THE HEALTH STATUS OF THE BHOPAL SURVIVORS
Item
- Title
- THE HEALTH STATUS OF THE BHOPAL SURVIVORS
- extracted text
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country to meet each other for an intensive dialogue
and to chalk out a common action programme.
Foreign countries
— sea mail — US $4.00 for all countries
— air mail: Asia — US $6.00
Europe, Africa & Australia
— US $9.00
North & South America —
US $11.00
•
Study and action-projects by local groups, re
gional camps to understand a local health problem
and its broader dimensions, health educational cam
paigns are other activities through which mfc has
grown and consolidated. The camp on lathyrism in
Rewa District in 1978, the educational campaign
against Oestrogen — Progesterone forte, about diarr
hoea and misuse of drugs are examples, mfc is also
an active member of the All India Drug Action Net
work.
All payments may be made
in the name of medico
friend circle and sent to:
ORGANIZATION
The medico friend circle is not a rigid organiza■km. It is loosely knit and composed of friends from
^irious backgrounds, usually medical to start with,
often differing in their ways of thinking and in their
modes of action. But the understanding that the
present health services and medical education system
is lopsided in the interest of the privileged few and
must change to serve the interests of the poor people
of India, is common conviction.
mfc is registered under The Societies Registra
tion Act 1860; No. MAH/902/Pune/81 and under
The Bombay Public Trust Act, 1950; Reg No. F-1996
(Pune).
Publications
The following are obtainable from the above
address on payment:
1. Subject-wise index of first 100 issues of
bulletin
2. Anthologies of bulletin articles
I — In search of Diagnosis
II — Health Care Which Way to Go
III — Under the Lens — Health & Medicine
(From Jan 1985)
3. Back issues of some of the bulletins (ask for
separate list)
4. Editorial guidelines for contribution to bul
letin
5. Background papers of some annual meets
(ask for separate list).
MEMBERSHIP
Anybody who broadly agrees with the perspec
tive and the rules and regulations of mfc is
welcome to become a member. Non-doctors are
encouraged to join. The membership fee is given
below. It is understood that members capable of
contributing more than the minimum will do so.
Conversely the. convenor can waive or reduce the
embership fees in deserving cases. For membership
rms and rules and regulations, please write to the
convenor.
R
•
Membership fees
Those'earning less than Rs. 750.00 p.m. —
Rs. 25.00 per year
Those earning more than Rs. 750.00 p.m. —
Rs. 50.00 per year
Membership fee includes subscription to the mfc
bulletin
•
Bulletin subscription
Within India — Rs. 15.00 per year
(add Rs. 3.00 for payments by
cheque)
Life subscription — Rs. 250.00
ravi narayan
convenor, medico
friend circle
326, V Main I Block
Koramangala,
Bangalore-560 034
Bulletin Back Issues
Xerox copies of mfc bulletin back issues are
available with the Centre for Education Al
Documentation (CED), 3 Suleman ChambM^
4 Battery Street, Bombay 400039.
In order to cover costs and at the same time
provide subsidies to deserving groups a graded rate
structure has been worked out and is available
on request.
•
For mfc members rate is —
i. set of 100 issues — Rs. 240
ii. specific issues — Rs. 4 each
iii. specific article — 0.60 p. per page
mfc Drug Campaign
For further details write to Anant Phadke,
mfc Rational Drug Policy Cell.
50 LIC quarters, University Road, Pune 411006.
medico friend circle
1PECTIVE
The medico friend circle is a group of socially
conscious individuals, interested in the health prob
lems of our people, mfc is trying to evolve an appro
priate approach towards developing a system of
health and medical care which is human and which
can meet the needs of the vast majority of the
population in our country.
The existing system .of medical care, we have
realized, is not geared towards the needs of the peo
ple. It requires a fundamental change. Such a change
would occur as a part of a fundamental change in the
total social system in the country, since the medical
system is only a part of the total social system. mfc
believes that the potential created by modern medical
science cannot be realized fully without a fundamen
tal change in the social system.
Wbat is wrong with the existing medical system
iU^India?
Though after independence there has been a
rapid growth of the medical services organised by the
Government, Private Practice remains the dominant
feature of medical care in India. In private practice,
medical care like any other commodity in the market
is available only to those who have money to pay.
The medical profession resembles any other commer
cial sector and therefore has been dominated by con
cern for money rather than for people. Commercial
competition and personal interests of doctors lead to
numerous malpractices.
This behaviour is encouraged and promoted by
profit oriented drug companies which dump many
useless or even harmful drugs onto the consumer by.
co-opting the doctors, through their sales promotion.
techniques.
mfc upholds the interests of the people and
* wants medical care to be available to every
one irrespective of his/her ability to pay
* wants to develop methods of medical inter
vention strictly guided by the needs of dur
people and not by commercial interests.
•
Since purchasing power is mainly concentrated
in urban areas, commercial medical practitioners are
also concentrated in cities and towns. This over
crowding of doctors is partly responsible for the
overgrowth of specialists. This has resulted in the
denigration of the role of a basic doctor to just a
“cough and cold” doctor. The training of doctors has
also been influenced by this situation. Hospital based
training by Western and Urban oriented speeja^ts
produces a graduate conditioned to urban and
tal practice. Therefore even after prolonged training
in a medical college, such a graduate is not capable
of dealing with the situation in rural areas.
mfc would work towards
* a pattern of medical care adequately geared
to the predominantly rural character of our
country and
* towards a medical curriculum and training
tailored to the needs of the vast majority of
the people in our country.
•
To further their narrow professional interests,
doctors have established a monopoly control over
medical knowledge and medical practice. Medical
knowledge has been jargonised and a halo has been
created around it. This monopoly and mystification
opens the door for domination by the medical profes
sion over patients and by doctors over nurses and
other paramedics.
mfc stands for
* popularization and demystification of medical
science and
* believes that different categories of medical
professionals be regarded as equal members of
a democratically functioning team.
•
Commercial interests demand a growing market
for drugs and medical therapies and this is partly res
ponsible for medical practice being reduced mainly
to curative services. It denigrates the primary role
of preventive and social measures. Drugs, surgery,
even vaccines have so far contributed marginally to
the improvement in people’s health in different coun
tries. In spite of the primary role of socio-economic
development in improving health of a people, a
wrong belief is promoted that medical intervention
— use of drugs, surgery etc., — is primarily respon
sible for improvement in the people’s health.
* mfc realizes the importance of curative tech
nology in saving a persons life, alleviating
suffering or preventing disability but
* stresses the primary role of preventive and
social measures to solve health problems on
a social level.
0
The government health sector is not commercial
and the PHC doctors are supposed to emphasize pre
ventive medicine. But this sector has not changed
the basic pattern outlined above. The doctor worki^fein a PHC is inclined and trained to do mainly
^Mtive work and generally reflects the typical atti
tude of the upper class, urban, elite professional.
Preventive measures when undertaken are therefore
reduced to pure technological and administrative
measures without any social content.
mfc stand for
* the primary importance of preventive mea
sures, planned and carried out with active
participation of the community and
3 for democratic decentralization of responsibi
lities wherever possible.
°
Medical practice in its existing form reflects and
reinforces some of the negative, unhealthy cultural
values and attitudes in our society, eg., glorification
of money and power, division of labourers into manual
and intellectual workers, domination of men over
women, urban over rural, foreign over Indian ......
mfc works towards
4 a kind of medical practice built upon human
values, concern for human needs, equality,
democratic functioning.
•
In the present medical system, non-allopathic
therapies are given a step-motherly treatment. Allo
pathic doctors call non-allopaths quacks without know
ing anything about their systems of medical care.
Equally unscientific are the claims of success made
by some non-allopaths and by some drug companies.
Prejudices, ignorance, self-interest have prevailed over
open-minded scientificity in this important area of
medical care.
mfc believes that
research on these therapies be encouraged by
alloting more funds and other resources and
* that these therapies be encouraged to take
their proper place in the modem system of.
medical care.
mfc thus tries to foster among medicos a current
upholding human values and aims at restructuring the
medical profession to enable it to realize the poten-'
tial created by modern scientific medicine.
mfc offers a forum for dialogue/debate, sharing
of experiences and experiments with the aim of realiz-1
ing the goal outlined above; and for taking up issues
Of common concern for action.
I
ACTIVITIES
mfc members are spread all over India and try
to propagate the perspective of mfc through their
work. Some members are engaged full-time in orga
nizing health projects in rural areas.
Bulletin
™
0
mfc is as of today, mainly a thought-current and
the monthly Medico Friend Circle Bulletin now
in its ninth year of publication, is the medium.
through which members communicate their ideas and
experiences to each other. The bulletin publishes
articles broadly reflecting the mfc perspective on
health problems. Running the mfc bulletin is our
chief common activity.
Anthology
Publication of the Anthology of selected
articles published in the bulletin has been a milestone
in the development of mfc. The first anthology — In
Search of Diagnosis — was very well received
and was rapidly sold out. KSSP translated it in
Malayalam (two editions). The second anthology —?
Health Care which way to go — is almost
sold out. Reprints of the first and second anthologies
and the third anthology — Under the Lens Health
and Medicine — are due shortly.
Annual Meet
£
°
Once a year mfc members gather at an All Incur
Annual Meet to explore a relevant topic through dis
cussion or to understand the functioning of a parti
cular health.care project in terms of a chosen topic.
Since 1974, annual meets have been held at Ujjain
(relevance of the present health services), Sevagram
(present health problems), Hoshangabad (Indian
nutritional problem), Calicut (community health
approach, role of doctor in society), Varanasi (unem
ployment among doctors), Jamkhed (community
health worker), RUHSA Project (community paedi
atrics), Tara (misuse of drugs’ by doctors), Anand
(prejudice against women in medical care), CINI,
Calcutta (alternative medical education).
The Annual Meet provides an opportunity
for far-flung medico friends from different parts of the
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... -
MEDICAL RELIEF
RESEARCH IN BHOPAL
The Realities and Recommendations
medico friend
circle
A summary report of a medical fact finding team's
investigation two months after the gas accident at
Bhopal, presented at the All India Convention of
People's Science, Democratic Rights and Environ
mental Protection Groups called by the Zahreeli
Gas Kand Sangarsh Morcha, Bhopal, 17-18 Feb 1985
medico friend circle
organization and bulletin office
326, V Main, I Block
Koramangala
■ ■
Bangalore - 560 034
Contributory Price
Rs. 2
COMMUNITY HEALTH CELL
326, V Main. I Block
Kore-mongala
Bangalore-560034
India
medical relief and
RESEARCH IN BHORAL
The Realities and Recommendations
INTRODUCTION
This report has been written by a group of doctors from
the medico friend circle (mfc) after collecting medical infor
mation from gas affected persons, interviewing doctors work
ing in Government hospitals, private practitioners and relief
workers, and by sifting through various available toxicological
literature and press reports.
The objectives of our investigation were as follows :
a) to understand the health situation of the victims;
b) to obtain information about the medical relief being
provided to them:
c) to get to know about the medical research being con
ducted in the wake of the Bhopal tragedy, and
d) to offer necessary recommendations to Government and
Voluntary bodies.
During the investigation, the group worked under the
following limitations :
The Government’s policy and effort to deny informa
tion, having instructed government as well as prvate
doctors not to divulge any medical details:
2) A lack of proper medical records; and
3) Given the constraints of time and resources available
to the group, the impossibility of conducting a systema
tic survey to generate primary data
1)
FINDINGS
On the basis of the evidence gathered, the group oncluded that a) in spite of the great confusion prevalent during the first
2
few days after the accident, the general public, voluntary
agencies and the medical staff of government hospital
worked ceaselessly with whatever facilities were at hand
in attempting to save as many lives as possible;
b) in spite of clear evidence of cyanide poisoning from 3rd
December 1984 the administration of the known
specific antidote sodium thiosulfate was banned. Only
after a fatal lapse of two months has this decision been
officially reversed, and even today clear guidelines for
its administration to patients have not been issued, nor
is the injection yet being made available in the quantity
required for massive detoxification of the affected
population;
c) the crucial information about the nature of the gas as
well as the findings of autopsy was with-held from the
medical community as well as the public by both the
Union Carbide and the Government, incapacitating the
treating doctors and creating unnecessary fear amongst
the people. In its place, misinformation was fed by the
medical officers of Union Carbide, Dr. Jaeger of the
World Health Organisation and the Ishwardas committee
of the Government of Madhya Pradesh in the form of
statements to the press, like ‘there is no evidence of
cyanide poisoning’ and ‘only lungs and eyes have been
affected’ :
d) In the absence of uniform guidelines from responsible
senior government doctors, the treatment was sympto
matic and consisted mainly of atropine (or homatropine)
and antibiotic medications for the eyes, oxygen and
bronchodilators for severe respiratory complaints,
antacid-antispasmodics for gastritis and paracetamol for
fever. Corticosteroids were also given in large quanti
ties, at first to save life and later in an attempt to
prevent lung fibrosis. Antibiotics were given freely and
in anticipation of a heavy wave of secondary infection
in mid-December, which, however, curiously did not
3
occur to the extent expected. Outside the Government
system, private treatment and sale of proprietary medi
cines, including expensive iron tonics and cough syrups
flourished without affording much relief.
e)
regarding the people’s state of health, various compla
ints persist which we concluded are due only to the effe
cts of the poisonous gas exposure.
— There has been remarkable improvement in the con
dition of the eyes, and the group has not found any
case of total blindness which can be attributed to the
gas However, a large number of people continue to suf
fer from blurring of vision and intolerance to bright
light, preventing them from pursuing their prior occu
pations.
— Thousands of people have developed chronic lung
disease as a sequel to the gas exposure, and it seems that
this will be a permanent handicap. Records of selected
patients subjected to sensitive lung function tests show
definite abnormalities suggesting both ‘obstructive’
(where air passages are obstructed) and ‘restrictive’
(where the lungs are unable to expand due to fibrosis)
lesions. X—ray evidence of fibrosis is also now becom
ing apparent.
— People also suffer on a large scale from gastritis, fever
and psychological stress of varying severity.
— Women have suffered from abortions, stillbirths,
diminished foetal movements, suppression of lactation,
abnormal vaginal discharge and menstrual disturbances.
f)
a large number of pregnant women were exposed to the
toxic gas, hypoxia, infection, stress and drugs, each of
which can cause damage to the foetus and result in
birth of deformed children No information has been
provided to women about this considerable risk to
enable them to exercise their choice of terminating
pregnancy within the period when abortion is safe.
4
g)
due to the unprecedented nature of this tragedy, a vast
array of medical research studies have been launched.
Even though research is essential in the present situation.
certain undesirable and even dangerous trends are emer
ging. The choice of research projects is being made
solely by government agencies without any consultation
with the medical community or the people. The people
are not being informed and their consent is not being
taken for inclusion into the studies and for the proced
ures to which many of them will be subjected. This is a
minimum medical ethic. The research interests of the
doctors are tending to take priority over the need to
provide service to the people.
RECOMMENDATIONS
On the basis of these findings, we are able to make the
following recommendations which we consider necessaryThe first five recommendations should be taken up on a
priority basis
1) That medical and pathological information be made
available to the public and to the medical community, inclu
ding clinical findings, laboratory investigations, treatment
records, autopsy reports and any further clues as to the
nature of the toxic substances involved in the tragedy.
2) That, in the wake of ICMR’s acknowledgement that cy
anide poisoning has occurred, the much delayed treatment by
sodium thiosulfate be administered to the affected popula
tion in the recommended dosage In order for this measure to
reach all persons who were in Bhopal at the time of the gas
leakage, the government of Madhya Pradesh must give wide
publicity to the arrangements made for total detoxification.
3) That the Government immediately publicise the poten
tial dangers involved to all pregnant women who were exposed
to the gas in the first trimester of pregnancy so that these
women can still take a timely decision to terminate pregnancy
5
To facilitate such a decision, adequate facilities for u'trasonography and amniocentesis must be provided without delay
This measure is particularly urgent as many pregnant women
are now crossing the safe period for termination of pregnancy.
4) That all exposed couples of reproductive age be advised
to aved conception until they are totally detoxified, To faci
litate this, immediate information about and supply of various
contraceptive methods must be arranged through all available
public and private channels.
5) That complete and unambiguous guidelines be provided
to medical and para-medical staff of government and non
government agencies concerned with the treatment and follow
up of gas victims.
6) That the government of Madhya Pradesh set up decision
making and review committees concerned with health services
to the gas victims and medical research on the effects of expo
sure, and that the members of such committees be drawn not
only from Government agencies but also include representa
tives of the affected people and members of professional asso
ciations and voluntary bodies.
7) That the Government set up a health care system to
reach the door step ofall gas victims. A cadre of paramedical
workers and medical social workers must be created to under
take the following tasks;
a) to provide on the spot treatment for acute symptoms
b) to identify chronic and serious cases;
c) to identify fresh cases;
d) to maintain comprehensive and regular health records for
the entire affected population; and
e) to give mass education to gas victims to understand and
tackle the problems of breathlessness and other chronic
symptoms.
In the formation of this cadre, the resources of voluntary
agencies must be utilised.
8) That duplicate health records be maintained for all gas
6
affected patients with one copy to be given to the patient.
9) That close monitoring of vital statistics in the affected
localities be carried out on a long term basis for detecting
trends of mortality and morbidity in the exposed population
for at least two generations.
10) That all research projects concerning the after effects of
the gas leakage on human beings be made public from the out
set and public debate be allowed and encouraged to consider
the propriety and relevance of the research.
11) That all researchers be required to gain the informed
consent of every individual (or guardian of that individual)
who is included in a research study or procedure of any sort.
12) That the results of all medical research be communica
ted in understandable language to the people who have been
studied Such communication must be offered as a rule prior
to or simultaneous to. but not later than, submission of these
researches for publication in scientific journals. The people's
review committees may assist the medical scientists in con
veying the research results back to the people of Bhopal.
13) The occupational health records of Union Carbide sho
uld be made available to all those persons who are interested
in them.
Bhopal
17 Feb 1985
Abhay Bang, Wardha
Ramana Dhara Hyderabad
Shyama Narang, Hyderabad
Mira Sadgopal, Bankheri
medico friend circle
organizational office
326, V Main, I Block
Koramangala, Bangalore 560034
An Appeal
Dear Friends,
This report written by a fact finding team from our circle
is being sent to you all for your support and action We invite
you to join us in our efforts to express solidarity with the
Bhopal disaster victims and their urgent need for effective
medical attention and justice. There is an immediate need 1) To support the local medical profession and health wor
kers with authentic technical information and manage
ment guidelines to help their efforts in patient care
2) To disseminate meaningful and demystified medical in
formation so that affected victims and their families are
reassured and helped through the crisis
3) To ensure that the efforts of governmental and non- gov
ernmental agencies become an expression of humane
welfare and not exploitation.
You can help us by doing one or more of the following :
(a) Disseminate this information to citizens groups, media
representatives, voluntary agencies, health and develop
ment activists to generate pressure on the governmental
machinery and the 1CMR for more effective action.
(b) Show this report to medical experts and scientists who
can give their opinion on the problems mentioned tn this
report. Send us point by point reactions/responses. Any
technical information, research findings and reports of
their investigations carried out which will help patient
management are most welcome.
(c) Any other forms of support including contribution to
support studies/investigations by our team and publi
cation of findings for professional and public awaren
ess. (Contributions by cheque/DD may be made in
favour of ‘medico friend circle—Bhopal Fund'.
Looking forward to your active involvement.
Yours sincerely,
Ravi Narayan
Convenor : medico friend
circle
® medico friend circle is a circle of friends with medical/
non-medical background who share the common con
viction — that the present health servicesand medical education
system is lopsided in the interest of the privileged few
and must change to serve the interests of the large
majority, the poor
We are committed to :
— people oriented medical care
— community oriented medical education
— demystification of medical science
— preventive and social measures in health care
— human value oriented medical practice
— equality, team work and democratic functioning
— medical interventions guided by people's needs and not
commercial interests
•— open minded, scientific attitude to non - allopathic
systems
@ mfc tries to foster among medicos and others a current
upholding human values and aims at restructuring the
medical profession to enable it to realize the potential
created by modern scientific medicine.
@ mfc offers a forum for dialogue/debate, sharing of
experience and experiments with the aim of realizing the
goal outlined above; and for taking up issues ofcommon
concern for action.
Concern for man himself and
his safety must always form the
chief interest of all technical
endeavours. Never forget this in
the midst of your diagrams and
equations.
—Albert Einstein
THE BHOPAL
DISASTER
AFTERMATH
an epider
and socio
A summary of the
'//tf
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 medical research
from becoming an instrument of
exploitation of human suffering
With a determination
to make medical research
an expression of
human concern
A summary of the epidemiological and socio-medical
investigation conducted by a team from the medico
friend circle, in Bhopal, 18—25 March 1985
Price Rs. 2. 00
PREFACE
The Bhopal disaster has been an unprecedented
occupational and environmental accident. Equally unprece
dented have been the imperatives for relief, rehabilitation
and research in the aftermath of the disaster.
The local situation has been extremely complicated and
dynamic. While health service providers and researchers
have had to face many medical challenges; government and
voluntary agencies involved in relief and rehabilitation have
had to face many logistical and organizational challenges.
For the medico friend circle too, i.n its intervention in
research and continuing education strategies in support
primarily of voluntary agencies, it has been both a challenge
and a thought provoking learning experience. The experie
nce of planning, organising, analysing and communicating
our research findings based on a modest study has brought
us further in touch with the apathy, vested interests and
status quo factors which obstruct action in favour of the
disadvantaged in society.
Having seen the intensity of health problems of the
disaster victims and the inadequacies in the strategies empl
oyed to ameliorate them we cannot but help raise critical
comments on all components of the social medical system
who are there to handle such problems.
Our objective, however, is more than critical analysis.
Through this epidemiological study we have tried to make
our own small contribution to a better understanding of the
health problems that prevail in the aftermath of the disaster.
We have also made suggestions for a more comprehensive
relief and rehabilitation strategy.
A word of caution here-most of our observations are of
the situation as it existed at the end of March 1985. Six
months have passed in the process of analysis, consensus
seeking and understanding our findings. During these six
months, many further developments—both positive and
negative—have taken place in Bhopal at the governmental
and the non governmental initiative.
We hope that this report will atleast help to highlight
to our readers among other matters that—
(i)
what people say and feel is as important evidence
as what we can discover through our over-mystified
medical technological'approach;
(ii)
in the absence of a community oriented epidemiolo
gical
perspective, decision
making
about relief
efforts following a disaster can be adhoc and often
irrelevant; and
(iii)
for research to be relevant to the lives of the people, the
findingsand inferences drawn must be communicated
to the health service providers and the patients them
selves through an effective communication strategy.
Finally we hope that through this report, we shall
stimulate debate, dialogue and a commitment to a deeper
understanding of the problem leading to more relevant and
meaningful interventions.
Bangalore
Ravi Narayan
2 Oct. 1985
Convenor
THE BHOPAL DISASTER :
ITS AFTERMATH
Introduction
The disaster that took place on the dark, wintry night of
2/3 December 1984 in Bhopal is the worst man made envir
onmental accident in recorded history. The shocking,
official estimates of 1754 human deaths, an equal number
of dead cattle and the physical and mental disablement of
over two lakhs people, by a mixture of toxic gases includ
ing Methyl Isocyanate (MIC), do not adequately express the
tragedy that has occurred.
The relief efforts, initiated immediately, were handi
capped 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 lack of
relevant information among the State and Central authori
ties.
The doctors at the Hamidia Hospital, Bhopal, where
hundreds 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 of 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
experts 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
development and testing of these theories, had they been
done properly, would undoubtedly have added immensely
to scientific knowledge. What is more important is that it
would have relieved the sufferings of thousands of people.
The local realities have, however, revealed the power stru-
2
gglesinthe medical community and how it ignores in the
process, the victims; the lack of human concern leading to
withholding of probable proper treatment; the indifference
of our medical and scientific community to communicate
with our largely illiterate but not unintelligent masses.
The Two Theories
The protagonists of the first theory, the ‘Pulmonary the
ory' believe that isocyanates of which MIC is one, damages
only those tissues with which they come into direct contact
and cannot be carried by the blood to internal tissuesand
organs. Thus MIC can damage only the lungs, eyes and skin
and this according to them explains the predominant invo
lvement 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 as a result of lung damageThis theory is strongly supported by a dominant section in
the Gandhi Medical College and the medical community in
Bhopal. They believe that early deaths were due to carbon
monoxide poisoning - one of the constituents of the rel
eased gases. They refuse to accept any alternative theory.
This theory cannot fully explain the varied symptoms of
the victims: nor the fact of multi-systemic involvement with
out lung involvement seen in many patients. While another
isocyanate, toulene diisocyanate (TDI) has been shown
to cause brain damage, the protagonists of the present
theory are silent as to why MIC cannot do so, too. Public
Health specialists in the U. S. say that this exposure can
lead to permanent lung involvement and blindness. This is
in contrast to the Union Carbide which maintains that MIC
can have no lasting damaging effects.
The main protagonist of the second theory, the 'Enlarg
ed Cyanogen Pool theory, is the Indian Council of Medical
Research (1CMR). In fairness to this body, it must be stat
ed at the very outset that it does not reject the first theory
3
but believes that both have important roles to play in
explaining the varied symptomatology.
This theory stemmed from the observation that the
tissues and blood of the dead victims were bright red in
colour. This occurs both in cyanide and carbon monoxide
poisoning. Haematological (blood) studies by ICMR ruled
out the possibilities of carbon - monoxide poisoning.
Cyanide on the other hand might have been inhaled
directly as hydrogen cyanide or might have been released
in the body after the breakdown of the MIC molecule.
Normally, there is a small cyanogen pool in the body
formed by the generation of small amounts of cyanide or
cyanogenic substance during normal metabolic processes.
These cyanide or cyanogenic radicals are converted into
relatively harmless thiocyanates by a liver enzyme called
rhodanase and excreted in the urine. Certain foods like
cabbage etc., and smoking are known to increase the
cyanogen pool as evidenced by an increased excretion of
thiocyanates in the urine. Cyanide/cyanogen interferes
with oxygen utilization in the body.
The protagonists of the enlarged cyanogen pool theory
have established that MIC in the body gets attached to the
haemoglobin by a process of carbamylation. They believe
that by a mechanism as yet unknown the cyanogen pool
within the body is increased. In these circumstances, its con
version to thiocyanate by rhodanase, can be accelerated by
administration of sodium thiosulphate (NTS). This is the
rationale in using NTS as an antidote for cyanide poisoning.
The resultant thiocyanates are excreted in urine, and this
can be used to test the proposed theory itself.
The ICMR conducted a double blind clinical trial using
sodium thiosulphate and glucose as a placebo on gas affect
ed patients in January. Majority of patients who received
NTS showed significant improvement and 10 out of the 19
4
patients showed an eight fold increase in urinary thiocyanate
levels. Those who received glucose did not show significant
changes. Unfortunately, and due to reasons best known to
itself, the 1CMR has not made the details of the findings of
this crucial trial, public. The opponents of the theory too
have conducted a trial-not double blind, which they say
does not confirm the hypothesis. They too have withheld
their findings from public scrutiny.
The Study by mfc
The mfc had decided at its annual meet held at the end
of January 1985, to respond to a series of appeals from
various non-governmental organizations(NGOs)and citizen's
forums to undertake an epidemiological investigation, so as
to support the victims and the NGOs in their struggle for
proper relief and a more meaningful rehabilitation process.
Some members of mfc visited Bhopal in mid-February to
assess the situation and the actual epidemiological survey
was conducted between 18-25 March 1985 by 11 members
of mfc and 3 friends from the Baroda Medical College.
It must be admitted that the mfc had neither the human
power nor the material resources to launch a full scale in
vestigation. Our initial, fact finding survey revealed :
all
(i)
official secrecy regarding
disaster;
(ii)
absence of open scientific debates;
(iii)
lack of encouragement to NGOs.
The mfc therefore decided to:
(i)
make an epidemiological assessment of the current
health status and health problems of the people;
(ii)
to examine the findings in the light of the two contro
versial theories;
(iii)
to evolve a critique of the medical reasearch and relief
programme;
information
on
the
5
(iv)
to make recommendations for a more meaningful relief
and rehabilitation policy.
The ICMR summaries of research 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 by a thorough physi
cal examination and undertook haemoglobin estimationsand
lung function tests. A criticism against this approach of reli
ance mainly on symptoms could be that it lacks objectivity.
However, we believe that a thorough study of symptoms is
a perfectly valid method of study as has been accepted in a
whole range of medical conditions like chronic bronchitis,
ischaemic heart disease, arthritis etc.
The study population
The study was a community based, case/control study.
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 1 0 km
away with the least exposure, which served as the control.
There was no area which was similar to JP Nagar in socio
economic and environmental characteristics and yet escaped
exposure and, therefore, Anna Nagar with the least 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 explicit that we
were not there to offer any financial compensation, medical
treatment etc. The slum dwellers were given a hand out in
Hindi explaining the role of mfc and a commitment was made
that the salient findings of our study and our recommenda
tions would be made available to them.
Sample Selection
The families for study were selected by random
sampling, an accepted statistical method used in community
6
based studies. 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 procedures
using 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
affected, were slightly better off economically but this is of
no significance in so far as morbidity rates in JP Nagar are
concerned. (For details of actual figures, see our Report.)
An unexpected finding was that people as far away as
Anna Nagar (our control population) were minimally exposed
and we observed a larger number of serious symptoms in
this group than one would expect. This fact narrows down
the differences in rates of symptoms observed between the
two populations. The health impact of the toxic gases on
the exposed population is therefo-e much greater than what
our study reveals.
The subjects described a broad range of symptoms aris
ing from most of the different systems in the body. 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 Nagar, the controls,
were also exposed to the gas, albeit to a small extent, the
latter also reported those symptoms. However, JP Nagar
residents had a much higher (statistically highly significant)
incidence of these symptoms compared to Anna Nagar.
7
The commonest symptom was breathlessness on accu
stomed exertion. The following symptoms were highly
significantly different (higher) in J P Nagar as compared to
Anna Nagar: cough with expectoration, chest pain, blurred
vision, photophobia, headache, fatigue, loss of memory
for recent events, weakness in exremities, muscle ache, ab
dominal pain, nausea, and anxiety/depression (see table).
The following six symptoms were also significantly different:
dry cough, breathlessness at rest, watering of eyes, skin
problems, bleeding tendency, and impotence. On grouping
the symptoms according to the systems, most of them are
related to the pulmonary system (respiratory), the gastro
intestinal system (digestive), the eye and the central nervous
system. It is important to note that this survey was cond
ucted more than three months after the disaster, and the
victims still continued to suffer so many multisystemic sym
ptoms. Moreover every individual in the J P Nagar sample
reported at least 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 gastro-intestinal, central nervous system and eye symp
toms in the absence of any lung findings. This cannot be
explained by the theory that the multisystemic symptoms are
due to hypoxia (decrease of oxygen in blood stream) secon
dary to lung damage. It points to the possibility of a cir
culating toxin in the blood, affecting all the systems.
Our findings also refute the speculation that much of
the present morbidity is due to a high prevalence of chronic
diseases like tuberculosis, asthma, bronchitis etc., and high
rates of smoking among the affected basti population.
Women in the reproductive age group reported menstrual
irregularities such as shortened menstrual cycles, altered
pattern 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
Salient Findings of the Study
Comparison of symptoms/investigations in J P Nagar and Anna Nagar
(expressed in percentage) (No. of cases are shown in brackets)
SI No
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Symptom
Breathless on usual exertion
Chest pain/tightness
Weakness in extremities
Fatigue
Anorexia
Nausea
Abdominal pain
Flatulence
Blurred vision/photophobia
Abnormal distant vision
Loss of memory for recent events
Tingling & Numbness
Headache
Muscleache
Anxiety/depression
Impotence
Haemoglobin (male) (mean gm%)
Haemoglobin (female) (mean gm%)
* Standard deviations of means
Annei Nagar
P Value
(129)
35.50
(49)
(74)
. 26.08
<36)
(97)
36.95 ■■ (51)
(120)
39.85
(55)
28.26
(98)
(39)
(86)
16.66
(23)
(79)
25.39
(35)
(102)
25.36
(35)
(114)
38.40
(53)
(65/141)
21.88 (21/96)
(67)
11.59
(16)
(81)
20.28
(28)
(99)
42.02
(58)
(108)
36.23
(50)
(65)
. 10.14
(14)
(12)
0.72
(01)
*
(1.79)
12.70
(1.35)
*
*
(1.46J
10.79
*
(1.34)
<<0.001
<<0.001
<<0.001
<<0.001
<<0.001
<<0.001
<<0.001
<<0.001
<<0.001
< 0.001
<< 0.001
<<0.001
<< 0.001
<< 0.001
<< 0.001
< 0. 05
< 0. 01
< 0.001
J P Nagar
87.16
50. 0
65.54
81.08
66.21
58.10
53.37
68.91
77.02
42. 0
45.27
54.72
66.89
72.97
43.92
8.10
14.68
12. 7
9
pattern in the same group before the gas disaster and the
difference was found to be stastistically significant.
Nearly half of the nursing mothers in J P Nagar reported
a decrease or complete failure of lactation.
8% of the men reported impotence.
The number of pregnant women in the sample is too
small to come to any conclusion about the effect of the
exposure on the outcome of pregnancy. We are conducting
a detailed study of pregnancy outcome in September 1985.
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 signifi
cantly different in both sexes in JP Nagar and Anna Nagar.
Mean haemoglobin concentrations in both males and femal
es were significantly higher in JP Nagar than in Anna
Nagar, suggesting that compensatory mechanisms in the
body had begun to respond to the hypoxia.
The mean values of lung function tests were statistically
significantly lower in JP Nagar as compared to Anna Nagar
particularly in the age group 15-44 and 45-60 in both sexes.
The pattern was primarily restrictive.
An important finding of grave significance is that 65%
of the working persons in JP Nagar experienced a drop
in income ranging from 20% to100°/o as opposed to only 9%
in Anna Nagar. This reflects the way in which the physical/
mental disability of the people caused by the disaster has
affected their
working
and
earning 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
10
theory alone even though pulmonary lesions can cause
peripheral hypoxia and hence muscular fatigue and so on.
On the other hand, the enlarged cyanogen pool theory can
better explain the varied and apparently unconnected
symptomatology. It must be emphasised that both theories
are probably playing a role in the causation of symptoms.
However, the ICMR has not tested the cyanogen pool hypo
thesis rigourously. It has studied only the seriously ill,
hospitalized patients and concentrated mainly on the lung
symptoms. They do not say whether the non-pulmonary
symptoms (symptoms not related to lungs) were also reliev
ed by sodium thiosulfate and curiously has not made its
findings public. One therefore, may also question whether
the cyanogen pool theory is fully valid.
It must be stressed here that the mfc is not rejecting
the cyanogen pool theory. It is only to point out that the
country's main medical research pody has failed to be
rigorously scientific in testing its own hypothesis.
Sodium thiosulphate therapy
We have already explained how sodium thiosulphate
(NTS) will help remove cyanide radicals from the body.
If the enlarged cyanogen pool theory has been established,
even as one of two causative factors the victims should rec
eive NTS treatment. Some of the local doctors and beaurocrats availed themselves of this, after the cyanide theory
was proposed, yet the affected people in the bastis were
not given the drug.
The ICMR at a meeting held on on 4 Feb 85, issued
guidelines for NTS treatment. 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 later with the argument that they are not convinc
ed of its efficacy. The question is not of a doctor's convict
ion. 'A doctor's choice of treatment cannot be arbitrary. The
11
question is whether there is scientific evidence in favour
of NTS therapy and whether there is equally strong, if
not stronger, evidence against the use of NTS in this
situation.
NTS 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 NTS therapy has
now been accepted but mass detoxification is still being
strongly opposed.
The trial with NTS 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 different investigatorsand the ICMR is unwitti
ngly lending support to the first theory, namely, that MIC
gas damages only tissues with which it comes into dirrect
contact.
What exactly happened to the gas victims?
So many months after the disastrous gas leak, one still
does not know what exactly has happened to those who in
haled the gases and are still surv:ving. This is not because
all attempts to unravel the mystery have failed but because
an integrated approach has not been taken 10 do so. Months
after the disaster, thousands of the survivors are still suffe
ring from debilitating symptoms which prevent them from
going back to work.
The medical community and the officialdom have been
adhoc in their efforts to render adequate succour to these
hapless victims. A powerful medical lobby in Bhopal have
opposed sodium thiosulfate, a treatment, with good potential
12
to the patients. They have no convincing argument for
their stand. The IMA, (Indian Medical Association) the
organisation which has authority over the medical profess
ion, has remained totally mute. The doctors as well as the
ICMR have concentrated entirely on those who were hosp
italised and have not evolved a holistic, community approach
to understanding the problem. The ICMR sponsored local
studies with exception of the NTS trials have lacked the
rigour and the epidemiological orientation that are neccessary 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
society and are 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 organi
sations have 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 al| attempts
were made to retrieve the Black Box of Kanishka, 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 research and follow up studies should shift focus
from hospital/dispensary based studies of seriously ill
patients to family/community based ambulatory
patients.
2.
Well designed clinical trials should be further initiated
using sodium thiosulphate as a therapeutic and
epidemiological tool to further establish the signifi
cant could role it could play in mass therapy.
13
Care, Surveillance and Rehabilitation
3.
Psychosocial assessment and consequent counselling
and rehabilitation are urgently required.
4.
Mass treatment with sodium thiosulphate based on
ICMR guidelines should be initiated maintaining good
medical records.
A surveillance programme should be undertaken to
assess risks to pregnant mothers, unborn babies and
new born babies. There should also be close monitor
ing 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 disaster victims is a
long overdue task necessary for mass treatment, co
mpensation and rehabilitation. This must be done
immediately.
5
Communication
8.
There is urgent need to evolve a continuing education
strategy for all health personnel including doctors
working in both government and non-governmental
centres. These could be through newsletters, hand
outs and informal group meetings.
The areas identified are:
(i) sodium thiosulphate therapy;
(ii) identification and management of psycho-social n
stress;
(iii) risks to mothers and unborn foetus and need
for surveillance;
(iv) family planning advice till completion of detoxi
fication;
(v) role of respiratory physiotherapy;
(vi) management of lactation failure;
(vii) caution against overdrugging;
14
need for open minded surveillance of high risk
groups;
(ix) importance of medical records.
(viii)
9.
There is also urgent need for dynamic creative nonformal health education of the affected community
through group meetings, posters and pamphlets 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) management of lactation failure including low
cost weaning foods;
(vii) importance of records and regular check ups;
10.
Occupational rehabilitation and compensation: In
the ultimate analysis care of illness, health education,
psychosocial counselling would be inadequate mea
sures if they were not backed by adequate monetary
compensation and urgent occupational rehabi litation of
the disaster victims. This would have to be
imaginatively done keeping their previous occupations
and the residual disabilities in mind.
Coordination
11.
The government machinery alone cannot handle such
a massive task. The government must adopt a policy
of enlisting 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 accident occurred, of the nature of the chemicals
released and of the reasons why the detoxification by
sodium thiosulphate has been so badly mismanaged.
medico friend circle
The medico friend circle (mfc) is a circle of friends with
medical /non-medical backgrounds who share the common
conviction that the present system of health services and
medical education is lopsided in the interest of the
privileged few and must be 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 education, demystification of
medical science and a commitment to the guidance of
medical interventions by peoples' needs and not commercial
interests.
mfc offers a forum for dialogue/debate, sharing of experience
and experiments with the aim of realising the goals
outlined above, and for taking up issues of common
concern for action.
For further
contact--
details
regarding mfc BHOPAL STUDY
Anil Patel
Ashvin Patel
ARCH
21 Nirman Society
A Ikapuri
Vadodara 390005
OR
ARCH
Mangrol (At & P.O.)
Via Rajpip la
Dist Bharuch
Gujarat 393 150
(A detailed report of the study including background,
objectives, materials and methods, observations and results,
discussion, recommendations, important appendices includ
ing proformas and references and reading list is also availalable on request from the mfc organizational office
326 1/ Main I Block Koramangala Bangalore 560034
Price Rs. 8. 00)
V
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AFTERMATH:
an epidemiological
and
socio-medical survey
medico
friend
circle
AC K N O WLE D G E M E NTS
To,
The people of Jaya Prakash Nagar and Anna Nagar for their warm and
welcoming attitude which greatly helped our study.
Rukmini Bahen and friends of SEWA and Ramachandra Bhargava
and colleagues of Gandhi Bhavan for their hospitality in BhopalThe Preventive and Social Medicine Department of Baroda Medical
College fortheir technical cooperation.
Friends of the Gujarat Sangharsh Vahini (Rashmi, Ambarish, Trupti,
Rajesh and Kaumudi) for their help in tabulating and analysing data.
Jan Vigyan Samiti, Kanpur and all our generous friends and members
for their donations, big and small.
A large circle of mfc friends and contacts for their support and
encouragement, and for their critical comments on the draft manu
script of this report.
I 2>O^'
COMMUNITY HEALTH CELL
47/1, (First
St. Marks Saad
BANGALO.iE ■ 5li0 001
ERRATA
Page
Line
1
3
'where' should read 'were'
6
34
'except' should read 'accept'
6
40
'polo' should read 'pool'
13
19
'weight (ii)' should read '(ii) weight'
43
24
'rigorouly' should read 'rigorously'
46
14
'Hindu' should read 'The Hindu'
52
16
'Gag' should read 'gas'
56
16
'muscie aches' should read 'muscle aches'
62
36
'paramteers' should read 'parameters'
63
31
'on' should read 'of'
65
7
'victims' should read 'victims'
TABLES
Page
18
Table No.
1C
'Others' in Anna Nagar 13.36 should
read '1 3.86'
24
3A
Blurred vision/photophobia
J P Nagar 77.02 (144) should read
'77.02 (114)'
A. Nagar 33.40 (53) should read 38.40 (53)
32
6C
After J P Nagar 468 should read (46.8)
35
7
15-44 Female FEV (Lit) in A.N. 2.25 (2.42)
should read '2.25 (0.42)'
ACKNOWLEDGEMENTS
To,
The people of Jaya Prakash Nagar and Anna Nagar for their warm and
welcoming attitude which greatly helped our study.
Rukmini Bahen and friends of SEWA and Ramachandra Bhargava
and colleagues of Gandhi Bhavan for their hospitality in BhopalThe Preventive and Social Medicine Department of Baroda Medical
College fortheir technical cooperation.
Friends of the Gujarat Sangharsh Vahini (Rashmi, Ambarish, Trupti,
Rajesh and Kaumudi) for their help in tabulating and analysing data.
Jan Vigyan Samiti, Kanpur and all our generous friends and members
for their donations, big and small.
A large circle of mfc friends and contacts for their support and
encouragement, and for their critical comments on the draft manu
script of this report.
1 '-\
COMM’jr.'ITY HEALTH CELL
47/1, (First hji:)St. Marks .load
BAWGALO.tE - &u0 001
THE STUDY TEAM
1.
Ashvin Pate! (Baroda)
")
( Co-ordinators
)
2. Anil Patel (Mangrol)
3. Daxa Patel (Mangrol)
4. Nimitta Bhatt (Baroda)
5. Manisha Gupte (Bombay)
6- Padma Prakash (Bombay)
7. Mira Sadgopal (Hoshangabad)
8. Marie D'Souza (Nandurbar)
9. Shirish Datar (Karjat)
10. Anant Phadke (Pune)
11. C. Sathyamala (New Delhi)
and three volunteers from Baroda Medical College
12.
3,
Ramesh Durvasula
Hemant Vithalani
Bipin Patel
iii
PREFACE
The Bhopal disaster has been an unprecedented occupational and environ
mental accident. Equally unprecedented have been the imperatives for relief, re
habilitation and research in the aftermath of the disaster.
The local situation has been extremely complicated and dynamic. While
health service providers and researchers have had to face many medical challenges,
government and voluntary agencies involved in relief and rehabilitation have had to
face many logistical and organizational challenges.
For the medico friend circle too, in its intervention in research and
continuing education strategies in support primarily of voluntary agencies, it has
been both a challenge and a thought provoking learning experience. The experience
of planning, organising, analysing and communicating our research findings based
on a modest study has brought us further in touch with the apathy, vested interests
and status quo factors which obstruct action in favour of the disadvantaged in society.
Having seen the intensity of health problems of the disaster victims and the
inadequacies in the strategies employed to ameliorate them we cannot but help raise
critical comments on all components of the social medical system who are there to
handle such problems.
Our objective, however, is more than critical analysis. Through this
epidemiological study we have tried to make our own small contribution to a better
understanding of the health problems that prevail in the aftermath of the disaster.
We have also made suggestions for a more comprehensive relief and rehabilitation
strategy.
A word of caution here—most of our observations are of the situation as it
existed at the end of March 1 985. Six months have passed in the process of ana
lysis, consensus seeking and understanding our findings. During these six months,
many further developments--both positive and negative--have taken place in Bhopal
at the governmental and the non-governmental initiative.
We hope that this report will atleast help to highlight to our readers among
other matters that—
(i)
what people say and feel is as important evidence as what we can discover
through our over-mystified medical technological approach;
(ii)
in the absence of a community oriented epidemiological perspective.
decision making about relief efforts, following a disaster can be adhoc and
often irrelevant; and
(iii)
for research to be relevant to the lives of the people, the findings
and inferences drawn must be communicated to the health service pro
viders and the patients themselves through an effective communication
stiategy.
Finally we hope that through this report, we shall stimulate debate, dialogue
and a commitment to a deeper understanding of the problem, leading to more relevant
and meaningful interventions.
Bangalore
2 Oct 1985
Ravi Narayan
Convenor
CONTENTS
Page
Acknowledgements
....
jj
Study team
. ..
jjj
Preface
....
jv
1.
INTRODUCTION
....
1
2.
OBJECTIVES OF THE STUDY
....
3
3.
BACKGROUND : TWO MEDICAL THEORIES
....
6
3.1
Pulmonary Fibrosis Theory
_
6
3.2
Enlarged Cyanogen Pool Theory
....
4.
5.
6.
8
12
MATERIALS AND METHODS
4.1
Sample population
....
12
4.2
Methods
....
12
4.3
Building rapport with the people
....
14
4.4
Plan of Analysis
....
15
....
16
OBSERVATIONS AND RESULTS
5.1
Non-responders—some observations
....
16
5.2
Comparison of samples
....
17
5.3
Socio-economic profile in the Bastis
....
18
5.4
Morbidity analysis
....
21
...
33
DISCUSSION
6.1
Role of Chronic Diseases and Smoking
....
38
6.2
Pulmonary Theory ; An assessment
....
39
6.3
Enlarged Cyanogen Pool Theory : An assessment
....
41
6.4
Magnitude of the Problem : An issue of Damage/Compensation
....
44
6.5
Thiosulfate controversy
....
45
6.6
Implication for research
47
v
7.
RECOMMENDATIONS
7.1 Community based Epidemiological Research
7.2
Mass Relief Programme
7.3
Listing of the victims; claims for compensation
7.4
Health Committees
7.5
A communication strategy on health related issues
APPENDICES
I
Proforma (6 sections)
II
English translation of Handout
III
ICMR minutes of 14.2.1985
IV
Study of Medical Relief
V
People’s Perception
REFERENCES
ADDITIONAL READING
CHAPTER 1
INTRODUCTION
Many months after the Bhopal gas tragedy, conflicting reports kept coming
in from Bhopal. There w?re reports that the gas victims continued to present at the
out patients departments with serious physical symptoms and they where getting
very little relief by the standard package of treatment which included antibiotics,
steroids, antacids, cough mixtures, eye drops and bronchodilators.
Doubts were being raised that the disaster victims were developing a sense
of dependence and were exaggerating their symptoms in order to draw more and
more benefits. It was also felt that the first wave of mortality and morbidity
had receded and that there was no significant residual damage and morbidity. The
feeling of "a// was well” was becoming stronger.
In February 1985, another dimension of the human suffering in Bhopal
came to light. The Indian Council of Medical Research (ICMR) came out with a
finding that the gas affected population of Bhooal was probably suffering from a
chronic cyanide like poisoning and that the use of an antidote - sodium thiosulfate—
could improve their condition. The situation was, however, further compounded by
a total clamp down of information by local state health authorities.
The medico friend circle (mfc) had decided at the annual meeting in
Bangalore, end of January 1985, to respond to a series of appeals from various
non-governmental groups and to undertake an epidemiological and medico social
investigation with the primary purpose of supporting disaster victims, citizens'
groups and voluntary agencies in their struggle for meaningful relief, rehabilitation,
justice, and for information.
However, at that point the collective knowledge of mfc was too inadequate
(cyanide poisoning was still in the future) for a meaningful formulation of the
problem in Bhopal. Naturally the formulation of concrete objectives for the study
was not possible either. This evolved as the study progressed in stages. It was
however felt that the mfc should collect its own field data and get first hand
information about the health status of the disaster victims.
A few mfc members had visited Bhopal in mid-February and had identified
certain urgent areas for action (1).
The team for this epidemiological study was in Bhopal from 15 to25 March
1985. It consisted of a voluntary group of clinicians, doctors working in community
health projects and health activists from different parts of India. During the stay and
subsequently as the collected data was being analysed, it was realised that two
medical theories to explain the continuing symptoms were competing to gain
supremacy :
i) The 'pulmonary' theory which believed that in view of the available
information about the effects of MIC, only extensive lung damage
(leading to diffused pulmonary fibrosis) and direct injury to corneas
of eyes could be expected.
ii) The 'enlarged cyanogen poo!' theory which believed that the effect of the
released gases on the patients was to increase the cyanogenic pool inside
their bodies leading to chronic cyanide-like poisoning.
Both these theories are explained further in the text. It is important to
realise, however, that this was not a purely academic controversy but a very serious
problem having a direct and immediate bearing on the lives of the people. The
controversy had resulted in the adherents of the pulmonary fibrosis theory (who
dominate the medical establishment in Bhopal) steadfastly refusing to treat the gas
victims on a mass-scale with sodium thiosulfate which had been advanced as an
antidote by the ICMR on the basis of its research findings. Tne net outcome of this
unseemly controversy was that the suffering of the people was continuing without
any relief in sight.
A study undertaken in a situation where two proponents of opposing
theories are busy in a controversy cannot ignore th°se theories. We did not. in
fact we consciously kept this controversy in mind and analysed our findings
accordingly. Needless to add that the study does not and cannot aim to provide
decisive arguments to resolve the controversy fully.
However the critical analysis does not remain narrowly confined to the
merits and demerits of the contending theories only. It goes much beyond that.
The inherent force of the logic of the criticism imoingas upon the much wider issues
of weaknesses in methodology, perspec'ive, orientatiin and setting of objectives of
medical research as it has been carried on in Bhopal. The serious gaps in the very
fabric of research efforts have direct and vital connaction not only with the
urgent issue of relief from suffering, damages and compensation to the victims of
the poison gas, but also with the issue of fixing the responsibilities on ell those
who have perpetuated the suffering of thousands of people of Bhopal.
We outline a series of conclusions and recommendations for urgent consi
deration by all concerned.
A summary of’his report is also being releasedin English for wider circula
tion and a lay version in Hindi for the gas affected people in Bhopal.
If, through this modest effort we have moved towards the establishment of
a 'people oriented science’ and endorsed tha peoole's 'right to know', we would
have felt that our efforts were more than worthwhile.
- medico friend circle
Justice is but truth in action and we cannot hope
to attain justice until we have the proper respect
for truth.
—Anon
2
CHAPTER
2
OBJECTIVES OF THE STUDY
The Indian Council of Madical Research (ICMR) has initiated over 22
reesearch projects to study the sub-acute, chronic and late effects of the Bhopal gas
disaster. The objectives of the medico friend circle (mfc) intervention in Bhopal
was not to duplicate the efforts of ICMR. We neither have the resources nor tne
aaccess to technical supports that are required for such efforts;nOr for that matter the
nmandate. We believe that the primary role of organising research linked to relief
aend rehabilitation efforts lies with the governmental and national institutions that
have been established with the tax payers' money.
In January 1985 when we first decided to undertake this study, there was
,'iiardly any official information available on the health situation of the gas victims of
Bhopal. The clamp down on information was unmistakable. From whatever little
imformation we could obtain, it was clear that people in large numbers were reporting
symptoms like shortness of breath, cough, excess lacrimation, fatigue headache, loss
of appetite, etc. This was a list of symptoms. Only symptoms, apparently uncon
nected to one another by underlying patho-physiological mechanisms, dominated the
scene.
Naturally at a meeting in Bombay we first set the following series of
(objectives.
(i) Assessing current health status and medico-social problems (ii) Prioritiziing in terms of magnitude and implication for rehabilitation (iii) Identifying health
[problems that required health education efforts (iv) Studying existing plan of relief,
iresearch and rehabilitation services and (v) Studying people's perception of these
services.
Later on, when the study was in progress in Bhopal, we came across
■more substantial information.
The conflict of two medical theories came
Ibefore us in sharp focus and the far reaching implications of this conflict for
■relief, rehabilitation, compensation etc. were tentatively grasped in those days.
'The objective was slowly evolving and finally came to be a thorough-going critique
<of the two medical theories and the implications flowing from them. Our initial
;act finding, appraisal of information and situation analysis, led us to identify a
tseries of issues of concern: (i) secrecy on any type of data/information on the
■ disaster; (ii) secrecy of ICMR research study plans; (iii) absence of open scientific
■ debate on research findings, (iv) the vertical, clinical and organ centred nature of
research projects; (v) the absence of encouragement to non governmental initiatives;
(vi) the adhoc and populist approach to relief and rehabilitation; (vii) the absence
of authentic scientific and research basad information for the medical teams
Iproviding services; (viii) tha absence of demystified but authentic information to
the disaster victims for their evolving mevement/struggle for a more relevant relief
and rehabilitation programme.
These concerns led to a reassessment of the Bombay objectives and a
series of new objectives emerged to best meet the emerging situation. These were( i) To assess the current health status and related problems of the people
on a sound epidemiological/ community basis;
( ii) To assess the findings in the light of the medical controversy between
'exclusive pulmonary pathology' vs. an 'enlarged cyanogenic pool'
leading/ to a chronic cyanide like poisoning;
3
(iii)
To evolve a critique of the ongoing research and medical relief
programme;
(iv)
To identify factors that have important implications for the relief,
rehabilitation strategy (including claims for compensation);
(v)
To assess the people's perception of the ongoing health care services;
(vi)
To make suggestions for a more meaningful relief/research/rehabilitation policy.
The health problem situation as it evolved in Bhopal which helped give a
final shape to the objective, has another interesting aspect which bears on metho
dology of the study.
During and after the study many have commented that our reliance on
symptoms is somewhat unsatisfactory, tnat they are subjective and therefore we are
on shaky ground and that more objective data like bio-chemical measurements.
X-rays etc. as were done by other groups (e.g. the Nagrik study) is missing in our
study, rendering it less solid. This faith and attachment to laboratory tests. X-rays
and other types of 'objective' tests is interesting but difficult to understand.
When predominance of a broad range of symotoms was the only important
fact known and even after the fact of 'enlarged cyanogen pool' came to be known,
what could be the biochemical-pathological tests that could be done in a sample
population so as to make our study more objective and less shaky? The only bio
chemical tests of real value, suggested by the 'cyanogen pool’ theory are augmented
output of urinary thiocyanate following intravenous sodium thiosulfate and study of
blood gases. Both these tests were of course, beyond our reach. However, that
should not mean that studies at less sophisticated levels like ours, have no objecti
vity about them.
With regard to X-rays, it should be noted that the place of chest-radiography
is extremely limited. Its only legitimate use is in the detailed follow-up of those
whose pulmonary function studies have shown very significant lung diseases (19).
Furthermore X-ray findings sometimes bear little relation to the patient's disability,
loss of function or severity of other symotoms (10) The other test which is of real
value is pulmonary function tests. The forced vital capacity (F V.C.) and the forced
expiratory volume in the first second (F.E.V. 1) are the simplest, most repeatable,
valid and among the more discriminating tests reflecting mechanics of breathing.
They have had most extensive trials during the past 25 years and regression equa
tions for predicted normal performance are better documented than for any other
respiratory test (10,19). We have in our study undertaken these tests.
Biochemical parameters, which are routinely studied in clinical settings
where the problem situation is much more settled and clear-cut, cannot be easily
and automatically used with a view to improve objectivity, in a situation like the
Bhopal gas disaster. This is completely new and unknown territory in so far as
little is known about MIC's effect on the body. To use such parameters would be
like shooting in the dark. These 'solid' 'objective' tests themselves do not
necessarily lend objectivity to any study in such an inherently difficult and ill-defined
problem situation. In doing so we are only reinforcing and perpetuating the popu
lar, mythical notions about scientific objectivity. To study symptoms is not
necessarily to be subjective—but about this later.
4
STUDY
AREAS
I & IS
CHAPTER 3
BACKGROUND : TWO MEDICAL THEORIES
The disaster that took place in Bhopal on the night of 2/3 December 1984
has been universally accepted as the worst man-made industrial and environmental
accident in recorded history. Forty tonnes of stored methyl■ isocyanate (MIC)
escaped into the atmosphere killing over 2500 people and over three thousand cattle
and affecting over two lakh people according to official estimates. These shocking
statistics do not adequately express the actual enormity of the human tragedy—of the
lives lost, the families disrupted, the people disabled and ill and the thousands
impoverished.
The relief efforts that were initiated soon after were handicapped by the
absence of authoritative information on the released gases; the unwillingness of the
Union Carbide company to part with authentic information; the absence of meaning
ful information among the relevant sanctioning, licensing and inspecting authorities
in the State and the Centre; the lack of preparedness of the local bodies and govern
mental health authorities to handle the unprecedented consequences of such a
disaster and the absence of technical or toxicological expertise on MIC among our
scientific community (1).
In the early hours of 3rd December 1984 when hundreds were pouring in to
Hamidia Hospital seeking medical relief, the beginnings of two medical theories
which would later on compete with each other to occupy the central position were
clearly discernible.
They are going to be the main focus of our report.
try to elaborate on these two medical theories.
In this chapter we will
They are (3.1) Exclusively Pulmonary Pathology Theory, which has
been referred to as 'Pulmonary theory' throughout this report. It is so called be
cause it claims that all the mortality and the prevalent morbidity in the gas hit
population of Bhopal is exclusively due to direct injury to lung tissues which over
a period will lead to diffuse pulmonary fibrosis.
((3.2) Enlarged Cyanogen Pool Theory, which for the sake of brevity is referred
to as 'Cyanogen pool' theory' throughout the report. This theory postulates chronic
cyanide poisoning of the victims due to enlarged cyanogen pool, in addition to
direct lung/eye damage.
It must be stated clearly and unambiguously at the very beginning that the
Indian Council of Medical Research (ICMR) which is the main protagonist of 'cyano
gen pool' theory does except the fact that lungs have been damaged by MIC gas and
a proportion of the morbidity may be due to that. It is, in fact, therefore the pro
ponent of mixed pathology, but for the sake of discussion and convenience, it is
called the protagonist of’cyanogen pool'theory. Supporters of pulmonary theory
include a dominant faction in Gandhi Medical College, Bhopal and has strong
support in the health department of MP Government. They are adamantly refusing
to accept any other theory, but their own theory. Naturally they are totally opposed
to cyanogen polo theory.
3.1
Pulmonary Theory
According to this theory, isocyanates, of which MIC is one member, are
6
toxic, irritant gases that directly damage the tissues they come in contact with-lungs
and corneas of eyes. The acute and long lasting pathological effects therefore are
to be seen only in lungs and eyes, and the effects of hypoxia secondary to lung
damage.
A small proportion of (about 5-10%) persons exposed to these substances
also develop sensitization (2,5).
The effects of isocyanates even in high doses on the gastrointestinal tract is
minimal (4).
It can induce blindness or visual impairment depending on the degree and
location of scarring (2,3).
Among the isocyanates toluene di-isocyanate (TDI) has been shown to
produce Central Nervous System (CNS) damage, manifested as loss of memory,
diminished mental capacity, persistent headache, personality changes, irritability,
depression etc (6) But any such effect by MIC on CNS has been dismissed as
anecdotal "because MIC is such a severe primary irritant it would be apt to produce
such a severe degree of irritation that death would occur before sufficient absorption
of the compound could occur to produce systemic effects" (6).
This brings us to the central point of the theory, which is to explain why
MIC exposure must produce damage to only lungs and corneas excluding all other
organ systems. Wny for instance MIC, an isocyanate, cannot have long lasting
CNS effects whereas another isocyanate, TDI, can have long lasting effect on brain
function?
Among the three isocyanates used in industry MIC is much more reactive
than the other two e.g. TDI and MDI (Methyl Di-isocvanate). It has been argued
that'/W/C/s so readily decomposed by water, the chances are "very very remote"
that this iso-cyanate could enter the blood stream.be whisked to internal organs
and produce damage there, by reacting with target proteins'. It is further argued that
'for the same reason MIC lacks the hardiness to be a carcinogen. Molecules of the
compound would have to penetrate the cell wall and reach the DNA to do their ge
netic dirty work. It is virtually unthinkable that molecules of MIC could survive
such a cellular journey’ (2,9).
This is the point : the high reactivity of MIC molecule renders it nonspe
cific and therefore it is bound to damage only those organs which come into
direct contact with it—lungs, eyes and skn. The skin may however escape because
MIC fumes may not penetrate the skin (3). The logical corollary of it is that long
term problems in survivors can be due to extensive lung damage and corneal damage
only.
Mr. W. Anderson, Chairman of Union Carbide Corporation, U. S. felt so
confident that in a letter of 3rd January 1985 (exactly one month after the disaster)
he wro'e to an activist group which is monitoring the Bhopal Disaster to say that
'those injured by Methyl Isocyanate (MIC) are rapidly recovering and display little
lasting effects
for example, no case of blindness' (11).
The pulmonary theory therefore, must reject any other explanation for the
presence of wide ranging symptoms in the community and also the treatment based
on alternative explanations.
7
For the same reason some U. S. Scientists have characterised such
reports of Cyanide Poisoning of the exposed population 'highly questionable'
and 'probably spurious'. They have further argued that there is no known
metabolic pathway that converts isocyanate into cyanide (2).
The clash of theories extends to the whole range of health problems in
Bhopal.
Thus according to the 'pulmonary theory' the large number of deaths in the
early hours of the morning of 3rd December 1934 were due to carbon monoxide
poisoning and to others the deaths were due to cyanide poisoning. We have no
definite information regarding the nature and quantity of dangerous gases that were
present in the atmosphere after the massive gas leak. However it is known that the
thermal decomposition of methyl Isocyanate can lead to the oroduction of a variety
of toxic substances including Carbon monoxide (CO) and Hydrogen Cyanide (4).
Tne temperature of toxic fumes gushing out of the tank was at least 1 20 degrees
centigrade (12).
An investigation was undertaken by the ICMR at a very early stage to sort
out this controversy. Particular attention was paid to find out clear evidence of
carbon monoxide and/or cyanide A large number of control blood samoles and
also samples of blood already preserved in the deep freeze in the Medico Legal
Institute and fresh samples from cases who subsequently died were examined for
evidence of carbon monoxide poisoning (carboxyhaemoglobin) or cyanide poisoning
(cyanomethemoglobin) by spectrophotometric analysis (14). In none of the samples
was there evidence of either.
In contrast to this, a study of 113 MIC affected people who themselves
reported to K.E.M. Hospital, Bombay showed carboxyhaemoglobin (COHb) at a
concentration of more than 2% in 93% of cases. (The normal levels of COHb in
blood are 0.5 - 0.8 %. In smokers the levels could be as high as 1 5%, the average
being b ring 5%) (13). This sample however is not a representative sample and the
control is lacking. Moreover aa»/sex structure and smoking status are not given
(8). Besdes, the effects of COHb levels less then 5% are controversial. COHb
levels of 20%, decrease tissue oxygenation and affect performance (10).
3.2
Enlarged Cyanogen Pool Theory
One of the most important developments of the complex findings among
Bhopal disaster victims has been the evidence favouring what may be termed an
'Enlarged Cyanogen Pool' theory. Professor H. Chandra of Medico Legal Institute
of Gandhi Medical College, Bhopal noticed in the early hours of 3rd December when
the first autopsies were being performed that even the venous blood of dead bodies
was cherry red in colour (so called arteiialization of venous blood). All the internal
organs, lungs, intestines, kidneys, brain, muscles, etc. were bright red in colour.
This led him to suspect that victims could have succumbed to cyanide poisoning
(14,15).
A visiting German clinical toxicologist Dr. Max Daunderer is reported to
have detected cyanide in the affected patients (14,15,17) Unfortunately his findings
could not be repeated because of technical and methodological problems (14,15).
ICMR set out to 'identify the presence of either the original products'. The objec
tive was to obtain a better understanding of the probable detoxification mechanisms
which would help in the prompt use of an antidote to remove toxic substance still
circulating in the body (14).
8
As has been pointed out in 3.1 above, attempts to establish the presence
of either carboxyhaemoglobin or cyanomethemoglobin in the blood failed. However
all the samples of all victims showed twin bands of oxyhaemoglobin(14) which is
an indication of a change in the nature of the haemoglobin molecule.
Special note must be taken here that from as early as the first week of the'
disaster, the ICMR approach to the problem pointedly ignored the theoretical notion
of the MIC molecule being too reactive to reach the blood stream and causing
damage to the internal organs.
Following a rapid study of available literature by Dr. Sriramachari it was
felt that the mechanisms of conjugation of isocyanate should be investigated
vigorously. The equivocal results in the increase of blood urea in fresh autopsy
tissue samples as well as qualitative reports of the presence of cyanide in tissue led
to the hypothesis that either due to inhalation of hydrogen cyanide from the conta
minant or cyanide radicals released by the breakdown of MIC within the body, there
was every likelihood of either acute cyanide or chronic cyanide poison operating
(14). This idea was reinforced by literature scan where in there is a reference to
the cyanide pool and its major excretory
cyanate (14)
CYANO
CN"
Minor
pathway
through urinary thio
PQ O L
------------*-
C-NS
■ Excretion.
/
Cyanocoba lamin.
pa+h. 7 minor "path'
*
z- iminothiazolidine
4- carboxylic acid.
HCb4 f
in expired air
HCNO
HCOOH-^ metabolism of
one carbon
compounds.
CO2
some excreted
in urine.
9
As shown in the diagram above, there is a cyanogen pool in the body
which normally generates extremely small amounts of cyanide radicals in the course
of normal metabolic procasses of the body. These cyanide radicals are easily
removed from the body by a process of detoxification which converts the cyanide
radicals into relatively harmless thiocyanates which are excreted as urinary thiocya
nates. This detoxification process is controlled by the enzyme called rhodanase in
the liver.
The process of detoxification by the rhodanase system can be accelerated
bv sodium thiosulfate if given in large amounts. This provides the rationale for
injection of sodium thiosulfate for the treatment of cyanide poisoning.
Also the amount of urinary thiocyanate excreted in the urine following
injection sodium thiosulfate gives an indirect clue of the size of cyanogen
pool in the body
And this provrdas the rationale for sodium thiosulfate as
an epidemiological tool of investigation of the hypothesis of 'enlarged
cyanogen pool' in the MIC exposed population of Bhopal to which we will
return in the Chapter 6.
This pool of cyanogen is proposed to have been enlarged in the MIC
exposed ponulation of Bhopal. According to the theory small quantities of cyanide,
but much larger than that which would be normally produced in the body, is con
tinuously contributed to the cyamgen pool of the gas victims from MIC molecules
which are attached to alfa chains of haemoglobin molecules - a process that is called
carbamylation of haemoglobin. Cyanide blocks the activiiy of a large number of
enzymes but the most important from the point of view of its effects is the enzyme
called cytochrome oxidase in all the cells wiich controlsthe oxygen utilisation of
theceils. This leads to under-utilisation or non-utilisation of oxygen at the cellular
level producing chronic hypoxia which is responsible for the whole range of
symptoms. At the same time carbon dioxide transport is also reduced. The study of
gases like oxygen and carbon dioxide in the blood may provide clues to disturbance
of gas utilisation and transport at the cellular level. The ICMR continued to pursue
its inquiry further to explore the idea of the cyanogen pool and its major excretory
pathway through urinary thiocyanate.
It decided to undertake a double blind clinical trial to find out the useful
ness of sodium thiosulfate injections on 30 patients. 10 out of 19 who were given
sodium thiosulfate showed marked clinical improvement and had an 8 to 10 fold
increase in the excretion of urinary thiocyante, whereas 1 out of 15 who got
injection glucose showed such increase (14). The full details of this most crucial
trial have not been made public and the findings have been contested by those who
uphold the 'pulmonary theory'. This controversy has been further discussed in
Chapter 6. The opoonents of 'cyanogen pool' theory claim to have conducted their
own study with sodium thiosulfate and the results were according to them, dis
couraging. However it is known that it was not a double blind clinical trial like
ICMR's and that full details of this trial have not been made public either 1
Alongside this investigation, studies of arterial and venous blood oxygen
and carbon dioxide levels were undertaken. This was to understand the state of
oxygen utilisation at tissue level and carbondioxida removal from the tissues.
Following are the salient findings of the investigation.
a) Level of oxygen in arterial blood was lower than normal (14)
b)
Similarly level of carbon dioxide in the arterial blood was also lower
than normal (14)
10
c)
Inspite of raised haemoglobin levels its oxygen carrying capacity was
lowered. There is a probability of some compensatory mechanism,
operating such as indicated by elevated levels of 2-3 Diphosphoglycerate
(2-3 DPG) in the blood which is one of the mechanisms to improve the
oxygen utilisation by the tissues (14)
d)
Following the treatment with sodium thiosulfate the carbon dioxide
level in venous blood increased, with improved clinical condition. This
preliminary observation tends to indicate that following administration
of sodium thiosulfate, patients appear to better utilise the oxygen. The
higher levels of carbon dioxide in the venous blood probably means that
venous carbon dioxide is being carried in solution. This could be dua
to some alteration in the haemoglobin molecule, possibly by mechanisms
such as carbamylation of end-terminal amino groups (14) .
All these findings such as increased haemoglobin concentration, twin
bands of oxyhaemoglobin, more than doubled normal values of 2-3 DPG in the blood
and clinical improvement, augmented output of urinary thiocyanate and rise in carbon
dioxide level in venous blood following sodium thiosulfate injections are unexpected
but highly suggestive.
These findings strongly suggested that tissue utilisation of oxygen in gas
victims is problematic. This is not a simple function of reduced diffusion—perfu
sion ratio leading to anoxia as one would expect in exclusive pulmonary damage.
The pathology is not only in the lungs, probably it is at a cellular level in
all the vital organs. Logically speaking it is not imperative for the theory to chase
only MIC molecule in the cellular processes. There may be other molecules deri
ved from MIC or other toxic gases which contribute to the cyanogen pool. The
cyanogen pool theory may stand or fall the critical tests but these findings if true
are in need of explanation.
COMMUNITY HcALTH CELL
47/1, (First Floor) Sc. Marks Soad
BANGAlO^S - 5u'O 001
CHAPTER 4
MATERIALS AND METHODS
4.1
Sample Population
Two bastis (slum areas) were selected for the study: ( i ) JP Nagar. which
was the worst affected, is situated right in front of the Union Cirbide factory;
(ii) Anna Nagar, which is about 1 0 km. south of the factory was selected as a control
(see mao) It is important to clarify here that no area in Bnopal which has similar
bastis was unexposed to MIC at the time of the disaster and hence Anna Nagar was
also exposed. However, it was one of the least affected areas. In the absence of
any available information regarding the quantum of gas exposure of various com
munities differences in postexoosure mortality can be taken as a criterion of difference
in qas exposure. Our assumption, therefore, in selecting Anna Nagar as the least
affected was based on the available mortality rates from the Department of Infor
mation and Publicity, Government of Madhya Pradesh - JP Naqar 2 34% and Anna
Naqar 0 32%. This assumption was further corroborated by our study-finding of a
difference in mortality between JP Nagar (36.6/1000) and Anna Nagar (7.9/1000).
in the three month period between MIC gas exposure and our study. Another
significant finding which justified this selection of samples was the fact that 45
persons (30%) out of our sample in JP Nagar had been hospitalised after the gas
exposure whereas the figure for Anna Nagar was one person (J.72%), a clear indi
cation of the differential exposure.
Both these bastis were more or less comparable with respect to housing,
sanitation and economic characteristics though there were some socio-cultural
differences among the two areas, in that the inhabitants of Anna Nagar ware predo
minantly migrant labour from the south who were, however, resident in Bhopal for
many years.
We decided on a sample size of about 180 persons of both sexes of more
than 10 years age for each basti (Tnis was basad on the assumption that
significant morbidity would be atleast 15% in JP Nagar and 5% in Anna Nagar.
We wished to have a 90% chance of finding this difference with significance level
of 5% in a two tailed tes’ i. e. 2a = 5% and B = 90%). It needs to be emphasised here
that the assumptions on which the sample size was computed, are quite stringent. For
our puroose sample siza is more than adequate. Since random selection of indivi
dual parsons was not possible, we decided to select at random 60 families from each
basti to yield the desired number of oersons. Random selection of families in both
bastis was fortunately possible because the ICMR had already provided a number
plate for each household. This provided the much needed sampling frame from
which random sampling of families was done with the help of random number tables.
Children below 10 years were excluded from our sample because of the
fact that their reporting of symptoms and pulmonary function tests would be
unreliable.
4.2
Methods
As will be noted by the readers, history-taking has been our most important
method of study. Methodological issues arising in respect of this method have been
discussed in Chapter 2—'Objectives of the study' and below in the section of
'Morbidity Analysis'. The following were undertaken during the study.
12
4.2.1
History-taking and physical examination of each individual
A detailed proforma was designed for the study which was to be administred to each eligible member of the selected families (Appendixl). It included
the following sections.
Section I : This included the following information about each household:
family composition; deaths or missing members since the gas leak; occupation;
income; history of smoking or chronic respiratory diseases (TB, asthma and chronic
bronchitis) of each membar. Details of loans taken by the family and compensation
received were also elicited.
Section II : This was to be filled for each individual in the household
included in the sample. It included details of occupation and income; change in
income due to illnass/disability following gas leak; certain details about exposure
and safety measures attempted; whether hospitalised after exposure and history of
smoking and chronic respiratory illnesses (TB, asthma and chronic bronchitis).
Section III : Every individual included in the sample was subjected to a
systematic enquiry of 26 symptoms. The patients own description of these
symptoms were listened to avoiding much direct questioning.
A general physical examination was also done including (i) height and
weight (ii) and (iii) pulse and respiratory rates for full one minute in resting posi
tion after lapse of considerable time to ensure relaxation (iv) eye examination
including cornea, lens, pupillary reflexes, distant vision and near vision (v) general
signs like oedema, jaundice, cyanosis (vi) examination of skin; (vi.) respiratory
system; (viii) cardiovascular system; (ix) central nervous system; (x) alimentary
system.
The parameters for each system are shown in Appendix I.
Section IV : This was for each woman belonging to the reproductive age
group included in the sample. It included menstrual history; history of gynaecolo
gical complaints before and after gas leak; pregnancy and its outcome; if a nursing
mother then details of lactation before and after exposure.
which included Forced Expiratory
Volume in 1st second (FEVI) and Forced Vital Capacity (FVC) for each individual.
PFTs were recorded by Morgan's electronic spirometer set as BTPS. Three readings
were recorded and the highest reading was taken for analysis.
4 2. 2 Pulmonary Function Tests (PFTs)
For the interpretation of PFTs, height of each individual was measured by a
straight aluminium rod on which a metal measuring tape was fixed. Weight was
measured by standardised bathroom scales. The sample size of PFTs was further
extended by additional observations on other families selected at random in both
bastis. PFTs were performed by a doctor who had adequate experience of using the
spirometer under field conditions.
4.2.3
Haemoglobin estimation using Sahli's haemoglobinometer was done on a
random sample of the two bastis.
4.2.3
An enquiry into the people's perceptions of the existing services was done
13
by administering a questionnaire (section vi) to one member of each family in
cluded in the sample. These included questions recording availability and accessi-'
bility of services, quality of service, type of treatment given, attitude of examining
doctor, cost of treatmant, and nature of doctor-patient communication.
4.3
Building rapport with the people
The mfc team arrived in Bhopal to undertake the study in the third week
of March 1985 (15th - 25'.h) . three and a half months after the tragedy. Numerous
teams of investigators and relief workers both governmental and non-governmental
had visited the selected bastis, made enquiries, offered or promised relief, raised
expectations about compensation and assistance.
For the mfc team to ensure, therefore, that it would still be able to get
reliable, authentic and relevant information it was necessary to counter this pre
conditioning of the basti dwellers and establish a meaningful rapport, free of sus
picion, of false expectations and a sense of dependency. We therefore, employed the
following strategy :
(a) Two days before the study, while selecting the samples the Coordinator
and a team member visited the selected bastis and had informal discussions with
some of the people explaining the objective of our study and the possible outcome;
(b) A hand-out prepared in Hindi was freely distributed among the basti
dwellers. It clarified the role of the mfc, explained about the need for a sample
and mentioned the possible follow up action. It specifically clarified that we were
not providers of service but were facilitating a more relevant plan of serivces
(Appendix II).
(c) During the actual survey, time was spent with each family answering
their numerous enquiries and listening patiently to their stories. Occasionally
when non-sample individuals/families approached the team members they were also
listened to and occasionally given an examination;
(d) A summary of findings was made and handed over to each person in
the sample; because we believed that it was a right of the people to get a record of
.the findings.
(e) In all our contacts with the people, it was very clearly stated that
though the team was a medical one, it was not going to provide any treatment nor
be involved with compensation claims. However, wherever it was necessary a
prescription was given though this was rather occasional;
(f) A commitment was also made that the salient findings of the study and
our recommendations would be made available to the people of the affected bastis to
help them demand their rights to meaningful health services.
This methodology of informal, frank and participatory communication had
its own rich dividends. The basti dwellers in both Anna Nagar and JP Nagar wel
comed us into their homes warmly and took us into confidence. They appreciated
our ’listening’ attitude and this generated a lot of cooperation and support to our
efforts. A major point of frustration for many of them was that though they had
received treatment from government and other services, they had felt that the doctors
were not taking them seriously and were summary in their approach. This affected
the credibility of the existing services.
14
Our decision to concentrate very consciously on rapport building ensured
that there was not one refusal among those who were present at the time of our
visits. Moreover although several health surveys are supposed to have been done
in these bastis, we found that in hardly any family, we had selected in our sample
was there any health survey done. There was, therefore, no question of families
being floodad witn same types of questions and getting conditioned, consciously or
unconsciously, to answer in a particular way or pattern.
4.4
Plan of Analysis
The plan of analysis of the data collected by us was as follows:
(i) All parameters in history, symptomatology and findings of clinical
examination and lung function tests have been quantified and the
percentage in each of the two bastis have been compared;
(ii) Relevant statistical tests have been applied to determine whether the
differences, if any, are statistically significant;
'
(iii)
Both the theories in the current medical controversy i.e. the pulmonary
fibrosis theory and the 'cyanogen pool' theory have been kept in mind,
consciously during the analysis to raise critical questions about both
these theories from our findings;
(iv)
Basically the important problem areas have been identified. There has
been no attempt to group symptoms into specific diagnostic categories
and both signs and symptoms have been taken into account in the
analysis.
He is unwise who acts without investigation—Charaka Samhita
15
CHAPTER 5
OBSERVATIONS AND RESULTS
5.1
Non-responders: some observations
In JP Nagar in the 60 families selected there were 203 eligible persons
whereas in Anna Nagar, the corresponding figure was 163.
In JP Nagar, 60 out of 208 individuals could not be interviewed and
examined, giving a non-rasponse rate of 29%. The corresponding figure for Anna
Nagar is 15% (25 out of 163).
Several home visits were made by the survey teams in both the bastis to
reduce non-response rates.
Wa feel that the given non-response rate in JP Nagar and Anna Nagar
will not have a significant effect in the differences in rates of serious morbidities.
Because, first, the age and sex structure of both responders and non-responders in
both bastis is more or less similar. Secondly there was not one case where a
person was at home but refused to cooperate. Had there been many such refusals
amongst non-responders "the results would have been biased in unpredictable
manner".
In JP Nagar majority of non-responders (about 60%) were out of town
mainly for the reasons of treatment or fear of another gas leak. Twenty five per cent
of them were out for work. At Anna Nagar about 50% were out of town for the
purpose of social visits whereas 25% were out for work.
There have been large epidemiological studies where non-responders have
been as large as 30%. This did not necessarily vitiate its results (22).
In the case of non-responders, if we are blind with respect to both exposure
and outcome then the difficulty increases (22). In JP Nagar we have no information
about the outcome in non-responders but we have recorded information that about
50% of them (28/60) were exposed to gas on 3rd December, in the remaining half
many may have been exposed but we have failed to record definite information. No
one among the non-responders in Anna Nagar was heavily exposed to MIC gas.
Thus with regard to exposure status we are not completely blind.
If we make an assumption (though it is unlikely in view of available
history of exposure in at least 50% of non-responders) that all the non-responders
in JP Nager and Anna Nagar were normal, this will have an effect of narrowing
down the differences in rates of morbidities between the two bastis. Even then the
difference in rates of all serious symptoms between JP Nagar and Anna Nagar
except for dry cough, lacrimation, breathlassness at rest and impotence remain
statistically highly significant.
The reduction In sample size due to non-response rate has also not effected
the outcome at all, because much greater differences in the rates of morbidity than
had been expected (or assumed) between the two communities meant that our pur
pose of finding significant differences (if there was any) would have been served
well even by much smaller size of the sample than the ones we studied.
16
5.
2
Comparison of samples of J P Nagar and Anna Nagar
Tables 1-A and 1-B show that both these sample populations are compara
ble with reference to age, sex structure, history of smoking habits and chronic disea
ses. Table 1-C shows that occupations and income levels are also comparable
though the J P Nagar population was probably socio-economically better off than
the Anna Nagar population. This income difference cannot however affect the
observed differences in morbidities between the two samples. Table 2 shows that
body surface areas (M2) calculated from height and weight records are also compa
rable in the two samples. This is particularly relevant in the context of pulmonary
function tests.
Comparisons of soma of the important characteristics of J P Nagar and
Anna Nagar populations (study/control populations)
Table 1 A
Age-Sex Structure
Age
Sex
11-15 years
M
F
1 6-45 years
M
F
46 +
M
F
J P Nagar
0/
zo
n = 148
Anna Nagar
%
n = 138
8.10
9.46
10.14
4.35
35.81
33.78
34.78
31.88
6 63
6.75
10.14
8.70
•
Table 1 B
History of smoking and chronic diseases
J P Nagar
% (n = 148)
Smoking (a)
Anna Nagar
% (n = 138)_____________
+
—
22.75
77.24
25.0
75.0
-r
—
9 58
90.41
10.37
89.62
Chronic
diseases (b)
(a) a smoker is one who has smoked at least one cigarette per day for at least one
year in a life time.
(b) chronic diseases specifically included asthma, chronic bronchitis,, tuberculosis
and others.
17
Table 1 C
Occupation and income levels
J P Nagar
Occupation
Anna Nagar
°7
/o
°/
/o
n = 148
n = 138
Unskilled
18.91
27.73
Skilled
7.43
8.73
Self-employed
13.51
15.32
Service
14.18
10.21
House work
29.72
24.08
Others
16.21
13.36
Per capita income per
month before gas exposure
Less than Rs. 50.00
4.68
4.58
Rs. 51 -75
10.93
22.93
Rs. 76-100
16.40
21.10
Rs. 101-125
14.84
13.76
Rs. 126 and above
53.12
37.61
5.3
5.3.1
Socio-economic profile in the bastis
Occupational structure
The residents of both JP Nagar and Anna Nagar were long term residents of
these bastis. Residents of JP Nagar were predominantly Muslims and Harijans with
a wide range of occupations that included daily wage labour, construction workers,
beedi rollers, cobblers, railway and factory employees, self employed artisans and
others. Almost 1 /5th (19%) of the working population in JP Nagar was unskilled.
18
Residents of Anna Nagar were, predominantly . Tamils. and.Maharashtrians
and had a similar range of occupatian apart from a large number of potters. The
percentage of unskilled workers was 28%.
The percentage of skilled persons in both samples was less than 10%. The
category 'others' in the table is mainly represented by students.
5.3.2
Income levels and change in income since gas exposure
The income levels of both the samples are shown in Table 1-C. JP Nagar
residents are generally of higher income levels as compared to Anna Nagar, e.g. before
the disaster 68% of the families in JP Nagar had an income more than Rs. 100.00/
capita/month whereas the corresponding figure in Anna Nagar was 51%.
After the disaster, in JP Nagar 65% (42 out of 64) of the working persons
experienced a drop in income ranging from 20% to 100% with a median of 50%
drop in income (Fig. 1)
In contrast, in Anna Nagar only 9% (6 out of 64) reported a drop in income
after the disaster. The extent of the drop in income was in the range of 20% to 55%
(Fig.1).
Two individuals in JP Nagar showed an increased income after the gas
disaster being exceptions rather than the rule.
(a) one person who was a loco-daily wage earner and got a job in the
loco-loading department after the event with an increased scale of pay;
(b) one woman (housewife) who started brick loading after the disaster as her
husband was not able to work after the disaster. Since our focus was on
individual income rather than family income such an instance of increase
is misleading. In actual fact with the husband being unable to work the
family income had not been increased.
5.3.3
Compensation received and loans taken
During the acute phase of the crisis the only source of income if at all was
the compensation received by families (only those who had deaths in the family)
and loans taken from money lenders and others locally.
Some of our findings were:
In J P Nagar
Compensation of Rs.10,000.00 was given to 8 persons (out of 26 reported
deaths). One non-respondent family had 5 deaths and 1 child survivor of 8 years in
an orphanage. We could not elicit compensation details in this case.
Compensation was also given to other families who did not have a death.
In our sample 2 persons got below Rs. 500.00; 3 persons between Rs. 500-1000,
4 persons between Rs.1000-2000 and 1 person between Rs. 2000-3000.
19
Table 1 C
Occupation and income levels
J P Nagar
Anna Nagar
%
n = 148
°/
Zo
n = 138
Unskilled
18.91
27.73
Skilled
7-43
8.73
Self-employed
13.51
15.32
Service
14.18
10.21
House work
29.72
24.08
Others
16.21
13.36
Occupation
Per capita income per
month before gas exposure
Less than Rs. 50.00
4.68
4.58
Rs. 51 -75
10.93
22.93
Rs. 76-100
16.40
21.10
Rs. 101-125
14.84
13.76
Rs. 126 and above
53.12
37.61
5.3
5,3.1
Socio-economic profile in the bastis
Occupational structure
The residents of both JP Nagar and Anna Nagar were long term residents of
these bastis. Residents of JP Nagar were predominantly Muslims and Harijans with
a wide range of occupations that included daily wage labour, construction workers,
beedi rollers, cobblers, railway and factory employees, self employed artisans and
others. Almost 1 /5th (19%) of the working population in JP Nagar was unskilled.
18
Residents of Anna Nagar were, predominantly.Tamils. ancLMaharashtrians
and had a similar range of occupatian apart from a large number of potters. The
percentage of unskilled workers was 28%.
The percentage of skilled persons in both samples was less than 10%. The
category 'others' in the table is mainly represented by students.
5.3.2
Income levels and change in income since gas exposure
The income levels of both the samples are shown in Table 1-C. JP Nagar
residents are generally of higher income levels as compared to Anna Nagar, e.g. before
the disaster 68% of the families in JP Nagar had an income more than Rs. 100.00/
capita/month whereas the corresponding figure in Anna Nagar was 51%.
After the disaster, in JP Nagar 65% (42 out of 64) of the working persons
experienced a drop in income ranging from 20% to 100% with a median of 50%
drop in income (Fig. 1)
In contrast, in Anna Nagar only 9% (6 out of 64) reported a drop in income
after the disaster. The extent of the drop in income was in the range of 20% to 55%
(Fig.1).
Two individuals in JP Nagar showed an increased income after the gas
disaster being exceptions rather than the rule.
(a) one person who was a loco-daily wage earner and got a job in the
loco-loading department after the event with an increased scale of pay;
(b) one woman (housewife) who started brick loading after the disaster as her
husband was not able to work after the disaster. Since our focus was on
individual income rather than family income such an instance of increase
is misleading. In actual fact with the husband being unable to work the
family income had not been increased.
5.3.3
Compensation received and loans taken
During the acute phase of the crisis the only source of income if at all was
the compensation received by families (only those who had deaths in the family)
and loans taken from money lenders and others locally.
Some of our findings were:
In J P Nagar
Compensation of Rs.10,000.00 was given to 8 persons (out of 26 reported
deaths). One non-respondent family had 5 deaths and 1 child survivor of 8 years in
an orphanage. We could not elicit compensation details in this case.
Compensation was also given to other families who did not have a death.
In our sample 2 persons got below Rs. 500.00; 3 persons between Rs. 500-1000,
4 persons between Rs.1000-2000 and 1 person between Rs. 2000-3000.
19
Figure-1.
Percent^8 change in income of individuals of both communities after gas exposure
Income (in rupees) per person per month
Income (in rupees) per person per month
•10
10-
Decrease in incom e in
J. P. NAGAR
ANNA NAGAR
20-
20
30-
-30
40-
•40
50-
■50
60-
■60
70-
-70
80-
-80
90-
-90
100-
-100
Twenty families in which there were no deaths and to whom no compen
sation was given had to take loans for medical treatment and for the migration during
'operation faith'. Many of them put iheir ornaments, vessels etc. on mortgage
In Anna Nagar
Seventeen families who did not have a death in the family had to take loans.
Most of them specifically mentioned that this was during 'operation faith' when they
went outside Bhopal for a while.
5.4
5.4
Morbidity Analysis
1 General comments
Before presenting the analysis of morbidity, two issues must be sorted out.
One, it must be stressed again that there is no population which matches
JP Nagar socio-economically or in respect to housing and sanitation which
was not exposed to the toxic gases on 3rd December, 1981. A control population
selected like Anna Nagar is not strictly speaking a 'non-exposed' population as it
should be but serves as a control population by virtue of being minimally exposed
in comparison to JP Nagar. This also implies that even in our control population
one would expect to observe some of the disabilities or debilitating morbidities in a
higher proportion of the population than would be the case in an unexposed control
area. Actually this is what we did observe and the Anna Nagar sample had de
finitely a larger number of serious symptoms in a sizeable proportion of persons stu
died (Tables 3-A to 3-C)
This is something which is quite unexpected and in fact narrows down the
differences in rates of symptoms observed between the two populations. The health
impact of the toxic gases on the exposed population is, therefore, much greater than
what our study reveals.
Seen in this background alone can one appreciate the devastating impact
on the health of highly exposed populations. Because in spite of the dampening
effect on the differences in rates explained earlier, the rates of many serious symp
toms (indicating widespread underlying damage to the physical and mental health of
the victims of the gas disaster) in JP Nagar are higher than Anna Nagar withan
extremely high level of significance (Table-3-A and 3-B).
Two, the dependence of the study on symptoms may be felt to be proble
matic by many, since it is 'subjective' and therefore less deoendable. As discussed
in Chapter 2 the problem situation as it was unfolding wassuch that one had few clues
as to the pathophysiological disturbances taking place in the bodies of the gas victims.
The only loud and clear clue was the people complaining of symptoms. What
biochemical pathological parameters could be included in the study to enhance the
objectivity of the study? None, except one as we have tried to argue above.
We acknowledge freely the problems’of relying on symptoms reported by
the individuals. We would, however, like to draw attention to the fact that even
in more understood problem situations like epidemiological studies of chronic bronc
hitis, emphysema, angina pectoris also, the most reliable too! of epidemiological
study is recognised to be the questionnaire. Of course, these tools as developed
by Medical Research Council (U.K.) and American Thoracic Society (U.S.A.) have
been standardised to varying extents. Similarly, the epidemiological too! in the
21
COMMUNITY HEALTH CELL
47/1,(FirstFloor)r:t/;‘
BANGAL03E - 5u0 0u1
It is not necessarily true that
since symptoms are reported by the individuals, they are subjective and hence less
reliable than biochemical measurements. The point is not whether we are using
so called subjective or objective measurements, the point is whether wa are employ
ing appropriate methods and tools to answer clearly the critical questions we are
raising in a given problem situation.
study of psychiatric disorders is also a questionnaire.
True, an important limitation of this study is non-standardization of the
questionnaire i.e. ability of the questions to elicit the same answers on two or more
occasions (reliability) and the ability of the questions to measure what was intended
(validity). Due to limitations of time this was not possible.
However the varied symptomatology presented by the subjects of the study
were not mentioned by them casually but given in graphic detail; words and exam
ples used by the patients while describing their symptoms clearly showed the gra
vity of the symptom as well as its effect on the person's day to daywork. The
different manner in which the symptom was described also showed that the person
was informing us of a problem based on his/her own experience and not just vague
hearsay expressions. This is particularly important since in the absence of signs in
the same proportion as symptoms, doctors attending on these people in busy
government clinics were often passing off the symptoms reported, as compensation
'malingering' or 'not of clinical significance'. We have every reason to believe that
these symptoms were real expressions of physical and mental ill health and many
should be accorded the same significance as the use of patterns of cough with or
without expectoration in the diagnosis of chronic bronchitis or the use of anginal
history in the diagnosis of Ischaemic Heart Disease.
The commonest symptom reported was breathlessness on usual exertion and
the specific descriptions recorded were: (1) while excessive talking; (2) on brisk.
walking; (3) doing house-hold work in a hurry; (4) fetching water and firewood;
(5) cannot go till the market; (6) little walking - say 100 yards; (7) while coughing;
(8) while riding a bicycle etc.
5.4.2
Symptomatology and signs - a comparison
Tables 3-A - 3-C show the difference in rates of the 26 symptoms that had
been enquired into in both the sample populations. It must be emphasised that a
symptom was recorded as positive only if it was present at the time of the study.
Five symptoms were not significantly different. These were blood in sputum, fever,
jaundice, blood in vomit, stool or malena and vomiting.
Six symptoms were significantly different. These were dry cough, breath
lessness at rest, lacrimation, skin problems, bleeding tendency and impotence.
Fifteen symptoms were highly significantly different. These were cough
with expectoration, breathlessness on usual exertion, chest pain/tightness, blurred
vision/photophobia, headache, weakness in extremities, muscleache, fatigue, loss of
memory, tingling/numbness, nausea, abdominal pain, flatulence and anxiety/depression. Moreover critical symptoms like breathlessness on usual exertion, lacri
mation, pain/tightness in chest, blurred vision, weakness in extremities, fatigue,
loss of memory, tingling/numbness, anorexia, nausea, flatulence and anxiety/depression were not reported in a monosyllable 'yes' but described in such graphic
detail that their presence could not be doubted.
22
5.4.3
Clustering
It was obvious from the study findings that most of the persons in JP Nagar
had more than one symptom present. To further study the pattern of clustering of
symptoms, we grouped the symptoms according to the system they naturally belong
to. Some overlap in such grouping is inevitable but it does reveal the overall pattern
e.g. an important symptom like breathlessness on usual exertion which is reported
with highest frequency does not squarely belong to one system like cardiovascular
or respiratory system alone. Both these systemscan with equal legitimacy lay claim
to this most frequent and crucial symptom and this is particularly important
since we are examining ci it ical ly two dominant medical theories in this study-'cyanogen pool' theory and 'pulmonary theory.'
All the symptoms were grouped together system wise as follows :
(a)
Pulmonary system (P)
The grouping of symptoms suggesting diffuse pulmonary fibrosis is based
on Harrison's Principles of Internal Medicine 10th edition, 1983 (Chapter
280, P.1567). They include breathlessness at rest and on accustomed
exertion, dry cough and cough with expectoration, weakness in extremities
and pain/tightness in the chest. To be included in this group the combi
nation of symptoms had to have cough with or without expectoration and
dyspnoea at rest or usual exertion.
(b)
Gastro-intestinal system (Gl)
They included anorexia, nausea, vomiting, abdominal pain and flatulence.
Table 2
Comparison between body surface area ( M2) in JP Nagar and Anna Nagar
according to age-sex (figures in brackets show S ,D)
Body surface area
(mean)
in Sq M2
n= 136
n = 137
1.23
(0.14)
1.22
(0.19)
F
1.22
(0.12)
1.15
(0.13)
M
1.49
(0.09)
1.51
(0.12)
F
1.37
(0.11)
1.35
(0.12)
M
1.50
(0.14)
1.53
(0.09)
F
■ 1.37
(0.09)
1.41
(0.22)
M
1.35
(0.04)
1.38
(0.15)
F
1.32
(0.06)
1.28
(0.05)
1 5-45 years
61 -Fyears
Anna Nagar
M
11-15 years
45-60 years
J P Nagar
Note: The differences in mean BSA's were tested by't' test — all the differences
were statistically non-significant <NS)
23
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 brackets.)
bl
No.
Symptoms
J.P. Nagar %
A. Nagar %
P. Value
*
P
(a)
1.
Dry Cougn
27.70 (41)
14 49 (20)
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 (I29)
35 50 (49)
< < 0.001
5.
Chest pain/tightness
50.0
(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)
< < 0.001
8.
Anorexia
66.21 (98)
28 26 (39)
< < 0.001
9.
Nausea
58.10 (86)
16.66 (23)
< < 0.001
10.
Abdominal pain
53.37 (79)
25.39 (35)
< < 0.001
11.
Flatulence
68.91
(102)
25.36 (35)
< < 0.001
12.
Lacrimation
58.78 (87)
42.62 (58)
< < 0. 01
13.
Blurred vision/photophobi a 77.02 (141)
33.10 (53)
< < 0.001
14.
Loss of memory for
recent events
45.27 (67)
11.59 (16)
< < 0.001
15.
Tingling/numbness
54.72 (81)
20.28 (28)
< < 0.001
*(a) P Values were calculated by X2 method.
24
<
0.01
Table : 3 B
Comparison of Symptoms reported by individuals in J.P.Nagar and Anna
Nagar. (Expressed in percentage. Numbers of cases are shown in brackets.)
(Symptoms significantly different but not analysed further)
SI.
No.
Symptoms
J. P. Nagar %
A. Naga’ %
P. Value
1.
Skin problems
29.05 (43)
11.59 (16)
<
2.
Bleeding tendency
9.45 (14)
2.89 (04)
< 0.025
3.
Headache
66.89 (99)
42.02 (58)
< < 0.001
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)
< < 0.001
(a)
*
0 01
Table : 3 C
Comparison of Symptoms reported by individuals in J.P Nagar and Anna
Nagar
(Expressed in percentage. Numbers-of cases;are shown in brackets.)
(Symptoms - Non-significant)
SI.
No.
Symptoms
J. P. Nagar %
A. Nagar %
P. value
*
1.
Blood in Sputum
10.13 (15)
7.24 (10)
N.S.
2.
Fever
27.70 (41)
i28'.98 (40)
N.S.
3.
Jaundice
0.67 (Of)
00
N.S.
4'.
Blood in vomit/stcol/malena
12.16 (18)
10.14 (14)
N.S.
5':
Vomitin'g
11.48 (17)
5.79 (C8)
N.S.
*(a) P Values were calculated by X2method.
25
(a)
(c)
Eye Symptoms
They included blurring of vision and or lacrimation.
(d)
Central Nervous System (CNS)
Disturbance or loss of memory and tingling and numbness.
The following symptoms were not included in this classification: impotence,
anxiety/depression, headache, muscleache, bleeding tendency, skin problems.
Table 3-D shows the incidence of the combination of these symptom complexes.
Some very interesting facts emerge.
As large as 63.5% (94/148) persons reported all the important symptoms
Only 2.7% (4/148) have symptoms which are exclusively pulmonary. Atleast
35.14% of persons do not have any pulmonary symptoms.
Tabla 3-E further explores the group of patients without pulmonary symptoms and
we found the following significant facts:
About 21% persons have Gl symptoms without pulmonary symptoms.
About 22% persons have eye symptoms without pulmonary symptoms.
About 15% personshave CNS symptoms without pulmonary symptoms.
In the last three categories symptoms of other systems may or may not
have been present.
An important further point of comparison between JP Nagar and Anna
Nagar with reference to this grouping of svmotoms is that every person in JP
Nagar reported atleast one serious symptom but quite a few in Anna Nagar
did not report any serious symptom.
Table: 3 D
Symptoms
Symptom groups
No /Total
%
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
35.14
(For . symptoms
included in
grouping
26
please
refer
4.4.3)
Table : 3 E
Symptom Complexes excluding Pulmonary System
Symptom Groups
No./Total
%
G.l. (with or without eye/CNS)
31/148
20.94
Eye (with or without GI/CNS)
32/148
21.62
CNS (with or without Gl/Eye)
23/148
15.54
Table : 4
Patterns of disturbance of vision in 10—45 yrs of population in J.P. Nagar
and A. Nagar (Figures in brackets indicate actual number )
J.P. Nagar %
Anna Nagar %
(D
74.24 (98/132)
(a)
28.57
(34/117)
Abnormal distant vision
(2)
42.0 (65/141)
(a)
21.88
(21/96)
Abnormal near vision
(3) ■
17.55 (20/114)
(b)
8.74
(9/103)
Corneal Opacity
(4)
4.7
( 7/143)
(b)
2.8
(4/138)
Blurring of vision
NOTE
1. Includes Photophobia.
2. Normal vision 6/9 — Distant Vision tested
by means of Snellen's chart
3. By means of near vision chart
4. In J.P. Nagar and Anna Nagar each there
are two central opacities.
(a) tested by X1
23
4d.f.l
P < 0.001
(b) tested by X2 d.f.l
P - Non-significant
27
5.4.4
Disturbances of vision
Table 4 shows percentage disturbance of vision of the age group 10-45 years
of population in both communities. Persons above 45 years of age have been
excluded because of the higher rates of cataract in this population which would
contribute to disturbance in vision.
Significantly higher percentage of individuals complained of blurring of
vision in JP Nagar rather than in Anna Nagar. As large as 42% in JP Nagar had
abnormal distant vision compared to 22% in Anna Nagar. The difference is highly
significant statistically. As to the abnormalities in near vision the differences
between the two populations are of some significance (but this difference misses 5%
level of significance very narrowly : X2d.f.1 3.62).
The difference in the rate of corneal opacities between the two communities
irrespective of their position on the cornea is not significant statistically (see Note 4
to table 4). However individual case histories had recorded that new corneal opa
cities had emerged after the gas leak in both JP Nagar and Anna Nagar.
Abnormalities of distan tvision, although large, cannot fully explain the
extent of blurring of vision in JP Nagar. Moreover significantly larger proportion
of abnormal distant vision in JP Nagar is itself in need of explanation. It is relevant
at this stage to point out that examination of eyes by trained ophthalmologists un
dertaken by other teams have so far failed to identify abnormalities in the anterior
and posterior chambers of the eyes to any significant extent ( 14 ).
The combination of these findings is unexpected but significant. The
experts had predicted that there will be no problems of vision of such magnitude and
whatever residual problems of vision there would be, that would be because of
corneal opacities.
5.4.5
Pulse/Respiration Rate/Hemoglobin Concentration
Tables 5-A, 5-B and 5-C show the comparisons of resting mean pulse rates,
resting mean respiratory rates and meaq hemoglobin concentrations, respectively
between the two samples and in both sexes.
Mean pulse rates and mean respiratory rates in both sexes in both JP Nagar
and Anna Nagar are not different statistically. However, mean hemoglobin concen
tration in both males and females is significantly higher in JP Nagar than in Anna
Nagar.
The higher concen'ration of hemoglobin is probably masking resting tachy
cardia and resting tachypnoea in JP Nagar but the degree of tachypnoea and tachy
cardia masked is not likely to be very high.
5.4.6
Other clinical findings
Clinical examination of all individuals in the sample showed the following:
(i)
9.4% (14/148) individuals in JP Nagar had rales and rhonchi in the chest
as against 2.1% (3/148; in Anna Nagar. The difference is significant stati
stically (P-' 0.026). Significantly higher rates of rales-rhonchi in JP Naaar
may well be duo to increased sensitization of the bronchial tree following
28
MIC exposure, but the rate is too small to account for the much higher rate
of breathlessness on exertion;
(ii)
We identified no case of cyanosis, a significant negative finding in view of
the fact that 87% of the individuals in JP Nagar have breathlessness on
exertion, have increased concentration of hemoglobin and that extensive
pulmonary damage is expected to have occurred.
(iii)
There was one case of oedema of leg, one case of hemiplegia (longterm
history) and one case of palpable hepatomegaly.
(iv)
There was one case of jaundice and no splenomegaly;
(v)
No significant findings in cardio-vascular system or central nervous system.
5.4.7
Effects on the Reproductive System Of Women
5.4.7,1
Gynaecological problems
The comparisons of symptomatology in this group of symptoms has been
done in two stages :
(i) comparison between symptoms in women of JP Nagar before and after
the gas leak (in the same women);
(ii) comparison between symptoms in women of JP Nagar and Anna Nagar
after the gas leak (between samples).
Tables 6 A, 6-B, 6-C, 6-D and 6-E show the comparison of mean mens
trual cycle lengths, percentage distribution of flow types, percentage distribution of
colour and oercentage distribution of dysmenorrhoea and leucorrhoea.
The salient findings are that women of reproductive age group in JP Nagar
have significantly shortened length of menstrual cycles after the exposure to the
gas compared to the lengths of cycles in the same group of women before, the gas
leak and lengths of cycles of women in Anna Nagar after the gas leak. Significan
tly more number of women in JP Nagar also had abnormalities of menstrual flowscanty, or heavy and blackish discharge (Tables 6-A - 6-C), dysmenorrhoea (Table
6-D), and leucorrhoea (Table 6-E), after the gas exposure when compared to the
internal/external control mentioned above.
It may be argued that increased rates of leucorrhoea in JP Nagar after the gas
exposure may be because of break-down in sanitary conditions due to the disaster.
The disaster obviously did not lead to physical destruction of the housings and
whatever sanitation that there was, people did not flee to refugee camps where
sanitory breakdown may be nearly total. Therefore this argument of sanitation is not
really applicable to the study.
5.4.7.2
Pregnancies and their outcome
Four women in JP Nagar and five women in Anna Nagar were pregnant at
the time of our study. There was one abortion in Anna Nagar and none in J P Nagar.
There was no instance of still birth. The numbers in the sample are too small to
29
Table : 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
85 05 (11.20)
n =59
Total
81.70
80.4
(13.20)
n = 145
(13.0)
n =132
• All the differences in mean pulse rates were tested stastically by 't' test and
found to be non-significant.
Table : 5 B
Mean Respiration
Nagar and Anna Nagar.*
Rate/minute (S D.) in males & females of J. P
ANNA NAGAR
J.P.NAGAR
Male
21.73
(3.98)
n= 69
21.21
(3.84)
n = 74
Female
21.84
(4.93)
n—70
20.92
(3.70)
n = 56
Total
21.87
(4.51)
n —139
21.09
(3.77)
n = 130
* All the-differences in mean respiration rates were tested stastically by't' test and
found to be non-significant.
30
Table : 5 C
(The figures
Mean blood Haemoglobin in gm.% in J.P. Nagar & Anna Nagar.
in brackets are S.Ds of means,
n = sample size.)
J.P. NAGAR
ANNA NAGAR
Male
14.68 (1.79)
n = 11
(a)
12.70 (1.35)
n = 17
Female
12.7 (1.46)
n = 20
(b)
10.79 (1.34)
n = 18
(a)
(b)
td.f26 = 3.18
‘d.f36 = 4.20
P
P
-
<0 01
< 0.001
Table : 6 A
Mean Menstrual cycle length in days in J.P. Nagar and Anna Nagar after
and before gas exposure. (Figures in brackets indicate S.D. in days.)
J.P. NAGAR
ANNA NAGAR
Before
After
Before
After
32.32
25.59
35.41
36.10
(13.51)
(12.04)
(20.09)
(19.89)
n = 31
n = 31
n = 29
n = 29
tj= 2.06
d.f. 60
P. < 0.05
ta = 0.131
d.f. - 56
P> 0.8
—
’j.a.
j.a.
differences In mean menstrual cycles length in days between J. P. Nagar and
Anna Nagar after the gas exposure.
tj.a
d.f.
P< 0.05
2.46
58
31
Table ; 6 8
Percentage distribution of Flow in J.P. Nagar & Anna Nagar before and
after the gas exposure. (Figures in brackets are number of cases)
NAGAR
J. p.
ANNA
NAGAR
Scanty
Excess
Total
Scanty
Excess
Total
5.5
11
100
2.6
18.4
100
(2)
(4)
(36)
(D
(7)
(38)
25.7
31.4
100
5.8
20.7
100
(9)
(11)
(35)
(2)
(7)
(34)
Before
After
X2 = 11.96
d f. = 2.
P < 0. 01
X2
< 1
d.f. = 2.
P > 0.50
Aft er the gas exposure
J. P. Nagar & Anna Nag ar
X2 = 7 8?
d. f. = 2.
P<0 025
Table : 6 C
Percentage distribution of colour of menstrual flow in J. P. Nagar and
Anna Nagar before and after the gas exposure. (Figures in brackets are No,
of cases)
J. P.
NAGAR
Black
Total
Black
Total
Before
5.8
(2)
100
(34)
0
(0)
100
(37)
After
46 8
(15)
ICO
(32)
88
(3)
100
(34)
ANNA
X1 - 14.46
X2 = 3.41
d.f = 1
d.f. = 1
P < 0.001
P - NS.
After the gas exposure J.P. Nagar & Anna Nagar
X2 - 12.03
d.f. = 1
P < 0.001
32
NAGAR
Table : 6 D
Percentage distribution of Dysmenorrhoea in J. P.Nagar and Anna Nagar
before and after the gas exposure. (Figures in brackets are number of cases.)
J. P. NAGAR
ANNA NAGAR
+ 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 = 9.21
d.f. = 1
P < 0.01
X = 0.71
d.f. = 1
P-N.S.
After the gas exposure
J. P. Nagar & Anna Nagar
X2 = 4.89
d.f. - 1
P < 0.05
Table : 6 E
Percentage distribution of Leucorrhoea in J. P. Nagar and Anna Nagar—
before and after the gas exposure
(Figures in brackets are number of cases.)
ANNA NAGAR
J. P. NAGAR
Before
After
NonSpecific
Leu.
Specific
Leu.
Total
NonSpecific
Leu.
Specific
Leu.
Total
15.5
(7)
22.2
(10)
0
(0)
35.5
(16)
100
(45)
100
(45)
16.6
(7)
14.6
(6)
14.3
(6)
14.6
(6)
100
(42)
100
(41)
X2 = 22.5
d.f. - 2.
P < 0.001
X2 = 1
d.f. - 2
P —N.S.
After the gas exposure
J. P. Naga r & Anna Nagar
X2 = 7.455
d.f. = 2.
P < 0.025.
33
>
reveal any significant changes. Moreover the foetuses which are likely to have
been damaged about three months ago at the time of the gas leak are now in the
second trimester and therefore, it will be a few mare weeks before the adverse impact
on pregnancies will be correctly estimatable.
5.4.7.3
Lactation
50% of nursing mothers in JP Nagar reported lactation failure or decrease
in output as compared to 11 % (1/9) of mothers in Anna Nagar.
5.4.8
Effects on Reproductive System : Of men
Impotence: Table 3-B shows that the percentage of men reporting symptoms
of impotence was 8.1% (12/148) in JP Nagar and 0.72% (1/138) in Anna Nagar
(significance of difference P<0.05).
5.4.9
Pulmonary Function Tests
Table 7 shows the comparison between the sampled subjects of JP Nagar
and Anna Nagar on two parameters of lung function measured in the study - Forced
Expiratory Volume in the 1st second (FEV1) and Forced Expiratory Capacity (FVC).
The difference between JP Nagar and Anna Nagar are statistically signi
ficant in bothisexes in the age groups of 15-45 and 46-60 years. The difference in
other age/sex categories are however, not statistically significant. This may be due
to smaller number of observations in these categories. The mean values in all these
categories and the FEV1/FVC ratio in all categories are diminished in JP Nagar in
comparison to Anna Nagar.
The pattern in the age groups 15?44 and 45-60 shows a restrictive type of
pulmonary function, while in the over 61’s the pattern is mainly obstructive.
5.4.10
Anxiety/Depression
From our field level interviews in which we spent much time listening to the
people's experiences we identified syndromes of anxiety and or depression in 43.92%
of the subjects (65/148) in JP Nagar and 10.14% of subjects (14/138) in Anna Nagar.
This difference is statistically significant.
From the sharing of experiences we gathered that there was much fear,
apprehension, anxiety symptoms, gas-phobia, fear of the restarting of the factory
operations and frank depression. In some cases there was some degree of mental
confusion.
5.4,11
I npairment of Memory
Many people described a definite change in their memory for recent events.
They narrated different examples of situations in which their memory seemad to fail
causing them much worry: e. g. (i) forgetting where something has been kept;
fii) forgetting whether a meal has been taken or not; (Hi) forgetting whether salt has
baen added to the 'dal' or not; (iv) forgetting the names of the children; (v) forgetting
the day or time; (vi) after coming out of the house forgetting for what purpose one
came out; (vii) students complained that they could not remember lessons or poems
learnt before the episode.
34
Table : 7
Distribution of Mean values of Body Surface Area (M2), FEV (Litre.), FVC
(Litre)
FEV/FVC% in different age-sex groups, in J. P. Nagar and Anna
Nagar. (a) * (Figures in brackets are S.Ds) n =■ number of persons in each
cell. P = P value.
BSA (M2)
Age-Sex
in yrs.
J.P
A.N.
FEV (Lit )
FVC (Lit.)
FEV,/FVC
J.P
J.P.
A.N.
J.P.
A.N.
%
A.N
10-14
1.23
(0.14)
n =4
1.22
1.59
(0.19) (0.74)
P = NS
n=4
1.93 '
(0.48)
1.72
(0.77)
P = N.S.
2.20
(0.51)
87.05
87.8
M
1.22
(0.12)
n=3
1.15
(0.13)
n =6
1.76
(0.84)
P = NS
1.77
(0.33)
2.07
(0 88)
P = N.S.
2.10
(0.40)
84.3
84.2
F
1.49
(0.09)
n = 45
1.51
(0.12)
n = 55
2.04
2.66
(0.47) (0.51)
P <1.001
2.39
(0.47)
P <0.001
2.99
(0.55)
79.1
88.9
M
1 37
(0.11)
n = 56
1.35
(0.12)
n = 52
1.64
2.25
(0-44)
(2.42)
P <0.001
1.97
(0.38)
P <0.001
2.54
(0.43)
76.3
88.6
F
1.50
(0.14)
n = 12
1.53
(0.09)
n=6
1.88
2.26
(0.53)
(0.19)
P <0.05
2.20
(0.43)
P <0.05
2.54
(0.24)
85.3
88.9
M
1:37
(0.09)
n = 11
1.41
(0.22)
n=7
1.51
(0 48)
P <0.01
2.13
(0.18)
1.86
0.58)
(P <0.01
2.48
(0.21)
79.8
85.9
F
1.35
(0.04)
n=2
1 38
(0.15)
n =4
0.94
1.91
(0.39)
(0.15)
P <0:02)
1.83
(0.35)
P = N.S.
2.17
(0.16)
61.8
88.0
M
1.32
(0.06)
n =3
1.28
1,39
(0.05)
(0.31)
n = 3 P <0.05
1.96
(0.31)
P = N.S.
2.13
(0.15)
63.4
86.2
F
15-44
45-60
61 +
*
(a)
1.90
(0.07)
All the differences in Mean Values between J.P.
each age-sex category were tested by 't'test.
35
Nagar & Anna Nagar in
Table : 8
Exposure History and safety Measures
Where at
the
time of leak
J P Nagar
Anna Nagar
Wet
towel
Blanket
Ran
out
Nil
Wet
towel
Blanket
Ran
out
Nil
In the Basti
5
7
124
8
9
6
64
52
Out of home
(in Bhopal)
1
-
1
2
-
-
2
5
Out of Bhopal
-
-
-
10
-
-
-
11
Total No. 148
Total No. 158
Note: Nil means remained in the house without safety measure.
Table : 9
Number of attacks (respiratory infections) in one month preceding the
study
Anna Nagar
JP 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 +
3
21
14
73
4
4
54
32
4
12
11
95
———
In statistical terms 67/148 subjects in JP Nagar (45.27%) and 16/138
subjects in Anna Nagar (11.59%) complained of this symptom. The difference is
highly significant.
Miscellaneous observations
5.4.12 School Performance of Children
A discussion with one of the school teachers in the affected area revealed
that the school attendance had fallen because many families had moved away, many
pupils had died or become too ill to continue. Of those who returned to school,
the teachers felt that there appears to be no visible physical effect but they are not as
'active'as they used to be. They do not go out to play that often. They are not rest
less when they have to sit for long periods in class as they used to be. Some of
them have developed a disinterest in school work. Even though all had not lost their
immediate kith and kin, many had seen their friends and cousins die and were affec
ted by this.
36
Many members of the team themselves observed this general listlessness or
apathy of the children, and many were dyspnoeic as well. The visual impressions
of these problems between JP Nagar and Anna Nagar was distinctly different, the
impression in Anna Nagar being similar to what one expects in an average slum
area - lots of children playing around, inquisitive, running about, active.
5.4.13
Effect on immunity/resistanoe
We enquired about the experiense of respiratory infections in the study and
control population in terms of number of attacks in the one month preceding the study.
Table 9 shows this finding. 73/148 in JP Nagar had many attacks of respiratory
infections while only 12/138 in Anna Nagar gave this history. In JP Nagar this was
often described as a continuous respiratory problem. This is an important suppor
tive finding but cannot be taken directly to mean a state of lowered resistance to
infection resulting in frequent upper respiratory infections but is strongly indicative
of it.
5.4.14
Enquiry into exposure and safety measures employed
Table 8 shows where the people in our sample were at the time of the
incident and whether they employed any safety measures (wet towel, blanket, run
ning out) to protect themselves against the gas leak.
The fact that many ran out and few used a wet towel is a good indication
of the lack of awareness or safety education of the residents of the bastis. Most of
them had no idea about the hazardous nature of the plant operation nor about measures
to protect oneself in the event of a gas leak. Even those who used a wet towel used
it by instinct rather than due to an awareness of precautionary messages.
Concern for man himself and his safety must always form the
chief interest of all technical endeavours. Never forget this in
the midst of your diagrams and equations.
Albert Einstein
37
CHAPTER 6
DISCUSSION
The present study is a community based, case/control study in randomly
selected samples of families. It provides a much more authentic picture of the
state of health of the gas affected communities than one can get from studies
conducted on inpatient/outpatient populations of the hospital, which is the chief
characteristic of the studies undertaken by the protagonists of the two medical
theories. Self selection in hospital based studies necessarily occurs which distorts
the community perspective. These efforts may give some understanding of the
quality of the problem, but give little information on the actual pattern and quantum
of morbidities prevalent in the.community. There is no substitute for community
based epidemiological studies. Our study has the merit of shifting the focus from
the health problems of hospital based patients to the health problems in the com
munity outside the hospital and dispensaries.
It is not too difficult to understand why the health establishment of
Bhopal including the dominant faction in the medical college of Bhopal did not
attempt such community based epidemiological studies.
However it is not easy to understand why the ICMR after having broken
fresh ground and hit upon a potent and fertile hypothesis of 'enlarged cyanogen
pool' theory did not go all out for community based epidemiological studies to ex
ploit its full potentials.
But before we go into such intriguing and intricate problems let us first
examine the role of chronic diseasesand smoking in producing the morbidity and
mortality in the Bhopal gas victims, and then critically assess the claims of
'pulmonary theory' in the light of our findings and available information.
6.1
Role of chronic diseases and smoking
Many have argued that a significant proportion of the mortality and residual
morbidity is reflective of the base line ill health including a higher prevalence of
chronic diseases like tuberculosis and higher smoking rates.
Our findings do not lend support to such speculation. Out of 26 persons
who died in our sample study of JP Nager after the gas exposure, one was reported
to have been a smoker and none to have had any chronic diseases.
The age/sex breakdown of the dead in JP Nagar are as follows
Age in
years
0-1
2-5
6-15
16-45
45 +
Male
1
4
2
5
—
Female
2
3
2
5
1
Among these only one 45 year old male was a smoker.
Women in JP
Nagar generally didn't smoke. Among the dead there were 13 women, 7 males
under 15 and 4 males between 16-45 who did not smoke.
38
The findings of the morbidity survey are also significant. A quarter of the
sample in both the communities — JP Nagar and Anna Nagar—were smokers
and yet most of the serious symptoms are significantly higher in JP Nagar than in
Anna Nagar. Moreover the given smoking rates in JP Nagar cannot fully explain
the micr h g rer symptom rates in JP Nagar. A similar argument would apply
to the chronic diseases as well which in our survey specifically included history
or tuberculosis, bronchitis and asthma. This was found to be around 10 oercent
in both communities and is much too small to explain the high rate of symptoms.
The question therefore we now come to is : How much do our study
findings support or question either of the theories? or to put it differently, how much
of our study findings can be explained by either of the theories.
6.2
Pulmonary theory : an assessment
Pulmonary theory's greatest strength is in its simplicity and plausibility..
The theory has a formidable backing of a range of western experts.
The adverse effects of isocyanates other than MIC, which are widely used
in industry, have been extensively studied. These effects are mainly confined to
lungs. Changes in the blood have never been implicated.
The probability of the MIC molecule's ability to enter the blood stream and
reach other organs, thanks to its supposed high reactivity, has been rated extremely
low indeed. Furthermore it has been argued that 'there is no known metabolic path
way that converts isocyanate into cyanide’ (14).
Autopsy findings have consistently shown damage to the lung tissue, of
course damage to the other organs has been shown too. Pulmonary function tests
have consistently shown impairment of ventilatory functions. In so far as MIC causes
direct damage to the corneas, impairment of vision is an expected finding.
The difference among the believers has been with regard to the type, extent
and duration of damage.
Thus the American Public Health specialists maintain that eyes and lungs
of a considerable proportion of the population will be greatly damaged. Sooner or
later many victims will succumb to suffocating onslaughts of emphysema, asthma
and pneumonia. Sizeable number of people could develop permanent blindness
due to damage to the corneas. The damaged lung tissue of victims makes them
much more vulnerable to common respiratory infections which could become fatal (9).
Then there are others who are much more optimistic about the extent and
duration of damage. Thus as we have already quoted. Mr. W. Anderson, Chairman
of Union Carbide, U. S. made a confident prediction as early as 3rd January 1985
that victims are rapidly recovering (11) .
These arguments favouring the 'pulmonary theory' are however general
without specific reference to the actual situation in Bhopal where massive exposure
to MIC gas has occured.
Let us now see how the 'pulmonary theory' stands up to critical exami
nation in the light of facts brought out in Bhopal.
39
6.
2.1
Deaths
The believers of the pulmonary theory have tenaciously held on
the idea
that the very high death rate following the gas leak was due to Carbon Monoxide
poisoning and not because of cyanide poisoning (besides pulmonary oedema).
As we have seen earlier, the ICMR studies have shown that blood samples
of the dead stored in deep freeze and the blood samples of critically ill patients
who subsequently died, showed no evidence of carboxy haemoglobin (carbon mono
xide combined with haemoglobin) (14). The K.E.M. Hospital study on 113 self repor
ting MIC exposed persons cannot lend support to the theory of carbon monoxide
poisoning either because of the reasons we have discussed in para 3.1, Chapter 3.
According to the theory one expects at least some of the post exposure
deaths to be due to lung infections. In our study out of 26 deaths in JP Nagar 52
occured within 5 days of the gas leak because of the direct toxic effect of the gas.
6.2.2
Diseases - Disabilities
It is here however that the theory runs most into deep trouble. The pulmo
nary theory cannot explain the high rates of symptomatology even 3 months after
exposure in a population which is not hospital bound. For instance it cannot explain
fatigue(81 %), blurring of vision (77%), muscle ache (73%), flatulence (68%), head
ache (67%), anorexia (66%), nausea (58%), excessive lacrimation (58%), tingling
and numbness (54%), loss of memory (45%), and anxiety depression(43%). Even
the most common and disturbing symptom like breathlessness on usual exertion (87%)
cannot be fully explained by this. (Table 3A)
The simultaneous presence of all serious symptoms suggesting
involvement of not only lungs but gastro-intestinal tract, brain and vision in
as large as 62% of the sample population in JP Nagar cannot be explained by
the pulmonary theory. (Table 3D). It is not the point whether all the above symp
toms are part of the symptomatology of extensive pulmonary damage; the point is, are
they all present simultaneously in such a large proportion of individuals who are not
so ill as to be in the hospital? True, ventilatory capacities are diminished in JP
Nagar significantly which supports the pulmonary theory, but even here the reduction
is not large enough to explain such a high rate of breathlessness on exertion, weakness
and fatigue. It obviously cannot explain exclusively non pulmonary symptoms
in as high as 15 to 21% (Table 3E). Even if we grant that there is extensive lung
damage in a large proportion of cases there should be commensurate clinical findings
in those individuals. One naturally would expect high rates of respiration and pulse
and cyanosis. None of these are found in our study (Table 5A and 5B).
This is an odd finding. One can of course argue that tachycardia and
tachypnoea in JP Nagar is masked by rise in haemoglobin (Table 5-C) which is a
result of hypoxia produced by extensive pulmonary fibrosis. But surely where
extensive lung damage is supposed to have occured because of MIC exposure one
expects'suffocating onslaughts of emphysema, bronchitis, asthma', etc. (9) with
attendent compromised gas exchange at alveolar level. This must lead to not only
hypoxia (low oxygen level in the blood) but also to retention of carbon dioxide in
the blood which in turn must lead to increased ventilatory efforts to wash out excess
build up of carbon dioxide.
Besides, 'cyanogen pool' theory can explain haemoglobin rise without
having to account for not much increase fri pulse rate or respiratory rate.
40
Looking at visual disturbances also we see an interesting set of facts.
The pulmonary theory explains and predicts visual impairments solely by virtue of
direct injury to corneas which may result in opacities producing visual impairment
(2,3). In JP Nagar only 7 out of 148 individuals have corneal opacities, of these
only 2 are central opacities which matter. The rate in JP Nagar (4.7%) is not
statistically significant when compared to the rate in Anna Nagar (2.8%). This ex
tremely low rate of opacities can obviously not explain 74% of blurring of vision in
JP Nagar which is statistically significantly higher than in Anna Nagar (Table 4).
Carboxy haemoglobin levels of more than 5% in large numbers of individuals can
explain this but there is no such evidence. The pulmonary theory cannot explain
either the high abnormal rates of distant vision in JP Nagar (42%) which is highly
significantly higher than that in Anna Nagar (22%) (Table 4). Finally the evidence
from the effects seen on the reproductive system is significant. A significantly
shortened menstrual cycle (Table 6-A), increased rate ol dysmenorrhoea (Table 6-D),
increased leucorrhoea after the disaster in the women (Table 6-E) and increased
percentage of impotence in men of JP Nagar (Table 3 BJ as compared to Anna Nagar
cannot be explained by the pulmonary theory.
Very high rates of symptoms implicating all the important systems in the
body call for a theory which can explain disturbances in all the systems by postu
lating a mechanism which must be operating in all the systems. 'Pulmonary theory'
clearly lacks the theoretical mechanism with an integrative power to account for the
wide range of symptoms in JP Nagar. 'Cyanogen pool theory' precisely achieves
this at least tentatively.
6.3
'Enlarged cyanogen pool' theory : an assessment
By postulating chronic poisoning by cyanide which is slowly released from
haemoglobin bound MIC, it suggests that at the cellular level in practically all the
organs oxygen utilisation has been impaired. The bewildering and apparently
unconnected wide range of symptoms can be explained with the help of this theory.
Our findings per se pose no serious problems to this theory.
This is very interesting but then excess cyanide radicals in the body fluids
have not been demonstrated. Its presence is inferred from increased levels of
urinary thiocyanate following injection of sodium thiosulfate. This however is not
its main handicap. Nor is the 'cyanogen pool' theory suffering from the handicap
of uncompromising dogmatism which characterises 'the pulmonary theory'. From
the very beginning, until now unlike 'the pulmonary theory' it doesnot claim to be
the only theory whicn can explain everything in Bhopal. It readily accepts that at
least a part of the human suffering may well be because of direct damage to the
lung tissue and eyes by MIC gas. Its main problem lies in a different area.
Events postulated and substantiated very tenuously to be taking place at the
cellular level cannot be directly connected to events occuring (symptoms) in a large
proportion of individuals in the community- The chain of links that connects the
two must be demonstrated at least tentatively. This has not been done. We
therefore now turn to a critique of the 'cyanogen pool' theory.
There are two kinds «f evidence both indirect, to suggest chronic cyanide
poisoning, (1) Inadequate utilisation of oxygen and removal of carbon dioxide indi
cates a metabolic block at cellular level. There is also some evidence that carbon
dioxide removal from tissues is increased after injection of sodium thiosulfate,
(2) The clear rise in the urine output of thiocyanate following injection of sodium
thiosulfate perhaps indicates an enlarged cyanogen pool.
41
However the data available on boWi the types of studies (changes in the
blood gases and urinary thiocyanate following sodium thiosulfate) is very scanty and
fragmentary, which makes informed and in depth examination of these studies almost
impossible. Furthermore these studies are done on hospitalised patients. To
extend the findings and lessons of these studies to home based ambulatory persons
as ICMR does is not acceptable on methodological grounds.
We find ourselves not equipped enough to appraise more critically the
meaning and interpretation of blood gas studies but we do offer our criticism of
the way a potent tool of epidemiological research such as sodium thiosulfate has
been used so far resulting in non-illumination of many critical areas of tox ic effects
on the human population.
In the double blind clinical trials carried out by ICMR and others on 30
hospitalised patients in Jan-Feb.1985 two outcomes were observed, one, clinical
improvement and two, urinary thiocyanate levels following sodium thiosulfate or
glucose as placebo (14). The released information so far does not say clearly as to
what was observed in the clinical outcome. However if we go by clinical criteria
used in subsequent studies (not double blind trial) which are made public, we can
make a reasonable guess as to what was probably observed, i.e. (i) weakness and
breathlessness at rest and (ii) increase even after mild exertion (14). From our point
of view these are only pulmonary symptoms constituting only a small proportion of
all svmptoms. They do not include non pulmonary symptoms like blurring of vision,
nausea, anorexia, flatulence, fatigue, weakness, headache, etc. And yet the minutes
of the ICMR meeting of 14-2-1985 (1 6) contained detailed guidelines for categories
of patients to be given injection sodium thiosulfate which included patients suffering
from acute and/or chronic symptoms relating to respiratory, gastrointestinal and
neuromuscular systems following MIC gas exposure.
This is clearlv far from satisfactory. There is no published evidence by
ICMR which says that a significant proportion of non pulmonary symptoms are re
lieved also. We are therefore, bound to question the explanatory power of the
'cyanogen pool' theory to account for high rates of non pulmonary symptoms. Also
ICMR data related to hospitalised patients, cannot say much about the community
where large numbers of persons have wide ranging symptoms. Based on such a few
and limited studies how can the cyanogen theory explain these symptoms in the
community ?
Have there been community based trials focussing on the whole range of
symptoms so that, even if indirect, evidence for existence of an enlarged cyanogen
pool and its extent in the community may be established ? No.
This is not all. Significantly increased urinary output of thiocyanate in
patients who are given sodium thiosulfate compared to those who are given only
glucose is not a finding which is non problematic. This is so, because we do not
know the effect of sodium thiosulfate on the urinary output of thiocyanate in a heal
thy population.
Going by whatever evidence ICMR has published so far, it is not adequate
enough to explain the wide range of symptoms in a high proportion of the
ambulatory population as revealed by our study.
This criticism clearly leads one to suggest that ICMR does not have adequate
evidence to substantiate the 'Cyanogen pool' theory or if it has got it for some
unknown reasons it has not made public full details 5 months after the disaster.
42
ICMR cannot make a claim that necessary information is being generated,
for how can it then issue two press releases giving details of guidelines for thio
sulfate therapy for the symptoms including non pulmonary symptoms ?
To summarise our arguments : On the night of 3rd December, between
100, 000 to 200, 000 persons in Bhopal got severely exposed to MIC gas
(14,18,12). A vast majority of them are still complaining of serious, debilitating
symptoms indicating involvement of many systems
According to the cyanogen pool theory each of these exposed persons has
an enlarged cyanogen pool in his/her body leading to chronic cyanide poisoning.
This whole population may be made up of different categories of people from the
point of view of the state of the cyanogen pool in their bodies and its manifestations
in the form of various symptoms.
There may be some who have been ill enough to be hospitalised, those who
have attended OPD only and those who belong to neither group, but have serious
symptoms nevertheless. Of course there may be various degrees of overlap here.
Similarly there may be various categories of symptom complexes in each of the above
described groups.
The idea is not to work out all possible permutations and combinations!
But along the two axes of symptom complexes and degree of seriousness of symptoms
a limited number of concrete epidemiological groupings/profiles may be present
which can be and must be identified.
The whole point of our criticism is that out of all such existing epidemio
logical groupings who together make the total population of gas victims, the ICMR
has chosen to study rigorouly only one tiny group: a seriously ill patients (hospitali
sed), whose pulmonary symptoms have been kept in focus. The rest have been
ignored. They remain unidentified, unknown and the existence or otherwise of an
enlarged cyanogen pool in these groups remain untested, although such a potent tool
of epidemiological investigation as sodium thiosulfate is available all through out!
Our arguments must not be understood to mean that our aim is to reject
the 'cyanogen pool' theory. The theory is to be rejected only when the arguments
advanced in its support are found wanting, untenable. Here we are not criticising
and rejecting the arguments which have been advanced in support of cyanogen pool
theory. On the contrary we are complaining, bitterly, that the possible, sensible
and comprehensive arguments in support of 'cyanogen pool' theory have not been
advanced because they have not been develooed. Without these arguments the
cyanogen theory remains untested and weak. And this is because ICMR has not
bothered to develop this theory and to build up the arguments by following relevant
lines of research so clearly suggested by the theory and the nature of problem facing
us.
This is the criticism of methodology, perspective, orientation and objectives
of research strategy. This has helped more than anything else to put the theory
under the shade before it was given a fair and rigorous trial. This is not a criticism
of the theory per se. Many have expressed fears that by this criticism we might be
forced to oppose the mass treatment of sodium thiosulfate. Far from it.
This fear arises in part from the fact that if gaps in evidence are highlighted
then the theory may suffer and with that sodium thiosulfate therapy might be
rejected and condemned. We do not agree. As we have tried to argue above, the
43
gaps in the evidence because of lack of efforts to build up evidence is not the same
as negative evidence. The theory cannot be rejected before it is properly tested.
The whole point is that the evidence can be and must be built up if the theory is
sound and is to be properly tested.
There may be some hesitation on account of the fear—again not really sound
that further trials may mean further delay in treatment and that it may not be ethical
to carry out such trials.
Taking the second point first : It is not ethical not to give benefit of treat
ment to the remaining groups. It is perfectly ethical to give them treatment especially
when we know that on the one hand there is a disturbing possibility of chronic cya
nide poisoning in such a vast number of people, and on the other hand sodium thio
sulfate is such a harmless drug.
Coming to the first point : Used as we are to a division and distance between
research and action, we may not be quick enough to grasp that this division and
distance is artificial and has no connection with the real world where efforts to
understand and solve the problems almost simultaneously is possible I
The science of clinical trials has advanced so much that with the help of
well established statistical methods like Sequential Analysis, a series of quick, short
duration, rigorous trials in the relevant epidemiological groups described above can
be easily mounted. From a minimum of data, reliable and valuable conclusions can
be drawn. We do not have to wait for a long time for the results of clinical research
to come through before the treatment is initiated.
It is also possible to initiate mass treatment on the one hand, since no
ethical problems are involved and launch well planned, comprehensive programmes
of research in the chosen epidemiological groups on the other hand so that the whole
scientific case to support 'cyanogen pool' theory may be built up and the treatment
is based on rational, scientific, foundations. Specific care should be taken that all
who are getting treatment should have proper records showing identity of person,
precise clinical description and outcomes.
These strange and inexplicable lapses of ICMR have other implications and
far reaching consequences not only for establishing the case for the 'cyanogen pool'
theory, and treatment and relief as we have seen above but also for compensation
damages for the gas victims and for continuing relevant research programmes.
6.4
Magnitude of the problem ; an issue of damage/compensation
We undertook this small and modest study within the severe limitations
imposed by man, material and time constraints. The purpose of the study was to
bring into focus the real issues of health that seemed to be out of focus.
To design and implement a much larger and more compiehensive series of
epidemiological studies (i) to elucidate and substantiate the 'cyanogen pool' theory
(ii) to help the suffering gas victims of Bhopal by way of medical relief (iii) to help
them put up claims for damages and compensation against the Union Carbide, can
not be undertaken by us.
The issue of compensation/damages for Bhopal gas victims is now before
the American courts. The crucial question is : How can medical evidence for tens
of thousands of gas victims be presented in the court? Fortunately American courts
44
accept epidemiological evidence in such cases as the Bhopal disaster. A represen
tative case from each of the relevant epidemiological groupings may be presented
before the jury. Once the jury is satisfied, it can then be given statistics of other
similar cases, based on proper epidemiological studies. The damage for all the
identified victims may then be awarded (20).
A detailed working out of epidemiological profiles and listing of the gas
affected population assigning each to one of the profiles is thus crucial to claim
damages from Union Carbide.
Easily between 50 to 70% of the ambulatory population in the severely
affected areas of Bhopal are still complaining of one or more serious symptoms
implicating different body systems like the respiratory/gastro intestinal/ ocular and
neuromuscular systems.
It has been estimated that about 100,000 to 200,000 people of Bhopal
suffered serious exposure to MIC gas (14, 18, 21). Since we have excluded chil
dren below 10 years from our study who constitute about 30% of the total population
we can give an estimate of suffering in 70,000 to 140,000 population. By most
conservative estimates the number of persons still suffering is between 30,000 to
60,000 at the lower end. We stress again that even the upper estimate is a severely
conservative estimate especially since it excludes children below 10 years who are
suffering also. Practically nothing has been thought about them let alone anything
being done for them thanks to the exclusive focus on the hospital population. .
6.5
Thiosulfate controversy
It is obvious that differences in theory can also lead to difference in the
treatment. But in Bhopal the differences about treatment have clearly gone beyond
academic differences.
The believers in the pulmonary theory in the beginning treated the gas
victims with bronchodilators, steroids, antibiotics, oxygen etc. This was the most
obvious line of treatment at first. However, the symptoms continued unabated
inspite of treatment.
Later it was known that cyanide poisoning was astrong possibility and
many including doctors themselves availed of thiosulfate injections to obtain relief.
ICMR issued guidelines for such treatment by 14th February 1985 based on the
findings of a double blind clinical trial which is accepted as one of the most rigorous
scientific methods of study.
Inspite of all this the medical establishment of Bhopal held back the
treatment from the gas victims and continued to put obstacles in the way of
implementation of this recommendation. Why ?
The minutes of the ICMR meeting of 14th February (16, Appendix-Ill)
specifically mentions that all participants (which included members of the opposing
medical lobby as well,) agreed finally to the guidelines and a decision to convey the
same to the health authorities in Bhopal as well as the Ministry of Health at the
Centre (to ensure adequate supplies of sodium thiosulfate) was also recorded. These
minutes were circulated to all the staff of the medical college recommending
necessary action on 18th February 1985. Nothing came of it. Sodium thiosulfate
is still not being given on a mass-scale to the gas victims. Besides this, a bogey of
45
supposed ill effects of treatment is being raised. The evidence produced is worse
than flimsy (2 out of 200 patients treated with sodium thiosulfate developed rash
and nausea-vomiting and 2 patients severely moribund died after sodium thiosulfate
treatment!).
At a symposium on pulmonary function held in the Medical College at
Bhopal on 24th March 1985, when a senior Professor was asked by the mfc team
why sodium thiosulfate was not being more widely used, when seniors like him had
given their consent to it earlier (Ref. appendix-ill ICMR minutes - 14-2-85), the
matter was brushed aside by a denunciation of ICMR and questioning the validity of
the double blind study. This reaction was indeed strange since if he had not been
satisfied with the results or methods of the trial, the dissent or objections should have
been raised and minuted in the proceedings of the meeting and ICMR should have
been required to release further details of the controversial trial.
On 3rd April 1985, Hindu, Madras carried a news report. Another senior
Professor Emeritus of the Medical College, Bhopal was asked by press reporters why
victims of the gas exposure were still not being given injection sodium thiosulfate.
The reply recorded was even more surprising. 'How do you expect me to administer
sodium thiosulfate to gas affected persons when I am not convinced about the need
for it - simplv because someone however eminent he is, has said it and patients are
asking for it ?'
Strange argument this! In invoking the doctors'right to choose the treat
ment one should not forget that this right is not arbitrary. The doctor is under
obligation to take cognisance of well tested scientific facts. In this case it is not
the opinion of the eminent person that is the issue. The issue is whether the
opinion is based on a rigorous scientific trial and whether there exists equally strong
arguments which contradicts the outcome of the trial. In the name of 'the doctors
right to choose the treatment' a doctor cannot ignore existing scientific evidence.
What is conveniently also glossed over is the fact that only a few months earlier
most doctors had accepted meekly the dictates of the health department banning the
use of sodium thiosulfate.
This is pathetic. Is there no one to pull up these 'eminent' people whose
behaviour is both unethical and unscientific?
In our country we have a body of health professionals - the Indian Medical
Association (I.M.A.). I.M.A. considers itself fo be a custodian of health of the
people. To fulfill this role it has also taken up the cause of merit in medical educa
tion. Thus not long ago it launched a tirade against introduction of village health
workers in the health services in rural areas. 'How can these illiterate villagers be
entrusted with such a sensitive and responsible task as diagnosis and treatment of
ill persons?’, it argued vehemently. Again, when it was a case of reserving a few
seats in medic; I colleges for Scheduled Castes and Tribes, it promptly jumped into
action raising a hue and cry, to defend the cause of merit, supporting the anti-reser
vation agitation which raised such untruthful slogans as 'people s health is in danger',
'save lives, abolish reservations':
Now here in Bhopal, months afterthe disaster, months afterthe establishment
of sodium thiosulfate as effective therapy, months later when thousands of gas vic
tims are still complaining of debilitating symptoms forcing them to stay at home
without jobs without income what is I.M.A. doing to reprimand the medical
estabishment in Bhopal which simply refuses to give a vital drug to the thousands?
Nothing. Just looking the other way. A body which is so concerned about heatlh
46
and lives of people should have decided a clear policy on the thiosulfate issue long
ago. It did nothing of the sort.
Emboldened by such tacit approval the medical establishment in Bhopal
continues to behave in a strange and arbitrary fashion throwing all pretences of
being scientific overboard and continues to deny a vital drug to gas disaster victims.
Strangely the ICMR too has chosen not to release the details of the study
and to allow this important trial to be subjected to wider and open scientific scru
tiny especially when its scientific worth is being questioned. Does it realise that
by not releasing this crucial information and critical data which could have helped
solve the controversy it has become partly responsible for the continuing suffering
of countless unknown, unfortunate gas disaster victims whose health may have been
further damaged — damaged even irreversibly ?
Implications for research
6.6
Because of ICMR's ambivalence and lack of openness even 5 months after
the disaster and even after being in possession of a potent tool (sodium thiosulfate)
not only to treat but also to investigate further the disease pattern, ICMR has
apparently made no progress in this vital area of research which demands our maxi
mum attention. Whatever information ICMR has released (ICMR update 10-3-85)
so far on the research it has sponsored is scanty and fragmentary.
It is a sad commentary on these research efforts that 5 months after the
disaster with a mass of population continuing to complain of serious symptoms, no
comprehensive picture of morbidity pattern in the community is put together either
by ICMR or the medical establishment of Bhopal.
A very large proportion of the exposed population have more than one
system's involvement. Intrinsic connections to all those disturbances must be clearly
understood. Based on this insight, a community based, integrated comprehensive
research programme should be mounted. Only this will reveal the true extent of
suffering and its pattern and probable causes. Quite a few research studies
sponsored by ICMR lack this integrated approach (Ref. ICMR update 3 0th March
1985 - Part II)
The approach of examining say 200 eyes, or 200 lungs and so on indepen
dent of one another lacks this integration. Strange as it may sound, but it seems to
derive its rationale—unconsciously—from the pulmonary theory model, wherein the
toxic gas directly hits the target organ (lung, eye etc.) to produce damage without
any intrinsic connections—which is at the heart of the 'cyanogen pool' model!
The focus of research should become suffering in the community (and not
only hospital based patients). Only when this happens, ICMR will mount well de
signed, clinical trials in the community using the potent tool of sodium thiosulfate,
to work out epidemiological profiles existing in the gas affected community:
i)
to find out who among the affected are relieved by it and who are not
relieved and to what extent.
ii)
to find out the pattern of improvement and extent of improvement
various groups of symptoms
Hi)
to find out what is the natural history of the range of serious symptoms
47
in
iv)
and to \\o-< c...' p.K.'e.'rrs A'nf degrees of disabilities
•
A small sub-sample of persons from each epidemiological category may be
selected to study the blood gases. We stress again that a series of such studies
must be done on the ambulatory populaton among which there may be 85,000 who
carry a serious morbidity load.
Using the potent tool of sodium thiosulfate in this way ICMR will be
able to establish not only the 'cyanogen pool'theory but also treatment schedules
for the suffering population.
Only from such studies we will have detailed epidemiological profiles of
those wno are going to recover with sodium thiosulfate and those who are not.
We would then need a mass survey to identify all such persons so that proper and
just damages may be claimed from the Union Carbide. It is obviously not enough
that Union Carbide be asked to pay darrrages for those who are dead. It must also
ba made to pay those who have been disabled - physically, mentally and
socially. Mr. W. Anderson, Chairman of Union Carbide should not get away with
statements that 'all is wall'with Bhopal.
Industrialisation is creating a high-risk environment for everyone. But
experience shows that it is the poor who face the highest risks and dangersThey get the dirtiest, most hazardous of jobs and poverty forces them to
live in the dirtiest environments. Yet few people pay any attention to their
plight, and even fewer are prepared to do anything about it.
The state of India's Environment
— a citizen’s report
Centro for Science and Environment
CHAPTER 7
RECOMMENDATIONS
Around 90,000 gas affected persons in Bhopal continue to suffer from such
debilitating symptoms as breathlessness on exertion, fatigue, headache, disturbed
vision, loss of memory, loss of appetite and more.
The physical and mental disability has meant loss of jobs and consequent
loss of income for the survivors (Fig. 1). 65% of working persons in JP Nagar have
reported a drop in income as against 9% in Anna Nagar. In atleast half of the working
population the rate in drop of income has been 50% or more. This is by any stand
ard a picture of massive socio-economic disruption. The suffering - atleast part of it
continues not because there is no remedy for it. Many, if not all, might have been
relieved if prompt and adequate treatment with sodium thiosulfate - an antidote
to cyanide poisoning was given to them.
This was not done, and it is still being withheld from them. We have tried
to make a case in the last chapter that the problem of medical relief, rehabilitation
and damage to the thousands of victims has been turned into a tangle due to the un
seemly conflict between the two medical theories.
Although outwardly the conflict is theoretical, it has little to do with scien
tific rigor and debate. The supporters of the pulmonary theory have dogmatically
stuck to their lame and indefensible theory and have successfully stalled mass treat
ment by sodium thiosulfate, thanks to the support they have in decision making and
power centres.
The supporters of cyanogen pool theory on the other hand after having made
a brilliant and bold breakthrough have chosen to lapse into a kind of inaction not
following up the theory to its logical end by undertaking relevant epidemiological
research, allowing the theory to remain vulnerable to attack.
Indian Medical Association, 'the custodian of peoples' health', is of course
looking the other way and lending indirect, if not direct, support to the pulmonary
theory.
The right atmosphere to make relevant, comprehensive and people oriented
recommendations is of course not there. Even then we would like to make recom
mendations based on our understanding of the problem situation so that, individuals,
groups, organisations and the gas victims may be helped, even if in a small measure
in their struggle to get justice and a better deal from the Union Carbide and from the
Government of M.P.
Of all recommendations we believe the most decisive and central is the
research-cum-action programme which is in a way linked to all the major issues of
medical relief, rehabilitation and compensation for damages.
The whole scheme of recommendations follows logically from it.
7.1
Community Based Epidemiological Research
7.1.1. The research endeavour must shift its focus from the present hospital or
dispensary based seriously ill patient orientation to a family and community based
49
ambulatory patient orientation so that the quantity and quality of the problem can be
clearly demarcated. Epidemiological profiles of ill health and disability in the
community need to be urgently built up. Well designed clinical trials using sodium
thiosulfate not only as a therapeutic tool but a potent epidemiological tool as well
need to be initiated on ambulatory patients in the community - to find out who is
and who is not relieved, extent of improvement and natural history of the range of
serious symptoms (e.g. breathlessness on exertion, disturbed vision, fatigue etc.)
This will enable it to test and substantiate the 'enlarged cyanogen pool' theory, to
help it establish mass therapy with sodium thiosulfate on a fitmer scientific base
than is the case today and to help refine, modify and consolidate profiles of signi
ficant epidemiological groupings so that classification of the entire gas affected
population becomes possible.
7.1.2 Since the possibility of chronic cyanide poisoning in Bhopal is very high
an ongoing surveillance programme covering the total affected population should
assess the risk to the unborn and newborn babies.
7.1.3 Health problems related to women's reproductive system should be conti
nually monitored.
7.1.4 Quite a high proportion of gas victims are suffering from psycho-social stress.
They must be properly rehabilitated.
7.1.5 In view of the possibility of lung damage it is necessary to have monitoring
of pulmonary functions for a much longer time since the process of lung fibrosis is
insidious and takes a long time to develop fully. Special care must be taken for
those whose pulmonary symptoms show no improvement after sodium thiosulfate
treatment. Similarly a special watch must be kept on visual disturbances since it
is closely related to work performance.
7.1.6. An important but neglected dimension of the existing research endeavour is
the lack of informed consent. This is a minimum medical ethic which even in the
unprecedented situation of Bhopal is reasonable, relevant and possible. People
must be informed about the test being done, their rationale and their informal/
formal consent be taken. This is their right and is the only way that medical
research becomes an instrument of human welfare and does not degenerate into an
instrument of exploitation of human suffering for esoteric research and career
advancement.
6.2
Mass Relief Programme
As we have discussed in Chapter 5, while the epidemiological studies are
underway, mass treatment with sodium thiosulfate can begin.
Special care must betaken to maintain medical records of each individual
containing a record of his/her symptoms, amount of sodium thiosulfate given and
outcome recorded in terms of improvemant/no improvement of symptoms and urinary
thiocyanate excretion if measured. The records system must be modified in the
light of new information emerging. A copy of the essential contents of the record
must be given to each individual.
7.3
Listing of the victims : claims for compensation
A list of all gas victims, each assigned to one of the epidemiological
groupings must be prepared. ’ This is of vital importance for the claims of compen
sation for all the gas victims.
50
Health committees
7.4
The tasks described in 6.2 and 6.3 are huge ones. The Government machi
nery however big cannot accomplish these tasks. Involvement of voluntary groups
working amongst people must become an integral part of the health service structure
if these tasks have to be accomplished properly and in time. This will also ensure
the people's right to know.
A communication strategy on health related issues
7.5
There is need to evolve urgently and immediately a continuing education
strategy for medical personnel and a health education strategy for people exposed to
the toxic gas as part of an overall community health approach to the disaster aftermath.
A multi-pronged approach using different groups of people should be developed.
The aim should be to translate existing knowledge and new knowledge derived from
ongoing research effort into supportive intervention in the lives of the people. This
will not only meet the people's need but also satisfy their right to information about
their own health.
7.5.1
We recommend that all health personnel involved in relief/rehabilitation ser
vices should be continuously educated and kept informed through news letters.
informal group meetings at regular intervals and other means and kept updated with
latest research results and guidelines emerging out of these. For a start the content
of this continuing education for health personnel must include
ICMR guidelines for sodium thiosulfate therapy and the scientific rationale
for this line of treatment.
ii) Disaster induced psycho-social stress and methods of management
counselling and supportive psycho and chemotherapv.
iii) Possible risk to unborn foetus, need for surveillance of pregnant women.
counselling about risk and helping couples with the decision to continue
or to take the option for MTP.
iv) Family planning advice and need for contraception till detoxification is
completed.
v) Role of Respiratory Physiotherapy.
vi) Low cost nutritious recipes for mothers whose babies have had to be weaned
due to effects on lactation.
vii) Caution against overdrugging particularly steroids and antibiotics - their
side effects and rationale for use.
viii) Need for open-minded surveillance of affected population especially highrisk groups to identify emerging chronic and long term effects.
ix) Importance of family based records and improving doctor-patient communi
cation of findings and treatment.
i)
7. 5. 2 We recommend that a dynamic, creative, non-formal health education of the
affected community must also be initiated including open group meetings, posters and
pamphlets with demystified health messages and audio-visuals. The health messa
ges must be built around the life style, culture and the existing socio-economic
situation of the people to have any impact or relevance. These should include
most of the areas outlined in 7.5.1 (above) This is particularly relevant since the
disaster aftermath has led to a socio-economic crisis in the life of the victims.
5,1
APPENDIX I
BHOPAL STUDY PROFORMA
Medico-friends circle, 17-25 March, 1385
SECTION I : INFORMATION REGARDING HOUSEHOLD
1,
House Number
Area/Basti
Head of household
Religion
Type of cooking fuel used
i) Firewood
ii) Cowdung cake
iii) Saw-dust
iv) Coal
2.
3.
4.
5.
6.
Composition of family:
No.
(tick whatever is used)
(v) Kerosene
(vi) LPG Gas
(vii) Other
(specify)
(start with household head - Do not
include members who are dead or
missing since Gag leak)
Age
Name
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Before
Loan
Compensation
52
After
Sex
7. Information regarding family members dead or missing since gas leak (include all deaths after 3.12.1984)
No.
Name
Age
Sex
Date
of
death
or
*
missing
Cause
History Stay
Chronic
Was he/
of
ing
lung
she
serious
in
Occupa Smok disease
present
illness this
ing
prior
tion
here
status
prior
basti
to
during
to
since
3/12/84
3/12/84 when gas leak
1.
2.
3.
4.
5.
-
6.
* Specify whether dead or missing : M = missing
D ~ dead
Name of Investigator
Date
SECTION II : FOR INDIVIDUAL MEMBERS OF HOUSEHOLD
1.
2.
3.
4.
5.
6.
7.
House No.
Area/Basti
Head of household
Name of individual
Staying in this basti
since when (month & year)
.
;
;
;
;
a) Occupation/job/
vocation
(Before gas leak)
b) Since when
(years, months)
c) Has gas leak affected
your job? (specify)
d) What is your present
occupation
...................
;
;
:
....................
Income data ;
Per day
Regular/
irregular
Per month
Before gas leak
After gas leak
8.
Where were you during the
gas leak
9.
Did you use any safety measures? How did you protect yourself? (water
towel, direction of running with respect bo UCIL, doors closed, open, etc.)
10.
Smoking status;
Current
11.
Nonsmoker
Past
Hospitalization for gas effect?
When?
For how long?
54
12.
Chronic illnesses?
Parti
culars
Yes/No
Chronic
illness
other than
respiratory
Chronic respiratory illnesses
Asthma
TB
Bronchi Lung
tis
cancer
Other
(specify)
Duration
13.
Number of episodes of the following in the past 3 months:
Disease
1.
Common cold
2.
Cough
3.
Fever
No. of attacks
Duration
Name of Investigator:--------------------------
:
Date
55
SECTION III : : EXAMINATION DETAILS
1. House No.
2. Area/basti
3. Head of household
4. Name of individual
5. Examination details:
:
:
:
:
Age:
Dry cough
2.
Cough with expectoration
3.
Blood in sputum (haemoptysis)
4.
Breathlessness at rest
5.
Breathlessness on accustomed
exertion
6.
Lacrimation
7.
Fever
8.
Chest pain or tightness
9.
Skin problems (itching,
burning, infection)
10.
Jaundice and its symptoms
11.
Blood in stool or vomil/malena
12.
Bleeding tendency
13.
Blurred vision and photophobia
14.
Headache
15.
Weakness in extremities
16.
Muscie aches
17.
Fatigue
18.
Lossof memory (amnesia) recent
19.
Tingling, numbness
20.
Anorexia
21.
Nausea
22.
Vomiting
23.
Pain in abdomen/burning
24.
Flatulence/heaviness
25.
Impotence
Yes
(Specify)
No.
Symptoms
1.
.......
I
I
1
I
If yes,
duration
6.
General examination:
i. Height
cms
ii. Weight
kgs
iii. Pulse rate
iv. Respiratory rate
7.
Eye examination:
i. Cornea
ii. Acuity of vision
iii. Pupillary reflexes
iv. Lens
Distant vision
R
L
Pin hole
Near vision
N8 — R
8.
9.
10.
11.
Jaundice (sclera)
Cyanosis
Skin examination
Oedema
12.
Respiratory system:
i. shift of mediastinum
ii. air entry
iii. foreign sounds
13.
14.
NR
PR
CVS
CNS
i. Muscle power
ii. Wasting
iii. Plantar
v. Knee
C
S
K
A
15.
Alimentary system:
16.
17.
18.
Anxiety/depression
Diagnosis
Remarks
i.
Liver
ii.
Spleen
iii.
Ascites
Name of investigator:
Date:
57
1:11
Illi I
SECTION IV : LUNG FUNCTION TESTS
1.
House No.
2.
Area/Bastt
3.
Head of household
4.
Name of individual
5.
I) Height :
cms
ii) Weight:
kgs
iii) Surface area:
6.
Lung function:
Recording
FVC
FEV,
1
2
3
Name of Investigator :
:
Date
58
SECTION V : ADDITIONAL PROFORMA FOR WOMEN
1.
House No.
2.
Area/basli
3.
Head of household
4.
Name of individual
5.
Marital status
6.
Menstrual history:
Age:
Past (since when)
Details
(cycle per month)
1.
Occurrence
2.
Dysmenorrhoea
3.
Flow
4.
Peculiarities
5.
Leucorrhoea
6.
Itching
7.
Burning sensation with urination
Doctors seen
7.
Yes/No
a.
Whether pregnant during gas leak?
b.
If yes, exposure during which month of pregnancy?
c.
Outcome of pregnancy:
Yes/No
Remarks (when, how, any peculia
rities?)
Details
1.
Spontaneous abortion
2.
MTP
3.
Still birth
4.
Premature delivery/live
5.
Full term
6.
8,
Present (after
gas leak)
Still pregnant (whether
foetal movements normal)
Lactation
(milk output)
Supressed
(significant)
Name of investigator:
Date:
Normal
SECTION VI ;
PATIENT'S PERCEPTION ABOUT AVAILABLE HEALTH
FACILITIES
1.
Where do you go for medical treatment?
a.
2.
Government dispensary
b.
Private doctor
c.
Self-medication
Can you walk down to the government hospital/dispensary?
How long do you have to wait in the dispensary in the queue for your turn to
come?
a.
examination
b.
getting medicines
4.
How many days of medicines are given at a time?
5.
a.
Do you get all the medicines from the government dispensary? Yes/No
b.
If not, do you have to buy any medicines from the market?
A few medicines/all the medicines
6.
Were the medicines useful?
7.
How was the behaviour of the government doctor?
a.
8.
(specify)
b.
enquiry
c.
examination
Were you referred to the hospital anytime during this illness?
advice
Yes/No
If yes, how was the experience at the hospital?
9.
Did you go to a private doctor? Yes/No
If yes, did he tell you anything different about your illness?
How much did you spend for private treatment?
a.
10.
b.
Doctor's fees:
Drugs
Has any doctor told you so far anything about the nature of your disease or has
given any advice?
Yes/No
It yes, what was the advice?
60
APPENDIX II
An English translation of a Handout in Hindi distributed among the
people of the bastis selected for the study.
To our brothers and sisters affected by the gas leak tragedy in Bhopal.
\Ne are a team of socially-conscious doctors and health workers belonging
to a group called the medico friend circle. As an expression of our concern for you
all we have come to try and help you in our own small way. We have come to
assess and find out whether there are any ways in which the medical relief and
advice that is being given to you can be improved.
Soon after the disaster some of our members came to Bhopal and were
involved in relief work. They also made suggestions to the government about
medical relief work based on their own experiences. These suggestions are also
available in Hindi. We have now come to investigate in detail what are the
health problems you still have three months after the disaster and to try and find
out what can be done for them. From these investigations and from an assessment
of the treatment services being given to you, we hope to make suggestions to the
government and to all those involved in health work of improvements that can be
made.
All of you have been affected by the gas leak. To find out the health
effects of this exposure it is not necessary to examine everyone of you. To find
out the main effects on your health it would be adequate to do a complete survey
on every tenth or twentieth house in the basti. From this survey it will become
evident as to how many of you are suffering from the different illnesses caused by
the gas exposure.
Whatever we find out on examinaiion of each of you will be written out
concisely in a note, a copy of which will be given to you. Apart from this we shall
also send you a copy of whatever other general recommendations we have about
improving your health status.
We shall explain to you what has been the effect of the gas on each and
every part of your body and what you should do to tackle this situation. Which
drugs are useful ? Which drugs are not useful ?
With your cooperation we shall try to decide whether there will be any
improvement in your lungs by the use of respiratory exercises. We shall teach you
these respiratory exercises. These exercises will also help to prevent further damage
to your lungs.
Brothersand Sisters - We are not working for government or any other
official agency. We have come here through the support of collections made from
many others who have contributed as an expression of their concern for you. We
are doing what we can through this low-cost venture and have come here volun
tarily. We are confident that you will give us your whole-hearted cooperation in
this work.
Yours
Bhopal Study Team,
medico friend circle
6f-"
APPENDIX 111
INDIAN COUNCIL OF MEDICAL RESEARCH
MINUTES OF THE MEETING ON THIOSULPHATE THERAPY IN MIC
EXPOSED POPULATION HELD ON 14TH FEBRUARY, 1985 AT HEAD
QUARTERS NEW DELHI.
1.0
Participants
Dr. J.S. Guleria
Dr. N.P. Mishra
Dr. P.S. Narayanan
Dr. P.N. Pande
Dr. K. Ramechandian
Dr. A. Rameiah
Dr. H.H. Siddiqui
ICMR Representatives
Dr. S. Sriramachari (Chairman)
Dr. C.R. Ramachandran
Dr. A.K. Prabhakar (Rapporteur)
Dr. R. Parhee
(Rapporteur)
2.0 The Chairman, Dr. S. Sriramachari, Additional Director General, ICMR, wel
comed the members on behalf of Prof. V. Ramalingaswami, Director-General, and on
his own. He explained that the purpose of the meeting was to discuss the different
aspects of use of Sodium Thio Sulphate (NTS) in MIC exposed population. He
also reiterated that the preliminary results of the double blind study conducted at
the 30 bedded community hospital at Bhopal had indicated the presence of
"cyanogen pool" in the exposed persons. He pointed out the several physiological
parameters and optimal time for urinary excretion of thiocyanate had since been
worked out and the method of monitoring could thus be standardised. He informed
that since the utility of NTS had been established, the criteria of selection and con
traindications, if any of cases, details of dosage, duration of administration should be
urgently worked out. Apart from the continuation of the Controlled Studies with
Thiosulphate Therapy, the questions relating to the extension of the therapeutic
measures to all patients with clinical symptoms should be decided.
On the basis of the double-blind trial conducted by Dr. Narayanan and
Dr. A. Ramaiah at Bhopal Dr. Guleria and other members of the group emphasised
that Sodium Thio Sulphate should not be withheld from affected victims and should
be made available to all patients with clinical symptoms. However, he cautioned
that strict criteria for use need to be laid down. This should include specific
criteria for selection of patients based on symptoms and severity of
exposure; as well as guidelines for maintenance of records; investigations; moni
toring for adverse reactions; and clinical and laboratory investigative follow up
paramteers. In addition, contraindication for use should be clearly spelled out.
He also mentioned that the final decision for use and/or stoppage of treatment
with Sodium Thiosulphate should be left to the judgement of the clinician.
Dr. N.P. Mishra, presented, in brief, his earlier as well as recent observations
on the use of NTS at Gandhi Medical Coll age, Bhopal. He mentioned that he had
observed adverse reactions in 2 persons among 200 individuals who had received one
injection of NTS. Severe gastro intestinal symptoms of vomiting and nausea, with
fever was observed within 10-20 minutes of injection. Dr. Mishra stressed that this
drug should be administered to hospitalised patients. In this connection. Dr. P.S.
Narayanan presented his experience with 322 injections of NTS administered to 76
patients. The only mild adverse reaction observed in 2 patients was feverishness
experienced several hours after receiving the injection which was relieved with
aspirin in one case. In view of this, the members of the group felt that NTS in
jections should be given to patients at hospitals, clinics and dispensaries under
62
medical supervision, with strict monitoring for adverse reactions. As it may not be
possible to admit all patients while they are under therapy, it was considered advis
able to keep the patients under medical observation for at least one hour after admi
nistering the injection.
Dr. Mishra informed that the predominant symptoms observed in patients
suffering from effects of MIC relate to the respiratory, gastro intestinal and neuro
muscular systems. In addition, patients with psychological symptoms are seen.
Dr. Narayanan emphasised that some patients present themselves with relapse or
recurrence of symptoms after having obtained almost complete relief from the acute
phase.
After considerable discussion, it was agreed that NTS injections should be
given to all patients with the following criteria;
1.
Patients suffering from acute and/or chronic symptoms relating to the respira
tory, gastrointestinal, and neuromuscular symptoms. The symptoms should be
causally related to possible exposure to MIC gas;
2.
Patients presenting with recurrence of symptoms after having obtained some
measure of relief from the acute phase;
3.
Recorded cases of acute pulmonary oedema and/or coma, that occured imme
diately following the episode, and who are currently symptomatic;
4.
Patients who have a history of death in their family, and also those who reside
within 2 km of the factory in the direction of the wind on the day of the tragedy
or in the vicinity of the factory.
It was emphasised that baseline clinical and laboratory data should be
obtained for all recorded cases. With regard to old cases, where records may
be available fresh baseline data should be obtained.
Detailed discussion was held regarding dose and duration of treatment. It is
generally understood that in acute or severe cyanide poisoning, 1 2.5 to 25 gm of NTS
can be administered as a single dose intravenously. However in the preliminary
trials, clinical improvement had been observed with I gm of NTS given as a single
dose, or in 3 successive doses. Giving allowance for the lime lag in the build up of
the cyanogen pool after its first depletion, it was felt that the subsequent injections
could be given after larger intervals. It was finally suggested that two regimens on
administration of NTS should be followed, viz:A.
Day
Day
1
2 to 6
-
B.
Day
Day
Day
1
3
5
- 1
- 1
- 1
2
1
grn
gm
NTS,
NTS,
gm NTS,
gm NTS,
gm NTS,
intravenous
- do -
- do - do - do -
Children should receive lower do'as appropriate to the body weight. Urine
levels of thiocyanate should be monitored initially prior to the injection, and then
daily, 3 hours after administration of the injection. Whenever possible, 24 hour
urine output should be monitored. Mixture Alkaline Diuretic with sodium chloride
33
should be administered to the patient to facilitate excreNon of thio y
’ hes or
duration of therapy. Therapy may be terminated if thiocyanate excre
should
remains at normal levels. The members of the group agreed that „i?,ifiriencj
not be administered routinely to pregnant women. The decision for us
ovprrise
upon the severity of the symptoms. Pulse rate, respiratory rate, response t
'
and level of physical activity should be recorded during therapy and afterwar
to evaluate the progress of improvement. Adverse reactions, if any, snou ~
._,fR
to the notice of the local senior physicians and health authorities including tn
It was also recommended that urine estimation of sodium thiocyanate snould
be standardised at all centres undertaking this investigation. For this PurP° ®'
Dr.A. Ramaiah was requested to help in standardising the procedure atthelab r tory, of the Medico Legal Institute at Gandhi Medical College, Bhopal. For quality
control periodical cross checking between the two laboratories should be worked oui.
Finally, it was recommended that Dr. A. Ramaiah should prepare a detailed
protocol on the laboratory monitoring of thiosulphate therapy in MIC affected
population. This would be circulated to all members of the group at the earliest.
All the participants including Dr. N. P. Mishra and Dr. P. S. Narayanan
agreed to the above recommendations. It was decided that the above information
should be conveyed to the concerned health authority in Bhopal as well as Min. of
Health so as to ensure adequacy of supply of NTS. The next meeting of the group
would be held after 3-4 weeks to review the progress of the studies.
The meeting ended with a vote of thanks to the chair.
****
6'4
APPENDIX IV
STUDY OF MEDICAL RELIEF TO GAS VICTIMS
Some members of the team visited various medical centres near JP Nagar—
the basti selected for our study. These included:
i)
a government polyclinic
ii)
the DIG Hospital—a 30 bedded hospital specially established for care of
disaster victims
iii)
three non-governmental private clinics in the adjoining area.
From these visits and interviews with the doctors, some understanding of
the dynamics of medical relief services emerged. The points specifically noted were
staff pattern, timing, availability of drugs, standard guidelines if any and doctors'
perceptions of the health problems etc.
Government Services
i)
The polyclinic was kept open 24 hours of the day. It was an ordinary
dispensary and did not consist of specialists from different branches as the
name suggests.
ii)
The DIG hospital was, however, staffed by specialists in medicine,
obstetrics, ophthalmology, paediatrics, EMT and surgery. It had 14 doctors
and a smaller number of paramedics. The out-patients department
was open from 9.00 a.m. to 1.00 p.m. and for one hour in the evenings.
About 600-800 patients were seen per day, resulting in long queues.
There seemed to be no problem of drugs - these being available in adequate
range and quantity.
There were no standard guidelines for investigating, diagnosing and treating
gas victims. The doctors used their own lines of treatment. Most of the
doctors interviewed had no definite knowledge about the role of sodium
thiosulfate nor had seriously reviewed the problem of danger to the foetus
and the option of MTP for pregnant women. There were no definite criteria
for referring patients to bigger hospitals. Facilities for routine biochemical
and microscopic investigations were available.
The DIG Hospital was also being used for the double blind clinical trial of
ICMR on the rationale/ efficacy of sodium thiosulfate. It had facilities for
blood gas analysis and measurement of urinary thiocyanate levels by
spectrophotometry. These were being carried out on all patients being
selected for a course of sodium thiosulfate injections.
iii)
Our interviews with doctors about the range of symptomatology and clinical
syndromes tney were seeing each day in the OPD'S revealed that even
though they thought that many parents were ill, they felt that many were
exaggerating and implicating the gas in all types of complaints. The
quality of reporting/recording these symptoms and findings of examination
were poor and would therefore, not be of much use in any type of
retrospective research studies.
65
On the whole though a medical service had been established and medical
teams were available to the gas disaster victims, we felt that these had not been
adequately oriented to meet the demands of the situation; there were no standardised
guidelines for investigation or management; and no continuing education or on
going communication of research and other information to the treating doctors to
support rational management. The doctors' attitudes were somewhat biased
against the phenomena of multisystemic symptomatology with many of them
perceiving this as malingering or compensation neurosis.
By and large due to inadequate planning the dispensaries were understaffed
and the doctors overworked. This was particularly true of the DIG hospital.
Non-government clinics
Three such centres were available near the basti. One of them was a free
clinic specially set up after the gas disaster with the help of a Muslim Charitable
group. The therapist was using mainly homeopathic medicines but also had
ayurvedic and allopathic medicines in his armamentarium. He used these 'depen
ding on the case’. He made tall claims of cure for gas related diseases as well as
other problems. Our intensive but informal talks with the basti people for three
days did not reveal any cases of substantial relief with his treatment schedules.
Another general practitioner had a clinic about 1 km. from the basti. He
was not an MBBS doctor but his clinic was overcrowded. He seemed courteous
and soft spoken to his patients but hardly examined anybody in detail. Injections,
antibiotics and prednisolone were liberally used. In his discussion with us he shared
that antibiotics, antacids, bronchodilators and steroids had been used by him to treat
the patients without much result. He did not know about the details of the use of
Inj. sodium thiosulfate or the medical controversy about it. However, he thought
that the advice given by a forensic expert (doctor of the dead as he described him)
regarding cyanide poisoning should be taken with 'a pinch of salt’. He also felt
that some of his patients who had been given injection sodium thiosulfate had not
benefited. He also shared with us that he himself had been exposed to the gas and
suffers from symptoms even now. Recently he had started taking an ayurvedic
preparation with 'gratifying results'.
The third practitioner was a lady doctor working near the basti. She had
closed down her clinic after the disaster for two months and could not tell us much.
She had used antacids, cough mixture and antibiotics without much results. Most
patients, she said, did not come back the next day in spite of their continued illness
since "they were too poor to pay fees every day". When asked specifically about
the problems of women, she felt that there had been an increased incidence of
gynaecological problems but since she did not undertake gynaecological exami
nations, she could not give further details. Most of these cases were referred to her
sister who was a trained gynaecologist. None of these practitioners had received
any communication or guidelines from the government health service doctors or
medical college and there was no coordination between them and the government
polyclinics or dispensaries.
66
APPENDIX V
PEOPLE’S PERCEPTION ABOUT AVAILABLE MEDICAL FACILITIES
Forty out of the sixty families selected in our study of JP Nagar were
included in the survey of people's perceptions of the available medical services.
One person from each of the families was interviewed and the questions asked are
given in Appendix I (study proforma, Section 6). The main findings of this survey
were :
(i) Choice of treatment : Seventy percent had gone to government dispen
saries and 82.5 percent had gone to private practitioners and only one was
on self-medication. Ten persons had not gone to any government dispen
sary and five persons had not gone to any private practitioner. Many had
decided to go to private practitioners because they were dissatisfied with
the experience in the government hospitals.
The distances were not too much and most people said they could walk
down to the government hospital or dispensaries
(ii)
Time at dispensary/hospital : Six persons said they had to wait 1-2
hours for their turn in the hospital, 8 persons - 2-4 hours and 13 persons
more than 4 hours. The delays were probably due to these service units
being understaffed and to overcrowded.
(iii)
Medication : Medicines were given mostly for 1-3 days in 70 percent of
the cases whereas 6 respondents said they had received medication for more
than three days. (This is inclusive of the practice in the private clinics).
Medicines were received free in the government dispensary by 70 percent of
the respondents. 5 persons mentioned they had to buy a few medicines
from the market.
Twenty five percent had no relief from the medication. 52.5 percent got
some symptomatic relief while one respondent mentioned that he got
substantial relief.
Interestingly the only therapy that was being given was drugs which were
being prescribed faithfully by the doctors in large doses and repeatedly with
no thought of over-medication. Many patients showed us platefuls of
coloured capsules and tablets which they had received from different
doctors in the same centres and in different centres. These were not very
effective but were continuously being prescribed in a sort of routine condi
tioned reflexl
(iv)
Forty percent said that the
doctors hardly made any enquiries, whereas 42. 5% mentioned that the
enquiries were sympathetic. 15 percent said that no examinations were
done, 37. 5% had cursory examinations and 25 percent had proper
physical examinations. 75 percent were given no advice other than
instructions for medication. One received some reassurance and only
one could recall being given some dietary advice.
(v)
Referrals to Hospital : Nineteen respondents were referred to hospitals
during the last few weeks. 9 felt the same after hospitalisation, 5 felt
worse and 3 got better.
67
Attitude of doctors and quality of care :
(vi)
The experience with private
practitioners, whom over 82.5 percent had consulted/ was not very
different except that the doctor-patient relationship was somewhat more
satisfying. All of them got a medication but no other advice.
Experience with private practitioners :
Ten respondents had spent upto Rs. 100.00 on treatment, 10 between
Rs. 100. 00 and Rs. 500.00 and 13 had spent more than Rs.500.00. No
doubt this was adding to the economic burden of the families and would
be reflected in the loans taken by many families. One family had spent
more than Rs. 3500/- on treatment.
(vii)
Health education : Thirty seven of forty respondents had been given no
inkling about the nature of the illness or any other supportive advise, e.g.
no smoking for those with lung complaints, special advise to women
who were pregnant, breathing exercises, psychological reassurance or
counselling. One mentioned that he had been told 'it was a recurring
illness'.
68
REFERENCES
1.
Bang, Abhay. et at
Medical Relief and Research in Bhooal - the realities and recommendations
medico friend circle report Feb. 1985
2.
Dagani Ron 1985
Data on MIC's toxicity are scant, leave much to be learned
Bhopal Report, C & EN Feb. 11, 1985.
3.
Anon
Methyl Isocyanate, Toxicology profile
4.
Rye, A.W. ( 1983 )
Human responses to Isocyanate exposure
J of Occup. Med, Vol. 15, No.3,March 1983
5.
NIOSH ( 1979 )
A recommended standard for occupational exposure to Diisocyanates.
US Dept, of Health Education & Welfare Publication No. 78 - 125, April 1979
6
Axford, A.T. et al ( 1976 )
Accidental exposure to Isocyanate fumes in a group of firemen
British J. of Indust Med. 1976. 33, 65 - 71
7.
Procter. N. H. and Hughes. J. P. (Ed)
Methyl Isocyanate
From Chemical Hazards of the work place J.B. Lippencote, Philadelphia, 1978
8.
Praful Bidwai ( 1985 )
Bhopal's unending tragedy - Times of India, 25th - 27th March 1985.
9.
Eklavya ( 1985 )
Bhopal City of Death A people's views of death - their right to know and live
Eklavya report, Bhopal.
10.
Bouhuys, A (1974)
Breathing—physiology. Environment and Lung Disease
Grune L. Stratton, N Y. London 1974.
11.
Anderson, W.M., Letter to the Peoples Research Institute and Environment,
Japan dated January 3, 1985, Consumer Interpol Memo No. 2/85(5),
19 February, 1985.
12.
Diamond, Stuart
New Strait Times, 15 February 1985
13.
Petersdrof, Robert K. et al (Ed.)
Harrison's Principles of Internal Medicine,
Mc-Graw-Hill, New York, tenth edition,
1983.
I
,*
14.
I.C.M.R. (1935)
Health effects of exposure to toxic gas at Bhopal—an update on I.C.M.R.
sponsored researches, 10th March 1985
69
15.
Sriramachari. S. (1985)
Pathology and clinical toxicology of the Bhopal disaster.
C.M.R. handout, New Delhi.
l.
16.
l.C.M.R. (1985)
Thiosulfate therapy in MIC exposed
Minutes of the meeting in l.C.M.R., 14th Feb. 1985
17.
Daunderer. M. (1985)
Methyl Isocyanate
Mimeograph
18.
l.C.M.R. (1985)
The Bhopal disaster - current status (the first nine days) and programme of
research.-
1 9.
Cduv, Florey and Leeder, S.R. (1982)
Methods for cohort studies of chronic Air-flow Limitation.
W.H.O. Geneva.
20.
Fera, Ivan
Will Justice be done? Illustrated Weekly of India, 31st March 1985
21.
Gopalakrishnan, K & Ganguly, T. (1984)
The way the killer works from Gassed-Bhopal's Night of Horror - Cover Story
of The Week - 16-22nd Dec. 1984 Malayala Manorama Publication.
22.
Mac Mohan B and Pugh T.F.
Epidemiology, Principles and Methods
Boston 1970
ADDITIONAL READING MATERIAL
1.
I.C.M.R. (1985)
Projectization of I.C.M.R. supported research.
2.
Ramalingaswami, V. (1985)
Medical Research Problems in Bhopal
I.C.M.R. handout, New Delhi.
3.
I.C.M.R. (1985)
Medical Research on Bhopal Gas Tragedy
Press release - 31 st Jan 1985
4.
I.C.M.R. ibid, press release, 12th Feb. 1985
5.
I.C.M.R. ibid, press release, 27th Feb. 1985
6.
I.C.M.R. (1985)
Guidelines for treatment of Bhopal Gas Victims
Press release, 4th April 1985
Non-Governmental Sources
7.
Delhi Science Forum (1985)
Bhopal Gas Tragedy - a report
8.
Bang, Abhay (1985)
Learning from the relief work - a report from Bhopal
medico friend circle bulletin - 109, Jan. 1985
9.
mfc (1985)
Medical Research in Bhopal - are we forgetting the people.
medico friend circle bulletin - 112, April 1985
10.
Bang, Rani & Sadgopal, Mira (1985)
Effects of the Bhopal disaster on women's health - an epidemic of gynaecolo
gical diseases- (Part - I) Mimeograph
11.
Bang, Rani (1 985)
Effects of the Bhopal disaster on women's health - an epidemic of gynaecolo
gical diseases (Part II) Mimeograph
12.
mfc (1985)
The mfc Bhopal Study - a press release
medico friend circle bulletin - 112, April 1985
13.
Banerji, D & Lakhan Singh
Bhopal Gas Tragedy - an epidemiological and sociological study
J N U News, Apri I 1 985
14.
Citizens Committee for Relief and Rehabilitation (1985)
Medical survey on Bhopal Gas victims betweer.104 to 109 days after exposure
to MIC gas
- report of a joint study in collaboration with Voluntary Health Association of
India, New Delhi.
71
MIC and Isocyanates
15.
Singh, Sarabjeet (1985)
Chemistry, fate, pharmacology and effects of methyl isocyanate.
Drug information desk handout.
Department of pharmacology, Gandhi Medical College, Bhopal.
16.
Patel Chest Institute (1985)
Adverse effects of MIC and related compounds (Phosgene, Hydrocyanic acid,
Carbaryl, Carbon monoxide) Mimeograph
17.
Cohen, S & Oppenheimer, E.
Biological formation and reaction of Cyanates, Chapter 20.
18.
Worthy. W. (1985)
Methyl Isocyanate : The Cnemistry of a Hazard
C & EN,11th Feb. 1985
19.
Lancet (1966)
Hazards of Diisocyanates
Editorial, Jan 1, 1966
20.
Lancet (1984)
Calamity at Bhopal
Editorial, 15th Dec. 1984
21.
Kimmerle, G & Eben A. (1964)
Toxicity of Methyl Isocyanate and its quantitative determination in the air.
Archiv Fuer Toxicologic Vol 20 p. 235-241, 1964 (German)
22.
Pozzani, U.C. & Kinkead, E.R. (1966)
Animal and Human response to methyl isocyanate
Presented to American Indust Hygiene Assoc. May 1966
23.
Smyth, H et al,
Range Finding Toxicity data - List 7
American Indust Hygiene Assoc. Journal 30 Sept - Oct. 1969 p. 470-76
24.
Melon Institute (1970)
Methyl isocyanate - acute inhalation toxicity, human
response to low concentration, guinea pig sensitization and
cross sensitization to other isocyanates special report—33-19
Chemical Hygiene fellowship - Carnegie Melon University
25.
Melon Institute (1963)
Range finding tests on Methyl Isocyanate
Confidential report 26-75
26.
Longley, E.O. (1964)
Methyl - di-isocyanate - a respiratory hazard
Archives of Environ Health, Vol. 8. p. 898, 1964
Australia.
72
—
27.
Le Quesne, P.M. et al (1976)
Neurological complications after a single severe
exposure to T.D.I.
British' J. of Indust,Med 1976 33, 72-78
28.
Bernstein, L. (1982)
Isocyanate - induced pulmonary diseases—a current perspective
J. Allergy Clin. Immunol. July 1982, Vol. 70
No- 1, p. 24-31
29.
Dewair, M.A. & Baur X.J. (1982)
Studies on antigens useful for detection of Ig E
antibodies in isocyanate sensitised workers.
J. Clin Chem Clin Biochem. Vol. 20, 1982, p. 337 - 340
30.
Baur X. et al (1984)
Acute airway obstruction followed by hyper-sensitivity
pneumonitis in isocyanate workers (MDI)
Journal of Occup. Med. Vol. 26, No. 4 April 1984
31.
Munn. A. (1965)
Hazards of Isocyanates
Ann. Occup Hyg 8 : 163, 1965
32.
Brooks S.M. (1977)
Bronchial Asthma of occupational origin
Scand. J. Work Environ Health, 3:53, 1977
33.
Union Carbide (1976)
Methyl Isocyanate
Product Information manual.
34.
Union Carbide (1985)
Telegram from Union Carbide Corporation, USA
on treatment of MIC pulmonary complications.
35.
Union Carbide (1985)
Bhopal Methyl Isocyanate - Investigation report
UCC, USA.
36.
Union Carbide (1982)
Operation Safety Survey of CO/MIC/Sevin units of
Union Carbide India Ltd. Bhopal Plant
May 1982 Report, UCC, USA«.
37.
OSHA, (1978)
Occupational Health Guidelines for MIC
OSHA, US Dept of Labour.
Others
Miscellaneous
38.
Doherty, P.A. et al (1982)
Congenital Malformations induced by infusion of
Sodium Cyanide in the Golden Hamster
Toxicol Appl. Pharmacol 64, 456-464
■ 73
39.
Loeser, E (1983)
Long term toxicity and carcinogenecity studies with 2,4/2.6
TDI (80/20) in Rats and Mice
Toxicology Letters 15 (1933) 71-81, Eiserier Biomedical Press
40.
Ministry of Health, Mozambique (1984)
Mantakassa : an epidemic of spastic paraparesis associated
with chronic cyanide intoxication in a cassava staple area
1. Epidemiology and clinical and laboratory findings in patients
2.
Nutritional factors and hydrocyanic acid content of
cassava products
Bulletin of W.H.O. 62 (3) 477-492 (1984)
41.
Durham, W.F.
Toxicology
From Dangerous properties of Industrial materials
Ed. Van Nostrand and Reinhold
42.
Bhar, B (1985)
Bhopal Tragedy
Annual conference souvenir - 1985
of Indian Associaton of Occupational Health.
43.
Ramachandran R. (1985)
Bhopal elusive answers
Frontline, Jan. 26-Feb. 8, 1985
44.
Eklavya (1985)
Bhopal— the state of the environment
A preliminary report on the 100th day after the gas disaster
Eklavya. Bhopal.
45.
Eklavya (1985)
Bhopal gas tragedy—Questions of a people's science
Exhibition booklet (Hindi)
Eklavya, Bhopal.
46.
Goswami, H.K. et al (1984)
Genetic assessment of Union Carbide Gas tragedy in Bhopal.
I—Effects on Somatic chromosomes and hemoglobin
Bionature, Vol. 4, No. 2, Dscember 1984.
47.
Varma. V.S. (1985)
Review of Literature on Cyanide Poisoning and treatment
Mimeograph
*
48.
t
Swamy B. (1985)
Antidote to MIC poisoning
Hitavada, 3rd May 1985
74
49.
Kinston, W. and Rosser R. (1974)
Disaster : Effects on Mental and Physical State
Journal of Psychosom. Research. 18 : 437
50.
Cobb. S and Lindemann. E (1943)
Neuropsychiatric Observations during the coconut grove fire
Am. Surgery. 117:814
51.
Lindemann. E (1944)
Symptomatology and management of acute grief
Am. J. Psychiatry 101 : 141
52.
Lifton. R and Olson. E (1976)
The human meaning of total disaster
Psychiatry 39 : 1.
'
53.
Titchner. J.L. and Kapp F.T. (1976)
Family and character change at Buffalo creek
Am. J. Psychiatry 133 : 295
54.
Stern. G. (1976)
From chaos to responsibility
Am. J. Psychiatry. 133 : 300
55.
Erikson. K. (1976)
Loss of Community at Buffalo creek
Am. J, Psychiatry 1 33 : 302
56.
Newman. C.J. (1976)
Children of disaster : Clinical Observation at Buffalo creek
Am. J. Psychiatry 133 : 306
57.
Rangell, L. (1976)
Discussion of the Buffalo Creek Disaster : The
course of Psychic trauma
Am. J. Psychiatry 133 : 313
58.
Murthy, R.S. et al (1985)
Mental Health Care Manual for Medical Officers. - Bhopal, April 1985
NIMHANS, Bangalore.
59.
ICMR (1985>
Minutes of Third meeting of the working group
on thiosulphate therapy of the MIC exposed population
held on 4th April 1985 at ICMR headquarters.
60.
ICMR (1985)
Press release of 5th May 1985 on Review meeting of
ICMR projects held in Bhopal on 3rd / 4th May 1985
T>
61.
Directorate of Information and Publicity, M.P.
Govt. (1985) Important toxicological findings
regarding MIC exposure. Review meeting of ICMR projects
Khabar, 5th May 1985
75
62.
Ibid
Report on Thiocyanate level in Bhopal water
News Item - 17th May 1985
63.
Narayan, T. 1 985
Personal communication from Bhopal - 25th May 1985
64.
Peters, C.G. et al (1985)
Acute cyanide poisoning.
Vol. 37, p. 582 - 586
Anaesthesia.
1982,
65.
Bowler, R E. (1944)
The Determination of Thiocyanate in Blood serum
Biochem : J 38 1944 p. 385 - 388
66.
Densen, P.M. et al (1967)
A chemical test for smoking exposure
Arch. Environ Health - Vol. 14, June 1967
67.
Waldholz. M. (1985)
Bhopal Death Toll, survivor problems still being debated.
The Wall Steert Journal, Thursday, March 21, 1985.
Available from mfc office
326 V Main I Block
Koramangala
Bangalore 560034
1.
2.
3.
4.
Medical Relief and Research in Bhopal-the realities and recommendations (Feb 1985)
Rs. 2.00
An Epidemic of Gynaecological Diseases:
effects of Bhopal disaster on Women's Health
--Rani Bang
Rs. 2.00
Review of available literature on MIC
and details of ICMR and other studies
Rs .2.0C
Rationale for the use of sodium
thiosulphate as an antidote in the
treatment of the victims of the Bhopal
gas disaster - a review
‘
Rs. 2.00
5.
The Bhopal Disaster--mfc bulletin 109
Rs. 2.00
6.
Medical Research in Bhopal--are we
forgetting the people--mrc bulletin 112
Rs. 2.00
7.
The Challenge of Bhopal—mfc bulletin 114
Rs. 2.00
8.
The need fora Communication Strategy
Rs. 2.00
76
medico friend circle
The medico friend circle (mfc) is a circle of friends with medicai/nonmedical backgrounds who share the common conviction that the present system of
health services and medical education is lopsided in the interest of the privileged
few and must be 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 education, demystification of medical science
and a commitment to the guidance of medical interventions by peoples' needsand
not commercial interests.
mfc offers a forum for dlalogue/debate, sharing of experience and
experiments with the aim of realising the goals outlined above, and for taking up
issues of common concern for action.
uriMf*
For further details regarding mfc BHOPAL STUDY, contact-Ashvin Patel
ARCH
21 Nirman Society
Alkapuri
Vadodara 390005
OR
Anil Patel
ARCH
Mangrol (At & PO)
Via Rajpipla
Dist. Bharuch
Gujarat 393150
©
Distorted Lives
Women’s Reproductive Health and Bhopal Disaster
medico friend circle
October 1990
Distorted Lives
Women s Reproductive Health and Bhopal Disaster
A community based epidemiological study of the effect of the
toxic gases on the menstrual pattern and pregnancy outcomes in
women affected by the Bhopal gas leak disaster
MEDICO FRIEND CIRCLE
(Regd. Off) 160, LIC Quarters
University Road, Pune 411 015
October
1990.
Contribution
Rs. io/-
TBIS STUDY IS DEDICATED TO THE GAS - AFFECTED WOMEN OF BHOPAL
WHOSE SPECIAL SUFFERINGS HAVE BEEN NEGLECTED AND WHO
CONTINUE TO SUFFER SILENTLY.
CONTENTS
1.
Acknowledgements
2.
Preface
3.
The Study T earn
4.
Background
5.
Chapt er
I
:
Survey Design & Methodology
4
6.
Chapt er
II
:
Observations & Results
18
7.
Chapt er
III
:
Discussion
29
8.
Annexure
I
:
Sample from the Indigenous
1
11
iv
1
Calendar
33
prepared for the survey
9.
Annexure
II
:
34
Study Proforma
(Translated from Hindi)
10.
Annexure
III
:
Effects of the toxic gases on
the
41
health of the women
(clinic based data)
11.
Annexure
IV
12.
Annexure
V
:
Problems in Deliveries post gas leak
44
A critique of the ICMR study on
46
pregnancy
outcomes and
Health
women
of
Reproductive
exposed
to
toxic
gases In Bhopal.
51
13.
References.
acknowledgement
The
*
gas affected women of Bhopal who rendered total co
and generous hospitality to the survey team.
operation
f
Mr.R.Dayal of Central Stores,
Jagori
Workers
Delhi;
of
Bhopal;
Action India,
Delhi;
Jaimlni
Dharamsala,
Bhopal;
Doctors from Jaimlni Nuraing Home and Bhopal Eye Hospital,
Bhopal;
Ekalavya, Bhopal;
Education and Communication,
*
Ram Badan Dubey,
SEWA, Bhopal;
and
Centre for
Delhi.
Chella Rajan and Arvind Rajgopal for help
with library Research.
*
Devan, Anita, Ashok and Sunitha for typing the manuscript.
*
Special
Delhi,
thanks
Murthy
of
AllMS,
thesis "A study on pregancy wastage in
whose
community”
to Dr.G.V.Sathyanaraya
was
of
great
help to
us
in
rural
designing
the
proforma.
I
*
Jana Vigyan Samiti,
Kanpur and numerous
other
gave donations for the Bhopal work
people
who
Friend
Circle.
1
concerned
of
Medico
PREFACE
The
Bhopal gas tragedy,
the blggeat and the worst man-made
dlaaster in the hlatory of human kind,
toll.
complete
Thouaanda
health
incapacitating
It
leak.
local
2nd
December,
skin,
eyes
chemical
ita
are atlll going through the hell
of
problems created by
this
1984 produced only local irritant effects on
and the lungs;
cannot
that MIC (methyl iso cyanate)
systemic
produce
effects.
There
the
as
has
the
gas
been
gas
exposed women and significantly increased the
It shows that
the
leak considerably altered the menstrual pattern of
spontaneous abortions and still births.
forward
affected
spontaneous
incidence
of
This study has not only
the neglected aspect of the health problems
people,
abortions
but has used the
-
sensitive
to assess damage to the
other less sensitive indicators used
of
indicator
pregnancies,
in
the
ICMR
compared
to
studies.
The increase in spontaneous abortions also point out
the possible mutagenic effect of the gas leak.
11
a
The present study
is one more significant addition to this evidence.
gaa
some
as
experts that the gases that leaked on the night of
mounting evidence to give a lie to this claim.
brought
gas
poisonous
argued by Union Carbide circle as well
waa
medical
has not as yet taken
to
It
must
be
made
clear
that
this
reproductive health of gas-affected women
suffer
also
from
covers
study
in Bhopal
many other health problems
only
the
that
they
and
related
other
to
systems of their bodies.
It
is
hoped
that serious
implication of
this
study
would
be
in
the
appreciated.
Ue
have
no words to apologise for
the
inordinate delay
publication of this study.
Anil
iilgaokar
Convenor
Medico
iii
Friend Circle
STUDY
THE
Chi ef
TEAM
MFC (Delhi)
C.Sathyanala,
Invea1i gator and Coordinator:
Survey Design:
Anil
Patel
(Mangrol),
Imrana Qadeer
(Delhi)
Survey T earn;
Devi
Kr1 pa,
Gyanvati ,
Mary Teresa,
Parvati,
Rama ,
Rani ,
Sumitra,
Rukmani,
(All
Sushila,
Runu,
Chaya,
(Rajasthan),
Arti
Vijayendra
and
Dhanjira and Umraj
(Hoshangabad),
Devinder,
and
Preeti
Chayanlka
Sudha,
Bharati,
Shanta,
Snehlata
Delhi),
Shashi,
Urtnila,
Vidya,
Halllka,
Jyotika,
from
Shanti,
Reshma,
Raj
Nirmala
(Sevapuri),
(Bombay),
Hina
(Baroda).
Clinic Tearn:
Rani
Bang
(Gadchiroli),
Sanjeev Kulkarni
Coding and Analys i s:
Bharati,
(Bankheri),
(Bangalore).
Farida and Snehlata (Delhi),
(Hoshangabad),
Tripti
Mira Sadgopal
and
Anil
Daxa
(Gadchirol1),
(Ahmedabad),
Patel,
Ambarish,
(Mangrol),
Abhay
and
Leela
Ashok
Thelma and Ravi
Ashvln (Baroda),
iv
Anant
Arti
(Pune).
(Bangalore)-,
Most
of
the
above participants
one
represented
of
the
following orgnlaationa :
Medico Friend Circle,
India,
Jagori,
(All
Mahila
Mukti
Morcha
(Sevapurl),
Further details of
C.
F
(GF)
20
Sahiyar
Delhi),
Narl
this study are available with
Jungpura Extension,
-
from
(Baroda).
SATHYAMALA
NEU DELHI
Sabla Sang,
and
Vlrodhl Manch (Bombay),
DR.
(Kangrol),
Saheli
Ankur,
(Rajasthan),
ARCH
110 014.
Action
Prayas
Atyachar
BACKGROUND
In
February
Bhopal,
1985,
in
a fact finding team of four doctors observed that
women
diminished
fetal
from abortions,
suffered
have
three months after the gas leak disaster
movements,
still births,
suppression of lactation,
and menstrual disturbances (1).
abnormal vaginal discharge
based on the information
Later,
on women from two affected bastis attending Gynaecological Clinic
two
women doctors reported the presence
pelvic
inflammatory
menstrual bleeding and suppression of
fact
finding
lactation
observations were
based
excessive
While the
(2).
on
unstructured
and the clinic based survey on a self -eelected sample
interviews,
and
team's
endocervicit1s,
disease,
therefore needed to be interpreted with caution,
were
they
indicative of an important area of morbidity that
both
of
number
large
The clinical conditions
menstrual and gynaecological disorders.
were
of a
required
detailed and sustained epidemiological investigation.
Tn March 1985,
organized
showed
a study, done between 104-109 days after exposure,
by the Nagarik Rabat Aur Punarvas
that
out of the 198 women examined,
gynaeco1ogica1
discharge
symptoms.
Leucorrhoea
or
Committee,
100 had
persistent
excessive
vaginal
was the commonest symptom noticed both in groups
severely exposed area and mildly exposed area.
had
bhopal,
from
Majority of these
no local or pelvic factor responsible for this symptom.
26.St of women from the severely exposed area the examination
cervical
smear
showed
presence
of
inflammatory
evidence of dysplasia in a small number of them.
pregnant
at
the time of the disaster,
trimester abortions
sectional,
(3).
In
of
with
cells
Of the 38 women
29 had first
or
second
The study organized by NRPC was cross
community based, using random sampling.
1
Ilowever,
this
had to be interpreted with caution because of
study
clinic
the
nature of the survey which expected the surveyed people to "walk"
upto the clinic thus introducing
In
the
a socio-medlcal survey carried out
same month,
medico
se1f—selection into the sample.
focused on the continued effects of
friend circle (mfc),
the toxic gases in Bhopal
the
by
(4).
The study shoved that between 50-
701 of the ambulatory population in the severely exposed areas of
Bhopal continued to have one or mono serious symptoms implicating
different
body
Among women in the
systems.
place.
alteration
The
was in the form
abnormalities in the menstrual
and
lactation
based,
dysmenorrhoea,
laucorrhoea,
a
population
The mfc study was
mildly exposed one through a
questionnaire
pre-designed
parameters and the use of
defined
findings
random
The
sampling.
of this study were therefore of greater epidemiological
However
significance.
too
suppression.
flow,
cycles,
shortened
of
cross sectional survey comparing a severely exposed area
with a
with
cycle had taken
a significant alteration in the menstrual
group,
age
reproductive
the
number
of women in the sample
small to comment on the effect of toxic gases
on
was
pregnancy
outcomes.
the
Although,
above mentioned studles/surveys were not designed
to systematically explore the effect of the leak on the menstrual
pattern of women and on the pregnancy outcomes,
way,
corroborated
they had,
a
in
the experience of social activists working in
these bastls and had underlined the urgent need to systematically
study
this
important
aspect of the health status
of
the
gas
exposed women.
Despite
official
this
urgent
established
need,
there
research
was no
institutions
2
indication that the
were
planning
to
appropriate
in
an
adequate
sponsorship
of
the Indian Council of Medical
respond
and
manner.
Research
of
the
on
menstrual health
preliminary
findings
least upto
May 1985,
outcomes
abortions
assess
held
the
at
adverse
This seemed to contradict the
an
increase
of the data because
authenticity
the
in
spontaneous
the
of
to
Official
imposed on all matters concerning the disaster.
was thus a need for an independent study that would assess
effect of the toxic gases on pregnancy outcomes and
health
menstrual
undertake this
Since
outcomes,
indicated that there had been no
of
toxic
Further,
women.
of the study on pregnancy
impressions
none
in the post gas leak period and it was not possible
Secrets Act
the
the
of
following the disaster.
popularly
There
However,
studies was designed to explore the effect of the
the
gases
(ICMR),
to look into
eeveral research studies had been launched in Bhopal
the effects of the gases on the different systems.
the
Under
gynaecological
the
women in Bhopal and
the
effect of the
gas
leak
objectives
the
decided
spontaneous abortions
on
the
to
overall
and pregnancy outcomes was beyond
morbidity
financial and other resources capacity of mfc,
limit
mfc
the
bask.
study
to
of
on
a
to
and
study
of
the
it was decided to
menstrual
still births in the period
patterns,
following
the gas leak.
Once the decision was made,
were
sent
carrying
women
letters announcing the proposed study
to several women’s organisations
out
of the survey.
for
help
with
the
The overwhelming response of
activists to this announcement indicated that
was a realistic and feasible proposition.
3
the
survey
I
CHAPTER
SURVEY DESIGN * METHODOLOGY
STUDY POPULATION AND CONTROL
Our study set out to find answers to three questions.
1.
what was the effect of the toxic gases on the
menstrual cycle of the non-pregnant women?
2.
what was the effect on the spontaneous abortion and
still birth rates of the women pregnant at the time
of disaster?
3.
the effect on the spontaneous
was
what
abortion
rate of the women conceiving after the disaster?
It
was
exposed
decided to undertake a retrospective study
population
for
purpose.
this
the
For
the
of
gas
purpose
"control",it was decided to study the same population
of
a
for
period of one year before the toxic exposure took place.
The reasons for selecting this form of historic control were:
The
studies
population,
both
1.
institutions
carried
out
earlier
governmental
by
on
the
gas
exposed
non-governmental
and
used distance from the Carbide factory
had
the
exposure
and
had
as
selected
indicator
of
population
from the low socio-economic strata residing 8-10
from
the
Carbide
differential
factory
as
the
selection
also
be
justified
mortality
rates in these areas.
However,
seemed
to
4
population.
control
by
the
an
kms
The
differential
the results from the
both the mfc i NRPC studies had revealed significant symptoms
gas exposure in the control population as well.
of
the mfc
In fact,
study had concluded that "a control population selected like Anna
Nagar
10
(colony
from Carbide factory)
kins
strictly
not
is
speaking a
'non-exposed’ population as it should be but serves as
a
population by virtue of being
control
JP
minimally
road
Nagar (colony across the
exposed
from
in
comparison
to
factory).
This also implies that even in our control population
one
expect
would
some
observe
to
of
the
Carbide
disabilities
or
debilitating morbidities in a higher proportion of the population
than
would be the case in an unexposed contorl
this
is what we did observe" (5).
find
a
hocio-economl cal 1y
as
Bhopal
Carbide
all
factory
Thus,
Actually
area.
it was not possible to
matched,
control
population
within
such colonies were
situated
down-wind
to
and
therefore could not
be
considered
the
'non
exposed ’
Selecting a control population outside of Bhopal would have
2.
created
the
availability.
unpaid
two
important
problems
of
logistics
and
resource
The survey was being carried out with the help
volunteers and with limited financial support.
large samples in two different cities would
have
of
To eutdy
stretched
the organisation’s resources beyond a limit.
However,
by
the
while
the problem of matched control could be resolved
studying the same population before and after the
gas
leak,
potential disadvantage of this survey design was the problem
of differential recall.
It
will be discussed later.
5
time-scale
The
the
of
study
design
repreaent ed
be
could
diagramatically as folloue:
1st
December
3rd December
1983
(Gas Leak)
1984
12 months
22-29
Sept ember
1985
Survey
Gas exposed women
10 months
(Study Population)
Of
the abnormal outcomes of
all
abortions and
not be too large.
pregnancy outcomes,
both
a
anomalies
In
(6).
of the
Further,
different
spontaneous abortion rates are considered to
and
specific
menstrual pattern,
length,
spontaneous
only
still births were selected since the population to
be covered could
be
pregnancy,
sensitive
indicator
of
chromosomal
order to asses the effect of the
gases
it was decided to study the changes in
on
cycle
menstrual flow and to study the occurrence of delayed and
missed periods.
Sampling the study population:
On
the basis of post gas leak morbidity and/or mortality
three
areas adjacent to the Carbide factory
were chosen for the
figures were available to us
from a study carried
study.
out
rates,
in
These
January
Community Health”,
1985
by the "Centre
of
Social
Medicine
and
Jahawarlal Nehru University JNU which covered
a population of 68,000 in 29 mohallas through a systematic random
sampling
of
*
6.66
households (7).
study were:
6
The areas selected for
the
JP Nagar
mortality rate 65.3/1000
morbidity rate 66%
mortality rate 46.7/1000
-
Kazi Camp
morbidity rate 54.60%
Kenchi Chola
mortality rate 35.7/1000
-
morbidity rate 91.9%
The
three areas selected for the study fell
13,
one
into Municipal
ward
of the officially recognized severely exposed wards
in
Bhopal .
Each of
the three areas selected consisted of more than one bast!
but were given area codes and were Identified by the name of
bast!
largest
in
that area by the Indian
Council
the
Medical
of
Research.
Thus ,
JP
Nagar
(area
code
01)
Risaldah Colony,
consisted
of
JP
Nagar,
Chola Naka, Shakti Nagar
and Rajgarh Colony.
Kazi Camp
(area code 02) consisted of Kazi Camp,
Slndhl
Colony,
Phoota
Old
Maqbara i part
of
Chola Road upto the Nallah.
Kenchi Chola
(area code 07) consisted of Kenchi Chola
&
houses along the North of the railway track
(Bhopal-Delh1
Each
line) upto Nishad Pura Yard.
household in these gas exposed areas has an ICMR plate and
using this ready made list of houses,
the random sample for the
study could be drawn. Since random selection of the individual
women
was not possible,
it
was
7
decided
to
select
random
households
cover all the women
and
In the reproductive age
group in the selected household. The number of households in each
were (according to the ICMR sample framework) JP Nagar area-1998,
Kazi Camp - 1950 and Kenchi Chola - 1300.
population
The total
in these areas was between 31,000 to 35,000 (8).
This formed our
study population.
;-
Sample Size
A
review of literature shows that there are very few
based
studies on pregnancy outcomes.
Even in the
population
estimates of spontaneous abortion rate vary widely both
available,
because of the definition selected and because of
adopted.
obtained
data
The
the methodology
in Khanna study in
rural
through prospective field observations over a period of
from
the
population of
village
overall rate of 100 abortions per
study
on
between
pregnancy
December
pregnancies
reported
&
the
abortion
To
pregnancies.
by the respondents,
10%,
260
the
in
detect
spontaneous abortions i.e.,
Assuming
that
2.09%
of
a
20%,
Delhi
ended in
still
rate
be
10%
of
increase in
the
rate
to
with an error of
pregnant women needed to appear in
a birth rate of 35/1000 population,
size
sample population that would
the
8
of
with the period of
months,
number of pregnant women would be 9000.
all
sample.
the
for the post gas leak period being 10
the
of
5% and error
observations
of
3351
the
(10).
community
two (old
an
Another
near
purposes of our study we assumed the ’’normal”
spontaneous
of
community
showed
3 -5 years
(9).
1000 pregnancies
May 1984
Punjab
indicated
12,000
in a rural
wastage
1983
roughly
births & 8.12% in spontaneous abortions
For
studies
few
yield
the
required
A random sample,
using
the random numbers table,
the
of 30% of the total households yielded
necessary number of 1506 households.
high
the
mind
of 29% In the earlier study of
rate
mfc
in
(11) another 10% of households were selected randomly
and
non-response
Bhopal
Keeping In
the interviewers
replacement
were specifically instructed in the criteria of
should the need arise.
Thus the number of households
from each area selected was : JP Nagar - 596,
Kazi Camp - 585 and
Kenchl Chola - 390 households.
METHODOLOGY
The Uorld Health Organisation defines spontaneous abortion as
any
before
dead
interruption of an
non-deliberate
pregnancy
the twenty eighth week of gestation in which the fetus
is
According to embryological
the
when expelled.
greatest
these
intra-uterine
loss
is during the week following
evidence,
implantation.
Since
early losses are not associated with any clinical signs or
as
symptoms,
they
abortions.
Since no previous study has been reported concerning
a
as
pregnancy
its
that
implantation
a few days,
except by
approximately
37.5%
which
so
aborts
not
clinically
of
Block
SK
defined
as
gestation,
(12).
fetal
its
suspected
delay in the onset of an otherwise
data
is
after
soon
normal
indicate
of those cycles which would otherwise
been thought to represent a prolonged luteal phase,
occult abortions
spontaneous
an occult abortion
existence is
The
period.
menstrual
unrecognized
of thia event,
the possible incidence
defined
largely
remain
In this study,
spontaneous abortion was
by the passing of products
9
have
were actually
loss occuring between 8 weeks and 28 weeks
signified
that
of
of
conception
or without abdominal cramps.
with
in Hindi
Since there is no equivalent
for the term "products of conception",
or the experience
"pieces of tissue",
aa "pieces of blood",
descriptions such
"expelled" were taken to signify products.
something
All
of
fetal
loss after 28 weeks of gestation was defined as still births.
By taking a cut off point of 8 weeks
the loWer margin of gestation,
i.e.,
we were missing out on the
occult abortions of gestational period of
was inevitable,
because to diagnose
is insufficient.
alone
to
available
two missed periods as
Further,
early
less than 8 weeks.
occult
abortions,
This
history
was
rto authentic information
help with the estimation of occult abortion
those
reporting
Hence
secondary amenorrhoea of less than 8 weeks
secondary amenorrhoea following the
among
leak.
gas
tabulated
was
A
and analysed separately from recognized spontaneous abortions.
delayed period was defined as one missed period while only if two
periods were missed (without the history of spontaneous abortion)
it was termed a missed period.
the
In order to asses the changes in
menstrual pattern following the gas
duration of menstrual flow,
regularity
changes
leak,
alteration in cycle length,
of cycle were studied;
in
the
and the
here irregularity was defined
as unpredictability of cycle.
For the purpose of analysis of spontaneous abortions,
death
FDR
both fetal
ratio (FDR) and cumulative incidence rate have been used.
la
defined as the number of spontaneous abortions
pregnancy
outcomes
(live
birth +
abortion).
Incidence
spontaneous
abortions per 100
rate
has
still
+
been calculated as
conceptions.
have been removed from all the tables.
10
birth
Induced
per
100
spontaneous
number
of
abortions
By its very timing to the gae leak,
retrospective
methodological problem
*
retrospective,
to
no supportive objective data;
Period
Menstrual
rely
secondly,
population studied;
a
atudy,
become aparent.
has
It
auch
In
data.
our study had to be baaed on
(LMP)
immediately
Firstly,
on the memory
crucial.
histories’
These
data,
several
identified.
factors
These
relating
include
elapsed
failure
since
the abortions to a particular event in a
of
woman’s
number
life,
a woman’s age at the time of pregnancy,
been
event,
the timing
the
life,
births and spontaneous abortions in a
total
of
are
one
have
the
gestational age of the fetus at the time of abortion,
of
with
In studies using recalled
to recall
time
*
th
aspects
discussed below with reference to spontaneous abortions,
the important variables in the study.
of
determination of Last
and thirdly,
becomes
since it la
recall
It has to rely on
three
woman's
medical treatment
and
and hospitalisation related to abortion and the social class
the educational
level of the women (
13 & 14).
These factors have been identified in long term studies where the
of time elapsed since the abortion have played a
length
role in recall of the event.
The period for recall
crucial
in our study
was only 21 months,which was not considered long enough to affect
appreciably.
recall
This
also meant that the total number
of
births and spontaneous abortions in a woman’s life and her age at
the
time
of
pregnancy
affecting recall.
incident
e
would not
However,
have
in these 21 months,
major
factors
an unforgettable
of the gas leak disaster had taken place and unlike
period prior to the disaster,
women were more likely
hospitalised in the post gas leak period.
more
formed
be
Therefore a relat. vely
accurate reporting of spontaneous abortion in the post
gae
COMMUNITY
leak period could not be ruled out.
326. V Main, HEALTH CELL
o
. 1
>
in
t .. .
,
Koramtnoala
I Block
Bangalore-560034 • X
India
A final methodological problem of recall was that relating to the
respondents' motivation in answering the proforma.
thia
which conaiata of queations of
kind
women respondents feel
the
In surveys of
the
nature,
intimate
embarraased or more importantly wonder how
collection of such information will be of benefit
to
them.
thia reluctance la expressed in the form of "inability
Often
While this was not considered a major constraint in the
recall".
context
of
of
the
disaster,
exaggeration
because
compensation.
Care
was
real problem
the
of incorrect association
individual
with
was therefore taken to explain
Hindi pamphlet,the need for accuracy.
possible
of
through
a
the random nature
Further,
of the selected houses together with the decision of not giving a
copy
of the proforma to the respondents helped in disassociating
the
survey from the process of assessing
monetary
compensation
for the individuals affected by the disaster.
With regard to the determination of the last menstrual period,
efforts were made to make the dates as accurate as possible.
population
in the selected bastis consisted of both
different
calendars,
was
phases
of
and the different festivals,
prepared.
all
&
Hindu
a ‘local
events'
was
the relevant dates (LHP,
completed,
English months and dates,
transferred
into
these
Muslim
calendar
assessing
the survey team was asked to write
date of
abortion,
delivery) in the same words as that of the respondent.
survey
Using
the
To be doubly sure that the mistakes in
LMPs were kept to the minimum,
down
the
the moon,
and
Hindus
Muslims who follow different Indigenous yearly calendars.
the
The
dates were
converted
date
After the
into
using the local events calendar.,
the box provided for it in
sample of the clendar is annexed.
12
(Annexure
the
- I).
of
proforma.
the
and
(A
History Taking:
A
pre-tested proforma in Hindi consisting of five
pre-designed,
sections was administered to the eligible members in the
I containing family composition and income levels
Section
be administered to the head of the family.
specifically
administered
all
to
reproductive age group in the sample.
to
married
women
in
the
IV & V were
Section III,
aborted
or
period or was currently pregnant
in the post gas leak
(See Annexure II
the time of the survey.
could
Section II was to be
be administered depending on whether a woman had
delivered
at
sample.
for a copy of
the
proforma ) .
Section
This
I:-
each household:
the
the
included
following information about
composition of the family, history of exposure to
dead or missing members in the family since
gas,
gas leak,
and the income of the family before the gas leak.
Section
II:-
This
married
women
in
reproductive
the
in
period
following
number
missed.
the
age group.
history
the
was
of
year
to be administered to all the
households
It
who
were
in the
included details of the menstrual
preceding the gas leak as well as in the
the gas leak.
times
selected
Specific questions related to
the menstrual period had been delayed or
The question were formulated in such
a way that it led
to the least amount of confusion and yet enabled the survey team
to
get
accurate
information.
regularity of menses the
For
instance
to
determine
proforma contained six questions.
13
The
also Included information on the
section
history
the women i.e.,
of
abortions,
still births,
number of
obstetrical
past
conceptions,
live births and the number of
alive at the time of the survey.
of
number
children
The family planning status and
the changes in libido were also recorded.
Section
This was for those women who had aborted after
III:-
Both spontaneous abortions and induced abortions
the gas leak.
Activity
were included.
pregnancy,
during
last menstrual
the
period date of abortion, description of abortion (onset,
symptoms)
fetal movements after gas leak in those who
aborted
changes
in
after 20 weeks of gestation
as well as reasons for Induction
in
case of induced abortions were recorded.
Sect ion
Thia was for women who had delivered a child
IV:-
live or still birth) after the gas leak.
It
included details of
the antenatal, delivery and post natal period.
Special attempts
were made to find out if any significant changes had been noticed
by the women after the gas leak (e.g.
and significant
changes between
changes in fetal movement)
this
delivery
and
previous
deliveries.
This was for women who were currently pregnant
Section V:during
that
it
Although the proforma
the time of the survey.
intended
at least a minimum of physical examination be carried
was not possible to do so because the majority of the
out,
survey
team consisted of people not trained in such skills.
The data for the study were collected between the 22nd and 29th
of September,
1985.
Throughout the survey,
a constant check was
maintained to assess the coverage of the sample population and to
reduce non response
considered
to a
minimum.
A
non-respondent
to be a person/househcld that could not be
14
was
contacted
If only the woman respondent was
even after two repeated vislte.
not contactable.
Information was taken from other members of the
This information
family (husband, mother-in-law, sister-in-law).
was however not used for the purpose of analysis.
from the door to door survey of the selected population,
Apart
G3,’8
QOe©3.0flical-cllnXc
*
examination
with facilities for internal
run in the bastis by qualified gynaecologists from our
was
reporting
Women
sample
not,
or
gynaecological/symptoms ,
team
of
the
A report of
the
whether part
were referred to the clinic.
a
(Annexure
findings in the women attending the clinic is annexed
III).
Training of the survey team:
The
survey team
belonging
consisted of two types of women,
training
working class who had undergone
the
to
majority
the
Community Health and were working as health workers for the
in
last
three years;
the other group consisted of middle class women with
or
medical
without
collection.
with
conversant
prepared
All
in
background
the
only
Hindi.
but
members
Hindi,
were
with
literate
and therefore
in
data
most
were
proforma
was
experience
the
but
The team members had volunteered
for
the
survey and were not paid any remuneration for their participation
in the survey.
About a month prior to the survey,
the
health
scepticism
the proforma was explained to
workers and was tested out
gave
ability to recall.
on
them.
The
way to a somewhat realistic assessment
initial
of
the
The proforma was then administered to several
15
households In the slums of Delhi and Bhopal and necessary chanjoa
were
made.
briefing
first
day of the survey period was
spent
in
the participants and in giving practical experience
in
The
During
administering the proforma in the bastis in Dhopal.
briefing,
column
each
the need to fill
question was explained,
every
on
emphasised and the survey team was asked to write out
the
reverse
that
they felt was relevant but which could not fit neatly
columns
the
the
explained
of
side
the
provided.
proforma
The
concept
any
of
other
random
information
into
sampling
was
and emphasis was placed on the fact that on no account
were the sample numbers to be changed.
CONSTRAINTS IN THE STUDY:
As
a consequence of the political climate prevailing
in
Bhopal
after the disaster, the study was constrained by several factors.
Although
these
they need to be
did not affect the overall quality of the
data,
stated to emphasis the tensions under which the
survey team had to function.
To begin with,
it was impossible to get any information from the
medical establishment in Bhopal.
This conspiracy of secrecy
was extended to
lengths
such ridiculous
information such as the ICMR
that
even
innocuous
maps of the bastis was treated like
the intervention of
ICMR's
classified documents.
It was only at
head office in Delhi,
that we were finally able to get some help
from
the
various
department
of
hospital.
16
Gandhi
Medical
College
and
survey
The
However,
In
first
1985,
of
the MP Government arrested the
Bhopal
and
detention.
preventive
seized
their
under
records
entering
issued
strict
the
affected
the bastis following the
arrests
warnings
The
area.
extremely
was
local people from the slums had also been
as
tense
‘outsiders
*
in
atmosphere
Health
These activists and doctors were branded
as terrorists and the HP Government
any
medical
and
doctors
in the Jana Swasthya Clinic (People’s
working
against
in
the dates had to be postponed because on June 25,
activists
Clinic)
conducted
1985.
sudden move,
a
to have been
July
vaa
up.
picked
Even previously sympathetic doctors from the medical community of
Bhopal refused help because of the media reports.
collection
data
number
the
survey was
in
large
a
in
Thus the number of volunteers available during the
far lees than that required.
survey began, the third
harraasment
problem
was the
constant
from the police. Since the safety of the proforma
waa of concern,
filled
to
of drop outs from those who had agreed to participate
survey.
Once the
The change
the repression by the MP Government led
and
dates
therefore had to be postponed.
The dates for
proforma
every night after the day’s work was completed,the
had to be
*
spirited
away to some
safe
place.
This resulted in the loss of some of the completed proforma.
17
II
CHAPTER
OBSERVATIONS AND RESULTS
Non-Respondents
Out
a random sample of 1571
of the total 5248 households,
selected for the study from the three areas viz.,
JP
Nagar
and Kazl Camp.
response rate,
Of
Kenchi
In order to compensate for
another 523 households were chosen as
were
Chola,
the
non
.
*
reserves
1632 responded giving
the total 2094 households selected,
Table I gives the reasons for non
non-response rate of 22.061.
response .
1
TABLE
Reasons for non-response (Flea.
in parentheses % of total)
Kazi
Kenchi
JP
Chola
Nagar Camp
Total
(%)
1.
House locked
34
70
49
153
(33.11)
2.
House not located
11
14
87
112
(24.24)
3.
Migrated/shifted out
13
26
10
49
(10.5)
4.
Form misaIng/incomplete
2
33
20
55
(11.9)
5.
Out of station
12
24
14
50
(10.8)
6.
Miscellaneous reasons
3
5
9
17
(3.67)
(converted into sewing
centre,
a
temple, shop).
7.
Empty house
5
5
5
15
(3.24)
8.
Disappeared with ICMR plate 5
4
1
10
(2.16)
9.
Refused to be surveyed
-
1
-
1
(0.21)
10.
Total
85
182
195
462
18
(100)
A
household vaa one that could not be
non-respondent
even
after
repeated
two
respondents
visits.
30%
Approximately
house vaa locked had gone out
whose
for
houaeholda
not
could
be located and
households belonged to consecutive numbers.
the
work
and
these
of
The reason for these
as told to us by th ICMR field
houaeholda,
missing
50%
about
of
In Kazl Camp,
could be contacted only very late in the evenings.
37
contacted
staff,
that while the houses were being numbered in Jan/Feb 1985,
was
about
100-150 families had put up their huts in the vacant land (Khabar
shifted out of the area.
1 <lak,
gas
Proforma
they
these families
in Kazl Camp and after a few months,
Khana)
their
had
Since these families moved in after the
non-response
would not
affect
the
results.
of 55 households were removed from the analysis because
As mentioned
either missing or incomplete.
were
in
the
chapter on methodology, during the survey period, due to constant
harrassment,
the completed proforma had to be shifted every night
to a safe place to prevent them being seized,
thus leading to
10% of the non-reapondent households had
misplacement of some.
shifted out of Bhopal permanently after the gas leak and
10%
of Bhopal on social visits.
out
were
the
one
Only
another
household
refused to be surveyed.
A.
GENERAL CHARACTERISTICS OF STUDY AND CONTROL POPULATION
A
total
of 8165 in
population
between the 22nd and 29th September,
1985.
the toxic gases on 2/3 December 1984,
individuals
Individuals,
the
gas
had
only
leak.
households
1632
was
surveyed
Of those exposed
to
253 (30.98/1000 population)
the
8165
43 individuals had moved into the area
since
died
following
Unlike
the
the
general
exposure.
slum'
Of
situations,
the
population in the area under survey is a stable population with a
19
history
of residence going several generations back.
relatively "nev”
residents of the
in
this
area
for more than ten years and in
‘patta’
received
basti JP Nagar,
Even
the
are settlers
1984,
April
had
for their residential plots declaring them
as
permanent residents.
there were 1486 married
In the population covered in the survey,
in the reproductive age group.
women
not
261 of these women
contacted during the survey as they were either
be
could
Thus a
work or had gone on a visit to the maternal home.
total
of
1225 married women formed our sample population.
59.76%
the
women
and
respondents were Hindus,
religions
to
belonged
other
than
respondents were between the ages of
20-29,
between
30%
the ages of
39.6%
Muslims,
these
two.
7.2%
15-19 years,
53.3%
on
out
of
0.65%
the
of
between
30-39 years and 9.45% were more
than 40 years of age.
373 of the women had a pregnancy outcome (livebirth,
still birth
or
spontaneous abortion) in the year prior to the gas
368
women
had a pregnancy outcome (live birth,
leak
and
or
still birth
spontaneous abortion)
in the period following the gas leak.
The
period l.e. ,
the period before gas leak (BGL) was
from
control
December
1st
(AGL) was
outcome
period
1985.
shows that the sample of women who had a pregnancy
in
BGL
period and in AGL period
reference to age, gravidity and religion.
not
study
and the
from 3rd December 1984 to 22-29 September,
II
Table
1983 to 2nd December 1984,
are
comparable
with
History of smoking was
considered an important variable although it is
known
that
smoking
is strongly related to spontaneous abortion cate
(15).
In
study population,
women
our
smoking and cultural
from smoking.
there is strong taboo
against
factors are powerful enough to prevent women
Hence history of smoking was not enquired into.
20
TABLE
Comparison
outcome
of
characteristics
(live birth,
of
still birth,
women who
a
had
pregnancy
spontaneous abortion)
before
and after gas leak (Figs in parentheses are the t of the total)
Before
Ago
gas
After
*
leak
gat
leak
**
n - 368
n = 373
15-19
17
(4.56)
31
(8.42)
20-29
247
(66.2)
237
(64.4)
30-39
102
(27.34)
88
(23.9)
7
(1-87)
12
(3.26)
14 2
155
(41.55)
132
(35.86)
3 & 4
120
(32.17)
130
(35.32)
5 «. 6
63
(16.89)
7
35
(9.38)
40 +
Gravidity
63 (17.11)
43
(11.68)
207
(56.25)
Religion
H indu
210
Hus1i m
163
The
161
(43.7)
(43.75)
—
—
Others
*
(56.3)
control
December
period i.e.
1984
from
now
from 1st December
on to be
1983
to
2nd
to
as
BGL.
referred
(Before Gas Leak)
The study period i.e.
September
1985
from
from 3rd December 1984 to
22-29
now on to be
AGL.
referred
as
(After Gas Leak)
21
Ban9alore-560034 - /
India
purpose of the study,
For th
*
necessary
considered
their
the current marital status was not
husbands in the gas leak would not affect
as
only
ten months had passed since
Contraceptive
usage
was enquired into as both
adversely
lUCDs can disturb the menstrual pattern.
1984
January
to
In
lost
fertility status
gas
the
leak.
tubectomies
In the period
only 19 women
September 1985,
tubectomy and only 4 had
B.
had
because the number of women who
had
and
between
undergone
lUCDs inserted.
EFFECT OF THE GAS LEAK ON THE MENSTRUAL PATTERN:
order
assess the effect of the gases
to
on
the
menstrual
pattern, only those women who were menstruating in the year prior
to as well as in the period following the gas leak were taken
that
the
menstural
histories could be
compared
period before and the period after the gas leak.
individual
women served as her own control.
and the length of the
describes
before
and
the
changes
after
gas
in
cycle
the
The
leak.
were taken.
duration
Table
flow
III
of menstrual flow
changes
in blood
flow
AGL is significantly different from that in BGL (p < 0.01).
22
each
Detailed history in
number of days menstrual
terms of regularity of the cycles,
the
571 women (46.6
of the woman respondents fitted this category and
percent)
lasted
between
so
in
III
TABLE
Comparison of menstrual blood flow before and after gas 1eak;
Duration of menstx'ual
BGL
AGL
(1-57)
19
(3.32)
blood flow
9
1 day
2-3 days
191 (33.45)
179
(31.34)
4-7 days
329 (57.61)
316
(53.34)
8+
17
(2.97)
33
(5.77)
I rr egu1ar
25
(4.37)
17
(2.97)
7
(1-22)
—
Stopped
in blood f 1 ow sign!f i cantly different between AGL &
Changes
BGL
(p < 0.01).
From each of the women,
enquired
into
for
the length of the menstrual cycle was
the BGL and AGL period and
changes
in
the
length of the cycle in this group of women is shown in Table IV.
This
table
has been computed on the basis of
cycle length of
her
women
the alteration
each individual woman after the gas leak
cycle length bfore the gas leak as normal
reported a shortening of cycle by
significantly different
from
for her.
keeping
14<;
of
5 days or more which is
the BGL period (p < 0.05).
23
in
TABLE
ration
*
Alt
IV
in cycle 1ength after gaa 1 eak
n » 571
Remained
sane
429
(75.13)
Increased by 5 or sort than 5 days
21
(3.67)
Decreased by 5 or more than 5 days
80
(14.01)
Irregular ly Irregular
34
(5.95)
7
(1.22)
Stopped
Alteration in cycle length significant p < 0.05
Table V describes the cyclical regularity of the menstrual cycle.
In
11.56%
women the menstrual cycle was
irregularly
irregular
after gas leak as compared to 5.6% women before the gas 1 eak.
V
TABLE
Change in the cyclical regularity of the menstrual cycle
gas 1eak
n
571
BGL
Cyclically regular
Irregularly irregular
32
Stopped
Change
(94.39)
539
(5.6)
the
cyclical
regularity
( p < 0.01).
24
498 (87.21)
66
(11.56)
7(1.22)
---
in
AGL
significantly
different
Menstrual
delayed
histories
missed
and
shows
Table IV
tried to ascertain
also
the
periods
before
number
of
and
after
with
women
episodes
the
at
gas
of
leak.
one
least
episode of missed/delayed periods.
TABLE
VI
Uomen experi encing at 1 east one episode of
BGL
mi used/delayed periods
i
AGL
n = 571
BGL
AGL
Delayed *
period
11
52
Missed *
period *
10
62
*
Delayed period
-
amenorrhoea of
*4
Missed period
-
amenorrhoea of more than 8 weeks.
5 to 7 weeks.
Difference is significant ( p < 0.001)
C.
EFFECT OF THE TOXIC GASES ON THE REPRODUCTIVE OUTCOMES:
1■St ill
births:
births in
in BGL
the
Tabls VII shows that the number of still
AGL period is
statistically
higher
than
(p < 0.01) period.
TABLE
VI I
St ill births in BGL and AGL Popula t i on
BGL
AGL
No.
of live births
348
240
No.
of still births
1
13
Difference is significant
(p < 0.01)
25
that
2.Fetal Death Ratio
In
that use retrospective case histories to assess
studies
incidence o£ spontaneous abortions in populations,
such an incidence is the fetal death ratio (FDR).
the overall fetal death ratio BGL i AGL.
gives
in FDR,
the
the measure of
Table
VIII
The increase
after gas leak is statistically significant.
VIII
TABLE
Fetal Death Ratio before and after gas 1eak.
No.
of live births + Still births
No.
of spontaneous abortions
Fetal death *
ratio
*
FDR
=
BGL (n = 373)
AGL (n =■ 368)
349
253
24
115
6.43
31.25
No. of spontaneous abortions
-------------------------------------------------- x 100
No.
of
spontaneous abortions > Live births +
Still births
Increase in FDR in AGL period is highly significant.
Table IX
like
wi th
1985
to
compares
like
J un e
FDR
i.e.,
19 85.
for the same calendar month periods,
between
The
January 1984 to June 1984
di f f erence
between BGL and AGL periods.
26
in
and
FDR i s signi fleant
TABLE
IX
Comparison of FDR for eimilar p<rlod» in BGL and AGL
Jan.1984-June 1984 Jan.1985-June 1985
Total No. of live births +
131
143
spontaneous abortions
17
51
FDR
11.49
26.29
still births
Total No.
of
Difference in FDR significant (p < 0.001).
3 ■ Cumulative
Risk
of
spontaneous
abortions
in
the
exposed populat ion.
Fetal
Death Ratio is basically a ratio and the denominator
does
not belong to the same population and therefore the risk involved
cannot be estimated.
In order to work out the risk involved,
cumulative risk has been worked out in the exposed and
population.
strength
the
unexposed
This would also give the relative risk, measure the
of casual relationship and the attributable risk
which
can help in measuring the magnitude of the problem in the exposed
populat1 on.
27
For thia purpose,
selected
1984
1984 are
to April
because they form a cohort whose outcome In the form of
spontaneous
occurrence
the conceptions of Jan.
abortion
of
by
will not be modified or distorted
exposure on 3rd December
1984.
the
Hence conceptions
in thia period forma a cohort for the unexposed population.
The
when compared to the abortion
rate
abortion rate in this period
in the period following exposure
January 198S - April
shown in table X la significantly less,
1.94,
the
attributable
fraction is 48.5%
conceived
risk is
7.44,
of all abortions
the
1985,
as
relative rink is
and the otiologic
occurring in conceptions
after the gas leak.
TABLE
X
Cumulative incidence o^ spontaneous abort ions BGL & AGL
Month of conception
Total no. of
concepti one
Total No. of
abort ions
Cumu1 at ive
inc idene e
Jan.
1984 - April 84
139
1 1
7.9%
Jan.
1985 - April 85
163
25
15.34%
Cumulative incidence calculated by
No.of spontaneous abortions
--------------- -------------- -xlOO
No. of conceptions
Cumulative incidence significantly different
28
( p < 0.05
)
III
CHAPTER
DISCUSSION
carried out ten months after
study
present
The
is community based in a
in Bhopal,
disaster
selected
toxic gases
menstrual pattern and pregnancy outcomes in the gas
the
has
formed the control.
In
the immediate aftermath of the disaster,
the
responsible for the disaster,
USA,
Corporation,
on
exposed
same population one year prior to the gas leak
The
population.
leak
gaa
randomly
of families and focusses on the effect of
sample
the
that the effects of the gases were local,
Carbide
Union
had maintained
affecting only the eyes
and lungs and that these effects were temporary.
This attempt at
minimizing the effect of the gases had been countered as early as
three months after the disaster on the basis of
March 1985 i.e.,
obtained
data
through epidemiological studies which showed
the
gases to have a mu1t1systemlc effect.
The results of the present study support the contention that
gases
have
affected
organs
other
than
eyes
lungs
and
Indicating damage to the reproductive system also of the
women.
be
exposed
temporary as it could be discerned even ten months after
increased
cyclical
duration
of
bleeding and in the
rhythm of the menstrual
of
the
The results of our study show a significant alteration
the menstrual pattern in the form of decreased cycle
number
by
The results also indicate that the effect was unlikely to
disaster.
in
the
women
cycle.
disruption
29
of
the
Significantly
higher
and
missed
have reported episodes of delayed
periods .
length,
The
effect of the toxic gases on the pregnancy outcomes
have
shown that both still births and spontaneous abortions
significantly higher in the post disaster period.
studied
The
are
increase
abortions is not confined to the immediate
post
gas leak period but the rates have continued to remain high
even
in
spontaneous
ten
months
spontaneous
after
the
disaster.
Further,
increase
the
in
abortions are not confined to only those pregnancies
conceived before the gas leak but pregnancies conceived after the
gas leak have also experienced a significantly higher termination
as spontaneous abortions.
The more refined Indicator of cumulative incidence shows that the
population
exposed
attributable
conceptions
is
at
risk being 7.44.
after gas leak,
a
relative
risk
1.94,
of
the
Of the spontaneous abortions
48.5% are a result of
exposure
in
to
toxic gases.
Thus,
contrary
to the hypothesis that the effects of the
toxic
gases are temporary and limited to the organs directly exposed to
them,
the
results
of the present study indicate
a
In addition
systemic poisoning along with a direct toxic effect.
to this,
continuous
the increase in spontaneous abortions suggests a strong
possibility that the gases are potentially mutagenic.
Spontaneous abortions as an index for detection of mutagens:
In assessing hazards posed by chemical agents,
are those agents that might cause cancer,
mutation, since
even
of special concern
birth defects,
their defects may not be detected for
generations and the damage caused is usually
30
or gene
years
or
irreversible.
assessing genetic risks,
while
Hence
mutation
which
to
detect
Increases in the mutation rates are two Important
small
selecting
for
with
and the ability of the system
detected
is
the rapidity
as
procedures
the
indicator.
aids
in
The
review
studies
population
criteria
of
epidemiologic
for
detection
of
mutagens conclude that monitoring population for fetal deaths is
one
the most important surveillance methods
of
with
specific
more
tests
as
such
in
biochemical
conjunction
cytogenetic
anaiys is .
Stein - st - al. have pointed out that
distribution
have
causes
wish
to
of
and
relied on observation made at birth or
are
information
inferences about the
specific congenital anomalies
that observations made at
emphasise
gestation
"most
a
valuable
and
largely
about congenital anomalies.
about their
later.
Ue
stages
of
source
of
early
untapped
Observations on
fetal
deaths are essential to an understanding of congenital anomalies;
to
solely on data from birth can lead to a false
rely
their natural history...
of
months
since conception.
loss
during
gestation
early
the
The Incidence of a defect at birth is
thus a function of the incidence of that defect at conception
in
of
Infants born at term are the survivors
which have suffered morbidity and
cohorts
view
and of the probability of
or
fetal
survival"
applying
currently
(17).
Using the model of Stein - et - al.,
estimates to the model,
available
possible
to
and by
Buffler has shown that it
evaluate the utility of monitoring for
spontaneous
abortions as an indicator of chromosomal anomalies in an
population (18).
among
live
births
is
exposed
Current estimates of all chromosomal anomalies
are
fairly consistent
31
as
are
spontaneous
Using the probabilities
abortions among recognized pregnancies.
of
with
fetuses
anomalies
aborting
fetuses
of
and
anomalies aborting in a hypothetical series of 1000
Buffler
has
detected
or
chromosomal
defective
pregnancies,
fetuses
would
be
by
spontaneous
only 5.31 of the estimated total
infants with
out
screened
leaving
abortion,
to be
anomalies
the
of
population
detected
birth.
at
Spontaneous
also appears to be highly specific in that only 6.61 of
abortion
all
that 94.71 of
shown
without
fetuses without anomalies ace aborted compared to an abortion
for fetuses with anomalies.
rate of 94.71
Thus,
spontaneous
sensitive
and
potential
of
abortion
rates,
specific indicators
a
hazardous
while
indirect,
for assessing
agent
chemical
are
mutagenic
the
in
both
the
exposed
populat i on.
The results of our study would indicate that the toxic gases that
leaked on the night of 2nd December 1984
Bhopal
are
increased
however,
needs
to
be
cytogenetic analysis.
abortions
in
substantiated
the
exposed
through
evidence
for
years
spontaneous
of
population,
biochemical,
There is also need to monitor the exposed
delayed long term effects for the next 20 or
population
and
This indirect
potentially mutagenic.
spontaneous
from the UCIL factory in
abortion rates could
Important surveillance methods.
32
form
one
of
30
the
Annexure
:
I
Sampl• from th® indigenous calendar prepared for the eurvey
Indigenous
Their Equivalent in
Calendar
English
Calendar
Amavaa
3.1.84
Rablal awful
upto 4 Jan 84
Rabial akhir
5.1.84
Makar Sankrantl
14.1.84
Purnlma
18.1.84
Magh (month beginning)
19.1.84
Amavaa
2.2.84
Jamadll awful
4.2.84
Baaant Panchami
7.2.84
Purnima
16.2.84
Phalgun (month beginning)
17.2.84
Hahashlvaratri
29.2.84
Amavaa
29.2.84
Jamadll akhir
5.3.84
Holl
16.3.84
Purnima
16.3.84
Chaitin (month beginning)
18.3.84
Amavaa
1.4.84
Ra jat
4.4.84
Purnima
15.4.84
Baiahaki
16.4.84
Amavaa
30.4.84
Shabhan
3.5.84
33
II
Annexure
Study Proforma (Translated from Hindi)
Section
I
1.
Date
2.
Area/Basti
3.
ICMR number
4.
Head of houaehold
5.
Religion
6.
Composition of
Information regarding Household.
family
(Start with the household head;
:
Include members who are dead and missing since gas leak)
No
Name
Age
Sex
Marital
Exposed to
If
status
gas - yos/no
symptoms
ill,
1.
2
.
3.
4.
10.
7.
No.
Economic status before gas leak
Name of the
Daily
No.
earning member
wage
of work
1.
2.
3.
4.
10.
34
of days
If on regular
salary monthly
Section
II
Menstural History (All married women between
15 - 44 years)
1.
ICMR No.
2.
Woman’s name
3.
Did you have a period thia month?
how long did It
last?
*.
If yes,
b.
If no, when was your last menstrual period?
c.
And how long did it last?
Did you have a period in
4.
month?
(Investigator
to mention the month prior to the LHP)
a.
5.
If yes,
how long did It last?
Did you have a period in
month?
(Investigator
to mention the month prior to that in question 4)
a.
6.
If yes,
Can
how long did it last?
you tell me,
after how many days do you get
your
period ?
7.
Does your period usually come after
days?
(Investigator to quote answer to question 6)
8.
Has your period been ever delayed since the gas leak?
a.
If yes,
b.
How many times did this happen?
9 .
how long was the delay?
Has your period been ever missed since the gas leak?
If yes,
how many times?
Did you get your period every month in the year
10.
before
the gas leak?
In
11 .
the year before the gas leak did you ever miss your
period?
a.
If yes,
how many times?
35
12.
Was your period ever delayed in the year before the gas
leak?
a.
If yea,
b.
How many times did this happen?
how long was the delay?
13.
Age of the youngest child?
14.
Did you conceive after this child?
a.
If yes,
b.
Uhat was the result of the conception?
month and year of
conception
(Investigator to take complete information)
15.
tell me the names of all your children who
Please
living at
No.
this time;
are
start with the oldest.
Age
Name
Sex
1.
2
.
3
.
4.
10 .
16.
Now
I
will
read out to you the names of your
who are still
living.
Is anyone missing?
(If
children
yes,
add
the name to the list)
17.
18.
Tell me about
the children who were born alive but died
subsequently.
If there were any,
Have
you ever given
give details.
birth to a child that was dead
birth?
If yes,
19.
give details.
Did any of your conceptions
(give details)
36
end in an abortion?
at
Family Planning status:
20 .
Tubectomy
(
)
Vasectomy
(
)
IUCD
(
)
Other
(
)
Date
None
21 .
there been
Has
any change in the libido since the
gas
leak?
Yours/husband * s
Signature of Investigator
Dat e
:For those women who aborted after the gas leak.
Section
III
1 .
ICMR No.
2.
Uoman’a name
3
Occupat ion
.
Were you engaged In heavy labour during your pregnancy?
Yes/No
4.
5.
Bast!
a.
Fetching water (Uptill which month)
b.
Fetching firewood ( ")
c.
Any other heavy work ( ”
The
last
menstrual
period
(Unite in the same way as
)
before
the
abortion
the woman states)
6.
Uhen did you abort: date and month
7.
Did you abort spontaneously or was it induced?
8.
If
it was spontaneous, give details about the abortion
(Complete Information la to be taken)
37
9.
If there
were fetal movements before the gas leak, was
there any change after the gas leak?
10.
If the abortion was Induced give reasons
Uhere was
It done and who performed it?
Signature of
Investigator
Dat e :
IV :
Section
women who delivered a llve/dead
For those
child after gas
leak.
1.
ICMR No.
2.
Woman's name
3.
Occupation
4.
Were you engaged in heavy labour during your pregnancy?
Bastl
Yes/No
a.
Fetching water
b.
Fetching firewood (
"
”
"
)
c.
Any other
(
“
”
”
)
(uptlll which month)
5.
Last menstrual period
6.
Date of delivery
7.
Fetal movements:
Same
Increased
Decreased
Remarks
Before gas leak
During gas leak
After gas
leak
8.
Any problem/complaint after the gas leak?
9.
Was
there
delivery as
any
difference between the labour
compared to your
complete information)
38
previous
ones?
in
the
(Give
10 .
Delivery
a.
Vertex
b.
Breech
c.
Forceps
d.
Caesarean
11.
End result
:
a.
Live child
b.
Dead child
(Fresh)
c.
Dead child
(Macerated)
12 .
Single / Twins
13.
Did the child cry immediately after birth?
a.
How long was it after birth ?
b.
Colour of the skin
c. Other reflexes
14 .
Any problem in breast feeding?
15.
Any congenital deformity?
16.
Sex of the child
a.
F ema1e
b. Male
c.
17 .
If it was a live birth.
a.
Is the child still alive and well?
b.
If ill, give details
c.
If dead,
18.
c.
Indeterminate
give cause of death
Health of the mother
a.
Alive and well
b.
Ill
c’
Dead (give cause of death)
(give details)
Sisnature of Investigator
Date:
39
V:
Section
For those women who are pregnant at the time of
the survey
1.
ICMR No.
2.
Woman's name
3.
Occupation
4.
Were you engaged in heavy labour ? Yes/No
Basti
a.
Fetching water
b.
Fetching firewood (
"
”
”
)
c.
Any other
"
”
"
)
(uptill which month)
(
5.
Last menstrual period
6.
Is there fetal movement?
7.
Any complaint during this pregnancy?
Signature of the Investigator
Dat e :
Examinat1 on
(to be carried out by a doctor)
a.
Abdominal girth
b.
Fetal heart sounds
c.
Per abdomen
d.
0 ed ema
e.
Blood Pressure
f.
Other
Signature of
the examining
Date of examination
40
doctor
Annexure
III
Ef f »ct« of toxic
on the health of the women (clinic baaed
data)
During the survey period (22-29 September 1985),
a gynaecological
clinic
was run simultaneously by qualified gynaecologists in the
survey
team
to
examine
women
with
problems.
gynaecological
Depending on the area where the survey team was carrying out
interviews,
Chola,
clinics were held at all
the three areas viz.,
JP Nagar and Kazi Camp selected
for the study.
the
Kenchl
The clinic
was housed in rooms provided by the bast! women and the necessary
equipment was loaned to us by voluntary organisations and private
dispensaries in Bhopal.
two
or
working with them.
nurses
women
offered us the services of
The clinic was open to all
in the survey area whether they formed part of the
through the pamphlet and the members of the
the
sample
Women in the area had been informed earlier about
not.
clinic
SEUA , Bhopal,
survey
the
team
were encouraged to refer women with gynaecological or obstetrical
problems.
Detailed
including
a
gynaecologists.
clinic.
history was taken and physical
pelvic
A
examination
total
of
was
done
343 women were
examination
by
examined
qualified
in
the
The characteristics of these 343 women were as follows.
41
Age
No. of women
*
(n = 343)
10 - 14 yrs.
2
0.58
IS - 19 yrs.
23
6.7
20 -
29 yrs .
183
53.35
30 -
39 yrs.
95
27.7
34
9.9
6
1.75
Hub1 Im
15 2
44.3
Hindu
191
55.68
40 +
Not
recorded
Religion
The findings
on clinical examination were aa
follows:
:
159
Clinically suspected malformed babies
:
6(3.77%)
Clinically suspectedd intra uterine growth
:
10(6.3%)
:
5(3.14%)
:
184
:
51
(27.7%)
:
21
(11.4%)
of pregnant women examined
Total No.
retardat1 on
Threatened/inevitab1e/ml ased/incomp1ete abortion
of non-pregnant women examined
Total No.
Complete abortion since gas leak
Pelvic
Inflammatory Disease
Menorrhagia/Polymenorrhoea
Cervical
:
eros 1on/Endocervicitis
Vaglnitis/Leucorrohoea
these,
Besides
neonatal
women
who
there
was
26
(14.1%)
:
45
(24.46%)
history of still births in
lost their children in the
recanalisation as they had been sterilized.
42
gas
(9.24%)
:
deaths in children born after gas leak in 11
had
17
leak
6
women,
cases.
4
requested
Since theae data are on a eelf selected sample of women attending
the clinic,
they need to be interpreted with caution.
suggest that probably the overall
data
The clinic
morbidity with regard
to
gynaecological problems in the exposed women has decreased in the
10
following
months
the gas leak as compared
However,
clinical studies in Bhopal.
the
to
earlier
it continues to remain high
as compared to clinic based studies in unexposed population; with
having
24.45%
vaginitis/1eucorrhoea,
eros 1 on/endocervlcitis,
disease.
from
11.4%
the case of women with leucorrhoea,
In
any
the
discharge
whitish
yellow,
foul smell or local irritation unlike any
commonly
vaginal discharge of infective
aetiological
women
diagnosis,
gynaecological
cervical
inflamatory
pelvic
with
the vagina was typically profuse,
without
found
and
with
14.1%
problems
need
thick,
origin.
with
to be
the
epidemiological
based
examination
at the field level and
investigations when needed.
43
above
investigated
appropriate treatment needs to be suggested.
population
For
study
for
establishing
mentioned
further
and
There is a need for
with
facilities
laboratory,
for
diagnostic
IV
Annexure
Probl ea« in D«Hverl»g Poet Gas Leak
From
the
surveyed
extensive
population,
history
regarding deliveries that took place after the gas leak.
of 253 women delivered in the AGL period.
had
(7.1%)
conceived
the rest
whereas
i.e.,
Of this only 18 women
235 women (92.9%) were already
At the time of gas leak,
had entered the third trimester of pregnancy.
time
21
movements.
(24.7%)
noticed
The
fetal
fetal
increase,
22
women
a decrease and in 13 women (14.6%)
the
fetal
(23.6%)
reported an
Changes in fetal movements were
by women who entered the 20th week
movements
pregnancies
as
women
the
movements had completely stopped.
also
89
in
women
reported
pregnant
A major symptom at
gas leak in these women was change
of
A total
in December 1984 - the month of disaster,
when the disaster occurred.
the
taken
was
were also considerably
of
gestation.
reduced
in
Only
compared to previous pregnancies.
these
1%
of
women reported painful contractions unlike fetal movements.
maturity appeared to be another problem.
Post
who
delivered in the AGL period,
given
have
and
32 women (12.65%) appeared
birth to post term babies as calculated
last menstrual period.
Almost all
Since culturally labour
labour.
Of the 253 women
second stage,
their
prolonged
is not divided into first stage
it was difficult to ascertain which stage
labour
had been prolonged.
labour
in
their
the women reported
from
earlier
However,
pregnancies
of
even women who had normal
reported
prolonged
difficult labour with labour lasting for more than 48 hours.
44
to
or
Women reported a decrease in breast milk production.
This was in
women who had successfully breast fed their earlier Infants.
the
women
223 women with a living child at the time of the survey,
(20.181)
noticed a considerable decrease in
breast
Of
45
milk
product i on.
All
these
symptoms
of
development
maturity
the child.
could
insufficiency
retardation,
could Indicate an
indicate
and
adverse
effect
on
Changes in fetal movement and
intrauterine
probable
therefore
hypoxia,
Intrauterine
'growth
an
Further studies are
needed to explore these findings systematically.
45
post
placental
while suppression of breast milk could have had
adverse effect on the growth of the infant.
the
V
Annexure
A critique of the ICHR etudy on pregnancy outcomes and
reproductive health of women expos cd to the toxic gases
in Bhopal
Complete neglect of gynaecological problems.
The
Indian
Council
their
(ICMR) and
the
Gandhi
have attempted to collect data on
the
outcomes in the gas affected population as part
of
Medical College,
reproductive
of Medical Research
longterm
Bhopal,
epidemiological study.
The
proforma
entitled
"ICMR/GMC study on longterm effect of MIC gas"collects morbidity
data
eye,
under conditions affecting
skin,
GIT,
the following organs viz.
hearing and mental.
No information is collected
regarding the gynaecological disorders
Questions
No.
following the gas leak.
49 to 54 to be administered to women between
ages of 15 to 49 years age group
only.
outcomes
are
Question
No.
and
question
pregnancy
status”
"pregnancy
status
49
on 3.12.84”.
related
to
in
No.
51
Since it
1985,
it is not possible to tell
information
administering
pregnancy
into
the
is not clear at
what
enquires
in relation to
and the date by which the collection of information
was completed,
gap
the
enquires about the ’’present
point of time this proforma was administered l.e.,
the gas leak,
lung,
the
between
proforma.
the
gas
from the proforma
leak
and
Since even as late
the
as
data were being collected for our study,
the
time
of
September
the
field
workers of ICMR were still administering their proforma on
long-
when
46
term effects, ve could say that the gap in information vaa for
This gap would relate to those women who war
at least ten months.
not
pregnant
at the time of the ICMR survey,
not
and who were
(their response to questions 49 & 51 being in
pregnant on 3.12.84
the negative) but who had conceived between these two periods and
had aborted before the proforma was administered to
1b
the firat
occurs in the
reporting
(See ICMR - GMC study proforma in
study.
ICIIR - GMC
under
where
stage
This
them.
Annexure
VI).
The
women who were pregnant at the time of the gaa leak or
at the time of the adminiatra11 on of the
pregnant
then referred to a team from the Oby
viait
proforma
of
MIC
the
affected
population
14 to 24 relate to
gas
Questions
leak.
at
(see
Bhopal”
pregnancy
second
effects
VI).
Annexure
outcomes following the
15 & 17 relate to the LMP &
EDD
of
the
pregnancy whereas for events occuring after the gaa leak
but prior to the administration of the proforma,
age is enquired into.
This is for abortion,
birth following the gas leak.
prepared
an
indigenous
still birth and live
events
calendar,
rechecking
these
may be very difficult.
It
a second stage of misreporting takes place
at
Since there were no written guidelines or report,
we
possible that
this point.
only gestational
As the study team of ICMR had not
important dates and gestation periods,
is
a
entitled "Epidemiological study of teratogenic
Questions
current
Members of thia
administer
thua referred and
women
are
proforma
Gynaecological department
of GMC Involved in the ICMR sponsored research.
team
were
are not in a position to comment on methodology of the ICMR - GMC
Both these proforma
relating
albeit
contain information,
insufficient,
to pregnancy outcome events only and do not attempt
to
collect information on either the gynaecological disorders in the
nonpregnant women or on the health problems related to pregnancy.
They
thus
perceives
This
information
vi ew
led to
changes
valuable
effects
which
to record such crucial
t'eflects the
inherent bias
women
in the menstrual pattern,
lactation etc.
information is
f rom the med i col egal and scientific points
enough
which
of
prolonged labour and suppression of
failui' e
the
loss
the
the specific toxic
regarding
dysmcnorrhoea,
also
has
such as leucorrhoea,
reported
medicine
aa vehicles for the product 1 on of tho
women
progeny.
While
the dominant vr i ew of modern
reflect
serious
v lew,
of
it
in medical research to the
problems o f women.
heal th
The inadequate and
faultily designed proforma did,
expected,
as
lead
to an under estimation of adverse pregnancy outcomes in the
ICMR
study.
During
research
sponsored
to
pregnancies
and
these
in
Bhopal
were
the
presented.
had
been recorded at
malformation
1.5
2%,
abortion
30%,
it
rates
Till
Of
the still birth rate was
2%
concluded
was
Comparing
1.4%.
in which spontaneous
that
3.5%,
congenital
the
although
had increased dramatically
Immediate post gas leak period,
date,
leak.
the time of the gas
still birth rate 1.8
was
ICMR
3259
results with hospital based studies,
abortion rate was 25
1985,
the
a total number
rate of congenital malformation
spontaneous
June
of
the Chief Investigators,
15% had ended in abortions,
these,
ICMR in Delhi in
results of the pregnancy outcome study of
preliminary
according
a meeting of
in
the
it had fortunately stabilized and
the current rates were all within normal.
48
In the meeting it was
alao
stated
floods,
up
dramatically
of social and environmental stress such as
periods
during
go
abortion rates "always”
that
because of
earthquakes
psychological
war,
factors.
The
participants of the meeting also expressed a sense of relief that
congenital
malformation had not gone up but cautioned
that
to watch was "now" when the women who had been in the first
time
at the time of gas leak would
trimester
deliver.
Uhile
these statements may sound unexceptional in themselves,
to
the
be
they have
understand
their
Firstly, there was enough evidence to point
to the
placed
implications.
the context of
in
both
to
Bhopal
toxic nature of the gases as could be seen by the high
extremely
mortality rate after the leak.
spontaneous
abortions
Hence it was more likely that the
and still brlths in
the
disaster period were due to the direct toxic effect on the
in
utero.
But
adverse outcomes were due to "stress" alone,
the ICMR team,
to
fetus
this was insufficient to explain the effect
pregnancies aborting several months after the gas leak.
high
post
immediate
in
If
the
by
as stated
neither was the statement substantiated by studies
support this
view
point,
nor were
we
able
supportive evidence through library research.
to
Secondly,
it must
also
be remembered that these statements were being made at
time
when
controversy
was raging about whether the
any
find
the
had
gases
temporary local effects only or whether they affected organs other
than lungs and eyes. Thirdly,
to the
embryo
and
fetus
ICMR's emphasis for assessing damage
seemed to rest
on the
assessment
of
congenital malformations alone, spontaneous abortion on the other
hand
was
without
considered
grave
a regrettable and unfortunate
implications.
49
fetal
loss
By
concentrating
terminating
study.
congenital
regarding
information
and
on
malformation
alone,
pregnancies conceived after the gas
in spontaneous abortions was lost in
the
Firstly,
This was regrettable on two counts.
have pointed to the systemic efect of the toxic gases,
probable
period
after
(as the conceptions
the
exposure)
to
Secondly,
studies.
spontaneous
monitor
potential
mutagenic
the
abortion
valuable
by
continuing
rates,
continuing
be
it
confirmed
the
long term
would have
environmental risk
Bhopal was being exposed to.
50
been
the
ICHR
it would
and their
were
by
leak
in
the
cytogenetic
studies
on
possible
to
population
in
references
1.
Bang,
Abhay et al (1985), Medical Relief and Research
In Bhopal,
2.
Friend Circle Report,
February 1985.
Bang,
Effects of the Bhopal disaster on
Rani (1985),
women’s
3.
the realities and recommendations. Medico
health
an
of
epidemic
diseases,
Part II Mimeograph.
Pregnancy
Outcome Survey
gynaecological
on
"Medical Survey
Bhopal
Gas Victims between 104 to 109 days after exposure
MIC Gas”,
16th
March to 21st March
1985,
by
to
Nagrik
Rabat Auc Punarvaa Committee.
4.
Medico
Friend
Aftermath
Circle
(1985),
The
Bhopal
: An epidemiological and socio
Disaster
medical
survey.
5.
Ibid, MFC
6.
Bora KC et al.
(editors)
(1982)
Progress in Mutation Research, Vol 3,
Elsevier Biomedical Press,
7.
PP 225
247.
Jawaharlal Nehru University (unpublished data),
An
epidemiological
and
sociological
study
(1985)
of
the
Bhopal Tragedy,
Centre for Social Medicine and Community llealth,
JNU,
New Delhi.
8.
Personal communications,
coordinator of
C ‘
?
51
1
ICMR sponsored
COMMUNITY HEALTH CEU
326> v Ma‘n, 1 Block
Ko<amcngala
BangaloreIndia
projects on gas leak disaster,
9.
A review of some selected studies
SP (1986),
Mohanty
on abortion in India,
10 .
Bhopal.
family welfare,
Journal of
14
Satya Narayana Murthy (1985),
A study of pregnancy wastage in a rural community,
All
India Institute of Medical Sciences, New Delhi.
11.
Op Clt,
12 .
Block
MFC
Occult
SK (1976),
Pregnancy - A pilot
Obstetrics and Gynaecology,
Ullcox
3,
Horney (1984),
and
abortion
14 .
recall,
120:
727 - 733.
Neet
JV
Accuracy of
American Journal
et - al.
(editors),
Epidemiology,
Genetics
DHEU,
Kline et - al.
Smoking
Medicine,
abortion.
297
:
793 -
Op clt Bora KC et - al.
17 .
Stein
Screening
-al.
England
of
of birth defects,
Epidemiology,
102
4,
Op clt Bora KC et - al.
275.
(1982).
a
fetal survival
on
American Journal
of
The effect of
52
Journal
Spontaneous Abortion as
the incidence
:
A risk factor for
:
(1982).
(1975),
Device :
the
796.
16 .
et
New
and
Public Health
1163, Washington.
spontaneous
18.
of
spontaneous
Service Publication, No.
(1977),
study,
65 - 8.
epidemiology of chronic diseases;
15 .
MD
Department of Social and Preventive Medicine,
thesis,
13 .
(4)
VI
frnnaxurw i
C.M.R.
I.
- G.M.Cn STUDY ON LONG TERM EFFECT OF MIC GAS ;
DEPARTMENT OF PREVENTIVE & SOCIAL MEDICINE,
GANDHI MEDICAL COLLEGE, BHOPAL.
NAME OF HEAD OF HOUSE HOLO :
(IN CAPITALS)
NAME OF INDIVIDUAL :
(IN CAPITALS)
ADDRESS :
New house hold, not interviewed
EDUCATION
(Key-iniler.ile
Literate
LOCALITY
2
Primary
SL. NO. OF FAMILY
Middle
5.
sl. no.
or MEMBER
Secondary
6
College
Technical 7)
TYPE OF HOUSE
Key- KUTCHA
Canvas
14.
q
Canvas
Thatched
etched
Concrete
4
Concrete
5.
OCCUPATION
(Key in instru
ction manual)
8.
9.
PRESENT/ABSENT IN
THE HOUSE ON THE
7.
NIGHT ON GAS -
TOTAL NO. OF FAMILY MEMBERS
(AS ON J-12-84)
LEAKAGE
Key- Present
B.
Absent
NO. OF GUESTS (IF ANY, ON
2)
(3-12-84)
16.
9.
IF ABSENT FROM
HOUSE WHERE WERE
PER CAPITA MONTHLY INCOME
YOU-
(IN RUPEES)
(Key-Nol in Bhopal
10.
In Bhopal
RELIGION
Key- Hindu
Muslim
Christian
2
Sikhs
J
4
Others
5
.7.
1
2)
IF IN BHOPAL WHICH AREA
(MENTION THE AREA BY
NAME) NOT TO BE CODED)
53
s 2 a
46
47
48
Closed
Z)
29.
22.
WHAT DID YOU DO WHEN
ALCOHOL
EVER
(Key-Yes
1
No
2
THE GAS LEAKAGE OCCUSEO
(Kev-Rt»n awoy
’
Went ouliSda 2
50.
Protected by
ALCOHOL-CURRENT
(Key-Yes
1
Do
2
wet cdotio to
>
face-
Stuycd indoor a
«.
DID YOU CONSUME
ALCBSOEEON the
sheet/
NIGHT Of EPlSCOE
(Please specify?
(Key-Yes
1
No
2
52.
IF YOU RAN AW AY, WHAT
(Key-Yes
1
Si.
No
2
2
3>
Both
55.
□='
CHEW TOBACO-CURRENT
MODE DIE YOU TAKE
By vehicle
1<k
51.
Covered with
(Key-JBy -Toot
49
CHEW TCHACO-evtR
(Key-Yes
1
No
2
NATURE Of WCRK TOK6
53
BY /OU BEFORE THE
54.
EFlfODE (SPECIFY)
IMMEDIATE EFFECTS
DID THE GAS EXPOSURE
have any effect
2K
IMMEDIATELY ON
ARE YOU ABLE T3 OO
THE SAME NCR
*
(Key- Yes
No
NOW
3.15.04-
1
(Ker-Yes
1
2>
No
2)
if
yes. continue if no.
PROCEED TO QUESTION 41.
54
54
IF YES
Condition
Effect
Were vou
Duration of
Duration of
Dates of hospi
Key-Yes 1
hosoital-
hospitalisation
illness in
talisation
(Not
ised
in days
days
(Not to be coded)
coded)
2
No
Name of Hospital
to
be
Key-Yes 1
No
1
2
3
1
6
5
4
7
LATER EFFECTS (ON Seton 4-12.1994 or later)
41. DID YOU DEVELOP ANY COMPLICATIONS
91
ON 4.12.1984 OR LATER.
(Key-Yea
No
1
2)
IF YES, CONTINUE, IF NO, CLOSE INTERVIEW. PROCEED TO ITEM 49 ONLY FOR MARRIED WOMEN BETWEEN 15-49 YEARS.
Condition
Effect
After how-
Duration of
Duration of
Dates of hospita
Key-Yes 1
many weeks hospita
hospitali
illness in
lisation
Key ♦
lised
sation
weeks
(Not to be coded)
Key-Yes 1
Key •
Key •
5
6
No
2
Were you
No
Name of hospital
2
•
1
2
J
4
55
7
/8
n 4 u
Within 1 week
Week
Week
Week
Week
Week
1-2
2-3
3-4
4-8
8-12
1
PREGENANCY
2
15-4? YEARS AGE GROUP)
•5
7
8
d)
e)
f)
g)
WOMEN
IN
No
Z
No
Giddiness! Chakkar >
1
2
1
Nu
2
3
M.TJ3.
4
Continuing
5
18
DURATION OF GESTATION AT THE
|
TIME OF OUT COME OP PREGNANCY |
54.
DATE OF OUTCOME
39
I
|
NAME CP INTERVIEWER
Key-Yes
1
No
Z
SIGNATURE OF INTERVIEWER
Bodyocfie
DATE
Key-Yes 1
No
2
NAME OF A.P-O.
Pain in the. limbs
No
2
Abortion
53.
Headache
’ Key-Yes
|------- I 37
L_ 1
(IN WEEKS)
AnxIctylGhobharaO
Itey-Yes
1
2
Still Birth
t
1
No
2
OUTCOME OF PREGNANCY
Key- Live Birth
1
1
Key-Yes
1
No
Key-Yes
Tiredness
Key-Yes
fatigue
Key-Yes
No
Key-Yes
PREGNANCY STATUS ON 3.12.1984
51.
c)
MARRIED
PERIOD OF GESTATION IN WEEKS
DID YOU DEVELOP ANY OTHER
COMPLAINTS AFTER 4.1X84.
b)
ONLY
PRESENT PREGNANCY STATUS
*♦
More' han 12 Week
a)
(ASK
5
-
Still Continuing
48.
STATUS
NAME OF STATISTICIAN
1
2
DATE OF SCRUTINING
Key tor occupation (No.lft)______________________________________________________________________________________________________
OX
Professional technical and 'elated worker.
01.
No. occupation
04.
Farmers, fisherman, iiunters, Lumpermon.
transport occupation.
09.
Occupation unreported.
07.
10.
related worker.
05.
03.
Craftsmen labour not. elsewhere clarified.
Members of armed forces.
11.
56
Sales worker
Worker in mines quarry
08-
Housewife.
Service workers.
06.
Worker in
EPIDEMIOLOGICAL STUDY OK TERATOGENIC EFFECTS OF MIC
in EXPOSTED POPULATION- AT BHOPAL
-JISTRATLON
Name of head of House hold
Name of Woman
Husband
Address
IF YES, GESTATIONAL ACE AT
1
THE TIME OF ABORTION
2
DID SHF. DELIVER AFTER
3
DEC.3,
4
1.
5
1984
No
■■ 2. Live birtfc 3.Still birth
DELIVERED ACE OF GESTATION
6
IF LIVE BIRTH
Is child alive 2. Died within
one week 3. Died within 7-28 days
1.Hindu 2.Huslia 3.Sikh
4.Christian 5
8.
4. Died later on
Others
23.
EDUCATION
1.
None 2.
4.
Graduate 5. Postgraduate/
Primary 3.
SEX OF CHILD
•1. Hale 2. Female 3. -Indeterminate
Secondary
24
DATE OF BIRTH
Profess ional
9
CURRENT MARITAL STATUS
14,_ ,
Months
ACE:
ACE AT CONSUMMATION OF MARRIAGE (vrs)
1.
4.
10
11
Single 2. Married 3. Widow
Separated 5. Divorced
PER CAPITA
MONTH
INCOME PER
"
TYPE OF HOUSE
3.
Block of huts 4.
12
[
|
13
27
ANY TREATMENT TAKEN FOR FTER!
Banglov
1
]
1—' 3]___ ,
DURING THE PERIOD OF GAS ||
No.
44
63
28.
NO. OF PREGNANCIES
29.
NO. OF LIVE BIRTHS
30.
KO. OF STILL BIRTHS
31.
NO. OF SPON. ABORTIONS
32.
NO. OF INDUCED ABORTIONS
33.
NO. OF INFANT DEATHS
Others
HISTORY OF CONSANGUINITY
1. Yes 2.
ACE AT FIRST CONCEPTION
cs 2. No.
1. Thatched hut 2. Masonary
5. Tents 6.
26.
44
70
71
(LESS THAN 12 MONTHS)
LEAK WHERE HAVE YOU BEEN
1.
Inside house sleeping no
34.
HALE
symptoms 2. Inside house
came out no symptoms
14
3
Inside house, symptoms ♦
4
Outside house, symptoms •
5
Outside are
*
6. Others
p.
CURRENTLY PREGNANT
72
NO. OF LIVING CHILDREN
73
female
35.
■74
TIME ELAPSED SINCE LAST DELIVERY(mths) I
(EXCLUDE ABORTION)
7C
36.
TOBACCO CONSUMPTION
1. No 2. Chewing 3. Smoking 4.
Both 5. Other
1. Yet 2. No
15
IF YES,
16
DURATION OF PREGNANCY (wks)
17
E.D.D
18
DID SHE ABORT AFTE
L.M.P
37
ALCOHOL CONSUMPTION
1. No 2. Regular 3. Occassional
38
WORKING STATUS
1. Housewife 2. Work in a office
DEC.3,
1
3
3. Work in a
1984
No
2 Spontaneous ahn—r im
Induced Abortion
39
TYPE OF WORK
1. Desk
57
abo1
3.
Domestic
MEDICO FRIEND CIRCLE
The
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Medico
health
and
professionals
activlata
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who
the
share
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believes that this system must be changed to serve the
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the poor.
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and community
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and
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a
experiments
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above,
with
orientation
demystification
of
sharing of experience
goals
outlined
and for taking up issues of common concern for action.
34-B, Noahir Bharucha
Anil Pilgaokar, Convenor,
Road, Bombay - 400 007.
59
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interests.
the aim of realising the
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interventions
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and
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pe[5
Effect of Bhopal Gas Leak
on Women’s Reproductive Health
MEDICO FRIEND CIRCLE
1877 Joshi Galli
NIPAN1
BELGAUM Dist
Medico Friend Circle
The Medico Friend Circle (MFC) is a circle of friends with
medical/non-medical backgrounds who share the common conviction
that the present system of health services and medical education is
lopsided in the interest of the privileged few and must be changed to
serve the interests of the large majority, the poor. MFC fosters a
‘thought current’, upholding human values, people and community
orientaion of health care and medical education, demystification of
medical science and a commitment to the guidance of medical interven
tions by peoples’ needs and not commercial interests.
MFC offers a forum for dialogue/debate, sharing of experience and
experiments with the aim of realising the goals outlined above, and
for taking up issues of common concern for action.
For further details regarding MFC—Women’s Reproductive Health
Bhopal Study, contact.
Dr C Satyamala
F-20 (GF)
Jungpura Extension,
New Delhi - 110 014.
[A detailed report of the study including background, objectives,
materials and methods, observations and results, discussion, recom
mendations, important appendices including proformae and references
and reading list is also available on request from the above address.]
Acknowledgement
MFC is extremely grateful to the following organisations that participated
in the survey viz: Sabla Sangh, Action India, Ankur, Saheli, Jagori, Prayas,
Mahila Mukti Morcha Sewapuri, Sahiyar, Nari Atyachar Virodhi Manch and
Search. Without their active participation and the help given by Ekalavya,
Jana Swasthya Kendra, Bhopal, this survey could not have been completed
successfully. We take this opportunity to express our heartfelt thanks and
empathy to the gas affected women who gave overwhelming response to the
sympathetic, concerned enquiries of the survey team.
Published by Padma Prakash on behalf of Medico Friend Circle ai
Bombay, Telephone: 26 07 25.
Effect of the Gas Leak on Women's
Reproductive Health in Bhopal
DURING the second half of March 1985, three months after the Bhopal
gas disaster, MFC conducted an epidemiological, sociomedical survey on
the effects of the toxic gas in the bastis of Bhopal [1]. The study showed
that between 50-70 per cent of the ambulatory population in the severely
affected areas of Bhopal continued to have one or more serious symptoms
implicating different body systems. Among women in the reproductive age
group, a significant alteration in menstrual cycle had taken place. The altera
tions were mainly in the form of shortened cycles, abnormalities in the
menstrual flow, dysmenorrhoea, (painful menstruation) and leucorrhoea
(white discharge). These findings were also supported by independent studies
carried out by Drs Rani Bang and Mira Sadgopal on women attending gynae
clinics in the affected bastis [2]. This evidence of extensive damage to the
different body systems especially to that of the reproductive system in the
women added to the already growing concern over the effects on the develop
ing foetus in pregnant women exposed to the gas. This concern had been
voiced earlier in February '85 by a fact-finding team of doctors [3].
Unfortunately at that time MFC was not in a position to assess the risks
to the foetus, since the socio-medical survey had covered only 50 families,
a number too small to measure abortion rates. However, as months passed
and no authentic information was available either on pregnancy outcomes,
or on effect on women’s reproductive system in general, MFC. despite its
ever-present limitation of resources, decided to design and coordinate an in
dependent survey on these two problems.
Letters requesting help were circulated to various women’s groups and the
overwhelming response of women activists indicated that the survey was a
realistic and feasible proposition. However, the study was beset by many pro
blems right from the start. To begin with, it was next to impossible to get
any information from the medical establishment in Bhopal.
This conspiracy of secrecy was extended to such ridiculous lengths that
even innocuous information such as the 1CMR numbering and the maps
of the bastis was treated as classified documents. The situation worsened
in June when in a sudden move the MP government arrested the doctors
and the activists of the Jan Swasthya Kendra under preventive detention.
This un-called for action of the government had the effect of terrorising the
basti people as well as the few previously helpful doctors from the Gandhi
Medical College. That the study took place at all was a reflection of the con
viction shared by the women activists participating in the survey and the
affected women from the bastis on its absolute necessity
Methodology of Study
The survey was conducted in three of the affected bastis which were selected
on the basis of the post-gas leak morbidity and/or mortality rate [4]. These
were J P Nagar (mortality rate 65.3/1000, morbidity rate 66 per cent), Kazi
Camp (mortality rate 46.7 per cent and morbidity rate 54-60 per cent), and
Kenchi Chola (mortality rate 35.7 per cent and morbidity rate 91.9 per cent).
The selection of the area and the sample was also facilitated by the fact that
the ICMR had already accomplished one important task fairly efficiently,
namely the division of the bastis into 13 areas and numbering of all the houses
providing the much-needed sampling frame.
Based on studies done elsewhere [5] which showed abortion recall of 82
per cent accuracy even after a lapse of ten years, a ‘historic controF was
decided upon. This was to be the status of the study population in the year
preceding the event of the gas disaster. Detailed information on the menstrual
cycles and reproductive history gathered from the study population for the
period from December 1983 to December 1984 (the year before the gas leak)
was to be the control for the period after the gas leak. This method of using
a historic control eliminated the problems of finding an identical popula
tion, even though it could have introduced an element of under-reporting
due to memory lapse. The families were selected by ‘random-sampling’, taking
into account a non-response rate of 25 per cent.
In many surveys of such nature, the quality of primary data, the informa
tion elicited from the study population, on which a number of sophisticated
statistical, (sometimes computerised) tests are done, is not good. A lot of
care was taken in this survey to ensure quality of work. For example, a lot
of attention was paid to the proper training of the survey team. One aspect
of this training was getting well-versed with the questionnaire. The survey
team consisted of tw'o types of women; the majority belonged to the work
ing class from the slums in Delhi or rural areas who had undergone training
as health workers and were working as health workers for the last three years;
the other group consisted of middle class women activists with or without
a medical background who had participated in other surveys during the course
of their work. All the members were literate but most were conversant with
only Hindi and, therefore, the proforma was prepared in Hindi. All the
members had volunteered and were not paid any special remuneration for
their participation in the survey. About a month prior to the survey, the pro
forma was explained in great detail to the health workers. At first the questionaire was greeted with some amount of scepticism as it seemed impossi
ble that women would remember their menstrual history in such details. The
questionnaire was, therefore, tested out on the health workers themselves,
most of whom were women in their twenties and thirties, and as each one
tried to answer the questions, it became apparent that memory recall was
not such a problem after all. The health-workers became convinced that if
they could remember their menstrual history of the last two years, given the
fact that no conscious effort had been made in the past to store this memory,
then surely women in Bhopal with the event of the gas leak acting as a spur
for memory recall would remember the menstural disturbances they had gone
through since the gas leak. The questionnaire was then administrered to some
of the households in the slums of Delhi by the health workers. Based on
the information collected the proforma was pruned and modified.
A)
Pregnancy Outcome
A total population of 8,165 in 1,632 households was surveyed from the
22nd to 29th of September, 1985. Table 1 gives the Foetal Death Ratio, which
indicates the toxic effect of the gas-leak on pregency.
2
Tabic 1: Foetal Death Ratio
•Before gas-leak
"After gas-leak
255
24
1
280
8.6
253
115
13
381
31.33
(1) No of deliveries
(2) No of spontaneous abortions
(3) No of still births
(4) Total no of conceptions (1+2 + 3)
(5) Foetal Death Ratio
***
• This is the events during the control period i.e. from January, 1984 to the 2nd
December, 1984 from now onto be referred to as BGL;
’• This is the events during the post gas leak period i.e from the ’rd December '84
to the 29th September ’85, from now on to be referred to as AGL;
••• FDR = 2 -r- 4 x 100.
The Foetal Death Ratio or the overall spontaneous abortion rate after
gas leak is 31.33 which is significantly higher than the spontaneous abor
tion rate of 8.6 before the gas leak.
Table 2 compares the quarterly distribution of spontaneous rates. The dif
ferences in the ratios between the quarters is statistically highly significant.
Difference in the rates of abortion between the three quarters. In the period
BGL and AGL are highly statistically significant.
Table 2: Quarterly Foetal Death Ratio Before and After Gas Leak
Quarter :
LB + SB-
BGL
No.
aborted
FDR
LB + SB
AGL
No.
aborted
FDR
JAN-MAR
APR-JUN
JUL-SEP
OCT-NOV
DEC
42
84
55
74
26
4
9
4
1
44
8.69
9.67
6.78
—
—
6
77
82
—
—
27
24
20
—
—
26.21
23.76
19.23
—
—
•
LB = Live Births, SB = Still Births.
B)
Effect on Menstruation
In the MFC study conducted in March 1985, it was observed that gasaffected women were suffering from short-ended menstural cycles, altered
pattern of discharge, dysmenorrhoea (excessive pain during menstruation)
and excessive white discharge. The difference was statistically significant [4],
In this study, an attempt has been made to study this change further.
It was found that out of the 571 women whose menstrual history was
studied in detail, in 2.97 per cent (17 women) menstrual bleeding used to
be for 8 or more days Before the Gas Leak (BGL). This proportion had gone
upto 5.77 per cent (i e, 33 women) After the Gas leak (AGL). 142 women
(i e, 23.87 per cent) reported change in the length of their menstrual cycle;
80 women (14.01 per cent) reported a shortening of menstrual cycle by seven
days or more. Table 3 gives the distribution in the affected women of this
change in the length of the menstrual cycle.
Menstrual histories also tried to ascertain the number of episodes of delayed
3
and missed periods before and after gas leak in this population. The results
are given in Table 4.
C)
Other Gynaecological Disorders
In February and March 1985, a clinic was set up by a gynaecologist, Dr
Rani Bang, with the help of Dr Mira Sadgopal, in one of the worst affected
bastis in Bhopal to assess the damage done to the reproductive system of
women. These two members of the Medico Friend Circle found that out of
218 women examined in this clinic, 90 per cent had excessive white discharge,
79 per cent had Pelvic Inflammatory Disease, 75 per cent had cervical ero
sion or endocervicitis (inflammation of the mouth of the uterus) and 31 per
cent complained of increase in bleeding [6].
The women who come to such a clinic do not constitute a random sam
ple; and those who are suffering are more likely to come to a clinic. These
figures, therefore, overestimate the incidence of the problem in the community.
But these figures were much higher as compared to those found in a similar
clinic in a basti about 10 km away and in absolute terms also these figures
are so startlingly high that they assume great significance. Similar findings
were reported by a study conducted by a group of voluntary organisations
[7]. It was, therefore, decided to run a similar clinic again in the same basti,
during the time of this September 85-survey. It was run by the same two
doctors, helped by a male gynaecologist, Dr Sanjeev Kulkarni.
During the five days of the clinic, 159 pregnant and 184 non-pregnant
women were examined. Out of the 184 non-pregnant women, 21 (i e, 11.4
per cent) were suffering from Pelvic Inflammatory Disease; 26 (i e, 14.8 per
cent) had cervical erosion/endocervicitis; and as many as 45 (i e, 24.45 per
cent) were suffering from inflammation of the vagina/white discharge. The
discharge from the vagina was typically profuse, thick, whitish yellow, without
any foul smell or local irritation, unlike any commonly found vaginal
discharge of inefective origin.
Table 3: Percentage Alteration in Cycle-length After Gas Leak
Remained same
Increased by 7 or more than 7 days
Decreased by 7 or more than 7 days
Irregular
Stopped
75.13 (429)
3.67 (21)
14.01 (80)
5.95 (34)
1-22
(7)
:
:
:
:
Table 4: Episodes of Delayed and Missed Periods Before and After Gas Leak
:
BGL
Delayed Periods
Missed periods
16
14
:
:
AGL
64
73
(Delayed periods—amenorrhoea flack of menstruation) from 5-8 weeks; Missed
periods—amenorrhoca of more than 8 weeks which was not reported as a spontaneous
abortion by the woman.)
4
Significance of The Findings
A)
Pregnancy outcome
Experts have pointed out that to assess the damage done to pregnancy
(including the incidence of congenital malformations-birth defects) due to
an environmental injury, the Foetal Death Ratio or the Rate of Spontaneous
Abortions is a very specific and sensitive indicator compared to the incidence
of congenital malformations found at birth [8], For example, some abnor
malities are never seen in full-term infants and the rate of all chromosomal
abnormalities in spontaneous abortions is more than 100-fold the rate at birth;
while 2.5 to 3 per cent of live-births show major birth-defects, numerous
studies have shown that 90 per cent of the conceptions with congenital ab
normalities abort in early pregnancy. Unlike the Indian Council of Medical
Research (ICMR) which has focussed its attention extensively on the incidence
of congenital malformation; in this study, rate of spontaneous abortion has
been taken as the indicator of damage to pregnancy.
The almost four-fold increase in the rate of spontaneous abortion after
the gas leak is highly significant and indicates serious damage to the reproduc
tive system of the gas-affected women. In at least two public health con
troversies in the US (one relating to Love Canal, and the other to the her
bicide ‘Agent Orange’.) Spontaneous abortion rate has been accepted as crucial
evidence in assessing hazards to human beings.
Those women who have conceived after the gas leak also show a higher
proportion of spontaneous abortions indicating a continued effect of the
toxic gas leak. This finding tallies with the findings of others that the poison
ing of the body persists even months after the gas disaster.
Though the survey done by ICMR reports no increase in the birth defects
after the gas leak, the highly significant increase in spontaneous abortion
rate as found in this study shows that this report by ICMR cannot be taken
to mean that “no damage has been done” to the reproductive health of
women. On the contrary, use of this more sensitive indicator shows a serious
damage to the reproductive capacity of gas affected women in Bhopal.
B)
Disturbance of Menstrual Cycle
Women are generally looked upon only as mothers. In the ICMR studies
also, only the effect of the gas leak on pregnancy was studied; neglecting
menstrual and other disorders. In this study, however, these problems have
also been consciously studied. That 23.87 per cent of women report change
in the length of the menstrual cycle adds to the evidence that women’s
reproductive health in general has been affected by the gas leak. 14.01 per
cent of women have reported that they get their menses more frequently AGL
as compared to BGL. These women are more likely to develop anaemia.
C)
Other Gynaecological Disorders
The clinic-based study on a non-randomised sample shows that many
women continue to suffer from inflammation of the cervix and other inter
nal organs due to the gas leak. The type of clinical findings shows that the
5
disorders have been caused by the pathological changes in the reproductive
organs brought about by the poisoning of the body due to the gas leak.
Fortunately compared to February-March 1985, the proportion of women
suffering from these gynaecological disorders has come down a lot in
September 1985. But still, this proportion, found 10 months AGL, is high
as compared to a normal population. This fact further corroborates the argu
ment that the gas leak has led to a continued generalised poisoning of the
body of the affected populaion.
Recommendations
1) The gas affected women of Bhopal have silently suffered from the
physical and psychological agony of abortions, menstrual disorders and in
flammation of their internal reproductive organs. These sufferings are in ad
dition to the other health problems caused by the gas leak. These specific
additional problems of women have not been properly studied and
documented by bodies like ICMR. This survey, conducted by voluntary ef
fort and planned and executed with meticulous regard for accuracy, has scien
tifically proved that the reproductive system of gas affected women has been
seriously damaged. Further study with similar approach be urgently con
ducted by the official agencies on an extensive scale to assess the status of
the reproductive system of each and every gas affected woman. On this basis
adequate compensation should be given to those who have suffered from
these problems.
2) The menstrual and other gynaecological disorders reported above should
be kept in mind by all health personnel in Bhopal, while dealing with their
patients. Women with these problems should be listened to with respect and
proper treatment be given to them. If these problems continue to be attributed
to ‘‘compensation-neurosis;’ or to “usual bad hygiene of poor women” these
women would continue to suffer silently due to this neglect. At least now
let there be a proper recognition of the fact of these gynaecological problems
and their cause. Would this be too much to expect from the health authorities
in Bhopal?
References
[1]
“The Bhopal Disaster Aftermath, An Epidemiological and Socio-medical Study”
MFC, March, 1985.
[2]
“Effects of Bhopal Disaster on women’s Health—An Epidemic of Gynaecological
Diseases” (Part I) Mimeograph, Rani Bagh and Mira Sadgopal, 1985.
[3]
“Medical Relief and Research in Bhopal—The Realities and Recommendations”,
MFC report, Abhay Bang et al, February, 1985.
[4]
“An Epidemiological and Sociological Study of the Bhopal Tragedy”, Centre for
Social Medicine and Community Health, JNU, unpublished.
[5]
‘Accuracy of spontaneous abortion recall’, Am J of Epid, Wilcox A J, 120 (5): 729-33.
[6]
See [2] above.
[7]
‘Medical Survey on Bhopal gas victims’: May 85 “The Nagrik Study”.
[8]
‘Spontaneous abortion as a screening device, the effects of foetal survival on the
incidence of birth defects’, Am J of Epid, 102: 275-90, 1975 Stein et al.
6
AGAINST ALL ODDS
The Health Status of the Bhopal Survivors
AGAINST ALL ODDS
Continuing effects of the Toxic Gases on the
Health Status of the Surviving Population
in Bhopal
Preliminary Report of a Medical Study carried out
Five Years after the Disaster
Coordinated by
Dr. C. Sathyamala
Dr. Nishith Vohra
K.
Satish
with technical help from
The Centre for
Community Health and Social Medicine
JNU, New Delhi
Copies can be had from
CEC
F-20 (GF) Jangpura Extn.
New Delhi-110014
oj-iiio
December 1989
For private circulation only
Contributory Price Rs 15/-
Cover Design: K.P. Sasi and Ratna Mathur
Printed at Kaipana Printing House, L-4 Green Park Extension,
New Deihi-110016.
CONTENTS
Pages
1. Voices From Bhopal
v
2.
Names of those who made the survey a reality
vii
3.
Introduction
1
4.
Part I : Continuing Effects of the Toxic gases on the
Affected Population in Bhopal
3
Part II : Critique of the Processing of claims by the
Directorate of Claims, Bhopal
32
6.
Annexure I : Rationale and Criteria for Diagnosis
41
7,
Annexure II : Preliminary Report on Psychiatric Mor
bidity
47
Annexure III: Copy of the 'Personal Injury Evaluation'
Form issued by the Directorate of Claims, Bhopal
49
5.
8.
aYta
vrtniFT
VOICES FROM BHOPAL
HT5J §Y 4q J
1)
ff’iaT I ^hY 3Y^ a
I
xstYtt aY, 60 aa, gara ant:
So many years have gone by ; it feels as though we will
never get well again.
Rashida bi, 60 years. Subhash Nagar
tT’TST I a?at^ OTF <ptr tY I
2)
ST'StJT o
SfpfY aatf
<fY a 7 STFtT
I
faf?TT aY, 49 aa, ^aY star
Sometimes I wish Allah would release us from this life.
would be better to die than have so much medicine.
It
Bilkis bi, 49 years, Kainchi Chola
ataY aY sea ^Y aiq i a-a'r
3) aa at aaaY farcaY aisY
<Yar ?
aar
stair aY^a, 40 aa, ato aY<> aaT
Now I am just a living corpse, death can come any moment.
What will happen to my children?
Abrar Mohan, 40 years, J.P. Nagar.
4) <5TrY snaaY aa ana ^r?a |Y aq i aaa a'Y caa
attY aY a§
a^aYT a aa ara i afa^a a'r aa ara? §Y |i
fa^tTYata, 60 aa,
aY® aa^
Thousands of people died then. If I had died too, I would
have at least escaped this torture. Now the future is only
hell.
Bihari Lal, 60 years, J.P. Nagar.
5)
htt
a"Y aaar | a?<Y ?aa faatT arq i sfY^x: aY wt TTat | ?
afaa, 19 aa, 'sst aarau
I feel I should simply die.
What is the use of living anyway?
Nargis, 19 years, Phoota Magbara.
v
6)
aa wa gwtaa Sr ht a rtf at w^r i aa tarf aaSr aa^<t fa? ja
a^r aaat i ata aaat f afa ata aa%, ^ar aaat ?
awaif, 35 aa, rafa aaz
Only death can relieve us of this misery now. Ever since the
gas, we can't even work. I have three daughters and three
sons. How will we ever manage?
Tarabai, 35 years, Garib Nagar.
7)
faaia Sr fan arat | fa aa aa aaiar faa
ffaata a<f | i sforc
|, aar ? aaa aaar | i
aatg^ta, 30 aa, tth affaa
I keep thinking I don't have many more days to live.
is this? Is it cancer?
Salimuddin, 30 years.
What
Ram Mandir.
NAMES OF THOSE WHO MADE THE SURVEY A REALITY
1. Survey Team {Genera/ Survey)
16. Satinath Sarangi
Bhopal
1. Anurag Modi
Bombay
17. Sudhama
Bhopal
2. Anu Gupta
Devas
18. Santosh
Bhopal
3. Christ Paul
Bhopal
19. Suresh
Bhopal
4. Farhat Baig
Bombay
20. Verghese Abraham
Bhopal
5. Jyoti Kapoor
Delhi
21. Shobha Sadgopan
Bombay
6. Joice Abraham
Bhopal
11. Survey Team {Medical)
7. Manoj Chaturvedi
Bhopal
8. Meenakshi
Delhi
9. Rajeev Singh
Delhi
10. Rajeev Jaiswa I
Bhopal
11. Rupande Panalal
Bombay
12. Sheena
Delhi
6. Dr. Mital Anukant
Bombay
13. Sanskruti Thaker
Bombay
7. Dr. Punya Brata Gun
Durg
14. Satyabrata Kar
Calcutta
8. Dr. Pradip Saha
Calcutta
15. Santosh K.C.
Delhi
/9. Dr. Prabir
Calcutta
1. Dr. Abdulla Manima
Kerala
v/2. Dr. Binayak Sen
Raipur
3. Dr. Gokul Dev
Kerala
4. Dr. Gautam Saha
Calcutta
,y5. Dr. Mira Shiva
Delhi
10. Dr. Prasanthan T
Kerala
V. Help with the Critique of Processing of Claims
11. Dr. Rajeev Lochan
Indore
1. Dr. Anil Sadgopal
Delhi
12. Dr. P. Sivashankaran
Kerala
2. Dr. Bhavna Parekh
Bombay
13. Dr. Vinod Joshi
Bombay
3. Dr. D. Banneijee
Delhi
14. Dr. Yogesh Jain
Delhi
4. Dr. Deshmukh D K
Bombay
5. Dr. Imrana Qadeer
Delhi
6. Dr. Mohan Rao
Delhi
7. Nalini Bhanot
Delhi
8. Dr. Suresh Babu
Kerala
9. Dr. Subadra Nair
Kerala
10. Sagar Dhara
Delhi
11. Dr. Ramana Dhara
USA
-12. Dr. Ritu Priya
Delhi
III. Survey Team (Women's)
1. Bharti
Delhi
2. Devi Kripa
Delhi
3. Gyan Wati
4. Maharani
5. Nirmala Kitchi S
6. Prem
7. Sarojini
8. Tul Tul
Delhi
Delhi
Delhi
Delhi
Delhi
Bhopal
IV. Technical Help for Survey Design
•/1. Dr. Imrana Qadeer
V2. Dr. Mohan Rao
3. Dr. Nayar
4. Subhash Ganguly
VI. Technical Help for Medical Diagnosis
Dept, of Community
Health and Social
Medicine, JNU, Delhi
Calcutta
1. Dr. Bhavna Parekh
Bombay
2. Dr. Gill H
Bombay
3. Dr. Satish Tibrewala
Bombay
4. Dr. Vikram Lele
Bombay
VIII. Special Thanks To :
5. Dr. Yatin Dholakia
Bombay
1. Suhasini Mulay and Tapan Bose of NRPC
for allowing us easy access to the NRPC data.
VII. Help with Coding and Analysis of Data
1. Aditi Aiyar
Bombay
2. Anurag Modi
Bombay
3. Dr. Bhavna Paiekh
Bombay
4. Farhat Baig
Bombay
5. Hari
Bombay
6. Himanshu Vohra
Bombay
7. Kinnari Vohra
Bombay
8. Dr Prakash Gangdev
9. Rupande Pannalal
10. Ravindranathan
11. Sujatha Modi
12. Sandeep Kanwar
13. Tul Tul
^4. Dr Binayak Sen
15. Dr Vinod Joshi
X6. Dr Yogesh Jain
17. Rajani Vohra
Bombay
Bombay
Delhi
Delh'
Delfr
Bhopal
Raipur
Bombay
Bombay
Bombay
2. Snehalata Gupta — Delhi, without whom we
would not have had a proforma to fill.
3.
Vamadevan, Ramesh, Anita Poovathingal,
Deenadayalan, Ravi, Nalini Bhanot — Delhi.
4.
Mittal, Bombay, for the use of his room.
5.
The team from the Centre for Community
Health and Social Medicine, JNU, Delhi.
6.
The Department of Psychiatry, J J Hospital,
Bombay.
7.
Centre for Education and Communication,
CENDIT, EKALAVYA for use of their Infra
structure Facility.
8.
ENVIROTECH for lending their Peak-flow
Meters.
And All Those Who Collected Funds For This
Survey.
10. Centre for Education and Communication, Delhi,
for financial help with the printing of this report.
9.
INTRODUCTION
In Bhopal, since the gas leak disaster of 2/3 Dec. 1984,
several studies, by both governmental and non-governmental
organizations, have been carried out to assess the health effects
of the toxic gases on the survivors of the disaster. The informa
tion gathered through these studies together with the evidence
from laboratory studies, have shown the gases to cause extensive
damage to several systems in the body, to affect reproductive
health by an increase in spontaneous abortions, still birth rate
etc, to decrease life expectancy due to premature senility and has
raised the serious possibility of delayed effects due to changes
in the immune system, genetic damage and mutagenic changes
in the survivors.
Apart from the effect of the toxic gases on physical health,
the traumatic event of the disaster, an event outside the range
of normal human experience, has had a serious, widespread effect
on the mental health of the victims, resulting in depression, ad
justment disorders and post traumatic stress disorders. The
disruption in family due to deaths and illness, fall in income be
cause of a decreased or a total inability to earn a livelihood has
contributed further to the overall decline in general health status
and in the sense of well-being in the individual and has led to
the destruction of the integrity of family and community life.
Around mid Jan 1987, two years after the disaster, the Madhya
Pradesh government, in order to provide medical documentary
evidence for all the claimants in the case against the Multinational
Union Carbide Corporation responsible for the disaster, initiated
the process of assessing personal injuries in approximately 6,00,000
persons who had filed claims. However in 1989, two years after
the process of medical evaluation had started, less than 10% of
the claimants had been assessed for personal injuries.
Therefore, when in Feb. 1989 the Supreme Court settled the
case against Union Carbide, the amount of money settled for
1
was not on basis of assessment of all the 6,00,000 odd claimants
but on the basis of some figures arrived at arbitrarily. The clari
fication order of the Supreme Court in May 1989 gave the figures
on which calculations for compensation had been based viz,
fatal cases at 3000, permanent total and partial disability at
30,000 temporary total or partial disability at 20,000, and
minor injuries at 50,000. According to the order, the basis
tor arriving at a figure of 30,000 permanent total and partial disaability was not on any epidemiological evidence but was based
on the assumption that, "it would not be unreasonable to expect
that persons suffering serious and substantially compensatable
injuries would have gone to hospitals for treatment." Therefore,
on the basis of records from the hospitals of cases treated at Bho
pal 30,000 was taken by the Supreme Court as that of permanent
partial and total disability.
A further shock awaited, when the MP government present
ed the numbers of claimants whose injuries had been assessed
and categorized. According to their affidavit submitted in the
Supreme Court in the Interim Relief Petition on 25th August, 1989,
out of the total 2,04,000 medical folders evaluated, 1,23,560 had
been categorized. Out of this, only 19 were in the category of
permanent total disablement and another 762 were in the categoty
of permanent partial disablement. An extrapolation meant that
out of the 6,00,000 claimants, approximately 4,000 would finally
be categorized as permanent partial and total disability, one seventh
of the already low figure on which settlement amount had been
calculated.
To challenge these figures of disablement, carrying out a
cross sectional study of the entire gas exposed population was
out of the question for any "voluntary" effort. We therefore,
limited our objectives to providing evidence to challenge the
methodology of categorization evolved by the Directorate of
claims, Bhopal Gas leak Tragedy, Madhya Pradesh.
2
PART !
Continuing effects of the toxic gases on
the affected Population in Bhopal
Preliminary Report of a Medical Survey
(15-22 Oct. 1989)
In the immediate aftermath of the Bhopal disaster, several
estimates were made on the quantum of morbidity in the sur
viving population. According to an ICMR manual, approximately
2,00,000 persons who had inhaled the gas "took ill". The Nagarik
Rahat Aui Punarvas Committee study reported that approximately
1,07,249 persons exposed to the gas were seen to have persistent
medical disability of "some kind or the other" in March 1985.
The Medico Friend Circle in their epidemiological study (March
85), observed that even in the population living 10 Kms from the
Union Carbide factory (Bhopal), that was chosen as the "Control"
population (this population also forms part of the ICMR control),
serious health problems could be discerned and that "strictly
speaking" it could not be considered non-exposed.
Broadly, the conclusion was, that almost the total population
that was axposed to the gas, suffered from health problem in the
immediate period following the gas leak or at least upt.ll March
85. Given the prognosis of these illnesses that was predicted
at that point of time, and the evidence available later through
published reports of the laboratory studies, the MP government's
assessment of personal injuries on the basis of medical evaluation
seemed to be grossly inadequate. Since, most of the voluntary
efforts which supplied some of the critical information weie con
fined to the first year of the gas leak, the evidence necessary to
challenge the MP government's estimate was available only with
the governmental organisations such as the ICMR, Dept of Relief
and Rehabilitation, (Bhopal Gas leak Tragedy) etc., involved with
medical research in Bhopal.
3
To carry out a cross sectional study of the entire exposed
population to assess current morbidity, was out of question for
any voluntary effort. The objectives of the study had to focus on
gatheiing information that would be of direct and immediate use
in strengthening the case of the gas affected victims.
The first step was in developing a critique of the methodology
of processing of claims adopted by the Directorate of Claims,
Bhopal. (A detailed critique of the processing of claims forms
Part II of this report).
Briefly, the methodology of assessing personal injury by
the Directorate of Claims, Bhopal, is based on a scoring system.
Each claimant is allotted marks for his/her suffeiing in the post
gas leak period as well as that on the date of examination. The
two scores are then compared to arrive at a category. This method
adopted by the Directorate of Claims, for evaluating personal
injuries, is based on inadequate information, is arbitrary, and works
against the interests of the gas victims.
—The medical record prepared by the Directorate of Claims
contains information relating only to injury, and there is no
information to assess the disability of a claimant. Yet,
the categorization process, claims to be able to differen
tiate claimants into the category of injured and/or disabled.
—A system, that uses marks to assess the health status of
the claimant, gives an inaccurate picture of the nature and
extent of injury and it also gives an inaccurate picture
of the current health status.
—The system does not take into account the possible future
outcome of each of the gas related effect on the claimant.
—The method of comparing the scores in the post exposure
period and current health status is arbitrary because the
conditions in the acute, sub-acute and chronic phase of a
'disease' cannot be compared.
—The scoring system in the current health status treats the
different body systems, investigations, and even specialists
opinion in an unscient'rfic manner by placing them in an
arbitrary hierarchy.
4
—The scoring system in the post exposure period is unfair
to the claimant because it is based solely on the production
of records by the claimant as proof of ill health, the onus
of proof for injury thus resting squarely on the claimant.
In order to substantiate the theoretical critique of the pro
cessing of claims, there was need for some hard data. The Second
step therefore lay in gaining access to the completed medical
records of the claimants who had been categorized by the Direc
torate of Claims, Bhopal. Although the Supreme Court passed
an order to the effect that the Directorate of Claims should
provide a copy of the medical record of the claimant, on the clai
mant's request, machinery necessary for this provision is yet to
be set in motion.
It therefore became imperative that evidence be collected
on the nature of injuries of the gas affected victims in Bhopal
today by using a different method for assessing their injuries.
Objectives of the Study
Keeping the critique of the processing of claims in view,
the following objectives were defined for the study.
1. To determine the status of claims in the gas affected po
pulation.
2. To determine the quality of claims' assessment r.e., medi
cal injury evaluation and categorization of the claimant.
3.
To determine the extent of current morbidity in the popu
lation.
4.
To assess the effect of gases on the children exposed to
them in-utero.
5.
To determine the natural history of "disease" in the affect
ed population.
6.
To explore the existence of "new" symptoms which
could indicate the delayed effects of the gas.
7.
To study the effect of gas on fertility.
Data Collection :
Data for the study was collected between the 15-22 Oct.
1989 by 34 persons who gave of their time and energy voluntarily.
5
This report presents the preliminary findings of the medical
survey based on only part of the data that has been analyzed and
covers the first two objectives. The final report with statistical
analysis of the complete data will be published later.
The Study Population :
The Study population was from 11 of the most seriously
affected and 1 from the mildly affected bastis in Bhopal. The
individuals surveyed in March 1985 (3 months after the gas leak)
from these bastis by the two non-governmental organizations viz
*
NRPC
and MFC
**
formed our study population. Rather than
take a fresh sample, the decision to study the individuals from
the NRPC and MFC sample was taken because of the possibility
of easy access to their medical records of March 1985 in the form
of the proforma filled by the earlier survey teams. Hence, although
it meant that a considerable amount of time had to be spent in
locating the households and individuals surveyed in the NRPC
and MFC survey (as five years had passed), the time was thought
to be well spent.
Apart from these previous studies' sample, a fresh sample
was taken to study the effect of the gases on the menstrual and
reproductive health of the women between the age group of 8
to 80 years.
Since, previously, several weeks had been spent by part of
the team in locating the households, rapport had already been
established with the basti people. Communication was facilitat
ed further by the distribution of a Hindi pamphlet describing our
objectives during the survey.
Table I gives a description of the study population.
♦NRPC : Nagrik Rabat Aur Punarvas Committee, Bhopal organized a study in
March 1985 in Bhopal, in collaboration with the Voluntary Health Association
of India and with the cooperation of Bhopal Relief Trust, Bombay. The survey
was carried out by a team of doctors and technicians from Bombay Municipal
Corporation.
“Medico Friends Circle, an all India group of medicos carried out a medical
survey in Bhopal in March 1985 with the help of their members and three doc
tors from the Baroda Medical College.
6
TABLE
I
Study Population
(For which Preliminary Data is presented)
Individuals Characteristic of Po
Covered in pulation
the present
Study
Original
Selection
Sample
Sample
Name of Basti
MFC (Group 1)
J.P. Nagar
107
Age group 1-15
Random, using ICMR
No.
MFC (Group III)
Anna Nagar
82
Age group+ 15
Random, using ICMR
No.
NRPC (Group II)
(1) Kainchi Chola
214
Age group----- 5
Random, using House
(2) Garib Nagar
(3) Oriya Basti
(4) Ram Mandir
(5) Phoota Maqbara
(6) Rajgarh Colony
No.
co
Sample
Name of Basti
(7)
Subhash Nagar
(8)
Railway Colony
(9)
Chola Mandir
Families included in
previous studies (MFC
& NRPC)
Individuals Characteristic of PoCovered in puiation
the present
Study
Original
Selection
Sample
169***
All age groups
—
Fresh Sample
(Group IV)
(1) J.P. Nagar
(2) Kazi Camp
397
Women 8-80 Yrs.
Random, using ICMR
No.
(Group V)
(3) Anna Nagar
283
Women 8-80 Yrs.
Hiouse to House
*AII Bastis except Anna Nagar fall in the seriously affected areas. Anna Nagar, though considered a
'control', is in reality a mildly exposed area.
**No. of Families covered.
Methodology
:
To assess injuries to the different body systems, the method
adopted in our study was the one that is followed in routine clini
cal practice. This was to arrive at a clinical diagnosis for each
of the individual surveyed based on history and physical exami
nation. The clinician was then to recommend a list of investi
gations and specialists' opinion to confirm the tentative diagnosis.
To assist in this effort, and to standardize procedures, a diagnos
tic criteria for each of the gas related condition was prepared along
with a standardized criteria for referral, to both specialists and for
investigations. (Annexure I).
The individuals in the sample were administered a pre-tested
pre-designed, proforma on their "health" status as well as a pro
forma seeking information about the family, by a non-medical
volunteer. This was followed by a complete history taking and
examination by a medical volunteer. Written instructions were
given to both the medical and non-medical volunteers for filling
in the proforma. In addition, the medical volunteers were given
a copy of the profile of the gas victims which was a compilation
of all the salient findings from several studies that has been carried
out since Dec. 1984, on the effect of the toxic gases on the body
systems.
The non-medical proforma was designed along the lines
of Claim Form, Part B, issued by the Directorate of claims, Bhopal,
with additional critical questions necessary to assess overall health
status. The medical proforma dealt with detailed 'history' tak
ing and clinical findings. The family proforma contained details
about the status of claims with regard to all the family members
of the individual surveyed.
Results
I.
Current Health Status of the Surveyed Population :
Almost all the individuals in the surveyed population in both
the seriously and mildly affected area were diagnosed by the exa
mining doctor in the survey team as either suffering from an ill
ness or requiring investigations and/or specialist opinion to rule
out an illness. The systems affected were respiratory, eye, gastro
intestinal, neuro muscular, musculo-skeletal, reproductive, and
mental health.
9
Each of the tables given at the end of Part I, give the details
of the number of persons from the sample who have been diag
nosed by the doctor in the Survey team to have an illness. These
diagnos.s have beejn made on the basis of history and clinical exa
mination, and remain to be confirmed by investigations. The
rationale and criteria of diagnosis has been annexed to this report.
1. Physical Health
A.
Respiratory System :
70% of the sample from the seriously affected area and 19.5%
of the sample from the mildly affected area reported breathless
ness as a symptom. Of those reporting breathlessness from the
seriously affected area, 72% could be diagnosed as having breath
lessness due to respiratory illness, which includes 55.6% who
are likely to have allergic alveolitis or chronic obstructive lung
disease (with or without a history of repeated infections); 4.5%
could be diagnosed as allergic alveolitis and 9.8% as chronic obs
tructive lung disease solely on the basis of history and Clinical
examination, but the diagnosis of the rest need to be confirmed
by investigations. In 27.5% of those reporting breathlessness in
the seriously affected area, it could be ascertained through history
that the breathlessness was not probably of respiratory origin.
Table II gives the distribution of the different respiratory illnesses
in the affected population.
B.
Gastro-intestinal system :
26% of the sample from the seriously affected area and 6.1%
of that from the mildly affected area had symptoms related to
upper gastro-intestinal system. Of those reporting upper gastro
intestinal symptoms from the seriously affected area, 42% possibly
suffer from atrophic gastritis; 24% from oesophagitis; 33% from
either of these two or duodenal ulcer. 2.8% of these had hepato
splenomegaly (englarged liver and spleen). Table III gives the
distribution of the different gastro-intestinal conditions in the
affected population.
C.
Eye:
From the seriously affected area, 71% of the sample and
35% from mildly affected area were diagnosed to have an eye
10
disease. Chronic conjunctivitis was diagnosed in 56% of the
seriously affected and 20% of the mildly affected sample, followed
by decreased visual acuity for both distant and near in 21% and
10%. Corneal opacity was seen in 3.4% of the seriously affected
sample and 2.4% from the mildly affected area.
The ICMR has admitted that there has been an increased
incidence of cataract in the gas exposed population following gas
leak. Our data shows an overall prevalence of 16% (seriously
affected) and 12% (mildly affected) cataract in the sample. When
prevalence of cataract is seen in relation to age, 8.4% of the sample
in the seriously affected and 3.7% of the sample in the mildly
affected, was seen to have cataract below the age of 50 years.
Table IV gives the distribution of diseases related to eyes.
D.
Neuro-musculo-Skeletal system :
66% of the individuals from the sample in seriously affected
area and 33% from the ^mildly affected area reported symptoms
related to neuro-musculo-skeletal system. 41% from seriously
affected area and 24% from mildly affected area reported muscle
ache; muscle fatigue in 30% and 8.5%; and joint pains in 27%
and 11% respectively. Table V gives the distribution of neuiomusculo-skeietal disordeis in the sample population.
E.
Sexual Disorders :
Of the surveyed population, 13% of the individuals in the
seriously affected area and 8.5% from the midly affected area re
ported a loss in Libido. Impotency was reported in 3.4% and 1.2%
respectively. Table VI gives the distribution of sexual disorders.
F.
Menstrual Disorders :
Even five years after the gas leak, a large number of women
continue to have menstrual problems. Unfortunately, in the pro
cessing of claims, gynaecological problems have not been given
adequate weightage. ICMR has infact categorically stated that
they do not have any evidence to show that an increase in dysfunc
tional uterine bleeding, chronic cervicitis, non-specific leucorrhoea
and, pelvic inflammatory diseases is gas related.
Our study shows that menstrual problems in the seriously
affected population is high, with 64.7% of women (19-44 years)
(W?
j IO
COMMUNITY health cell.
326, V Main, I Block
^0-aniongala
bangalore-560034 " ■
India
/
in the seriously affected area and 47.6% (19-44 years) in the midiy
affected area reporting at least one symptom related to gynae
problems.
The distribution of gynae problems show an increase in dysmenorrhoea, irregularity in menstrual cycle, excessive vaginal
discharge, increased blood loss during menstruation, shortening
of menstrual cycles and scanty periods, in women aged 8-80 years
in the seriously affected area. Table VII and VIII give the overall
prevalence of gynae problems in women aged 19-44 years and
their distribution.
2. Mental Health
Post traumatic stress disorder (PTSD)
*
is a disorder which
characteristically develops following a psychologically traumatic
event that is generally outside the range of usual human expe
rience. This disorder is well described in survivors of several na
tural and man-made disasters eg; Coconut Grove, Buffalo Creek
disasters and among Vietnam veterans and prisoners in concentra
tion camps.
PTSD increases over a period of time and has infact been
described in survivors of prisoners of war. World war II, even
after a lapse of 40 years. It is also well known that "manufactur
ed" disasters as compared to natural disasters, regularly produce a
higher prevalence of PTSD.
Using the diagnostic criteria of DSM III R, an attempt was
made to study the prevalence of PTSD in the survivors of the
manufactured disaster in Bhopal. In the surveyed population
PTSD was diagnosed in 39% of the individuals in the seriously
affected area and 26% of the mildly affected. Adjustment disorders
with or without depression were diagnosed in 18% and 10%
respectively. 27% and 21% in the seriously and mildly affected
area had psychiatric symptoms which needed further exploration.
Thus almost 80% of the individuals in the seriously affected area
and 56% in the mildly affected area reported symptoms related to
mental health. Table IX gives the distribution of psychiatric ill
ness in the surveyed population.
•For further information on PTSD refer DSM-III-R. "Diagnostic and Statstical
Manual of Mental Disorder", 3rd Edition.
12
Referral to the psychiatrist in the survey team:
Presence of one or more symptoms related to mental health
was the criteria used for referral to the qualified psychiatrist in the
survey team. Due to a lack of time only 70 out of the 317 in
dividuals thus referred, from both seriously and mildly affected
area could be examined by the psychiatrists. Out of these 70
examined, diagnosis of PTSD was confirmed in 40 individuals
(57.14%); Adjustment disorder with or without depression in 10
(14.3%); and 3 individuals were diagnosed to have other psychia
tric illnesses. 17 of the total 70 individuals examined i.e. 24.3%
were not found to be psychiatrically ill. The clinical severity
ranged from moderate to severe in 45 out of 53 psychiatrically
ill individuals i.e., the illness was severe enough to affect their
day to day living grossly. A preliminary statement on the psy
chiatric morbidity as assessed by the psychiatrists is annexed
(Annexure-ll).
II.
General Morbidity
A.
Fever :
Animal studies and studies on the immune system in the gas
affected population have shown an adverse effect of the toxic
gases on immune response. Repeated infections could be one
of the manifestations of such a disturbance, fever being an accept
ed indicator. Three or more episodes of "definite" fever in 3
months is a reflection of repeated infections with a resultant cycli
cal effect on health of the affected population. Fever in the last
week is a reflection of current ill health in the population surveyed.
23.57% of the total population surveyed reported fever last
ing for more than 3 days in the week preceeding the date of survey.
Three or more than three episodes of fever in the last three months,
was reported by 31.76% of the individuals surveyed (Table X).
B.
Medications :
In the seriously affected area more than 40% of the indivi
duals were on some form of allopathic medication on the day of
the survey, whereas in the mildly affected area 20% were on medi•Two psychiatrists from the Department of psychiatry, J J Hospital, Bombay
formed part of the survey team.
13
cation. Allopathic medicines are generally more expensive and
the fact that even five years after the gas leak, an impoverished
population continues to spend its meagre earnings on medicines
is a reflection of the status of health. Table XI gives the number
of individuals who were on some form of allopathic medication
in the surveyed population at the time of survey.
C.
Individuals diagnosed to have tuberculosis :
Since the gas leak, a large number of individuals are being
diagnosed, rightly or wrongly, as having pulmonary tuberculosis,
ICMR claims that there has been a real "flare up" of tuberculosis
since gas leak as a result of toxic gases. 25 individuals from the
most seriously affected area and 2 individuals from the mildly
affected area reported that they had been diagnosed as having
pulmonary tuberculosis by a "doctor". The prevalence in the most
seriously affected area i.e., 7.8%, is three and a half times higher
than the national average whereas, in the mildly affected area,
only 2.43% had been diagnosed to have tuberculosis which com
pares well with the national average of 2%.
*
Of the individuals who reported a diagnosis of tuberculosis
only 10 (or 37%) were on anti-TB treatment currently. The rea
sons for not taking treatment was not inquired into. Table XII
gives the details of those who were diagnosed to have tuberculosis
in the post exposure period.
The National Tuberculosis Control programme is known to
have a high default rate, the 'default' being the reflection of the
inability of the programme to maintain adequate follow up. If,
as the ICMR states, there has indeed been a flare up of tuber
culosis in the gas affected area, the authorities concerned should
have taken up case detection and treatment in a more concert
ed way. The fact that only 37% of the individuals who were
diagnosed to have tuberculosis are taking anti TBtreatment isasad
reflection of the state of medical relief to Bhopal victims.
*We are not in a position to confirm the diagnosis in these individuals due to lack
of information about the basis of diagnosis. A large number of gas victims are
being diagnosed as tuberculosis on the basis of chest X-ray findings which in
the case of gas victims may not be an adequate tool as the toxic gases them
selves are known to have caused similar chest X-ray findings.
14
D.
Impairment in the ability to work :
The respondents were asked an open ended question re
garding their ability to woik before and after gas leak. Overall,
from the individuals in the seriously affected area, 90% of those
engaged in an income generating activity and 90% of those engag
ed in non-income generating activity reported a decrease in their
ability to carry out the respective activities since gas leak. Table
XIII gives the detail of the reported inability to work. Although no
attempt was made to assess a fall in income in those whose ability
to carry on income generating activity has been affected, it goes
without saying that all 90% of persons in the sample (and their
families) have experienced a fall in income since gas leak lesulting
in a further socio-economic deterioration.
III.
Status of Claims
According to the Directorate of Claims, Bhopal, approximately
6,00,000 individuals have registered their claims under the Bhopal
Act. On the basis of the critique of the processing of claims,
there was a need to collect information on the problems related
to filing of claims, completion of formalities for medical evalua
tion and a need to assess the parameters by which the personal
injury of a claimant was being assessed by the Directorate of
claims.
A.
Problems related to the filing of claims :
Table XIV gives the status of claims of the 403 individuals
surveyed and the status of claims of all the individuals in their
families. Approximately 20 to 30% of the individual in the sample
had not filed their claims. A major reason for not filing claims was
that initially, when claims were being registered, those aged less
than 18 years were informed to register their claims along with
one of the parents. This rule was changed laterand all individuals,
irrespective of age, were to be considered as separate claimants.
Since this information on the changed criteria for filing claims
was not communicated adequately by the Directorate of Claims,
a sizeable proportion of the population (aged 5-23 yrs as of today)
is yet to file claims for injuries suffered. Approximatly 61% of
those who had not filed claims gave this as the reason.
The other important reasons for not filing claims were the
inconvenient procedures (long queues, delays, loss of wages).
15
and inadequate information on the procedure. Three of the res
pondents reported that they were too ill to stand in the queue.
B.
Problems related to the procedure of personal injury evaluation :
The Directorate of Claims, Bhopal has claimed that 40% of
the registered claimants have not "turned up" for medical exami
nation despite being sent three notices.
Among the surveyed population who had filed claims, app
roximately 20-25% are yet to be medically examined for personal
injury evaluation. Among reasons for not "presenting" them
selves for medical examination, 58.3% had not received a single
notice; 18.3% coud not go on the appointed day because of ill
health or loss of wages. Either because they were not in town on
the appointed day or were delayed in reaching at the appointed
time, 13% of the individuals were refused examination.
C. Assessment of the parameters used by the Directorate of Claims
in persona! injury evaluation :
The entile method of personal injury evaluation as devised
by the Directorate of Claims, Bhopal, revolves around the ability
of the claimant to produce medical records documenting his/her
injuries since the gas leak.
1.
Availability of OP records :
Table XV gives details of the number of individuals who re
ported symptoms in the immediate post gas leak period (0-1 month)
and their ability to produce records for out-patient treatment in
that month. Out of the 98% of the individuals in the seriously
affected area who reported symptoms in the immediate post gas
leak period, only 35% could produce record as "proof" of their
treatment.
2.
Availability of in-patient records :
It may be argued that even if the claimant was unable to
produce out-patient record, a claimant so ill as to have stayed in a
hospital could surely be able to produce some proof for hospital
admission.
16
Table XVI gives details about the availability of records
for hospital admission in the post exposure period
.
*
Out of the
total of 200 episodes of hospital admission in the sample from the
most seriously affected area, only in 53.5% of the cases, records
were available.
3.
Quality of
Medical
Injury Assessment
:
Since we do not possess the medical records of the respon
dents prepared by the Directorate of Claims, Bhopal, we are not
in a position to comment on the quality of history taking, and medi
cal examination of the examining doctors.
4.
Adequacy of investigations ordered and referrals given:
According to the "Guidelines For the Medical Officers" pre
pared by the Directorate of Claims, Bhopal, the investigations the
examining doctor can order for a claimant are chest X-ray, Pulmo
nary Function Tests (PFT), Exercise Tolerance Test (ETT) and
Urinary thiocyanate (UScn).
The method of categorization evolved by the Directorate of
Claims, claims to assess "disability". Since there is no infor
mation contained in Part B of the medical records prepared by the
Directorate, the attempt made is probably to assess "functional"
impairment. For measuring functional impairment of the res
piratory system, PFT and ETT are the only two investigations listed
in the guidelines to medical officers.
Chest X-ray is one of the
important investigations for diagnosis of illness.
As the table XVII shows, PFT and ETT are done in barely
14% and 1% of the sample surveyed whereas chest X-ray is done
for more than 70% of the sample surveyed. To measure functio
nal impairment of the respiratory system, at least a detailed PFT
and ETT with a Dyspnoea Index should be carried out in all the
claimants complaining of dyspnoea.
Of the sample, our assessment is that more than 60% require
PFT and ETT before the impaiiment in their respiratory function
can be measured.
♦Great effort and time was taken by the survey team to go through all the records
a respondent possessed which would perhaps not be the case in the medical
assessment camps.
17
Accoiding to an ICMR guidelines, all individuals having res
piratory, gastro intestinal, or neuro-muscular symptoms should
have their urinary thiocyanate measured. Since this is a suggest
ed investigation for measuring the toxins in the body, this investi
gation remains significant. The Directorate of Claims has carried
out this investigation in 77% of those they have assessed for per
sonal injury from the sample whereas, the survey team's recommen
dation is that it should be carried out in 83% of the sample.
In terms of referral to specialists, it is obvious from the fact
that only one person from our sample was referred by the Direc
torate of Claims to a psychiatrist, a gross under estimation of
psychiatric illness is taking place. According to the survey team,
80% of the sample population need to be referred to a psychiatrist.
The failure on the part of the examining doctor assessing personal
injuries, could be due to the faulty criteria requiring 3 symptoms
or more for a referral, or could be a deliberate attempt on the part
of the Directorate of Claims to underestimate psychiatric morbi
dity. All individuals with even one psychiatric symptom need to
be referred to a psychiatrist since a Graduate medical officer does
not possess the necessary skills to unmask all the psychiatric
symptoms.
Similarly, in terms of referral to an ophthalmologist, all per
sons with any eye disease need to be referred for correct diagnosis
and treatment. According to the survey team, 64% of the sample
need referral to an ophthalmologist while only 17% had been
referred by the Directorate of Claims.
Conclusion :
18
1.
70-80% of the gas affected population in the seriously
affected area and 40-50% from the mildly affected area
in Bhopal suffer from a medically diagnosed illness even
five years after the gas leak.
2.
The major systems affected are respiratory, eye, gastro
intestinal and musculo skeletal.
3
A large proportion of women from both the seriously
affected and mildly affected area continue to report mens
trual disturbances.
4. Post traumatic stress disorder (PTSD) is gas related and
therefore a definitely compensatable disorder. Mental
health problems, particularly PTSD is a serious problem,
among the survivors.
5.
The process of personal Injury Evaluation as carried out
by the Directorate of Claims is designed to underestimate
both the nature and volume of injuries in the gas affected
population.
6.
Categorization of claims is being carried out by the Di
rectorate of Claims on the basis of insufficient investiga
tions and specialists' opinion.
7.
A considerable proportion of the population is yet to file
claims or to be assessed for personal injury evaluation.
Recommendations :
1. More concerted effort should be made to contact all the
affected people to register claims and for assessing per
sonal injuries.
2. Personal Injury Evaluation should be on the basis of a
pathophysiological diagnosis and not on an arbitrary
scoring system. The diagnosis should include a battery
of investigations which must be carried out in all claimants
who require it before the verdict of 'no injury' is given.
These investigations should range from gastroscopy in
all those reporting upper gastrointestinal symptoms to
measuring the different parameters of the immune system
even in those reporting only cyclical illhealth or repeated
infections.
3.
Serious effort is required to assess the mental health
problems both for claiming 'damages' and for treatment.
4.
The processing of claims for personal injury evaluation
should not be an exercise unrelated to the provision of
medical relief and rehabilitation of gas victims. The issue
of medical relief and rehabilitation continues to be a major
need of the gas victims even five years after the disaster.
5.
At present the Directorate of Claims expects the victims
to provide proof of their own injuries. Instead, the onus
should be with the government and the Union Carbide
Corporation to prove that the victims are not injured.
19
N3
O
TABLE
II
Respiratory Illness
Sample
Number
Breathlessness Due to Respiratory Illness
Reporting Dyspnoea Allergic ANeio litis
Dyspnoea of Respira
Chronic Obstructive
Lung Disease
tory Origin
H/o Re
peated
RTI
No Hfo
Repeated
RTI
H/o Re
peated
RTI
No H/o
Repeated
RTI
H/o Re
peated
RTI
No H/o
Repeated
RTI
Pulmonary
Tubercu
losis
Others
Dyspnoea
&
Cause
Group 1
89
2
2
4
5
18
16
11
4
27
Group II
136
4
2
10
3
46
13
19
4
35
Total
Gr 1 + Gr II
225
(70.04%)
6
(2.7%)
4
(18%)
14
(6.2%)
8
(3.6%)
64
(28.4%)
29
(12.9%)
30
(13.3%)
8
(3.6%)
62
(27.5%)
Group III
16
(19.5%)
—
—
1
(1.2%)
—
6
(7.3%)
1
(1.2%)
1
(1.2%)
1
(1.2%)
6
(7.3%)
RTI — Respiratory Tract Infection
H/0 — History of
TABLE III
Gastro-Intestinal Illnesses
o
O
0>
03 O
6.3 Q
<
1 <c
y
u □’ -<
03, c)
Sample
Illnesses of Upper GJ. System
No. Reporting Upper ■
Oesopha
Oeso
Oeso
GJ. Symp Atrophic
gitis or
phagitis
toms
Gastritis
phagitis
or Atrophic Duodenal
Ulcers
Gastritis
Hepato
Sp/enoMega/y
Ulcers in
Others
the Mouth
Group 1
35
18
8
5
4
1
3
3
Group II
48
17
12
6
13
8
5
16
Total
Gr 1 +
Gr II
83
(25.9%)
35
(42.16%)
20
(24.1%)
17
(20.48%)
9
(2.8%)
8
(2.5%)
19
(5.9%)
5
1
1
3
0
0
2
11
(13.3%)
Co ni
d’ r-
Group III
0
TABLE
IV
Eyes
Sample
Number
Cataract
Corneal Opacity
Visual Disturbances
Phlycten Pterigium Chrowith Eye ------------------------------------------------------------------------------------------------------ nic
Diseases Age <50 <50
Conjun
Dimini Dimini Dimini
Total
One
Both
ctivitis
shed
shed
shed
Eye
Eyes
Distant Near
Distant
& Near
Group 1
83
14
8
22
2
1
16
6
0
11
9
66
Group II
146
13
16
29
6
2
17
15
14
14
18
113
Total
Gr I4-Gr II
229
(71.3%)
27
(8.4%)
24
(7.5%)
51
(15.9%)
8
(2.5%)
3
(0.9%)
33
(10.3%)
21
(6.5%)
14
(4.4%)
25
(7.8%)
27 ,
(8.4%)
179
(55.8%)
Group III
29
(35.4%)
3
(3.7%)
7
(8.5%)
10
(12.1%)
1
(1.2%)
1
(1.2%)
4
(4.8%)
3
(3.7%)
1
(1.2%)
5
(6.1%)
12
(14.6%)
17
(20.7%)
Note:
Since a person can have more than one Eye Ailment at the same time. Percentages are calculated on Total sample to Give Preva
lence.
TABLE V
Meuro - Musculo - Skeletal Illnesses
No. comp Muscle
Ache
planing
of Rele
vant
Symptoms
Sample
Muscle
Fatigue
Joint
Pains
Peri
pheral
Neuritis
Group 1
75
49
34
38
11
Group II
137
8
62
50
27
Total
Gr l + Gr II
212
(66.04%)
132
(41.1%)
96
(29.9%)
88
(27.4%)
38
(11.8%)
Group III
27
(32.9%)
20
(24.4%)
7
(8.5%)
9
(11.1%)
2
(2.4%)
TABLE VI
Sexual Disorders
Loss of Libido
Impotency
Sample
Number of
Individuals
Covered
Group I
107
16
10
Group II
214
27
1
Total
Gr l + Gr II
321
43
(13.4%)
11
(3.4%)
Group III
82
Note :
7
(8.5%)
1
(1.2%)
The Percentage is on Total Population and not sex or Age
Specific.
23
TABLE VII
Women Reporting Distrubances in Menstrual Cycle in the
Last Three Months
Sample
Total Num
ber of Wo
men 8-80
Years
No. of Wo
men in the
Age Group
of 19-44
Years
No. of Wo
men Mens
truating
Currently
No. of Wo
men with
Menstrua!
Distur
bances
Currently
Group IV
397
213
(53.65%)
173
(81.22%)
112
(64.73%)
Group V
283
169
(59.71%)
124
(73.37%)
59
(47.58%)
TABLE IX
Psychiatric Illness
Sample
No. Re
porting
Psychia
tric
Symptom
Post Tra
umatic
Stress
Disorder
{PTSD)
Adjust
ment
Disorder
with
Depres
sion
Group I
99
52
10
6
31
Group II
172
74
32
11
55
Total
271
Gr I + Gr II (84.42%)
126
(39.25%)
42
(13.08%)
17
(5.3%)
86
(26.79%)
46
(56.09%)
21
(25.61%)
6
(7.32%)
2
(2.44%)
17
(20.73%)
Group III
Adjust
ment
Disorder
Note : Percentage Taken out from Total Sample.
24
To Rule
out
Psychia
tric
Illness
TABLE VIII
Pattern of Menstrual Disturbances in the Last Three Months
Sample
Total
DysmenNumber
orrhoea
of women
Menstrua
ting Cur
rently
(8-80 yrs)
Irregular
Cycle
Increased Shortenec/ Scanty
White
Cycles
Periods
Discharge Blood
Loss
Amenorrhoea
Delayed
Cycles
Group IV
246
104
(42.27%)
66
(26.82%)
59
(23.98%)
42
(17.07%)
23
(9.34%)
21
(8.53%)
18
(7.31%)
7
(2.8%)
Group V
162
42
(25.92%)
20
(12.34%)
22
(13.58%)
17
(10.49%)
6
(3.70%)
12
(7.40%)
12
(7.40%)
0
TABLE X
Individuals Reporting Fever
Sample
No. Reporting one Epi
sode of Fever for > 3
Days in the Week Pre
ceding Survey
No. Reporting Three or
< Three Episodes of
Fever in the Last Three
Months
Group 1
31
(28.97%)
32
(29.90%)
Group II
45
(21.02%)
67
(31.30%)
Group III
19
(23.17%)
29
(35.36%)
Total
95
(23.57%)
128
(31.76%)
TABLE XI
Individuals Taking Some Allopathic Medication on The Day
of the Survey
Sample
Number of Individuals
Number of Individuals
Taking Allopathic Medication
Group I
107
42
(39.25%)
Group II
214
85
(39.71%)
Group III
82
19
(23.17%)
Total
403
146
(36.22%)
26
TABLE XII
No. of Individuals Diagnosed as Having T.B. in the Post
Exposure Period
Sample
No. of Indivduals Diag
nosed to Have T.B.
No. on Anti T.B. Treat
ment Today
Group 1
11
(10.28%)
3
Group II
14
5
(6.54%)
Group III
2
(2.43%)
1
Total
27
(6.7%)
9
TABLE XIII
Effect of Gas on the Abiity to work Today
No. Engag Number
ed in Nonwhose
incomeability to
Generating
carry Non
Activity Be income
Generating
fore Gas
Leak
Activity
Affected
Today
Sample
No. Engag Number
ed in In
whose abi
come-Gene lity in in
rating Acti come Gene
vity before
rating
Gas Leak
Activity
Affected
Today
Group I
62
(57.94%)
56
(90.32%)
61
(57.0%)
52
(82.24%)
Group II
75
(35.04%)
67
(89.33%)
147
(68.69%)
134
(91.15%)
Group III
56
(68.29%)
29
(51.78%)
39
(47.56%)
17
(43.58%)
27
TABLE XIV
Status of Claims
Status of Claim
Individuals Co
vered in Present
survey
Total individuals
als Exposed to
Gas (Age + 5)
in Families Sur
veyed
Total Number
403
861
Number Who Filed Claims
323
(80.14%)
589
(68.40%)
263
(81.42%)
449
(76.23%)
21
23
Number Assessed for Per
sonal injury by Directorate
of Claims
Number who have been
intimated about their Cate
gorization
TABLE XV
Immediate Post Exposure Health Status (0-1 mth) as Judged
by Availability of Records for Out-Patient Treatment
Sample
No. of Individuals with
Immediate Symptoms
after Gas Leak
No. of Individuals who
could Produce Records
for O.P.D. Treatment for
the Immediate Post-Ex
posure Period
( Group I
105
(98.13%)
31
(29.52%)
Group II
209
(97.66%)
83
(39.71%)
Group III
71
(86.58%)
13
(18.30%)
Total
385
(95.53%)
127
(32.98%)
28
TABLE XVI
Availability of Records for Hospital Admission
Exposure Period
*
Sample
in Post
No. of Hospital Admissions No. of Admissions for
which Records are Avail
able
Group I
67
37
(55.22%)
Group II
133
70
(52.63%)
Group III
34
10
(29.41%)
Total
234
117
(50.00%)
'Post Exposure Period is from 3/Dec/1984to Date of Survey.
29
8
TABLE XVII
No. of Individuals Referred for Investigation/Specialist for Personal injury Evaluation by Directo
rate of Claims
Sample
No. Examined Number Referred for Relevant Investigation
No. Referred to Specialist
nal Injury
Evaluation
X-Ray
PFT
ETT
USCN
Ophthal
mologist
Psychia
trist
Group 1
83
68
(81.92%)
13
0
67
23
0
Group II
143
114
(79.72%)
24
2
99
19
1
Group III
37
9
(24.32%)
0
1
12
3
0
Total
263
191
(72.62%)
3
(1.14%)
178
(67.68%)
45
(17.11%)
1
(0.38%)
37
(14.06%)
TABLE XVIII
No. of Individuals Referred for Investigation/Specialist by the Survey Team
Sample
W
Total No.
Examined
by Survey
Team
Number Referred for Relevant Investigation
No.
Referred to Spe
cialist
X-Ray
PFT
ETT
USCN
Ophthal
mologist
Psychiat
rist
Group 1
107
89
89
89
97
83
99
Group II
214
136
136
136
179
146
172
Group III
82
16
16
16
57
29
46
Total
403
241
(60%)
241
(60%)
241
(60%)
333
(83%)
258
(64%)
317
(79%)
PART II
Critique of the processing of claims by
the Directorate of Claims, Bhopal
The claim form issued by the Directorate of Claims, Bhopal
Gas Leak Tragedy, Bhopal, consists of four parts, viz Part A, Part B,
Medical Record Abstract and the Personal Injury Evaluation forms.
Part A contains details of the income, employment and the
occupation of the claimant and is to be filled in by the person con
ducting the interview.
Part B contains the Medical record of the claimant. In this
part, items 1 to 8 are related to personal identification. Item 9
and 10 record the medical history (of illness, treatment taken etc.)
since the gas leak. Item II lists the present symptoms (on the
examination date) the claimant has under respiratory, gastroin
testinal, mental, musculoskeletal, eye, and gyneic/obsteric. Item
12 records the relevant cLnical findings on physical examination
by the examining doctor.
If the examining doctor feels that certain investigations are
necessary, or that the claimant needs to be referred to a specialist,
the appropriate forms are filled and the claimant is given the date
of appointment for investigation/examination by a specialist.
Once all these formalities are completed, the evaluating doctor
summarizes the clinical findings in the Medical Record Abstract
on the basis of which the Personal Injury Evaluation form is filled.
The completed forms along with all relevant documents are sent
to a Panel doctor who categorizes the claimant into one of the
six categories of injury and disabil ty.
Personal Injury Evaluation :
The methodology of assessing personal injury by the Direc
torate of Claims is based on a scoring system. Each claimant is
32
allotted marks for his/her suffering in the post gas leak period as
well as on the date of examination and the two scores are com
pared to arrive at a category.
Assessment of injury in the post exposure period:
The Directorate of Claims defines the post exposure health
status as the state of health during the period immediately after
exposure to gas till the current medical examination. The exa
mining doctor writes down the history of the claimant since ex
posure (night between 2/3 Dec. 1984 till the date of interview)
including places where treated (i.e. names of emergency camp,
government hospitals/dispensary) dates of treatment and name
(s) of treating doctor(s), only to the extent that the information
is discernible from record/treatment papers produced by the clai
mant. "Marks" are given to the claimant on the basis of docu
ments produced by him/her as proof of signs and symptoms
s/he had, treatment received indoor/outdoor and investigations
carried out in the post exposure period. (See Annexure-lll).
—The scoring system of evaluation followed for assessing
post exposure health status is subjective because it is to
be on "facts available in the records produced, adjudged
by the examining doctor" (emphasis supplied).
—The scoring system in the post exposure period is unfair
to the claimant because it is based solely on the records
produced by the claimant
.
*
It is said in "the Guidelines
For the Medical Officers", Directorate of Claims, "the seve
rity of injury was at its peak during the immediate post
disaster period", and the inability on the part of the clai
mants to produce documentary evidence, for no fault of
their own, should not weigh against them in the process of
estimating injuries.
—The design of the scoring system to assess post exposure
health status is irrational/illogical. For example, the treat♦It is well documented that in the immediate post leak period, the relief camps
were flooded with the victims and the camps were under - staffed. In the re
sulting chaos, at times even death certificates were not issued. Even as late as
Aug. 1985, the Heerji Committee sent by the Prime Minister observed that the
health cards then in use were more or less identification cards and did not pro
vide a running history of all Pathological, radiological data and medication pro
vided.
33
merit received at inpatient and that received in the outpatient
is given separate scores and a person who was or is so ill
that she could not leave the hospital ward to receive out
door tieatment will forfeit 14 marks.
—The design of the scoring system in the post exposure
health status is faulty. Although the maximum marks a
person can receive is hypothetically 100, because of faulty
scoring system under "investigations" and also because
the obstetric/gynaeic system is included in this 100, the
maximum marks a male or a female in the non-reproductive
age group can get is only 79 and the maximum marks a
woman in the reproductive age group can get is 85.
Assessment of current health status :
"The Guidelines for Medical Officers" for medical documen
tation of claimants issued by the Directorate of Claims gives speci
fic instructions for filling the medical record form for present sym
ptoms, criteria for ordering investigations and referring to specia
lists.
—The method of ascertaining the 'present symptoms' is not
standardised. The guidelines state that the meaning of
each symptom should be explained to the claimant. How
ever there are no guidelines on how these symptoms are
to be explained. For instance, there could be wide diffe
rence in explaining the symptom "depression" by two
doctors.
—The lists of symptoms given in the form does not include
all the symptoms necessary to arrive at a clinical diagno
sis. For instance, the symptom "recurrent recall of the
disaster event" is important at arriving at a diagnosis of
post traumatic stress disorder and this symptom has been
left out.
—The reproductive health problems of women have not been
given adequate importance.
The form includes irre
gularity of cycles" and "vaginal discharge as the two
complaints whereas the post disaster studies have shown an
increased number of women complaining of menorrhagia,
dysmenorrhoea, dyspareunia. With respect to pregnancies
34
at the time of gas leak or thereafter, women had multiple
abortions and this has not been taken into consideration.
—The guideline that only those complaining of three or more
psychiatric symptoms are to be referred for psychiatric
evaluation is arbitrary.
—General health status as recorded in the form (R) is subjec
tive as there are no specific guidelines for adjudging a clai
mant's health to be good/fair/poor.
—The guidelines for referring claimants for specific investi
gations is arbitrary. For instance, the procedure for referr
ing a claimant for "Pulmonary Function Tests" only if s/he
becomes breathless on "40 steps brisk walk" is not a
standard test, and may not be adequate to unmask breath
lessness in a population that earns its livelihood through
physical labour. Further, previous studies have shown that
even those who are breathless on carrying out 'normal'
work had abnormal pulmonary functions.
The assessment of the current health status is also based on
marks given to positive findings under different heads viz: symp
toms, signs, investigations and specialist opnion.
—The effects on different systems in the body is given une
qual weightage in terms of scores with respiratory system
on top of the hierarchy. This is without any scientific
foundation. The assumption implied in the claim form
that the respiratory system is the most important system
in the body and that effect on this results in maximum
dysfunction, works against claimants who have serious
disorders in systems other than respiratory. For instance,
a person who has severe post traumatic stress disorder and
is unable to carry out even the simple tasks of living with no
other system involvement, can aspire to get a maximum
possible score of 6 (six) while another person whose repiratory system has been affected will get a maximum of 36.
—Similarly, the different weightage given to different investi
gations is also arbitrary. For instance, in the claim form.
X-rays get maximum marks in the score sheet i.e. 15 where
as Pulmonary Function Tests get only 4 while, from past
35
findings, it has been found that even persons who have
normal chest X-ray can have abnormal Pulmonary Function
Tests.
—The practice of giving different weightage to different in
vestigations also works against claimants who have nonrespiratory system findings but are suffering from the effect
of gas on systems which cannot be diagnosed by any of
the investigations that are being administered in evaluating
personal injury. For instance a claimant complaining of
pain in the abdomen or discomfort in the upper abdomen,
fullness after small meals and loss of appetite could have
atrophic gastritis, a pre-cancerous condition that can be
diagnosed only through gastroscopy and biopsy
.
*
A
claimant with such complaints will forfeit his/hei rightful
share of the compensation money for serious progressive
permanent damage to health because the condition is not
being diagnosed through necessary investigations.
Finally a system that uses marks to assess health status,
does not give an accurate picture of the nature and extent of
injury and it also does not give an accurate picture of current
health status. The scoring system does not tell how seriously
ill the claimant is or if a single system or multiple stystem in
the body is affected: it does not tell whether the condition is
prognosed to deteriorate or improve and whether the damage
is permanent or not.
The process of categorization of the claimants :
The scores obtained by the claimant for post exposure health
status and current health status is totalled separately and the panel
doctor compares the two scores as well as looks at all the medical
information given in the record to arrive at one of the following
six categories of injury/disability.
(a)
The claimant aforesaid has suffered no injury.
*A person suffering from atrophic gastritis may infact get only 1 (one) of the total
marks of 100 because of no clinical findings and because she/he may not have
been referred to a specialist as referral is on the "discretion" of the examining
doctor.
36
(b)
The claimant aforesaid suffered physical/mental injury
and the same has been treated
*
and the same has not
deteriorated into permanent injury.
(c)
The claimant aforesaid suffered physical/mental injury
which despite treatment has deteriorated into perma
nent injury.
(d)
The claimant's aforesaid physical/mental injury has
resulted in temporary partial disablement.
(e)
The claimant's aforesaid physical/mental injury has
resulted in permanent partial disablement.
(f)
The claimant's aforesaid physical/mental injury has re
sulted in total disablement.
Of these six categories the first three are meant to be pronoun
cements on the state of injury and the latter on disability. Although
no definitions of injury and disablement are given, explanations re
garding each category is given in the 'guidelines for evaluation of
medical record forms and categorization of claims' issued by the
Relief and Rehabilitation Department, Bhopal Gas Tragedy, M.P.
According to the guidelines:
If the claimant does not score any mark in post exposure
health status and if any symptom in the current health status
is not supported by positive findings in clinical examination
and/or investigation, she falls in category (a) i.e., no injury.
If the claimant scores in post exposure health status and the
score in current health status either remains the same or de
creases, s/he falls in category (b) i.e., temporary injury/cured.
If the claimant scores in post exposure health status and the
score in current health status increases inspite of the treat
ment s/he falls in category (c) i.e., permanent injury not
amounting to disablement.
If the post exposure health status of a claimant shows posi
tivefindings in physical examination and/or investigations (i.e.,
* It is also medically and legally incorrect to say that the gas victims have been
cured/treated. If there is anything at all that everyone agrees about the gas
affected victims (this includes ICMR). it is that there is no treatment for the
effect of toxic gases.
37
s/he has records to prove all this) suggestive of continuing
illness resulting in disablement, but the current health status
shows either complete recovery or improvement, (the degree
of improvement being such that it does not fall in the cate
gory ot disablement), s/he falls in category (d) i.e.,temporary
partial disablement.
If the post exposure health status shows any organ/system
involvement resulting in partial disablement and it remains
the same even in the current health status, she/he falls in
category (e) i.e., permanent partial disablement.
If the post exposure health status and current health status
both show an organ/system involvement ot total and per
manent nature, she/he falls in category (f) i.e., permanent
disablement.
Although the guidelines do not define injury and disability,
there are International definitions and classifications of injury and
disablement.
According to WHO, International Classification of Impai
rments {injury), Disability and Handicaps:
"In the context of health experience, an impairment (injury)
is any loss or abnormality of psychological, physiological or
anatomical structure or function".
and
"In the context of health experience, a disability is any res
triction 01 lack (resulting from an impairment) of ability to
perform an activity in the manner or within the range consi
dered normal for a human being."
According to this definition, disability is to be assessed on
the basis of a person's ability or inability to perform the different
tasks of daily living i.e. ability to perform the functions of per
sonal care, household activities, disability in effective marital and
family role, disability in occupational role, behaviour changes in
terms of social role etc. Disability as defined can be assessed
only if a person is observed for a period of time long enough to
give adequate information on the effect of injury on ones daily
living.
38
The categorization of the claimant in the process of personal
injury evaluation is based on part B of the medical record which
contains information on the effect of the gas on the physical and
the mental health of the claimant. Part B of the medical record
has no information that could even begin to assess disability as
defined internationally.
By international classification, thus, the categories (d), (e)
and (f) "explained" in guidelines for Categorization are with
out foundation and are based on non-existent information in
the claim form.
Therefore by definition the claimant cannot be categorized
into (d), (e) and (f) on the basis of information available in
the medical records.
Categories (a), (b) and (c), according to the Guidelines, are
meant to classify injuries into: no injury, temporary/cured and
permanent injury, on the basis of records produced by the claimant.
The process of categorization is designed in a way that puts
the onus of providing proof for injury on the claimant.
Only if the claimant can produce well-documented evidence
(medical records) which explicitly state the symptoms/signs
s/he may have had in the post exposure period, only if s/he
provides records or proof for all hospital admissions, investi
gations, only then will s/he be even considered injured in the
gas leak.
If the claimant is unable to produce any medical record for
the post exposure period and even if his/her health is affect
ed today, (i.e., at the time of evaluation) he/she will be put
in category (a) i.e., not injured.
If the claimant's condition remains the same or deteriorates
(even if the claimant does not regain the pre-gas leak health
status) s/he will be put in category (b) temporary/cured.
Thus, for example a person scoring 30 for the post exposure
health status and 15 in the current health status and a person
whose post exposure health status score was 60 and remains
60 in the current health status will both be put in category
(b) temporary/cured.
39
Only if the claimant's score increases in the current health
status as compared to post exposure health status (techni
cally supposed to reflect a deterioration in the health stautus)
will s/he be put in permanent injury. This is again irrational
because claimant A getting a score of 25 in the post exposure
period and 35 in the current health status will be put in (c)
e. permanent injury; whereas a claimant B getting a score
i.
of 60 in the post exposure period and the score remaining
same in the current health status will be put in category (b)
e. temporary/cured.
i.
Thus, the assessment of injury by the method arrived at by
the Directorate of Claims, Bhopal is not just arbitrary but verges
on the ridiculous.
To categorise a claimant who has serious gas-related prob
lems today but who is unable to produce 'proper' records as "not
injured" or "temporary/cured" is an injustice of great magnitude.
It must also be remembered that the evaluation of personal injury is
being carried out almost 4 to 5 years after the disaster, and to cate
gorise an injury that exists even today as temporary is outside the
realm of science.
Given all this, it is not surprising that the Directorate of Claims,
Bhopal has categorized the 1,23,560 (categorized so far) into:
51,584 — no injury (category a)
64,064 — temporary/cured (category b)
By inadequately examining the claimants (clinically and
through investigations) and by evaluating the injuries and cate
gorizing them with the use of faulty tools biased against the gas
victims, the Directorate of Claims, Bhopal has 'defined' away the
injuries of more than 90% of the victims as 'no injury' or 'temporary
injury'.
40
ANNEXURE - I
RATIONALE AND CRITERIA FOR DIAGNOSIS
Ref : Text Book of Medicine, Harrison, Ed-11; and ICMR
Publications on Bhopal Gas Victims.
RESPIRATORY SYSTEM
1.
Allergic Alveolitis (DRO-A)
A. Rationale for Diagnosis
B.
1.
Isocyanates (TDI, MDI, HDI) are known to cause this
disease.
2.
Symptoms of dyspnoea, cough, expectoration described
in Bhopal Victims.
3.
Pulmonary Function Tests showing Restrictive pattern
described in about 30% of gas victims.
4.
Transfer factor of Carbon Monoxide is reduced.
5.
Lung biopsy and broncho-alveolar lavage showing
changes of alveolitis.
6.
Immune system abnormalities reported in almost 90%
of gas victims.
Criteria for Diagnosis
1.
Dyspnoea with or without cough and expectoration.
Dyspnoea is at rest, or on exertion, continuous and
progressive.
2.
Fine crepitations particularly at the bases.
3.
No evidence of emphysema or airway obstruction.
4.
Presence of clubbing.
41
II.
Chronic
Obstructive
Lung
Disease (DRO-C)
A. Rationale for Diagnosis
B.
III.
1.
Isocyanates (TDI) are known to cause this disease.
2.
Symptoms of Dyspnoea with or without cough and
expectoration described in gas victims.
3.
Evidence of airway obstruction as suggested clinically
by presence of rhonchi and obstructive pattern on PFT.
4.
Evidence of
victims.
Hyperinflation on X-ray chest, in gas
Criteria for Diagnosis
1.
Dyspnoea, progressive and continuous with or without
cough and expectoration.
2.
Clinical evidence of Emphysema (Barrel shaped chest.
Hyper-resonant note on percussion liver dullness pushed
down. Cardiac dullness obliterated).
3.
Evidence of airway obstruction (H/O wheezing, pro
longed expiration, rhonchi).
4.
Crepitations, if present, are coarse.
Dyspnoea of Respiratory Origin (DRO)
A. Rationale for using this term
According to ICMR 75% of gas victims with Dyspnoea
had no clinical signs. Many of this patients on investiga
tion will demonstrate evidence of Allergic Alveolitis or
Chronic Obstructive Lung Disease eg. Restrictive or Obs
tructive pattern on PFT, and can thus be diagnosed after
investigation as either Allergic Alveolitis or
Chronic
Obstructive Lung Disease.
B.
Criteria for Diagnosis
Persons with continuous, progressive dyspnoea with cough,
with or without expectoration or any abnormal finding on
examination of respiratory system but not fullfiling the
criteria of Allergic Alveolitis or Chronic Obstructive Lung
42
Disease are clinically diagnosed as Dyspnoea of Respira
tory Origin (DRO). After investigations most of these
patients will be diagnosed as either Allergic Alveolitis or
Chronic Obstructive Lung Disease or some other Respira
tory illness.
IV.
Dyspnoea ? Cause
A. Rationale for Diagnosis
In 50% of the gas victims complaining of Dyspnoea, the
symptom seems grossly out of proportion to the clinical,
Radiological and Pathophysiological findings. Here the
mechanism may be:
B.
(i)
Minimal Pathological changes in bronchi and alveolar
wall.
(ii)
Psychiatric problems lowering the threshold for sen
sory perception.
(iii)
Some unknown (obscure) mechanism.
Criteria for Diagnosis
These persons have progressive or continuous Dyspnoea
on exertion but have no other symptoms or signs suggestive
of involvement of Respiratory System. Some of them on
investigation may turn out to be showing evidence of
Respiratory illness but in many of them it may not be so.
In these cases, one of the mechanisms described above
may be the cause of dyspnoea.
V.
Recurrent Respiratory Tract Infection
A.
(RTI)
Criteria for Diagnosis
Repeated attacks of cough with yellow expectoration and/or
fever lasting for few days.
If recurrent RTI are associated with dyspnoea the diag
nosis is made as DRO-A, DRO-C or DRO with Respiratory
Tract Infection (DRO-A with I, DRO-C with I and DRO
with I).
43
Bronchial Asthma
VI.
A. Rationale for Diagnosis
Toxic gases in Bhopal are known to have exacerbated
Bronchial Asthma in patients who suffered from it before
gas leak and are known to have caused it in some others
due to hypersensitization.
B.
Criteria for Diagnosis
A person with episodic dyspnoea, with absence of symp
toms in between the attacks.
VII.
Pulmonary Tuberculosis
A. Rationale for Diagnosis
Toxic gases in Bhopal are known to have caused a "flare
up" of Tuberculosis in persons who already had the infec
tion, active or inactive.
B.
Criteria for Diagnosis
1.
Clinical evidence of cavity.
2.
H/o Haemoptysis
3.
Persons who are diagnosed by some doctor as having
Pulmonary Tuberculosis.
Since the diagnosis of Pulmonary Tuberculosis is con
firmed only after Acid Fast Bacilli (AFB) are demons
trated in sputum (which in most patients is not being
done in Bhopal), a differential diagnosis of DRO also is
given since the possibility exists that many of them may
not have Tuberculosis.
EYES
I. Chronic Conjunctivitis
A. Rationale for Diagnosis
ICMR has reported symptoms of itching, lacrimation, burn
ing and foreign body sensation without physical signs.
This is due to chronic Conjunctivitis which may be in
fective or allergic in nature.
44
B.
Criteria for Diagnosis
1.
Reported symptoms burning, watering, itching, foreignbody sensation and photophobia. Even if one symptom
is reported by the patient spontaneously, without physi
cal signs.
2.
Presence of two or more symptoms on direct question
ing, with or without clinical signs.
3.
Conjunctival congestion.
Cataract
II.
A. Rationale for Diagnosis
Increased incidence reported by ICMR.
young adults.
B.
Reported in many
Criteria for Diagnosis
Opacity of lens with iris shadow, as seen under a torch
light.
III.
Corneal Opacity
A. Rationale for Diagnosis
Reported in gas victims. The toxic gases in acute phase
caused corneal ulceration which healed with opacity.
B.
Criteria for Diagnosis
As seen by torch light.
IV.
Diminished Vision
A. Rationale for Diagnosis
Vision can diminish due to cataract, corneal opacity or re
fractory error. Refractory errors were reported higher in
the gas exposed population in 1985.
B. Criteria for Diagnosis
Distant vision:
Vision less than 6/12 mtrs. using the standard Snellen's
chart.
45
Near vision :
Considered diminished if person cannot read the news
paper at a distance of 30 Cms. or cannot thread a needle.
GASTRO-INTESTINAL SYSTEM
I. Atrophic Gastritis
A. Rationale for Diagnosis
Endoscopy with biopsy done in 50 gas victims with upper
Gastrointestinal symptoms showed Atrophic gastritis in all
of them. Both free and total acidity were reduced with
many having achlorhydria.
B.
Criteria for Diagnosis
Persons complaining of pain or discomfort in epigastric
region, fullness after small meals and loss of appetite.
Among the general population such a patient will be diag
nosed as non-ulcerative dyspepsia since many alternative
conditions can be diagnosed. Also, the correlation bet
ween atrophic gastritis and upper Gl symptoms is not good.
Among the gas victims the available evidence indicates
not only an extremely high prevalence of Atrophic Gastri
tis but a better correlation with upper Gl symptoms.
II. Oesophagitis
A. Rationale for Diagnosis
Reported in gas victims.
B.
Criteria for Diagnosis
Retrosternal burning, epigastric burning, both before food.
Epigastric tenderness may be present.
MUSCULO-SKELETAL SYSTEM
A. Rationale for Diagnosis
Muscle ache, joint pains and muscle fatigue (severe enough
to prevent the person from working) is reported. The
pathophysiology is not known.
B. Criteria for Diagnosis
Whenever muscle ache, fatigue and joint pain are reported.
46
ANNEXURE //
Department of Psychiatry
Sir J.J. Group of Hospitals and Grant
Byculla, Bombay 400 008.
Date
Medical
10th
Nov.
College
1989
PRELIMINARY REPORT ON SURVEY OF PSYCHIATRIC
MORBIDITY IN BHOPAL GAS LEAK VICTIMS
In December 1984 when the mishap took palce, it resulted
in a high incidence of mortality and morbidity. The morbidity
included physical as well as psychological disturbances. Earlier
reports on psychological disturbance revealed that a large number
of people exposed to the gas had psychological disturbance in
the form of Generalized Anxiety Disorder, Depression, and Adjust
ment Disorders. Post traumatic stress disorder (also known as
Post Disaster Stress Syndrome) was not found in any of the vic
tims interviewed according to these previous studies.
Post traumatic stress disorder is a collection of a number
of symptoms and signs occuring after being exposed to an event
which is extremely stressful and which does not fall in the domain
of ordinary day-to-day life events and which most normal people
would find overwhelming, e.g. Earth quake, floods, fire, Prisonerof-War, combat, traffic accidents, air crash, train accidents—
industrial disaster e.g. Gas Leak.
The current study was primarily conducted to determine
whether any of the gas victims suffered from PTSD. The impli
cations of this diagnosis are far-reaching.
The data were collected by Dr. Vinod S. Joshi— Lecturer,
and Dr Anukant Mittal — Registrar, Deptt. of psychiatry. Grant
Medical College and Sii J.J. Gr. of Hospitals. Bombay. The pro
ject was carried out by the Department ot psychiatry, G.M.C./
47
J.J.H. voluntarily and there was no grant or any financial aid avail
able. The details of the study are as following:
400 patients who were earlier examined for medical and psy
chiatric morbidity were reassessed. Of these 400, there
was possible 350 patients who could be having a psychiatric
disorder. Of these 350 suspected cases, 40 patients were
examined by us (VSJ, AKM).
The results are as shown below:
Total No. N =
70
Post traumatic stress disorder
40
Adjustment disorder with dep
ressed mood
7
Depression
3
Other diagnosis
1
Compensation Neurosis
1
Paranoid Disorder
1
Delirium
Nil Psychiatry
17
Of the 53 psychiatrically ill patients, none of them had re
ceived a diagnosis of PTSD earlier. The clinical severity ranged
from moderate to severe in 45 patients which is to say that their
day to day functioning was severely affected. Since a large
body of literature on PTSD is available e.g. Pitman et al found a
life time diagnosis of PTSD in 40% of Vietnam Veteran interviewed
by them, (Am. J. Psy. May 1989, 145 : 667-669), in our opinion
the presence of PTSD could be correlated with the gas-leak.
48
Dr Anukant Mittal
— Registrar
Dr Prakash Gangdev
—
Dr V S Joshi
— Lecturer
Di Alan De Sousa
— Professor
Dr D K Deshmukh
— Asst. Professor
Lecturer
ANNEX URE.-HI
BHOPAL GAS LEAKTRAGEDY
PERSONAL INJURY EVALUATION
CENTRE
CODE
Xex
REGISTRATION RO
NAMEi -
0 TO
1
e
•
$
26
*
20
TOTAL
M4RKS
7 tli MONTFtc
1 YEAR
AFTER
6 th MONTH
21
*
6
4
‘
11
2-23
24-25
*
20
3
•
IB
1
29
30-31
*
14
2nd
MONTH
•coli^nn
MTH
to
YEAR
1
TREATMENT
I P
■
<
17
•
TREATMENT
0 P
Investigations
Severe
Max-Mk'3 ‘column
5
• 32
3
•
33
2
*
34
0
a
35
10 • 36-37
5
•
30
3
*
39
2
•
40
0
•
Al
10 • 42-43
5
* 44
3
* 45
2
•
46
0
47
*
10 • 48-49
Moderate
Kild
Norma 1
To tai
X-ray
Urine SCn.
.
Others
SYSTEMS
RESP
G.I.T.
—
nax-Mkd 'colunui
SYMPTOMS
—
-
3
r
•
O8ST L
CYMAEC .
CNS/
MUSCULOSKELE- MENTAL
TAL
50
□
•
51
3
-
52
3
• 53
3
•
se
j
•' sy
d
•
60
3
i 61
3
* 62
54
OPHTH.
TOTAL
MARKS
r • 55 IS-56-51
-3 ■ 63
IS ‘64-65
CLINICAL
SIGNS
’C'
117
table
CURRENT HEALTH STATUS
t a b le
POST EXPOSURE H E A L T H STATUS'
'B '
TIME SINCE
EXPOSURE
EVAULATING
doctor*
please sc-: overleaf lor gutdlines
NOTES
Total maximum marks for post exposure Health Status and Current Health
Status are 100 each.
Post Exposure Health Status means the state of health during the period
immediately after exposure to gas till the current medical examination.
KEY FOR
SCORING: Post Exposure Health Status.
Scoring is to be done on facts avail
able in the records produced, adjudged by the evaluating doctor.
KEY FOR
SCORING • Current Health Status.
67
— One mark for each symptom (4)
68
— | mark for each symptom (2) to be rounded to whole numbers
69
— | mark for each symptom (2), to be rounded to whole numbers.
70
— One mark for 3 symptom (2).
71
— One mark for 3 symptoms or less; two marks for 4 or more
72
— One mark for 1 symptom, two marks for 2 or more symptoms (2).
73
— One mark
symptoms (2).
76
— O-Good: 1-Fair, 2-Poor; (2).
77
—6 Marks.
78
— 3 marks.
79
— 3 marks.
80
— 5 marks.
81
— 3 marks.
82
— 2 marks.
83
— 1 mark.
87—93
— Marks to be alloted according to severity out of maximum marks
alloted.
96—101
— 8 marks for any one positive finding; 12 marks for any two positive;
15 marks for 3 or more positive findings. In this case fifteen marks
are to be divided according to the severity of each findngs keeping
in view that the total does not exceed 15. The abnormal X-ray column
is to be given mark when none of the condtions mentioned is present
but there is any other abnormality
104
—4 marks for 75% derangement; 3 marks for 25-75% derangement; 2
marks for 2.5% derangement (4).
105
— 3 marks for severe derangment; 2 marks for moderate derangement;
1 mark for mild derangement (3).
106—109
— 4 marks for 1 mg. No smoke-No tobacco; 107—3 marks for 1 mg. Yes
smoke-No tobaccoO; 108—3 marks for No smoke-Yes tobacco; 109—2
marks for 1 mg Yes smoke-Yes tobacco; (Enter marks in the column
applicable)
110—m
— 2 marks; 111-112 — 1 mark each.
I
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