Against All Odds: Continuing effects of the Toxic Gases on the Health Status of the Surviving Population in Bhopal
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- Title
- Against All Odds: Continuing effects of the Toxic Gases on the Health Status of the Surviving Population in Bhopal
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AGAINST ALL ODDS
)
The Health Status of the Bhopal Survivors
Of
COMMUNITY
Call No
Acc No
CELL
HEALTH
--------------
Author : __££ZE.h/_y£L
......
-,.a£ JJILjz.
Date of
Signature
'urn
I
I
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
C EC
F-20 (GF) Jangpura Extn.
New Delhi-110014
0I-I1IC
OU&T-
December 1989
For private circulation only
I
Contributoryf Price Rs 15/portage Extra
° I?-
Cover Design: K.P. Sasi and Ratna Mathur
Printed at Kaipana Printing House, L-4 Green Park Extension,
New Delhi-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
5. 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
8. Annexure III: Copy of the 'Personal Injury Evaluation'
Form issued by the Directorate of Claims, Bhopal
49
at ai?a
VOICES FROM BHOPAL
1)
?aa HRf ?t nq; ^at aaat | arat
a 5'fa 1
Wt<?T at, 60 a<T, gina aaT
So many years have gone by ; it feels as though we will
never get well again.
Rashida bi, 60 years. Subhash Nagar
2)
$ar aaar |
g;qx <prr ?r 1
’'HT H at
Sfpft
STPTT
U’tJT | 1
«ft5 49 aa,
®t?n
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
3)
at aarat farcat art
^tai ?
vpr at
^t atq 1 a^at aa aar
SfaiT Ht^T, 40
Sjo <fVo a^TT
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)
tariff srraat aa aaa area ft a<j 1 ?wa at
aaaH & aa ara 1 xfar^r at st?
^t 1
ft art at
fa^TKtHTa, 60 atf,
'ft® ’T’FC
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)
ips at anar | a?at
faaix an? 1 at*FT nt w ttht | ?
HfTTH, 19 aT, 'EZT HSrsTU
I feel I should simply die.
What is the use of living anyway?
Nargis, 19 years, Phoota Magbara.
v
6)
a* gataa if ax an? at u^r i ua
aair aa^xt f«r?fa
aft aaat i ata aaut | uh ata aa%, ^ht uaur ?
aixTaif, 35 uu, xrxta aux
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) faaru if
urai | fa> ua wu aurur ha % ir^nra a<V 11 ^ax
UUT ? SRa aSHt | I
I keep thinking I don't have many more days to live.
is this? Is it cancer?
Salimuddin, 30 years.
What
Ram Mandir.
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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 I
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
eflorts 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 carrv 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
gathering 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 suffering 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 unscientific 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 i.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 Rahat 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.
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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 beqji 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-Skeleta\ 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-skeletal 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. Menstrua! 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)
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in the seriously affected area and 47.6% (19-44 years) in the midly
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 ga.
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 anti
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 TB treatment is a sad
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 resulting
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. Approximate 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
I
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 persona! 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 impai.ment 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
According 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 :
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 serious V
mensaffected and mildly affected area continue to report
trual disturbances.
18
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
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TABLE V
Neuro - Musculo - Skeletal Illnesses
Sample
No. compplaning
of Rele
vant
Symptoms
Muscle
Ache
Group I
75
Group II
Muscle
Fatigue
Joint
Pams
49
34
38
11
137
8
62
50
27
Total
Gr r+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%)
Peri
pheral
Neuritis
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%)
I
I
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
Group IV
Group V
Total Num
ber of Wo
men 8-80
Years
397
283
No. of Wo
men in the
Age Group
on$-44
Years
No. of Wo
men Mens
truating
Currently
No. of Wo
men with
Menstrual
Distur
bances
Currently
213
(53.65%)
(81.22%)
112
(64.73%)
169
(59.71%)
124
(73.37%)
59
(47.58%)
173
TABLE IX
Psychiatric Illness
Adjust
ment
Disorder
To Rule
out
Psychia
tric
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%)
Group III
21
(25.61%)
6
(7.32%)
2
(2.44%)
17
(20.73%)
46
(56.09%)
Note : Percentage Taken out from Total Sample.
24
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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 I
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 Me
dication
Group I
107
42
(39.25%)
Group II
214
85
(39.71%)
Group III
82
19
(23.17%)
403
146
(36.22%)
Total
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 I
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
Sample
No. Engag Number
No. Engag- Number
whose
ed in Non
ed in Inwhose abiability to
incomecome - Gene - Hty in in carry Non
rating Acti come Gene- Generating
Activity Be income
rating
vity before
Generating
fore Gas
Activity
Gas Leak
Activity
Leak
Affected
Affected
Today
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
I
TABLE XIV
Status of Claims
Individuals Co
vered in Present
survey
Status of Claim
Total individuals
a/s 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
I
TABLE XVI
Availability of Records for Hospital Admission in Post
Exposure Period*
Sample
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.
I
29
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31
PART li
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.
I
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 cl.nical findings on physical examination
by the examining doctor.
I
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 disability.
Personal Injury Evaluation :
The methodology of assessing personal injury by the
torate of Claims is based on a scoring system. Each claims
32
is
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*lt 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 resuiting 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 provided.
33
ment 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
>rre"
gularity of cycles" and "vaginal discharge" as the two
complaints whereas the post disaster studies have shown
increased number of women complaining of menorrha i »
dysmenorrhoea, dyspareunia. With respect to pregna
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
I
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
/// 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 or 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 one's 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)
i.e. permanent injury; whereas a claimant B getting a score
of 60 in the post exposure period and the score remaining
same in the current health status will be put in category (b)
i.e. temporary/cured.
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
I
ANNEXURE
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.
B.
Rationale for Diagnosis
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
A.
B.
Disease (DRO-C)
Rationale for Diagnosis
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/0 wheezing, pro
longed expiration, rhonchi).
4. Crepitations, if present, are coarse.
III. 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.
CO
Minimal Pathological changes in bronchi and alveolar
wall.
GO
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
A.
Respiratory Tract Infection (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
VI. Bronchial Asthma
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.
II. Cataract
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.
46
Criteria for Diagnosis
Whenever muscle ache, fatigue and joint pain are reported.
ANNEXURE //
Department of Psychiatry
Sir J.J. Group of Hospitals and Grant
Byculla, Bombay 400 008.
Date
Medical College
10th
Nov.
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 implications 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 of 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 received 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
Lecturer
Dr V S Joshi
Lecturer
Dr Alan De Sousa
Professor
Dr D K Deshmukh
Asst. Professor
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ANNEX UR£-H/
BHOPAL GAS LEAK TRAGEDY
PERSONAL INJURY EVALUATION
CLAIM
FORM
CEHTRK
NUMBER
T
/•G tf
6
MUNICIPAL
HA RD I
17
17
TT
Tu
9-
NAMEi 19
18
TIME SINCE
EXPOSURE
0 TO
1
2nd KTH to
6Ui MONTH
MONTH
ftox-MK$ *CQ1 ymp
3
o
7
REGISTRATION NO.
CODE_____
£
20
A
21
26
4
‘ .27
7 th
1
MDNTR.C
YEAR
TOTAL
M4RKS
• 23
20 <4-25
1..‘ 27
14*30-31
2
‘ JJ
1
AETSR
1 YEAR
TREATMENT
I P
A
*
3-J J*
TREATMENT
O P
I
Investigations
X
Nax-Mks*c;lumn
Uj
w
Moderate
Severe
•
33
2
38
•
39
2
44
1 *45
2
5
* 32
5
•
5
*
3
Kild
Norma 1
34
0
40
0
•
46
•
To tai
35
10
•
36-37
41
10
*
42-43
0
* 47
10
-
48-49
MUSCUL
CNS/
X-ray
cn
s
Urine SCn.
*
Others
Q>
CL.
SYSTEMS
G.I.T.
RESP
O8ST
L
GYHAEC .
OPHTH.
OSKELE MENTAL
TAL
TOTAL
MARKS
L^ •_
Q> °
flax-MX3 ‘column
“
3
•
50
3
-
52
3
•
53
3* 54
3 - Sb
(8 - 56 - 571
3
*60
J
•
61
3
■ 3
-
/<y*64-G?|
51
SYMPTOMS
M
T
J
CO
g
62
'
63
CLIN 1CAJL
SIGNS
117
116
1 15
Total or tables
A + B
GENER
SYSTEMS
3
£y
0BST. 6
GYHAEC.
Max-KXS •COLUMN
•65
SYMPTOMS
0
* 76
?
CLINICAL
SIGHS
“
2
SPECIALIST
OPJ.N ION
X
L«J
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RES?
AL
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96
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97
67
£ «
77 I 3
r
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101
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A. • 02
63
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93
[30*94--9a
70
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• 78
1
79
A ‘ 80
2
09
1 • 90
2 • 91 G » 92
88
. 4) T5
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104
105
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TOTAL
u
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1- 73
2
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• 72
2
69
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106
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X
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in
£
0
h
TOTAL
HARKS
OTHERS
OPHTH.
2
Investigations________
I . i
I
. I URINE SCn. > 1
3
100
MENTAL
68
2. ‘
87
RAY
73
<v
66-
A
CNS/
MUSCUL
OSKELE
TAL
d 2__ I
-D
E
m
U
V
O
u o
_
YL
loj.
marks
2
1081 102.
1LQ.
— __ —
30
LL3xJ-LA
119.
119
130
122
123
TOTAL or TABLES C+D
DATE »’
1^1
TOTAL OF TABLES
A*B*C»O
SEAL t SIGNATURE OF
EVAULAT1NG DOCTOR*
please
sc*:
overleaf for gutuxincs.
1
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
76
77
— One mark
— O-Good; 1-Fair, 2-Poor; (2).
— 6 Marks.
— 3 marks.
— 3 marks.
— 5 marks.
— 3 marks.
— 2 marks.
— 1 mark.
symptoms (2).
78
79
80
81
82
83
87—93
— Marks to bo alloted according to severity out of maximum marks
alloted.
96—101
— 8 marks for any ono 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 25% 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—111
— 2 marks; 111-112 — 1 mark each.
Position: 93 (20 views)