m'ajority...
Finally the fourth part of the analysis looks at
the much broader social 'and political condition's
which appear to be the foundation upon which
significant health improvement can occur. This
final section thus le’adg to specific proposals for
change based on the primary need for collective
pressure from the poor, ag the only realistic start
ing point for a solution to the related problems of
ill-health and social injustice.” I can only add that
the author has succeeded in what she intended to
do.
Prabir seem to be sore because this book
“rejects the alternative approaches usually sugges
ted and so rejects their creators (after all it is
these people who might have profited from, reading
“Rakku’s Story.”) It would have been fair to
“Rakku’s Story” if Prabir had pointed out what in
his view was the mistake in Sheila Zubrigg’s argu
ments for “rejecting” “alternative approaches.”
This is not to say that this book does not have
weaknesses. But since it is not the purpose of
this letter to review the book, I would not go into
• the strengths ’and weaknesses of this book. I can
only say that this book, as well as “Health-care in
India” are quite readable sources of analysis of
socio-economic and political aspects of medical
care, containing valuable information and wideranging arguments. Prabir has the right not to ag*ree
with the authors. But certainly these books ’also
have a right to a fair treatment in the pages of MFCBulletin.
—Anant Phadke
Pune.
1) “Rakku’s story” by Sheila Zubrigg, pp. 234,
price Rs. 10- 2) “Health care in India”.
Both books are available with—Centre For
Social Action, Gundappa Block, 64, Pemme Gowda
Road, Bangalore — 560006.
Injectable Contraceptives
Padm'a Prakash in her write tip on Injectable
Contraceptives (May 1985) mentioned the high
percentage of menstrual irregularities observed in
the ICMR trial study. She s'aid that one ‘argument
that is being used is that since Indian women are
in any case anaemic, amenorrhoea would in fact
help them in the long run’. In the ICMR study an
equally high, if not higher, percentage of excess
bleeding was reported. Instead of checking the
haemoglobin levels of these women separately,
the investigators merely checked group averages
and said the values were not different. In fact ex
cess bleeding w’ag a significant problem in this
study.
—kamala java rao
7
RN.27565/76
Kifc bulletin: JULY 1985
News from Bhopal
Jana Swasthya Programme
Four organizations working amongst gas vic
tims, viz., Nagrik Rabat aur Punarvas Committee
(NRPC), Trade Union Relief Fund (TURF,
Bombay, Union Carbide Karmachari Sangh and
ZGKS Morch’a joined hands on June 1 to form a
Joint Health Committee. The joint health committee
has
undertaken
the
task
of
organising
a Jana -Swasthya
Programme as a construc
tive challenge to the government as part of
the on going people’s struggle. The purpose would
be to establish a working alternative based on a
humane and scientific approach and on the principle
of patient’s right to know. Health cards containing
all basic information regarding the progress of
treatment and medication would be issued to e'ach
patient, something which the Chief Minister refused
to do in his meeting with the Morcha delegation
on May 8. Careful medical record of each patient
would be maintained so that these could be used
as evidence in litigation against Union Carbide.
Components
The Jana Swasthya Programme would consist of
the following components
a) Three sodium thiosulphate clinics, each with
a capacity to give 100 thiosulphate injections
per day, or 3000 injections per month.
The first clinic has started operating on June 3.
b) A respiratory physiotherapy programme to be
started after organising the above named three
clinics
c) A programme for gynaecological land ante natal
check ups and monitoring of newborn babies to
be added later.
d) A psychiatric clinic to be 'added later.
The beginnings
The first Jana Swasthya Kendra was started
on June 3 to m'ark the observation of the comple
tion of six months of the tragedy. This Kendra was
started in the open ground within the Unjion Car
bide premises where the Morcha forced its entry
through ’agitation on May 18 and has been doing a
■dharna there since then. After laying the founda
tion stone of a people’s hospital lat this site on
June 3, the Joint Health Committee declared this
ground as the ‘liberated zone’ to be utilised for the
welfare of gas victims.
The Drug Action Forum, Calcutta and the
West Bengal Junior Doctors’ Association have
Editorial Committee :
kamala jayarao
anant phadke
padma prakash
ulhas jaju
dhruv mankad
abhay bang
editor: ravi narayan
Regd. No. L/NP/KRNU/202
jointly 'undertaken the responsibility of making
two voluntary doctors available on rotation under
the auspices of the RAS. The second team has al
ready arrived. The first two West Bengal teams,
along with three members of the medico friend
circle, have played a crucial role in working out
the detailed plans, recording systems and treat
ment schedules, and in organising the first Kendra.
Another doctor from Bcnaras Hindu University
has joined this te’am. A group of young doctors at
Bombay’s KEM Hospital has decided to work with
us on rotation on a voluntary basis from mid-June
onwlards. Another young doctor from Bombay is
’expected to join this team full time on behalf of
TURF. The mfc activists have assured us of their
continuing technical support.
Future need
Although the work has started on the health
front, we require a great deal of support in terms,
of more doctors, paramedical workers, technical
consultation, specialists in the fields of gynaecology
and obstetrics, physiotherapy, psychiatry, paediat
rics etc. A number of complicated medical ques
tions need to be investigated and answered. Special
research projects, in coordination with the Jana
Swasthya Programme, need to be undertaken in the
areas of biochemistry and biophysics. We are deter
mined to throw a challenge to the government by
providing a constructive alternative.
—Rashtriya Abhiyan Samiti, Newsletter,
5 June 1985.
For further information contact:
Rashtriya Abhiyan Samiti,
c/o R. K. Sharma, E.W.S. 87, Dhobi ghat
Behind Char Bungalow, Bhopal 462002.
Convenors Note: mfe’s involvement in Bhopal includ
ing support to above programme wi l be discussed at
mid annual core group meeting in Patiala (end July) to
arrive at a wider consensus.
mfc anthologies
The I & II anthologies (reprinted) are ready.
The III will be ready by the end of July. We regret
the delay.
AUG-SEPT Joint Issue
A joint August-September 1985 (116-117)
issue of the mfc bulletin will be sent in September,
reporting on the core-group discussions on the role
of mfc, the mid course assessment of the Bhopal
interventions and the focus of the next annual meet.
Views and opinions expressed in the bulletin are those of the authors and not necessarily
of the organisation.
Annual subscription — Inland Rs. 15-00
Foreign ; Sea Mail — US $ 4 for all countries
Air Mail : Asia — US $ 6; Africa & Europe — US $ 9; Canada & USA — US $ 11
Edited by Ravi Narayan, 326, Vth Main, 1st Block, Koramangala, Bangalore-560034
Printed by Thelma Narayan at Pauline Printing Press, 44, Ulsoor Road, Bangalore-560 042
Published by Thelma Narayan for medico friend circle, 326, Vth Main, 1st Block,
Koramangala, Bangalore-560 034
^pt' l(=t^'S
THE BHOPAL DISASTER AFTERMATH*
an epidemiological and
medico—social investigation
A sum ary of the report
I
medico friend circle
September 1985
&
A summary of the Epidemiological and Medico-social
investigation conducted by a team from the medico
friend circle, in Bhopal, 18-25 March 1985
medico friend circle
organization and bulletin office
Contributory Price: Rs.2.00
326 V Main I Block
Koramangala, Bangalore 560034
(A detailed report of the study including
I
background, objectives, materials and methods,
observations and results, discussion.
recornmendations, important appendices including
proformas and r ferences and reading list is
also available on request from the address
mentioned above. Price Rs.6.00)
t
THE BHOPAL DISASTER! ITS Al TERMATH
The disaster that took place on the dark, wintry night of
2/3 December 1984 in Bhopal is the worst man made environmental
accident in recorded history• The shocking, official estimates
of 2500 human deaths, an equal number of dead cattle and the
physical and mental disablement of over two lakhs people, b
a mixture of toxic gases including Isocyanate (MIC), do not
adequately express the tragedy that has occurred^
The relief efforts, initiated immediately, were handicapped
and hampered by the lack of authentic information on the nature
of the gases released; by the unwillingness of the Union Carbide
to release information and by the lack of relevant information
among the State and Central authorities.
The doctors at the Hamidia Hospital, Bhopal, where hundred
of the victims rushed, were faced with an acute emergency which
they never anticipated, of whose exact nature they had no
inkling, and for the treatment of which they had no ready sources
of information*
Since the nature ot the toxic gases released into the atmosphere
had not been made public either by the Union Carbide or by the
Centre (which sent high .level technical expe ts to Bhopal), this
had to be a conjecture based on reason and visible evidence.
Soon, two theories emerged to account for the varied
symptomatology and stunning mortality of the victims* The
2
development and testing of these theories# ha
they been done
properly, would undoubtedly have added im-nsely to scientific
knowledge.. What is more important is that it would have relieved
the sufferings of thousands of people. The loc 1 realities have, howe
ver, revealed the power struggles in the medical community and how it
icnor- s in the process, the victims; the lack of human concern
leading to withholding of probable proper tr
indifference of our medicalan
tment; the
scientific com unity to
communicate with our largely illiterate but not unintelligent
masses.
The Two Theories
The protagonists of the first theory, the •pulmonary’
theory believe that isocyanates of which MIC is one, camages
only those tissues with which they come into direct contact and
cannot be carried by blood to internal tissues and organs. Thus
I
MIC can damage only the lungs, eyes and skin and this
explains the predominant involvement of the eyes and lungs
in the Bhopal victims. They also believe that symptoms, if any.
related to other systems must be due to hypoxia caused by lung
damage. This theory is strongly supported by a dominant faction
in the Gandhi Medical College, Bhopal. They believe that early
deaths were due to carbon monoxide poisoning--one of the
constituents of the released gases. They adamantly refuse to
examine any alternative theory.
3
6
The ICMR summaries of res - arch undertaken and press
releases available to us were inadequate and sketchy. We
decided that we would go primarily by the broad range of
symptomatology with which the patients in the community were
presenting. We supplemented this bya thorough physical
examination and undertook hemoglobin estimations and lung
function tests. A criticism against this approach of reliance
mainly on symptoms could be that it lacks objectivity. However9
we believe that a thorough study of symptoms is a perfectly
valid method of ^udy as has been accepted in a whole range
of medical conditions like chronic bronchitis, ischaemic
heart disease, arthritis etc.
The study population
Two slums were selected for the study: (i) J P Nagar
situated in the close vicinity of the Union Carbide factory
and the worst affected by the gas leak, (ii) Anna Nagar, 10 km
away with the least exposure, which served as the control.
There was no area w’.ich was similar to JP Na ar in socio-*
economic and environmental characteristics and yet escaped
exposure and. therefore, Anna Nagar with the leadt
exposure was
the best control that could be chosen.
Rapport was established with the people by explaining to
them our objectives and making it very explicity that we were
....7
1
not there to offer any financial compensation^ medical
treatment etc. The slum dwellers were given a h nd out in Hindi
explainin
the role of mfc and a commitment was made that the
salient findings of our study and our recommendations would
be made available to them.
Sample Selection
The families for the study were selected by random
sampling. Only subjects above 10 years of age were selected.
Those less than ten years were excluded in view of their
probable inability to report symptoms correctly. All details
were entered in a pre—designed proforma. In addition, lung
function tests were done by standard procedur s usin
a
◄
portable spirometer by a doctor fully familiar with measuring
these under field conditions.
Observations
The two slum populations were similar in age and sex
composition, in the number of smokers and of people with long
standing respiratory problems like asthma. Tuberculosis etc.
The JP Nagar residents who were the more a fected, were
slightly better off economically i ut this is no significance
in so far as morbidity rates in JP Nagar are concerned. (For
details of actual figures, see our Report).
8
The subjects described a broad range of symptoms. Each
symptom was described in such graphic detail that it was
obviously based on the patient*s own experience and could not
be malingering or wild imaginations as some are apt to allege.
Since these symptoms could arise due to different causes and since
the residents of Anna Na arf the controls9 were also exposed to the
gas, albeit to a small extent, the latter also reported those
symptoms. However, JP Nagar r sidents had statistically highly
significant incidence of these symptoms.
The common st symptom was breathlessness on accustomed
exertion. In addition, they complained of cough, chest pain.
blurred vision, head ache. fatigue, loss of memory for recent
events, abdonimal pain, nausea, watering of eyes and impotence.
It is important to note that this survey was conducted more than
three months after the disaster, and still the victims suffered
with so many affects. Moreover every individual in the JP Nagar
sample reported atleast one serious symptom but many in the
Anna Nagar sample did not report any such. Probably the most
crucial finding of significance was that 35% of the patients
had gastrointestinal central nervous system and eye symptoms
but no lung findings which favours very greatly the possibility
4
of a system poisoning rather than secondary effects of lung
damage.
Women in the reproductive a e group reported menstrual
irregularitie
such as shortened menstrual cycles, altered pattern
....9
9
of discharge, pain during menstruation and excessive white discharge.
These symptoms were compared not only between the two populations.
but also with respect to the pattern in the same group before the
gas disaster.
Nearly half of the nursing mothers in JP Nagar reported
lactation failure.
Salient Findings
(expressed in percentage)
Number of cases are shown in bracket
— —=—=—=—=:——————=3-"a3!
J P Nagar
Anna Na ar
P Value
Breathless on usual
exertion
87.16 (129)
35*50 (49)
0.001
2
Chest Pain/tightness
50.0 (74)
26.08 (36)
0.001
3
Weakness in extremeties
65.54 (97)
36.95 (51)
0.001
4
Fatigue
81.08 (120)
39.85 (55)
0.001
5
Anorexia
66.21 (98)
28.26 (39)
0.001
6
Nausea
58.10 (86)
16.66 (23)
0.001
7
Abdominal pain
53.37 (79)
25.39 (35)
0.001
8
Flatulence
68.91 (102)
25.36 (35)
0.001
9
Blurred vision/
photophobic
77.02 (114)
38.40 (53)
0.001
Abnormal distant vision
42.0
21.88
0.001
SI No
1
Symptom
<
4
10
*
10
10
Salient findings contd..*.
SI No
4
Symptoms
JP Nagar
Anna Nagar
P Value
11
Loss of recent memory
45.27 (67)
11.59 (16)
0.001
12
Ingling & numbness
54.72 (81)
20.28 (28)
0.001
13
Headache
66.89 (99)
42.02 (58)
0.001
14
Muscle ache
72.92 (108)
36.23 (50)
0.001
15
Anxiety/depression
43.92 (65)
10.14 (14)
0.001
16
Impotence
8.10 (12)
0.72 (01)
0.05
17
Hemoglobin (M)
(meanJB>gm%)
14.68 (1.79)*
12.70 (1.35)* 0.01
18
Hemoglobin (F)
(mean gnt&)
12.7 (1.46)*
10.79 (1.34)* 0.001
* Standard deviations
8% of the men reported impotence.
The number of pregnant women in the sample is too small and
we intend to study pregnancy outcome separately.
Many residents had symptoms of anxiety, and some had
frank depression. Many had loss of memory for recent events.
Mean pulse rates and respiratory rates were not significantly
different in both sexes in JP Nagar and Anna Nagar. Mean hemoglobin
concentrations in both males and females were significantly higher
in JP Nagar than in Anna Nagar.
....11
11
The mean values of lung function tests were loxver in JP Nagar
as compared to Anna Nagar particularly in the age group 15-44
and 45-60. The pattern was primarily restrictive.
An important findings of grave significance is that 65% of
the working persons in JP Nagar experienced a drop in income from
20% to 100% as opposed to 9% in Anna Nagar. This reflects the way
in which physical/mental disability of the people has affected working
capacities.
The causative factor
The presence of such varied symptoms suggests the involvement
of more organs and body systems than the lungs alone* These cannot
be explained by the pulmonary theory alone even though pulmonary
4
lesions can cause peripheral hypoxia and hence muscular fatigue
and so on.
On the other hand, the cyanide theory can better explain
the varied and apprently unconnected symptomatology. However, the
ICMR has not tested the hypothesis vigorously. It has stu ied only
the seriously ill, hospitalised patients and concentrated mainly
on the lung symptoms. They do not say whether the non—pulmonary
symptoms (symptoms not related to lungs) were also relieved by NaTS
and curiously has not ma e its findings public. One, therefore, may
also que tion whether the cyanide theory is fully valid.
It must be stressed here that the mfc is not rejecting the
cyanide theory. It is only to point out that the country’s main
medical res arch body has failed to be rigorously scientific in
testing its own hypothesis.
••••12
12
Sodium thiosulphate therapy
We have already explained how sodium thiosulphate (NaTS)
will clear cyanide radicals from the Ixxiy. If the cyanide
theory has been established* even as one of two causative factors
the victims should receive NaTS treatment. Some of the local
doctors availed themselv s of this* af er the cyanide theory was
proposed.
The ICMR at a meeting held on 4 Feb 85* issued guidelines for
NaTS tr atment. The medical group of Bhopal* which was opposing the
treatment* was also present at the meetings* according to the
minutes. Yet they opposed the treatment with the argument that they
are not convinced its efficacy. The question is not of a doctor’s
convictions. A doctor’s choice of tr atment cannot also be arbitrary.
The question is whether there is scientific evidence in favour
of NaTS therapy and whether there is e ually strong* if not stronger*
evidence against the use of NaTS in this situation.
NaTS with its specific action is a better therapeutic agent than
the non-specific remedies that are being used for the lung symptoms.
A dominant section of the doctors of Bhopal are thus guilty of
delaying treatment and by not revealing the findings of its clinical
trial* the ICMR too has to accept part of the blame for the continuing
suffering of the victims.
After a few weeks of controversy the NaTS therapy has now been
accepted but mass detoxification is still being strongly opposed.
13
The trial with NaTS is not the only study launched by the
ICMR. It has sponsored many other studies on the Bhopal victims.
but they lack an integrated approach. Thus lungs, eyes etc., are
being examined independent of each other, by dif erent investigators
and the ICMR is unwittingly lending support to the first theory.
namely, that MIC gas damages only tissues with which it comes into
direct contact*
What exactly happened to the gas victims?
So nany months after the disastrous gas leak. one still does
not know what exactly happened to those who inhaled the gases and
arc still surviving* This is not because all attempts to unravel
the aay»terr
failed but because an integrated approach had
not b^en taken to do so* Months after tae diodwiex, ten& of thousands
of the survivers are still suffering from debilitating symptoms
which pr vent them from going back to work.
The medical community and the officildom have been adhoc in
their efforts to render adequate su cour to these hapless victims.
A powerful medical lobby in Bhopal with unscientific bigotry
have opposed NaTS, a treatment, with good potential to the
patients. They have no convincing argument for their stand. The
IMA, the organisation which has authority over the medical
profession, has remained totally mute. The doctors as well as the
ICMR have concentrated entirely on those who were hospitalised
and have not evolved a holistic, conwnunity approach to understanding
the problem. The ICMR sponsored local studies with the exception
14
of the NaTS trials have lacked the rigour and the epidemiological
orientation that are nec ssary in arriving at a meaningful
understanding of the problem*
A point of utmost significance is that the victims of the
Bhopal gas disaster mostly belong to the lowest strata of the
society and not in a position to fight for their rights, be it
medical aid or monetary compensation* It is, therefore, not
very surprising that the government and its organisationshave
shown marginal interest in the after effects* It also reveals
a lack of interest among our scientific community in investigating
an environmental disaster of an unprecedented nature* On the other
hand, one can observe the striking contrast with which all attempts
were made to retrieve the Black Box of Kanisbka, whose mid-air
explosion resulted in the death of only 326 persons but needless
to remind of the upper socio-economic class*
Recommendations
Research
1* The r search an
follow up studies should shift focus from
hospital/dispensary based studies of seriously ill patients
to family/comnunity based ambulatory patients*
2. Well designed clinical trials should be further initiated
using sodium thiosulphate as a therapeutic and epiedemi©logical
tool to further establish the significant role it could play
in mass therapy.
••••15
15
Care,Surveillance and Rehabilitation
3» Psycho social assessment and ccnsequentcounselling and
rehabilitation are urgently required.
4. Mass treatment with sodium thiosulphate should be initiated
maintaining good medical records.
5. A surveillance programme should be undertaken to
assess risks to pregnant mothers, unborn babies and new born
babies. There should also be close monitoring of the gynaecological
problems of women.
6. It is necessary to have a long term surveillance of lung
function in view of the postulated damage to lungs and
resultant lung fibrosis. Similarly eyes should be examined
regularly.
7. A comprehensive listing of all gas disas■er victims is a
long overdue task necessary for mass treatment, compensation
and rehabilitation. This must be done immediately.
Communications
8. There, is urgent need for evolving a continuing education
strategy for allhealth personnel including doctors working
in both governmental and non—governmental centres. These could
be throu h newsletters, handouts and informal group
meetings. ™he areas identified are: (i) sodium thiosulphate
therapy; (ii) identification and management of psycho-social
stress; (iii) risks to mothers and unborn foetus and need
16
16
for surveillance; (iv) fairily planning advice till completion of
detoxification; (v) role of respiratory physiotherapy; (vi) management
of lactation failure; (vii) caution against overdrugging; (viii) need
for open minded surveillance of high risk groups; (ix) importance
of medical records.
9. There is also urgent need for a dynamic cr ative non-formal
health education of the affected community through group
meetings,posters and pamphle s with information and messages
built around their life style, culture and existing socio-
economic situation.
The areas identified are* (i) sodium thiosulphate therapy;
(ii) ongoing research programmes and informed consent; (iii)
risk to unborn and new born babies; (iv) Family Planning advice;
(v) respiratory physiotherapy; (vi) manag- ment of lactation
failure including low cost weaning foods; (viii) importance of
r cords and regular check ups.
10. Occupational Rehabilitation and compensation.
In the ultimate analysis care of illness, health education,
psychosocial counselling would be inadequate measures if they
were not backed by adequate monetary compensation and urgent
occupational rehabilitation of the disaster victims. This would
have to be imaginatively done keeping their previous occupations
and the residual disabilities in mind.
....17
1
17
Coordination
11• The government machinery alone cannot handle
such a massive task. The government must adopt
s policy of enlising the help of all non-governmental
agencies and groups wishing to work in Bhopal. This
enlistment must be active and supportive.
and finally
12. It is imperative that the victims as well as the entire
country must be provided with all the details of how the
Occident occurred, of the nature of the chemicals
released and of the reasons why the detoxification by W
sodium thiosulphate has been so badly mismanaged*
medico friend
circle
bulletin
I
OCTOBER
1985
STRATEGIES FOR ENVIRONMENTAL
HEALTH ACTION
Dhruv Mankad*
A)
INTRODUCTION
The term environmental health has a wide
scope, encompassing the relationship between health
and habitat, air, water, work place and so on.
Although the theme has been discussed since
long, the Bhopal tragedy has brought it into sharp
focus. Milder versions of Bhopal have been occuring
frequently but the actions taken have been in the
form of spontaneous protests by local people in the
affected area. Many times, investigative journa
lists have brought such issues to light e.g. plight
of villagers around the ACC cement factory at
Sevaliya in Gujarat or the Grasim episode. Later,
after some local action, interest has died down. It
is only after Bhopal that planned action at an all
India level is taking place.
There was a time when capitalistic indus
trial development encroached upon the lives of the
workers only — both at the workplace and in the
homes which were not very far away from the fac
tories. But the ever expanding, blind industrial
development process during the present phase of
capitalism, has spread its tentacles over the
lives of all but the highly privileged few, both in
urban as well as rural areas. Thus Occupational
Health has been
subsumed by Environmental
Health and the effects of the nature of industrial
development on health is no longer a concern
of the workers only. Though, the analysis of the pro
blem and the solutions offered, would differ from
class to class. But, any such movement would cer
tainly pose certain basic questions regarding, the
rate and the nature of present industrial growth.
B)
STRATEGIES ADOPTED BY THE PEOPLE
People have always
against encroachments
reacted spontaneously
by alien elements on
* A note for discussion at the MFC-annual Meet, Patiala 25-29
July 1985.
their ways of life. A brief overview of strategies
used may help in formulating future strategies.
1) The working class, looked upon as merely
a tool in the production process, has always been
the first one to bear the brunt of the effects of a
new technology.
i) One of the most successful health movements
of workers was the Black Lung Movement of coal
miners of the USA. Loy Rego, writing in The Socia
list Health Review 1:3 puts down the reasons for
its success as1—
a) the workers strength vis-a-vis the mine
owners, for coal is a key item.
b) public sympathy.
c) capacity of the workers to shut down mines.
All this was possible because of the mass
nature of the movement as reflected by the fact
that many folk songs were written on the work
lines.
ii) Even when the positipn of the working
class was weak, partially successful actions
have
been initiated. For instance, a newspaper report
in a local daily in Gujarat regarding the plight of
workers in the slate-pencil industry, spurred a social
worker to file a writ petition in the Gujarat High
Court. The report filed by the Committee appoint
ed by the HC forced the State Labour Department
to make surprise checks which controlled some of
the problems of lime dust.
INSIDE
N. T. P — a dialogue
4
Banned Pesticides
6
News irom Bhopal
7
Fronj the Editors Desk
8
2) Growth of industries in the rural areas
under the guise of decentralization has meant a
direct threat to the rural people as well as to agri
culture- Farmers too, have successfully fought this
-encroachment.
iii) Citizens of Ward 12 in Ratlam had moved
a local trial court to direct the Municipal Council
to construct proper drainage for the locality. The
State High Court affirmed the trial court’s order.
The Municipal Council approached the Supreme
Court, who turned down the plea and directed the
Council to carry out the work. In his judgement,
Justice V. R. Krishna Iyer observed that the citi
zens could “use the law and call the bluff of the
municipal body’s bovine indifference to its basic
obligations.'’
i) In Sevaliya in Gujarat, around 14,000 far
mers were affected by cement dust from the ACC
cement factory. After several years of memorandagiving and lobbying, they adopted a strategy of
no-tax campaign and gheraoed the management of
the factory. As a result, a precipitator was immedi
ately installed. The workers of the factory were
sympathetic to the farmer’s demands but were afr
aid that they would lose their jobs if they joined
the struggle and therefore kept out of it.
C)
1) Mass actions are almost always successful,
even when only partially. They also have the ad
vantage of the heightened environmental health
concern being passed down the generations and
across geographical areas as evinced by the Black
Lung Movement and the Chipko Movement.
ii) The famous case of the Chipko movement
of Garhwal is well known. The women of Chamoli
and other villagers in Garhwal, in a unique fashion,
protested against the senseless destruction of
forests by contractors by embracing the trees. In
lesser known incidents, women have adopted
novel ways to protest against cutting of trees. In
1978, womei of Bhuyander villages in the Chamoli
region, stole the axes of men from nearby villages
who had come to cut the trees and refused to ret
urn them till they agreed to go back.
2) Actions against industries by the citizens
are more likely to succeed if the workers of the
industry concerned as well as other allied indust
ries are directly involved. This is shown in the
case of Zuari Agro Chemicals. On the other hand,
vvorkers are more likely to succeed in their struggle
tor better work environment if they acquire the
sympathetic participation of all the affected people
as is seen in the Black Lung Movement.
3) As pointed out earlier, the anarchic capita
list development of industries now threaten to dest
roy the lives of ordinary citizens mainly of those
living in and around cities.
Citizens too, have adopted various
to combat this menace:
ALL THESE INSTANCES SHOW CERTAIN
COMMON PATTERNS :
3) While dealing with Government bureaucracy
and Industry executives, mere rhetoric and agita
tion is not adequate. Sometimes information made
public wields power. For this it becomes important
•that scientists are involved.
strategies
i) A Citizens Anti Pollution Committee was
formed in 1975 in Goa against the air and water
pollution by the Zuari Agro Chemical Industries.
It took cut a morcha in protest, but to no avail.
Later, three political parties supported the Com
mittee and a threat was given by the All India Port
and Dock Workers’ Federation to boycott un
loading of raw materials for the Birla factories at
various ports. The company had to bow down and it
paid compensation to farmers and provided clean
drinking water facilities to the affected villages. A
water treatment plant was also installed.
4) An educated population having the support of
scientific information might be able ho carry out a
sustained struggle for better environment as is seen
in the case of Gwalior Rayon, Mavoor. In contrast
to this in another Birla owned factory at Amlai the
movement of local villagers only petered out after
the management gave some flimsy promises. In the
former case, the people admit that support of KSSP
was vital for the movement.
5) Women have a direct stake in the protection
of forests. They are more easily mobilised for such
actions than men, who sometimes are in favour of
contractors in order to protect their jobs. Chipko
and other movements in the Chamoli region point
to such a situation.
ii) At Mavcor in Kerala, Gwalior Rayon dis
charged effluents into the once clear Chaliyar
River, beginning from 1948. Fish died, skin infec
tions spread. In 1963 people protested but pro
mises given were forgotten. The protests persisted
during 1965, 1967, 1968, and 1973. Finally in
1978-79, Kerala Shastriya Sahitya Parishad brou
ght out a report which concluded that the problem
persisted because of the callousness of the factory
management to employ the available know how of
effluent treatment. In 1979, in a massive agitation,
people broke down a company erected bund to pro
tect its own water intake. Thus, it was forced to
lay a pipe line to dump the effluent in a far away
brackish water-stretch.
D)
STRATEGIES FOR ACTION
From the on going account, it is clear that it is
possible to select one or more from several strate
gies used, to make Environmental Health Action
sustainable and successful.
1)
Information Gathering and Disseminating :
Done in a planned,
conscious
manner or
in an unplanned, unconscious and lexperiential
manner, this is the first and vital step in the right
2
direction. It helps to make people concerned con
scious of the problem and breaks the ice for the
people to speak out.
either disinterested or actively against such move
ments for the fear of losing jobs, in case the indu
stry is forced to close down.
2) Lobbying etc : First, lobbying could also
serve the above purpose. The existing democratic
institutions should be utilised for this. Lobbying
among legislators and political parties is a useful
strategy for gaining support from ‘within’. Although
there is always the possibility of opportunist politics
entering the movement in this way, if one guards
against it consciously and if the decision making is
democratic enough, it could be combated.
In such a case, it is imperative on the part of
the aggrieved party to explain to the workers their
problems and also to include in their demands, the
demands of compensation and alternative employ
ment for the workers in case the industry is closed
down partially or wholly. This may ensure also the
involvement of workers.
3)
2) It is a • common belief that lack of safety
measures, non-implementation of safety rules and
compensation laws in case of accidents or occupati
onal health hazards are highly prevalent in the un
organised industries. Under the guise of decentra
lization this sector has mushroomed during the
past few years.
Publicity and public opinion building :
Due to widespread experience of environ
mental piracy by various industries, people are be
coming sensitive to environmental issues as also
are the government bodies, bureaucracy and the
executive. Wide publicity in the existing media
newspapers and magazines has its impact. With the
tradition of public interest litigation picking up
in our judicial process, even newspaper reports are
now being converted into writ petitions by various
High Courts and the Supreme Court.
But, given its nature, the workers have little
strength to fight it. They can do so only at the risk
of unemployment or even losing their lives. While
the stronger, more organised workers enjoy a better
work environment.
i)
4) Legal Action: Action can be initiated aga
inst environmental offenders under the Prevention
of Pollution Acts, Factories Acts and other Acts
governing the worker management relationships,
Municipalities Acts (as in the Ratlam case) and
finally as writ petitions in the State High Courts
and
the
Supreme
Court
invoking
the
Fundamental
Rights
and
the
Directive
Principles enshrined in our Constitution. Though
the efficacy of such actions is limited if nothing
else, they serve the purpose of highlighting the
issue. This strategy is particularly useful for citi
zen’s actions and the unorganised section of work
ers who have little strength vis-a-vis the industry
and the state.
.
Fifct, one needs to examine this be’ief.
a) Mine workers would be considered as organised workers. A survey of 11 coal mines totalling
9643 workers showed the prevalence rate of all cate
gories of
pneumoconiosis
as
10.8%.
A
survey of 7,653 underground miners with 5 or
more years of service in the Kolar Gold fields re
vealed the incidence of silicosis to be as high as
43 8%.
b) The accident rate in coal mines during 1977
was 0.47 fatal accidents and 4.33 seriously injured
persons per 1000 persons employed. Textile work
ers are also an organised section of the working
class. Injuries reported for 1978 in textile factories
were 54.32^% of total reported injuries in the
industries during the year. While it employs on an
average 26.62% of total number of workers emplo
yed.
5) Direct Actions: Whether the aggrieved are
workers, farmers or ordinary citizens, men or wo
men;, this form of protest works best if properly
organised and properly carried out. The success de
pends upon the strength and ability of the aggriev
ed to be able to hit the concerned at the place
where it hurts most. It could take the form of a
strike action in a key industry (as in the Black
Lung Movement), prevention of movement of key
raw materials and finished products (as in the
Gwalior Rayon Case), no tax campaigns (as in ACC
Sevaliya case), or simply creating a bad image of
the offending industry’s high selling product.
This shows that the quality of work environ
ment for the organised working class is also not
good. That for the unorganised working class would
certainly be deplorable
ii) Even then, it is true that unorganised work
ers have very low strength Vis-a-vis their manage
ments and the State. Therefore, they are unable to
initiate actions on their own. They need greater
outside support and help than does the organised
working class.
6) Certain problem areas :
While surveying
environmental
ill -------health’ and actions against it,
— ‘—
one comes iup against certain tangles defying pat
solutions:
iii) Now, the question arises, as to whether in
the existing situation in India where the environ
mental health movement is in its infancy, it is bet
ter to support a stronger section where chances
of success are high or to take up the cause of those
1) It is commonly observed that if aggrieved
citizens
plan
action against an offending
industry, the workers and their Trade Unions are
(Continued on
3
page 8)
National Tuberculosis Programme —A dialogue.. ..
author’s information I am quoting only one exam
ple of Eskimo population around the Arctic circle
in whom the annual rate of infection was 25%
(highest ever known) but after the introduction of
a very intensive programme of diagnosis and treaty
ment among the Eskimos, the rate of new cases
diminished to the levels observed in some Euro
pean countries eg. France. Thus the rate of inci
dence of disease and the risk of infection decreas
ed by 20% per year. Mass BCG campaigns were
not used (Rouillon et al Tubercle (1976), 57, 275299).
It is not possible to discuss the entire article,
published in mfc bulletin No. 105., as it would mean
discussing rationale of the programme in great
detail. However, we would like to point out a few
inconsistencies. The rationale of the programme is
already adequately
documented
and
for
additional reading the author may resort to K.
Toman's book “Tuberculosis Case finding and
Chemotherapy; Questions & Answers” — a WHO
Publication.
a) Intercepting Transmission is not a mirage
The only sure diagnostic tool for tuberculosis is
bacteriological examination, which has high degree
of sensitivity and specificity. Other tools like
x-ray or tuberculin are less specific and variable
from place to place depending on the users experi
ence and training. It is generally known and adequa
tely documented that about 50% to 60% of the
x-ray positive bacteriologlcally negative patients
are not having active TB. It is, therefore’ unethical
to close the diagnostic process on the basis of x-ray
reading and treat a patient as TB when he could
be suffering from a serious non-TB condition. As
regards use of tuberculin testing as a diagnostic
tool, we may not need to comment much.
1.
Thus it could be seen that when one wants to
treat ‘Tuberculosis,’ he has to be reasonably certain
of the diagnosis which the doctor can only be with
the help of bacteriology. So we feel the best servi
ces to the chest symptomatics, that has been provi
ded to these people is the extension of sputum diag
nostic services throughout the length and breadth
of this country. To us it appears almost revolutionary
extension oi scientific finding.
The quote of the article picked up from Dr.
D. Banerji’s article does not find any place in the
article but rather contradicts his statement. What
is ailing the programme is the fact that even today
80% of felt need patients are turned away without
subjecting to the most scientific way of case-findingIndeed it is tuberculosis' patients who themselves
showed the way to integration of services to General
Health Services. There is,, in addition, sound admini
strative justification for dealing with all the health
problems of a community as an integrated whole,
demanding an integrated approach. Even as early
as I960’ it was foreseen that extension of TB ser
vices to the community will be furthered with deve
lopment of infrastructure of general health servi
ces eg. through multipurpose worker or community
health guide. So today atleast fortnightly or month
ly visit to the patient’s, home can be made through
this extension.
“Never io the hi 4ory of human TB, a reduc
tion in transmission has been brought by a
specific medical intervention. ’
Medical literature is full of instances where it
has been achieved by medical intervention. For
1.
b)
2
Author’s personal experience
While we do not disagree with the author that
his experiences in two DTCs must have been unfor
tunate, we feel that if he keeps the overall
perspective of the health programirtes in view,
he will choose to change his opinion even with the
same experiences On DTP. The solutions thus does
not lie in attempting to remove inadequacies in
NTP alone but rather in the entire health services
system.
3.
Chemotherapy
The author wants costly effective drug regimens
to be made available in the DTP. There is no dis
agreement on this. But the system which delivers
these regimens must be adequately strong for the
regimens to be effective and regimens must have
higher acceptability. Researches are still being
carried out to find out what could be the problems
of delivery to be encountered. However, an opera
tional study conducted by Dr. Daily showed that
Isoniazid -j-Thioadetazone regimen (82% Trial
efficacy) achieved 60% sputum conversion by 56%
drug regularity while Biweekly Streptomycin +
Isoniazid (94% Trial efficacy) achieved 68% sputum
conversion due to poor regularity of 31%. Short
course Chemotherapy regimens with 100% trial
efficacy have an intensive phase of 2) months with
4 drugs to be given preferably under supervision.
So acceptability of short course drug regimen is a
big question mark. Besides this, the author must
remember that under a “vertical malaria pro
gramme” even a five days radical treatment cannot
be effectively delivered to the population. A six or
a nine monthly regimen is a very different matter
altogether. The point is — do the people conform
more with a six monthly regimen compared to a
12 monthly or 18 monthly regimen. This is a cru
cial question, cost comes later. There are other'
questions as well eg. availability of drugs, adverse
reactions due to drugs, their management. Hence
before unleashing this treatment measure on a
wide scale over the entire country, it requires to
be studied. On a pilot basis the new Short-course
drug regimens are being tried. We hope our pro
blems are solved soon and we are able to extend
the benefit of our findings for general use.
4
In Dr. Sen’s presentation, cost has been made
out to be the only reason. But the reason is some
thing else. It is the ability to deliver the measure
which requires more emphasis.
NTP alone. However, it is only by analysing the
short comings of the NTP that we can move forward
towards a more rational and humane policy for
tuberculosis. And certainly the present lamentable
condition of the BTC’s is not accidental, but a pro
duct of the entire strategy for tuberculosis, which
is in turn part of our health policy.
3. With regard to the question of chemother
apy, we can deal with the question of efficacy and
compliance later. Before that, we must answer two
questions.
a) To the safety of thiacetazone adequately
demonstrated, expecially considering that other
alternatives are available.
Dr. (Mrs) P. Jagota Senior Medical Officer
NTI, Bangalore - 3.
The reply
Dr. Jagota’s reply to my article is a disappoint
ment. I do not claim to be an expert on tuberculosis
and I would have been happy to have been proved
wrong in the points I had made, through scientific
reasoning. However, her whole accent is on defend
ing the system at all costs.
To take her points one by one:
1. a. Relative
merits of sputum
smear and
X ray as diagnostic tools: It has never been our
contention that patients should indiscriminately
be started on tuberculosis treatment on the basis
of an X-ray shadow alone. The contradiction exists
within the NTP. Examination of the records of any
District Tuberculosis Centre (DTC) will show that
a large proportion of cases under treatment are
‘sputum negative X-ray positive’ and their entire
treatment consists simply in a monthly doling out
Of INH TH. Does the NTP seriously believe That
these patients have tuberculosis or does it not? If
it does, then they should receive safer and more
effective treatment. It it does not, then these pati
ents should come off treatment.
Please refer to Toman,—page 103.
“Thiacetazone in doses of 150 mg. daily given in
a single dose has about the same toxicity as PAS
(other drugs have less-B.S) its side effects includ
ing rashes, jaundice and bone-marrow depression.
Gastrointestinal upsets seem to be somewhat more
frequent with thiacetazorie, especially in Asians.
Moreover, cutaneous reactions appear to be more
serious than with other drugs. Thus
exfoliative
dermatitis or Stevens,—Johnson syndrome may
occur if the drug is not stopped.”
See also Toman page 120, where a detailed
study on thiacetazone toxicity is reported. “The
investigation suggested that thiacetazone might be
too toxic for large scale use in the population
of .Singapore, whether Chinese, Malay, or Indian”.
May we Isnow what the NTl has done to moni
tor drug toxicity in the field?
b) Why has the Government released second)—
line TB drugs in the open market and at the same
time prohibited their use in the NTP (upto district
level)?
Although these questions have been raised in
the article Dr. Jagota does not address them.
As for the problem of acceptability of regimes,
it is my view that all questions of patient compli
ance are answerable in terms of the effort that has
been made to fit programme design and implemen
tation to the social milieu in which the programmes
are executed. In other words, the customer is always
right. Today
‘patient compliance’ views the
patient as a passive consumer and measures the
extent to which he is able to adopt the norms of an
extraneous system. A truer view of patient compli
ance would look at the dynamic interaction that
takes place at field level between the pati
ent and the treatment system. To say that a pro
gramme has ‘low acceptability’ is simply to beg
the question.
Dr. Jagota says that ‘researches are still be
ing carried out to find out what could be the pro
blem of delivery to be encountered’. The efficiency
of ethambutol against human tuberculosis has been
known since 1961, of rifampicin since 1968. What
has been done all these years?
Binayak Sen, Daili Rajhara
If tact no physicians of any integrity would
treat patients on the basis of X-ray findings alone
Sputum negative X-ray positive patients are (pro
perly) diagnosed to have tuberculosis on the basis
of a series of clinical observations and therapeutic
trials to exclude non-tuberculosis disease. Perhaps
it is only a vertically oriented Government pro
gramme like the NTP that can afford to be so care
less with its clients.
Incidentally, it is interesting to find Dr. Jagota
talking about horizontal integration. She could
not have read the second paragraph of the article
too closely. However, as long as integration remains
merely an administrative concept, devoid of social
and political content, it will be ineffective.
1 .b) Dr. Jagota claims that medical literature
is full of instances where reduction in transmis
sion has been achieved by medical intervention.
This is a revolutionary claim, and will interest
well known epidemiologists like Mckeown and
Navarro greatly. However, to back it up, she should
try to produce some-what more solid evidence than
her example about ‘Eskimos around the arctic
circle’. It is perhaps a measure of the futility of
the NTI that they should think that this kind of an
example could be extrapolated to the Indian situa
tion.
Coming now to ‘author’s personal experience’
we agree whole heartedly that the solution does
not lie in attempting to remove inadequacies in the
5
BANNED
PESTICIDES
(severely restricted in the US), Aldicarb (catego
rised as extremely hazardous by WHO), carbofuran^ monocrotophos, oxydemetonmethyl 1, DDVP
(all categorised as highly hazardous by WHO) are
used in the country today.
Pesticide use in India has multiplied 20 times
between 1960 and 1980 and it is estimated that
the nearly 100,000 tonnes of pesticides which will
be consumed in 1984-85 will help the country save
slightly over 10 percent of foodgrains production.
India's hunger for pesticides can be estimated from
the fact that although indigenous production has
grown at the rapid rate of 14 percent in the eighties
—43000 tonnes in 1980-81J—imports exploded
seven times, in terms of value, in three short years
from 1978 to 1980. By 1989- 0, pesticide consum
ption is expected to average 120,000 tonnes. The
agricultural sector accounts for two thirds of con
sumption and five states—Punjab, Gujarat, Andhra
Pradesh, Tamil Nadu and Maharashtra—use over
50 per cent of that.
India has an Insecticide Act, which empowers
authorities to monitor the registration, packing,
labelling, import, manufacture, sale and use of
pesticides. Before a pesticide is registered, the
Central Insecticides Board scrutinises data on the
acute, long term toxicity and the antidote. But it
ensures no safety measures beyond the mandatory
danger label. In addition, the world’s leading ex
porter of pesticides, the United States^—16.5
percent of total exports and the EEC—5.15 per
cent of export^—exercise little or no control over
the export of banned pesticides. In 1976, for inst
ance, some 30 percent of US exports were of pro
ducts whose use has been banned in the US.
In terms of tonnage, atleast 70 percent of all
pesticides consumed on Indian farms are banned
or severely restricted in Western countries and
identified by the WHO as excessively toxic or
hazardous. The proportion is even higher in the
case of pesticides used in public health programmes
such as malaria eradication. For instance, DDT,
banned many years ago in several countries beca
use it leaves intolerably high residues in soil water,
food and the human body and is suspected to be a
carcinogenic, is used liberally in India. Current
annual consumption of DDT is 3500 tonnes in
agriculture used over an area exceeding 2). 5 million
hectares and 4000 tonnes in public health
The effect of this indiscriminate use of pestici
des is as expected. According to Praful Bidwai, wri
ting in “The Times of India”, India may account
tor a third or more of all the 500,000 cases of pes
ticide poisoning estimated by WHO to occur every
year in the underdeveloped countries. Individual
instances of pesticide poisoning are
rarely
reported for
tracing
it to
a
pesticide
is a long process. The
worst affected are
the agricultural and the anti malaria workers who
spray and apply pesticides. At the Indian Science
Congress in 1985, Devika Nag and UK Misra of
the King George Medical College, Lucknow, said
that workers who sprayed these agrochemicals repo
rted visual impairment, dislike of bright light and
night blindness. Nag added that exposure to these
pesticides led to mental disturbances, anxiety, in
somnia and depression. There is evidence to show
that areas of high pesticide use also have a high
incidence of paralysis.
Another danger substance is BHC, two and a
half times as toxic as DDT, banned in European
Economic Community countries, suspended and
cancelled in the US, and also suspected carci- ,
nogen, but which covers 8 percent of the country’s
net sown area; estimated consumption in 1982]:
33000 tonnes. Methyl parathion 20 times more
•toxic than DDT is also banned in the West, but
3000 tonnes is consumed every year in India, over
12 million hectares, the highest coverage for any
pesticide. Heptachlor, three times more toxic than
DDT, banned in the US and withdrawn from the UK,
is still consumed in India: 150 tonnes annually.
DBCP (dibromochioropropane), banned in the US
for producing infertility and stomach cancer, is
used in India on wheat and other crops. Herbicide
2, 4-D is a basic ingredient of ‘Agent Orange’, the
defoliant used with brutal effect in Vietnam. India
has an installed manufacturing capacity of 1135
tonnes for this herbicide, and an annual coverage of
3.33 lakh hectares.
No one is secure. A recent WHO study, which
analysed cereals, pulses, milk, eggs and meat sam
ples from across the country7 found that 50 percent
of the samples contained pesticide residues and in
more than 30 percent of the samples, the residues
were Far in excess of the tolerance limit. Studies
done by the Indian Agricultural Research Insti
tute, Delhi, show that pesticide residues in vegeta
bles coming to Delhi markets are 20 times the
permissible limit. Samples of bottled milk in Maha
rashtra were found to contain 4.8 parts per mill
ion (ppm) to 6.3 ppm of DDT and 1.9 ppm to 6.3
ppm of dieldrin in about 70 per cent of the samples
analysed. The permissible limit for the two com
pounds in milk is 0.66 ppm. A study by GS Dhariwal and RL Kalra, of the Punjab Agricultural Uni
versity found that all samples of milk from around
Ludhiana contained DDT and 73 per cent had resi
dues more than the tolerance limit. Drunk by a
India’s insecticide regulators have approved
some of the most toxic pesticides like Phosvel,
Dieldrin and Chlordane. In fact EPN, an insecti
cide that has been banned in other parts of the
world, has been listed by the UN as not approved
for registration by India; it is, however, in the
list of approved pesticides for
1983. Lindane
6
/1
O'! R?three month old child every day, would result in a
DDT intake nine times higher than that accept
able. In fact DDT and BHC residues were found to
be present in all 75 samples of human milk collec
ted from Punjab. The babies were drinking 21 times
the accepted daily intake of DDT and BHC'from
their mother’s milk.
*
This report which was released last month
announced in mfeb 116-7 is a comprehensive re
ference book on the State of India’s land, water,
forests, dams, atmosphere, habitat, people, health;
energy and living resources. It also includes two
chapters on agents of change and the politics of
environment. The health chapter covers four
important areas —
Bhopal has brought to light another pesticide
hazard, the raw materials and intermediates manu
factured and stored at the plants. Very little is
known about these processes or the toxicity of the
chemicals involved. The Economic Times recently
reported that a leading pesticide emit located at
Jogeshwari in Bombay which manufactures ethylene
dibromide, a highly toxic pesticide included in the
UN list of banned products and described by the
National Cancer Institute in the US “as the most
potent cancer causing substance found in the ani
mal test programme’ is now putting up a plant to
manufacture glyphosphate. They intended to use
chlorbniethylphosphonic acid (CPA) in the pro
cess; CPA is a chemical used in chemical warfare.
Hazardous Products
The Bhopal Disaster
Occupational Hazards
Mosquito-borne Diseases
A must lor all those concerned about environment
and health.
News from Bhopal
Another hazard is the possibility of misuse of
such chemicals by the manufacturers. In June and
October 1975. Hindustan Ciba Geigy Ltd tested the
safety of its Nuvacron pesticide on more than 40
Indian volunteers aged between 13 and 57. All of
them stood around while an aircraft loaded with
the pesticide solution sprayed them with it over
four days. This use of humans as guinea pigs was
reportedly approved by WHO and had the sanction
of the Indian Insectidide Act which requires that
aerial spraying measurements be done under prac
tical conditions to prove the safety of the chemical.
A preliminary outline of a pilot model of a
comprehensive health care programme for the gas
victims has been drawn up by Smarajit Jana, Anant
Phadke, Mira Sadgopal and others, and is being
circulated for wider comment. It is hoped that
NGO’s will adopt this model and implement it and
dialogue with the government to adopt it on a
wider scale.
*
*
The Jana Swasthya Kendra has restarted the
administration of sodium thiosulphate from 9th Sep
tember and is considering the possibility of organi
zing an independent
rigorous
double blind
clinical trial along with the estimation of urinary
thiocyanate levels. A pamphlet written by Anant
Phadke on the Why’s and How’s of sodium thiosul
phate will be published shortly.
indiscriminate use of pesticides leads to dimi
nishing returns. A recent FAO study found that in
1980, 432 species of arthropods were resistant to
atleast one, and often several insecticides, an inui^ase from 25 in 1954. In Gujarat, cotton farmers
spray their fields 20 to 30 times more often than
before with more toxic and expensive pesticides,
which today account for over half of cotton cultiva
tion costs. In the Vidarbha region of Maharashtra,
expenditure on chemicals has increased 340 per
cent in the years without any increase in the aver
age yield. In Andhra Pradesh, the state with the
highest consumption of pesticides at a staggering
15000 tonnes a year, at least 15 species of pests
have become resistant to all commonly used agro
chemicals.
Child care activities which include a random
sample survey of childhood morbidity, a pictorial
health exhibition on child care to be shown in the
bastis, and immunization programmes are being
planned.
*
*
♦
The Relief Commissioner of Bhopal, Dr. Ishwar
Das reported that (i) sub acute syndromes of MIC
toxicity have now become evident in those who
survived the exposure; (ii) though the main symp
toms related to the respiratory tract, symptoms
involving other organs were also being observed;
(iii) about 2500 women have delivered since the
gas tragedy and both the number of still births and
malformed babies were alarmingly high. Eighteen
women had delivered malformed babies and the
number of still births had doubled; (iv) those suff
ering from lung disorders would not be able to
In fact, the spectacular spurt in pesticide use
has resulted in secondary pest outbreaks, because
the chemicals have killed off natural enemies of
pests like birds, spiders and worms. Such outbreaks
are sometimes more destructive than the primary
pestilence and much more difficult to control.
Source :
Banned Pesticides, Sunita Narain: The State of India's
Environment—1984-85, The Second Citizens’ Report *
7
mfc bulletin: OCTOBER 1985
RN.27565/76
undertake any physical labour again and would have
to take medical treatment for another 10 years or
more; (v) visual acuity of survivors has been badly
affected and many of them cannot do without specta
cles. (source: THE HINDU, 18 September 1985).
*
*
*
A health education pamphlet in Hindi on the
effects of gas exposure and the treatment required
has been produced by Anant Phadke and will be
published in collaboration with Eklavya, Bhopal. A
Hindi translation of the mfc Bhopal study report will
also be published by Eklavya shortly.
*
*
*
*
A study on the effect of the toxic gases on pre
gnant women in Bhopal was undertaken by a team
of over thirty volunteers from different voluntary
organizations and institutions including medico
friend circle, Action India, Sabla Sangh, Ankur,
Saheli, Jagori, Prayas, Mahila Mukti Morcha Sevapuri, Sahiyar, Nari Atyachar Virodhi Manch and
St. John’s Medical College. The survey was done
from 22 to 29 September 1985 and was coordinat
ed by C. Sathyamala of mfc.
❖
*
*
A workshop On Relief and Rehabilitation of
gas victims was organized On 28-29 September
1985 by the Madhya Pradesh Vigyan Sabha, the
Delhi Science Forum and the Kerala Sastra Sahitya
Parishad.
(Continned from page 3)
workers whose needs are greater but chances of total
success are low.
The answer could be in affirmative to both in
part. It would be prudent to aim for total success
by supporting the organised and enlightened sec
tions of workers possessing some leverage. On the
other hand low key actions like publicity, lobbying
and legal actions would ensure partial successes
for the weaker unorganised section of the working
class.
F) ROLE OF GROUPS LIKE MFC : Being
what it is, MFC can be looked upon chiefly as a
resource group. It could provide technical help on
Editorial Committee ;
kamala jayarao
anant phadke
padma prakash
ulhas jaju
dhruv mankad
abhay bang
editor: ravi narayan
Regd. No. L/NP/KRNU/202
its own or by referring people to experts/resource
/centres known to it.
1) Carrying out Studies : Any movement strong
or weak, spontaneous or planned would need a
solid information base if it is to have a lasting im
pact. MFC could undertake studies in the field or
the impact of environmental degradation on health.
2) Publicising the issue : MFC members
could write in the popular press, in medical journals
etc. about environmental health issues thus publici
sing it and lending it credibility.
3) Direct medical intervention : As in Bhopal,
under extraordinary circumstances in case of an
environmental disaster, MFC could intervene
medically by providing medical relief and long term
rehablitation as a part of an ongoing people’s
movement.
Iions the Editors desk. . .
The next annual meeting of the medico friend
circle will be held in the Bombay-Pune region in the
last week of January 1986 (the exact venue will be
announced soon). The theme of the meeting will
be Issues in Environmental Heplth — a case study
of pesticides.
The Bhopal disaster has been the stimulus for
selection of this topic but we do not plan to discuss
the acute problems of the Bhopal gas disaster vic
tims. We shall focus on wider environmental health
issues and problems in India using pesticides as
an illustrative case study.
As preparation for this meeting, we have in
cluded in this bulletin Dhruv Mankad’s article on
Strategies for Environmental Action which was
prepared for the Patiala meeting and also a review
of the pesticide problem from the recently relea
sed “The State of India’s Environment 1984-85^—a
Citizens Report.”
A
special issue on all aspects of the
pesticide problem is being planned for next month.
All readers who have come across relevant and
thought provoking material on this topic are requ
ested to send us references, xerox copies or small
articles/ notes immediately.
Further details about programme, background
papers and plan of discussions will be an
nounced shortly.
Views and opinions expressed in the bulletin are those of the authors and not necessarily
of the organisation.
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Edited by Ravi Narayan, 326, Vth Main, 1st Block, Koramangala, Bangalore-560034
Printed by Thelma Narayan at Pauline Printing Press, 44. Ulsoor Road. Bangalore-560042
Published-by Thelma Narayan for medico friend circle, 326, Vth Main, 1st Block,
Koramangala, Bangalore-560 034
- Media
MF_BHOPAL_1B_PART 1.pdf
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