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A
DARK BACKDROP
Bhopal
is well known as the site of the world's worst industrial
disaster in 1984. What is less well known is that a medical
disaster of unmatched proportions continues to re-victimise
the gas victims to this day.
Health problems: what and how many?
Following the disaster on December 2nd-3rd 1984, the Indian
Council of Medical Research [ICMR] – a government agency
– concluded, on the basis of mortality figures, that
over 520,000 exposed persons had poisons circulating in their
bloodstream causing different degrees of damage to almost
all the systems in the body.
Today, well over 120,000 chronically ill survivors are in
desperate need of medical attention and an estimated 10 to
15 people are dying every month from exposure-related illnesses.
While official figures report well over 5000 deaths attributable
to exposure, a government agency – the Centre for Rehabilitation
Studies in Bhopal – reports 2165 deaths attributable
to toxic exposure in the year 1997 alone. Unofficial and more
correct estimates place the current death toll at over 20,000.
Breathlessness, persistent cough, diminished vision, early
age cataracts, loss of appetite, menstrual irregularities,
recurrent fever, back and body aches, loss of sensation in
the limbs, fatigue, weakness, anxiety and depression are the
most common symptoms among survivors. The alarming rise in
cancers, TB, reproductive health problems and others such
as growth retardation among children born after the disaster
remain undocumented. The official agency for monitoring deaths
has been closed since 1992.
Lack of information
Union Carbide (now Dow Chemical, following the February 2001
merger) continues to claim over 60 years of research (including
research on human 'volunteers') on methyl isocyanate (the
gas that leaked from the Bhopal pesticide plant) as “trade
secrets”. There is more than enough research to suggest
that by withholding information, propagating misinformation
and the withdrawal of funds meant for medical care, Union
Carbide has impeded the health care efforts of the victims
to help themselves. The ICMR in turn stopped all research
into the health effects of the gas in 1994 and is yet to publish
the findings of the 24 research studies it had carried out
up to that point involving over 80,000 survivors.
In the absence of medical information, no treatment protocols
specific to exposure-induced multi-systemic problems exist.
Of the two official publications resembling treatment protocols,
the most recent by the ICMR is 11 years old and covers little
except the management of respiratory problems, and the vast
majority of the medical community in Bhopal is not even aware
of its existence. As a result, drugs for temporary symptomatic
relief have been the mainstay of medical care ever since the
morning of the disaster. This indiscriminate prescription
of steroids, antibiotics and psychotropic drugs continues
to compound the damage caused by gas exposure.
System failure
So many government hospitals have been built in Bhopal since
the 1984 disaster, that, as the International Medical Commission
on Bhopal [IMCB] has observed, there are more hospital beds
per 1000 population here than in the USA or Europe. The Comptroller
and Auditor General's annual reports suggest that excessive
commissions, and not concern for victims' welfare, is the
real motive for building these huge hospitals that house seldom-used
expensive equipment.
Government initiatives towards identification of survivors
have resulted in confusion, corruption and utter discrimination.
Consequently there are no credible official figures of the
number of victims and the degree and extent of injury. Similarly
lacking are systems to document the health status and treatment
given to hundreds of thousands of survivors under long-term
medical care.
Given the nature of chronic exposure-induced illnesses and
the need for continuous medication, systematic efforts towards
finding non-toxic drug alternatives or drug-free therapies
is long overdue. Such initiatives are even more imperative
in the context of the rich possibilities offered by long-established
indigenous systems. However, systems of health care such as
Ayurveda, Unani and Yoga that are known to provide sustained
relief – without contributing to the toxic load –
have been given only token recognition within the official
system of medical care in Bhopal. The government budgetary
allocation to “alternative” medical care is under
1%. The Bhopal Memorial Hospital trust [BMHT] does not recognise
"alternative" therapies at all.
Despite repeated advice from medical professionals, including
the [IMCB], a community health perspective has failed to inform
health care delivery among the gas-affected population. Budgetary
allocations to community health services have remained under
2% and there are no government or BMHT (Bhopal Memorial Hospital
Trust - the hospital built with Carbide's money) community
health workers. As a consequence, such vital areas as health
education and community involvement in medical management
remain neglected.
While the corporation continues to evade liability for contamination
of community water sources, the government has done little
to protect over 5000 people from additional exposure and injury.
Both Union Carbide [now Dow] and the Indian government are
in possession of information on the hazardous and persistent
nature of these pollutants, yet no effort is being made to
assess the damage, or plan for remediation.
The failure of state government agencies [despite spending
over US $43 million of public money] to offer sustained relief
has meant big business for private doctors and nursing homes.
In the severely affected areas, most of the meagre compensation
has been spent on private doctors, nearly 70% of whom are
not even professionally qualified, yet they constitute the
majority of the medical care providers.
The BMHT (originally set up by Union Carbide) has also been
found to be prescribing drugs that do more harm than good.
Dr. Rajiv Bhatia, Medical Director of the Department of Public
Health in San Franscisco, has audited over 400 prescriptions
given to chronically ill patients in the Trust's community
clinics with alarming conclusions.Creating possibilities:
Sambhavna
It is indeed a shocking situation – people surviving
against the most gruesome odds – a company carrying on
with “business as usual" – a government that
is about to close its files on the "expendable people"
of Bhopal – and the prevalent system of health care most
probably doing more harm than good.
This seemingly impossible situation provides the context for
Sambhavna's existence. Sambhavna is a Sanskrit / Hindi word
which means "possibility". Read as two words, sama
and bhavna it means “similar feelings” or “compassion”.
Although despair often prevails in Bhopal, the Sambhavna Trust
believes in the possibility of stopping the medical disaster
in Bhopal and that the secret lies in generating compassion.
The work carried out by the Sambhavna Trust over the last
five years has demonstrated that it is possible to evolve
simple, safe, effective, ethical and participatory ways of
performing research, monitoring and treatment in Bhopal. Although
small compared to the magnitude and complexity of the disaster,
the clinic run by the Sambhavna Trust has provided direct
treatment to over 10,000 people and given support to a further
10,000 through its health initiatives in 10 communities close
to the Union Carbide factory.
The Sambhavna Clinic
The Bhopal Peoples' Health & Documentation Clinic [the
Sambhavna Clinic] curves a white wall around the corner of
two quiet streets, half a kilometre from the disused Union
Carbide factory. It is still a long walk for most of the survivors
coming for care and many come on cycles or auto-rickshaws.
It is a modestly sized residential building renovated for
clinic use. A tall and shady mango tree, a tiny herbal garden
and rows of potted medicinal and flower plants create an ambience
of tranquility in the clinic.
Trustees of Sambhavna
Doctors, scientists, writers and social workers who have been
involved with various aspects of the disaster from day one
make up the eight member Board of Trustees that administers
Sambhavna. Several have received national and international
recognition for their scientific and social contributions.
Aside from the Managing Trustee who is paid a monthly honorarium
of US $106, all trustees work on a voluntary basis and meet
three to four times a year. Decisions are made through a consensus
among the members of the Board.
The clinic staff
Among the 20 staff members of the clinic: 9 are survivors
of the disaster; 8 are women; 9 are under 30 years of age
and 4 are above 40; 4 are qualified in medicine, 2 of whom
are specialists; 5 are post graduates; 4 are graduates and
7 are educated to school level. Employees of Sambhavna are
paid favourable salaries in comparison to other local non-government
institutions and a ratio of 1:3.5 is adhered to in determining
minimum and maximum salaries.
Most if not all, decisions regarding the day-to-day and long-term
work of the clinic are taken by consensus at the weekly meeting
of the full-time staff members. A coordinator is chosen every
two months from among the staff members.Activities of the
Sambhavna Clinic:
The Sambhavna Clinic carries out a range of interlinked activities:
1. Medical Care
2. Community Health Work
3. Research and Monitoring
4. Documentation
5. Seminars and Training
1. MEDICAL CARE
Provision of appropriate medical care is one of the central
activities of Sambhavna. The guiding principles regarding
medical care include the following:
a. The medical care of the survivors should be based on
the principle of "First do no harm": therapy administered
to patients must not compound the injuries sustained as
a result of exposure.
b. Therapies that do not contribute to the toxic load of
the body are integrated into provision of medical care as
far as possible.
c. Integrated systems of therapy must be based on the specific
symptom complexes presented by the survivors as opposed
to attention to individual symptoms.
d. A proper system of registration and constant monitoring
of the effect of therapeutic intervention and research into
the health status and efficacy of treatment must be integral
to the provision of medical care.
Medical care at the Sambhavna Clinic consists of the following:
I.
Allopathic care
II. Ayurvedic care
III. Yoga
IV. Pathology
V. Preparation and distribution of medicines
I.
Allopathic care:
Allopathic care at the Clinic distinguishes itself in its
attention to the development of treatment protocols for
specific symptom complexes, weeding out unnecessary and
harmful drugs and including Ayurveda and Yoga in the overall
treatment regime.
From April 1 2000 to March 31 2001, 962 persons, most with
history of severe exposure and chronic illness registered
for allopathic care. During this period, 7265 people made
follow-up visits.
Allopathic care is provided through three different units:
I
(a) General medicine
Here, a detailed exposure history, history of illness
and other significant information of the person is recorded.
The person is physically and clinically examined and appropriate
advice for treatment is offered. All clinical data is
recorded in the person's individual folder and subsequently
computerised.
I (b) Gynaecological care
The Dominique Lapierre City of Joy Sambhavna Gynaecology
Clinic is the only facility in Bhopal that provides regular
cervical screening, examination and treatment to survivors
of the disaster. State of the art facilities such as colposcopy
and LLETZ are available only at this clinic. Two gynaecologists
and a gynae health assistant run the clinic. Community
health work focussing on gynaecological health issues
is carried out by two health workers. Between April 2000
and March 2001, 950 visits were made to this clinic.
I (c) Mental health care
Health care for such symptoms as panic attacks, insomnia
or disturbed sleep, anxiety, depression, irritability
and impaired memory is provided by a psychiatrist who
visits the clinic two days a week. In the year 2000–2001,
1272 people came for mental health care.
II.
Ayurvedic care
Significant features of Ayurvedic health care at Sambhavna
include the use of medicines described in standard texts
rather than factory-manufactured drugs, predominant use
of herbal drugs over mineral preparations and the use of
modern investigative facilities and tools for objective
assessment. Between April 1 2000 and March 31 2001, 5291
people received Ayurvedic care.
There are two units in Ayurvedic care – General medicine
and Panchakarma Chikitsa.
II
(a) General medicine
After a thorough examination based on Ayurvedic principles,
people are treated from a range of 32 herbal powders,
12 plant sap extracts, 17 medicines of earthly and animal
origin and 53 herbal combinations.
II (b) Panchakarma Chikitsa
Panchakarma, literally meaning “five procedures”,
is a part of Ayurvedic therapy specially for detoxifying
the body. It involves massage with medicated oils, medicated
saunas, medicinal purging, hot fomentation and other procedures.
It is particularly beneficial for chronic conditions.
In the year 2000–2001, 574 people were registered
for Panchakarma care for between seven and 14 days.
III Yoga
Yoga has been found to be particularly beneficial for people
suffering from chronic diseases involving the respiratory,
musculo-skeletal, neurological and endocrine systems. Yoga
therapy at Sambhavna consists of instruction in different
combinations of Asana [physical postures], Pranayama [breathing
exercises], and Shodhana kriya [cleansing actions]. The
Yoga therapists identify exercises that positively impact
the systems and organs related to the individual's particular
disease process.
IV Pathology
The clinic's pathology laboratory is equipped to carry out
routine, microscopic and bio-chemical tests for blood, urine,
sputum and vaginal and cervical smears.
V Preparation and distribution of medicines
Sixty-four Ayurvedic medicines are manufactured inhouse
using locally collected or purchased herbs. Herbal medicines
prepared at the clinic include: Churna [single herb and
herbal mixture powders], Kwatha [decoctions], Taila [oils],
Vati [tablets] and Lepa [poultice].
All medicines are provided free of cost. In dispensing medicines
we take the utmost care to ensure that people are well informed
about what they are taking.
2. COMMUNITY HEALTH WORK
Sambhavna believes in empowering the community and the individual
to take control of its and their health. The four community
health workers at Sambhavna are the only ones of their kind
in all Bhopal. Between April 1 1998 and March 31 2000, the
community health workers carried out the following activities:
a.
Health and health care surveys
b. TB hare and health education
c. Monitoring and house visits
a.
Health and health care surveys
Door-to-door surveys of five communities with a total
population of about 10,000 were carried out to generate
a database on the demography, health and health care status
of the residents, as well as their social, economic and
environmental condition. Health workers also identify
persons in need of special medical attention and ensure
that this is made available either at the Sambhavna clinic
or elsewhere.
b. TB care and health education
Sambhavna pays special attention to the control of TB
at a community level. Despite official knowledge regarding
the unusually high prevalence of TB in the survivor population
[over three times the national average] there are no official
initiatives in this direction.
Work in TB care consists mainly of education, identification
of people with symptoms, supervision of treatment and
constant health monitoring. Much of this work is shared
by the patient leaders, recovered TB patients in the community,
who provide much effective inspiration and guidance.
c. Monitoring and house visits
Monitoring the health of people receiving care at the
clinic through house visits is an activity that distinguishes
Sambhavna from others. This is done by community health
workers to:
i. evaluate the quality of care and patient satisfaction
ii. find out the efficacy of treatment [or its absence]
among drop-outs
iii. ensure compliance of treatment regimes
3. RESEARCH & MONITORING
With its limited resources the Sambhavna Clinic has completed
two research projects and two more are underway. The government
stopped monitoring exposure-related mortality in 1994 but
Sambhavna continues through a method known as Verbal Autopsy.
Research projects completed by Sambhavna are:
i. Assessment of drug distribution in gas affected Bhopal
This study concluded that only 16% of prescriptions were
rational, and that there was little difference in the quality
of prescriptions issued by qualified and non-qualified practitioners.
46% of most sold drugs were found to be harmful or useless.
ii. Effects of Yoga therapy on Chronic Respiratory Disorders
related to the Union Carbide gas disaster in 1984. Findings
include significant and sustained improvement of lung function
in all subjects and discontinuation of medication by more
than half of those in the study.
Verbal Autopsy
Verbal Autopsy (VA) is a scientific method of proven validity
used for establishing the cause of death of individuals
in a community. This is particularly useful in situations
where the proportion of deaths occurring under medical care
are low and where no autopsies are carried out. VA has been
successfully employed in India, Bangladesh, Kenya, Nigeria,
Philippines, Egypt, Indonesia and several other countries,
to determine the cause of death of individuals in various
circumstances.
The VA assessment panel consists of three eminent physicians
of the country. The Head of the Verbal Autopsy group at
the London School of Hygiene and Tropical Medicine, UK is
Sambhavna's advisor.
The information collected through VA up to March 31 2001
conclude that of the 81 cases of death monitored through
this project, 56 cases [69%] shows that there was a strong
association between exposure and subsequent death.
4.
DOCUMENTATION
Much information on the December 1984 Union Carbide disaster
in Bhopal and its aftermath is lost, unavailable or classified.
A large part of information that is actually available, remains
within the tight-knit circle of bureaucrats, scientists, medical
researchers and academics. Government efforts to collect and
distribute this information are absent and non-government
initiatives towards documentation of the continuing disaster
are rare.
The Sambhavna Clinic's documentation unit collects, collates,
and distributes medical and other information related to the
disaster. All information is made available to the Clinic's
staff, survivors, researchers, journalists and others. Quite
possibly this is the only public repository of documents of
its kind.
5. SEMINARS & TRAINING
The Sambhavna Trust has organised the following seminars involving
local, national and international medical professionals, scientists,
environmentalists and survivors' organisations.
i.
Current Medical issues of the December 1984 Union Carbide
disaster November 30 1996
ii. Gynaecological and obstectric problems related to the
December 1984 Union Carbide disaster May 6 1997
iii. Possibilities in Ayurveda in the treatment of diseases
caused by the Union Carbide disaster in Bhopal September
20–21 1997 [national conference]
iv. Pollution and the threat to life in Asia August 30 1998
[international conference]
v. No More Bhopals 4–5 December 1999
An
international conference organised in association with the
Bhopal Medical Appeal–UK
Several members of the Sambhavna Clinic have participated
at various local and national seminars. The research paper
Effects of yoga practices for respiratory disorders related
to the Union Carbide gas disaster in 1984 was presented at
the XVI World congress of Asthma in Buenos Aires, Argentina
on October 17– 20 1999.
Sambhavna members have also participated in the following
training programmes:
- Panchakarma therapy at Durg, Akola, Nagpur and Kotakkal
Aryavaidyashala, Kerala
- Community control over Tuberculosis at Southern Health Improvement
Samiti, Calcutta
- Cervical cytology at the Cama and Albless Hospital, Mumbai.
Sambhavna's Funds
Sambhavna's main source of income is the compassion of the
international community. Resources so far have consisted of
small contributions from a large number of individuals in
Japan, the UK, the USA and India.
On the 10th anniversary of the disaster, the Bhopal Medical
Appeal, Sambhavna's UK-based support group, published an advertisement
in The Guardian, which raised over £70,000 from well
over 5000 individuals. Subsequent advertisement campaigns
that aim to raise awareness and funds have generated an additional
£50,000. We have also requested and received funds two
US-based foundations – The Threshold Foundation and the
Kapor Foundation as well as the Foundation Anna Villa Rusconi
in Italy. Donations are also received at the clinic from survivors
and their sympathisers.
Sambhavna's Expenditures
Sambhavna's annual expenditure in running the Bhopal Peoples'
Health and Documentation Clinic has been under US $30,000.
Major expenses have been salaries, the purchase of medicines
and equipment, renovation and furnishing. Income and expenditure
statements of Sambhavna are prepared and audited for every
financial year [April–March]. The clinic runs on a very
tight budget requiring judicious attention to all expenditure.
Since the Sambhavna Clinic opened in 1996 it has:
•
Developed several safe, effective and cheap treatment
methods for care of persons presenting particular symptoms
or symptom complexes
• Created a model for minimising the use of unscientific
Allopathic drugs in the care of the survivors
• Demonstrated the efficacy and public acceptance
of Ayurveda and Yoga in the treatment of exposure-related
illnesses
• Presented objective data to show superior efficacy
of Yoga therapy in the treatment of respiratory disorders
• Demonstrated the applicability of VA as a scientific
method for monitoring deaths resulting from chemical exposure
• Generated data to draw attention to neglected areas
of research on the health consequences of the disaster
• Gained encouraging support from the gas-affected
communities, survivors' organisations and the local medical
community
• Presented a working model for developing community
control over TB
• Created a system for collective and consensual
decision-making
• Applied innovative means to raise funds locally,
nationally and internationally
In July 1999 the Sambhavna Trust received an award from
the Tajiri Muneaki Memorial Fund, Japan for "outstanding
meritorious services rendered to the victims of Bhopal
gas disaster".
Limitations and failures
The limitations and failures of Sambhavna, many but not
all, due to resource constraints, are listed as below:
• The number of people offered care is only a fraction
of the survivors in need
• The distance of the clinic from the severely-affected
communities presents a real problem for many people
• A substantial number of people treated have not
received sustained relief and the problem of relapse of
symptoms remains
• The patient-load on individual doctors is increasingly
difficult to manage
• As yet we have not managed any epidemiological
or clinical research studies on the long-term health consequences
• We have now begun regular treatment of cervical
cancer
Sambhavna's
beliefs:
The limits of modern medicine in taking care of modern industrial
diseases are becoming increasingly apparent. Evolution of
an appropriate system of health care, monitoring and research
for survivors of Bhopal is of consequence to us all worldwide.
It
is possible to combine traditional and western systems when
evolving appropriate care for sustained relief to chronically
ill survivors in Bhopal.
Individuals can and should be active participants in their
own healing. Communities can and should be collectively
involved in all aspects of public health.
It is possible to evolve systems of health surveillance
and environmental monitoring with the active participation
of the community of survivors. Our work in documenting the
long-term consequences of exposure is part of the survivors'
ongoing struggle of memory against forgetting.
It is possible to depend upon the compassion of ordinary
individuals and generate enough funds to run our clinic
without corporate charities, large grants from foundations
or government assistance.
It is possible to generate opportunities for hope through
creative and collective intervention in a situation of despair.
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