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Chapter 2: STORY OF BHOPAL
The first major call for environmental health work came suddenly and unexpectedly in
December 1984 in the form of the Bhopal Gas Disaster. At that time, CHC3 was taking
over as convener of the medico friend circle4 (mfc) and as the editorial office of the mfc
bulletin for the years 1985-86.
The disaster was unprecedented, killing thousands of people overnight and permanently
injuring several thousand more. While the local residents and the rest of the world were
still coming to terms with the disaster, mfc received requests from local groups and civil
society organisations for their involvement with the relief efforts. These requests started
arriving when the mfc annual meeting was being held in December 1984, where it was
decided unanimously that the group will get involved with the campaign for relief and
justice at Bhopal. The reasons for their involvement were many and urgent.
Confusion was aplenty. Doctors had various theories on how the affected should be
treated. The guilty company, Union Carbide, had refused to share information on the
nature of the gas that had leaked, and the government was not making any serious
efforts to enquire or communicate the information either. Without this information,
whatever treatment regimes had been initiated were based on whims, and several lives
were being lost due to inappropriate treatment. Groups from the affected community and
the society at large questioned the stance taken by the government and the company.
CHC along with several other members of mfc initiated a process of research,
communication and rehabilitation of the victims of the disaster. The monthly mfc bulletin
carried updates of these activities from the field. The priority was to identify and address
the gaps in the ongoing process of relief and rehabilitation.
In an effort to empower the affected communities and the local physicians with the
necessary information, a unique and innovative communication effort was made in the
form of an informative illustrated manual called ‘Hamari Sehat Hamari Ladai’ was also
drafted with the Ekalavya trust.
mfc was also one of the first civil society groups to initiate a detailed research exercise
at Bhopal. This study systematically revealed the health impact on the exposed
3.
The society (SOCHARA) was registered in 1991. Until then, CHC was the only identity of the organization.
4.
mfc or medico friend circle is a national platform for health practitioners to discuss and act on issues of equityoriented public health importance. For more information, visit their website at: http://www.mfcindia.org/main/
perspective.html
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communities. The nature of these health effects suggested a chronic cyanide poisoning
like mechanism, which added evidence to the existing controversy about how the health
effects were caused. Several recommendations were given to the government and other
groups based on this study, and a call was made for the use of evidence-based sensitive
action. One recommendation was the controversial support to the use of a compound
called ‘sodium thiosulphate’ to detoxify the victims. Later on, the results of a detailed
study by the Indian Council of Medical Research supported the use of thiosulphate
for the treatment and rehabilitation of victims. An epidemiological review paper was
also published with the available evidence on mortality and morbidity due to Bhopal
tragedy. The evidence generated through these processes was continuously updated
and presented at international conferences including the Permanent Peoples Tribunal.
Later that year, mfc also organised a meeting on Pesticides and Health where the health
impacts of the production and use of chemicals in agriculture was discussed.
Shiv Vishvanathan, a well known anthropologist wrote later about mfc’s scientific report
on the health situation in Bhopal as “probably the most sane, compassionate piece
of scholarship on the problem of relief in Bhopal” (8). An excerpt from that article is
provided in Box.2, which is followed by a detailed report on CHC’s involvement in the
Bhopal campaign.
Box.2: Excerpt from ‘Imagination of a disaster’, by Shiv Vishwanathan (8)
“But what is most fascinating is the manner in which text and context are related.
Voluntary health specialists have repeatedly advocated that the focus of study
should be suffering in the community, rather than the patient as an isolate in the
hospital. The first they argue, leads to a holistic view of disease while the latter
propagates a reductionist view of illness and an atomistic view of the patient. The
latter view which underwrote the pulmonary model, is based on numerous vertical
studies rather than an integrated search for interconnections. In a telling paragraph
the MFC report suggests, ‘The approach of examining say 200 eyes or 200 lungs and
so on independent of one another lacks this integration. Strange it may sound, but it
seems to derive the rationale – unconsciously – from the pulmonary model, wherein
toxic gas directly hits the target organ (lungs, eyes etc) to produce damage without
any intrinsic connections – which is at the heart of the ‘cyanogen pool’ model’.
It is this anthropology of gestalts that is fascinating about the report. What it offered
were two clusters which deserve further exploration:
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Patient as an analytical grid --> patient as a person
Clinical gaze of the doctors --> victim’s speech aids diagnosis
Focus of diagnosis is the hospital --> focus of diagnosis is the community
Diagnoses as mechanics of cause and effect --> diagnosis as an analysis
of inter-relationships
Pulmonary Model --> Cyanogen Pool Model
Anti Thiosulphate --> Use of Sodium Thiosulphate as a critical tool”
“How many Bhopals will it take to shake us out of our apathy?” (9)
Advocacy for the right to health of the affected community
CHC took up the editorial chair of the mfc bulletin at
the end of 1984. Following the Bhopal5 Gas Disaster6,
the editorial of the January 1985 edition of the mfc
bulletin (10) expressed that it was time to question:
–
the corporations, about their ethics and
functioning,
–
the government, about transparency and their
role in protecting people, and
–
the people, about their awareness and role in
remediation.
mfc was a signatory to the public statement released
on December 22, 1984 by 14 civil society groups in
Bombay (now Mumbai). Stating that the tragedy Figure 2: mfc bulletin - January 1985
at Bhopal was not an accident but a crime against
people, civil society was urged to press for the following demands made in the statement:
•
Establish citizens committees for monitoring rehabilitation work
5.
Bhopal is the capital of Madhya Pradesh state of India.
6.
The factory responsible for the disaster was owned by Union Carbide, an American based multinational company.
This facility produced compounds which would eventually be used in manufacturing pesticides.
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•
Punishment for guilty parties, including the corporation, state governmental
authorities and central governmental authorities
•
Rehabilitation, compensation, and aid for victims
•
Upholding the right to information
•
Review existing laws
•
Conducting environmental and epidemiological studies around existing and proposed
industrial sites
•
Upholding rights for workers, unions and citizens committees
Health problems of the victims
Several health problems were noticed by victims, doctors and researchers. The mortality
itself was high, but morbidity reflected multiple target organs – problems with vision,
breathing, digestion, aches and pains, generalised weakness, menstrual abnormalities,
in-utero problems, lactation failure and psychological effects (11). These were managed
symptomatically by the medical fraternity. Breathing problems persisted amongst many
of the exposed, even months after the disaster. No information was made available to
women who were pregnant at the time of the disaster about the potential effects of the
chemical on the outcome of pregnancy. The option of Medical Termination of Pregnancy
(MTP, or elective abortion) was not discussed with them by the medical officers.
Gaps in knowledge and communication
The mfc study in Bhopal7 and other research revealed that a lack of communication was
a major obstacle in the intervention and rehabilitation activities there (12). A continuing
education strategy for the local doctors and the affected people was recommended as
a necessary intervention to meet this gap. The lack of translation of existing knowledge
into supportive intervention was another major gap. Mental health too was identified as
a neglected dimension of the rehabilitation efforts. These shortcomings led to ignorance,
confusion, controversy and anarchy, and reduced the effect of intervention at the field
level.
A community health approach was suggested as the best method of communication
between various levels of stakeholders, keeping the participation and needs of the
7.
Details of this mfc study are available in the next section of the report titled ‘Research efforts to guide and support
remediation’
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community in mind. It was recommended
that one “must see the situation in totality
to understand true measure of the problem”.
Integrated community based epidemiologically
sound research and collaboration between
governmental and voluntary agencies was
also suggested.
However, availability of information did not
improve greatly with time (13). To make
matters worse, there was rampant miscommunication in media, and withholding
of information by the company and the
government. An effort was made to inform
the local doctors, victims and health workers
about the health situation following the
disaster, through a Hindi publication by
Eklavya and mfc called Hamari Sehat Hamari
Ladai (Our Health, Our Struggle) (14).
Figure 3: Cover of Hamari Sehat Hamari Ladai
Figure 4: A collage prepared from the pages of Hamari Sehat Hamari Ladai
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Sochara - Building Community Health
Figure 4 presents a sample of the illustration and text from ‘Hamari Sehat Hamari Ladai’.
It was a comprehensive illustrated manual on the health problems faced by the affected
communities. The intention was to empower them with the requisite knowledge. The
information provided was not just about the diseases and treatment, but also about
the peoples’ right to information and the right to appropriate healthcare. The manual
was an innovative intervention in communication, and was probably the first time in the
country where such an effort was made in knowledge translation for people affected in
an environmental health tragedy. mfc, through this and other efforts, may have provided
the only credible medical and health related information to the community (8).
Continued discussions within mfc
The theme for the January 1986 mfc meeting at Khandala was ‘Issues in Environmental
Health – a case study of Pesticides’. The theme was decided due to concerns that
emanated not just from the Bhopal tragedy, but by the developmental model being
adopted in India which appeared to neglect health impacts to marginalized communities.
The focus of the discussion was the researching of environmental health problems, using
pesticide exposure as case study. An issue of the mfc bulletin (15) was dedicated to this
topic, excerpts from which are presented in Box.3. A compilation of papers (16) was also
released during the meeting.
Advocacy efforts in the Bhopal Campaign continue to be strong, and this campaign has
exposed the shocking lack of accountability of the government. Though there have
recently been some small positive turns for the affected community, the events following
this disaster leave a disturbing question in mind: For whom is the government really for
- People or Corporates?
Box.3: Contents and Excerpts from the “Pesticides and Health” issue of the mfc
Bulletin (15)
Health of the Environment: A Statement of Concern “The question clearly is: What sort of development do we want?”
Editorial
“Why Environmental Health? Why Pesticides?
Those of us involved in health and health care issues cannot fail to recognize the
gravity of this situation or do we? Since this ecological insensitiveness is at the cost
of human health.”
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Common pesticides: The Health and Environmental Hazards
“DDT – Environmentally persistent;
carcinogenicity; hazardous to avian life”
virtually
non-degradable;
suspected
Pesticides used in India and banned abroad
DDT: banned in Australia, Colombia, Greece, UK, USSR, Poland, Switzerland, USA
Pesticides and Health: some case studies
Occupational Health: “…found that there is an unnecessary risk to workers health”.
Environmental Health: “This crippling deformity, later given the rather long winded
name of ‘Endemic Familial Arthritis of Malnad’ (EFAM) appears to be linked with
pesticide use.”
Beating the pesticide mafia – need for consumer action
“As consumers we should ask ourselves whether we wish to continue allowing
ourselves to be poisoned.”
The Dirty Dozen Campaign
“The selection of the 12 most hazardous pesticides have been made to carry out an
international public education, media and lobby campaign to pressure governments
and manufacturing industries to act more responsibly…”
“The disaster became a tragedy only later” (8) due to the poor decisions and rehabilitation
efforts made by the government, for which, the affected communities continue to pay
the price.
Research efforts to guide and support remediation
From the mfc bulletin
Updates from ongoing research work by mfc members and the rest of the scientific
community were published in the mfc bulletin. Abhay Bang of mfc reported that the
symptomatic treatment given to victims of the tragedy, and the lack of documentation
and certification of victims was making the situation worse (17). Findings of a study on
Womens’ Health (18) by Rani Bang and Mira Sadgopal of mfc found that gynaecological
symptoms and signs were significantly higher among the affected population in
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comparison to a ‘control’8 population. The Nagrik (citizen) Study (19) facilitated by
the Voluntary Health Association of India highlighted that the thiocyanate levels were
relatively high in the subsoil lakes, filtered water and blood (where they were three
times as compared to controls from Bombay). This was the first clear evidence of the
magnitude and nature of environmental contamination in the area. A plea was made to
the research community to share findings with the affected community.
The mfc Bhopal Study
The field work for the mfc Bhopal study (20) was carried
out in March 1985 and the report (21)(22) was published
in October 1985. CHC was involved in the analytical and
advisory roles of this cross-sectional study. The objectives
of the study were to:
•
assess the current health status on a sound
epidemiological basis,
•
assess findings in the light of the controversy between
the pulmonary pathology theory and chronic cyanide
poisoning (cyanogen pool) theory
•
evolve a critique of the ongoing medical research and
relief, identify important factors influencing the relief
and rehabilitation,
Figure 5: Cover of the mfc
Bhopal study report
•
assess peoples’ perceptions about the ongoing health services, and
•
make suggestions for more meaningful relief, research and rehabilitation policy.
Summary of the study report:
JP Nagar and Anna Nagar, two areas of Bhopal, were selected as the ‘study’ and ‘control’
areas respectively, due to their similar socio-demographic structures but different
exposure histories to the gas. Study participants were questioned on various symptoms
(covering all organ systems), following which physician examination, lung-function tests
and haemoglobin tests were conducted. The collected information was quantified and
statistical comparisons were made between the study and control areas. A survey was
8.
One of the methods in Environmental Epidemiology is to compare the health situation in two similar areas,
one which is exposed to the hazard/intervention in question and one which is not exposed. This may help the
researchers further understand the health impact of the hazardous exposure.
Sochara - Environmental and Health Report
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also conducted with a Peoples’ Perceptions questionnaire to evaluate ongoing relief and
rehabilitation services.
The analysis showed that 21 of the 26 symptoms inquired about were significantly9 higher
in the study area, and that “every individual from the study area reported at least one
serious symptom whereas there were many who did not report any symptom from the
control area” (21:p.26). “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 percent of the sample population of the study area cannot be explained by the
Pulmonary Theory” (21:p.40). The evidence supporting the cyanogens pool theory10 was
mainly indirect (21:p.41), but the presence of a wide variety of unconnected symptoms
was its main support.
Questions were also raised about victims’ compensation, the thiosulphate controversy and
on further health research in Bhopal. Several recommendations were made to improve the
situation of ill-health and injustice at Bhopal, and these have been summarized in Box.4.
Box.4: Recommendations from the report of the Bhopal epidemiological study by
mfc (21)
Research
1. Focus should shift from hospital based studies of seriously ill patients to family/
community based ambulatory patients.
2. Clinical studies to validate use of sodium thiosulphate for mass therapy.
Care, Surveillance and Rehabilitation
3. Psychosocial assessment, counselling and rehabilitation are urgently required
4. Mass treatment with thiosulphate based on ICMR guidelines, maintaining good
records.
5. Monitoring and surveillance programmes for assessing risks to pregnant mothers,
unborn babies and newborn babies, and gynecological problems.
6. Important to have long term surveillance of lung function and eye symptoms
9.
Statistical tests are applied to check if the difference in proportions of a particular health problem between two
areas can be explained as a chance occurring. The outcome of these statistical tests is a probability figure or
‘p-value’.
10.
Health effects due to long term exposure to cyanide compounds within the body following environmental exposure
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7. Comprehensive list of all victims for mass treatment, compensation and
rehabilitation.
Communication
8. Evolve a continuing education strategy for all governmental and non-governmental
health personnel through newsletters and informal group meetings. Identified
areas include:
i)
Sodium thiosulphate therapy; Management of lactation failure
ii) Identification and management of psycho-social stress
iii) Risks to mothers and unborn foetus and need for surveillance
iv) Family planning advice till completion of detoxification
v) Role of respiratory physiotherapy, Caution against overdrugging
vi) Need for surveillance of high risk groups, Importance of medical records
9. Dynamic creative nonformal health education of affected community with
information built around their lifestyle, culture and socio-economic status. The
areas identified include:
i)
Sodium thiosulphate therapy; Respiratory physiotherapy
ii) Ongoing research programmes and informed consent
iii) Risk to unborn and new born babies; Family planning advice
iv) Management of lactation failure including low cost weaning foods
v) Importance of records and regular checkups
10. Occupational rehabilitation and compensation: to be done imaginatively keeping
in mind their previous occupations and the residual disabilities.
Coordination
11. The government must adopt a policy of enlisting the help of all non-governmental
agencies and groups wishing to work in Bhopal. This process must be active and
supportive.
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.
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Addressing gaps in knowledge
The pathogenesis11 due to gas exposure was argued around three hypotheses in the mfc
report:
–
Lung damage
–
Increased cyanide in the body (cyanogen pool)
–
Psychological effects post disaster
Following the mfc study, attempts were made to address the identified knowledge gaps.
A literature review was conducted on the use of the hypothesised antidote sodium
thiosulphate12 (23). Symptoms and signs in victims indicated that the causative factor
for the health problems was cyanide poisoning. The results of three other studies also
suggested multi-system findings. Also, in several separate cases significant improvement
in health was noticed following treatment with thiosulphate. A double-blinded clinical
trial13 by ICMR also clearly suggested that thiosulphate significantly reduced symptoms
in patients. Guidelines were prepared and provided to local doctors on the use of
thiosulphate for treating victims.
A literature review titled ‘Health impact of Bhopal disaster – an epidemiological
perspective’ (24) was prepared 198714. The paper summarised the health situation in
Bhopal.
There was limited knowledge of the health effects of the chemical exposure that
occurred. The identity of the released chemicals itself was a subject of debate.
Medical personnel also found themselves unable to handle this unusual situation,
pointing towards the inadequate training and preparation for industrial disasters. The
economically disadvantaged communities bore a double burden of disease – malnutrition
and exposure to hazards of industrialization. Therefore there was an urgent need for a
toxicological investigation to aid rational therapeutic care (treatment and rehabilitation)
of the victims. The symptoms and signs of exposure in victims, pathological findings in
organ systems during examination and autopsy, and analysis of chemical agents provided
clues to answer the above questions.
11.
Pathogenesis implies the mechanism through which a disease evolves
12.
Sodium thiosulphate reacts with the cyanate ions in the body to produce thiocyanate, which gets excreted through
the urine.
13.
This method is considered the gold standard in Epidemiology. An intervention is randomly allocated to the study
population, and results provide evidence on the effectiveness/efficacy of the intervention.
14.
This was prepared by Dr Thelma Narayan as a part of her MSc thesis at LSHTM
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The report described the disaster as an explosive, acute, point epidemic. The state
government classified the degree of exposure of various areas using mortality rates
of each area. Many additional factors were not taken into consideration though. For
example, each grave used on the night of the tragedy was counted as one death though
several bodies were buried in each.
Also, many families had fled from the scene, which led to the victims list being incomplete.
Information on wind direction and atmospheric conditions were neither disclosed nor
considered while classifying exposure. The demarcation of the total exposed area itself
was a difficult exercise, the reasons for which were:
-
No clear idea about the distance beyond which there was no exposure/effect15
-
Mass migration post disaster led to a decrease in exposed population.
Box.5 shows the data on death counts following the Bhopal disaster from published
reports. The variations in the figures illustrate the importance of defining the method
of estimation when such data is presented. Without adequate description, such figures
become non-interpretable.
Box.5: Mortality in Bhopal (24)
Death rates reported in various studies differed from each other based on:
–
study design (including time of study) and sample
–
reporting of deaths in various hospitals
Table: Data of post-exposure mortality in Bhopal from pre-1986 studies
Investigator
Time of study
MP state government Early post disaster
ICMR
Shortly after disaster
Anderson et al
10 days post exposure
Banerji et al
1 month post exposure
Patel A et al
3 months post exposure
Sathyamala et al
9 months post exposure
15.
Crude post exposure death rates
Severe: 23.4/1000
Less hit: 3.2/1000
48.5/1000 (males)
40.5/1000 (females)
Worst hit areas: 30/1000
Severely hit areas: 65.3/1000
Severely hit: 86.6/1000
Less hit: 7.6/1000
Severely hit area: 33.8/1000
This is a constant dilemma encountered for most environmental exposures.
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A review of the available epidemiological evidence on the health impact of the Bhopal
disaster was also a part of the same MSc paper. The conclusions of the paper have been
listed in Box.6.
Research following the Bhopal tragedy saw the use of epidemiological, qualitative and
participatory techniques. Evidence was built over time, both by the government and the
civil society, but translation of knowledge into action was inexplicably and inexcusably
lethargic by the government.
Box.6: Conclusion of the paper ‘Health Impact of Bhopal Disaster – An
Epidemiological Perspective’, by Dr Thelma Narayan (24)
The Bhopal disaster has been a human tragedy of immense dimensions. The suffering
caused is incalculable. Important tasks remain ahead for the provision of the best
possible care for the victims and for the prevention of such events in the future.
There is a need, first, for the measurement, understanding and documentation of
the impact of the disaster on the health of those exposed, so as to be able to provide
rational care. It is necessary also to document the seriousness of the effects so as
to prevent an easy erasure from human memory of the event. Epidemiological skills
could help in this effort as described in this report.
At the present time it is known that similar small-scale ‘technological disasters’ occur
frequently. Larger scale disasters could also occur. Hence, along with the deeper
causes of these disasters being tackled, there is a need to have a strategy to deal
with such events.
Outlines for this are as follows:
It is necessary to have epidemiological data for an adequate understanding of
the effects on human health. This would include data regarding the numbers and
demographic structure of the population at risk, the age/sex/area distribution of the
fatalities if they occur, and similar data regarding morbidity.
Through collaboration between clinicians and epidemiologists, it would be necessary
to evolve simple, standard criteria for assessment and documentation of morbidity.
Similarly, a method to assess exposure needs to be evolved.
Collaboration and communication between administrators, service providers and
researchers is important.
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Close contact and communication with the affected people is the most important
factor. In the absence of this, once could easily slip into esoteric, theoretical exercises,
which are meaningless to the problem at hand.
These efforts have to be seen in the context of the broader issues raised by such events.
In Bhopal, these would include: the economic relationship between multinationals
and countries of the third world which determine factors like technologies and safety
systems used; the exploitative relationship with the workforce and the local community
to maintain high profit margins; the siting and safety systems of hazardous chemical
plants; legislation regarding an implementation of safety controls; the workers, and
communities, right to information; the role of pesticides; and the acceptable limits
to the chemicalisation of our world. The true causes of the disaster and the scope to
prevent such events in the future are/be in the matrix of these issues.
Solidarity with the campaign for community health justice
For their involvement with research and advocacy in Bhopal and encouraging the use
of thiosulphate in treating exposed individuals, some mfc members were arrested and
monitoring by intelligence officials over a period of few years (7).
Solidarity through media
Mfc constantly reminded the media and society about the impacts and consequences
of the Bhopal tragedy (25). They also critiqued the role that was played by the media
in communicating news from Bhopal (26)(27), as the media are important stakeholders
in campaigns for social justice. Emphasising the importance of availability and
accessibility of scientific information, mfc stated that, “Illness of some people are given
more importance than those of poor people and nameless” (26). It was re-iterated that
industrial and environmental hazards were not an unavoidable occurrence but rather
organized violence against fundamental rights of humanity, health and access to justice
(28). All in all, the “Communicating Bhopal” experience was a mixed bag, the media
playing a supportive role in some situations and falling short in some others.
Solidarity through international conferences
The Permanent Peoples Tribunal (29) published two CHC-SOCHARA papers (24)(30) in
the tribunal report (Figure 6), one on the epidemiological evidence of health impacts,
and the other on industrial hazards.
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