The scientific and medical response to the immediate Bhopal crisis constituted an extraordinary pulling together of hospitals, medical personnel and social services in the area. Coping with a disaster of this scale was unheard of anywhere in the world, and there was widespread admiration for those who responded, often risking their own lives in the process.

However when the long term after effects of this disaster began to appear, it was obvious that the social, political, and legal climate was inadequate since there was little experience in dealing with a major environmental release. Scientific and medical personnel needed access to accident-related and toxicologic information to understand the causes and potential consequences of the disaster. Union Carbide, the primary repository of this information, faced with lawsuits and the prospect of bankruptcy, closed down its channels of communication. On the other hand, the extreme sensitivities of the local and national government bodies towards all aspects of the disaster, coupled with the lack of expertise and funds, resulted in an inadequate response on India’s part to meet the urgent health care and social recovery needs of the community. Whereas local health professionals and the interested scientific community abroad expected a flood of information from a disaster of this magnitude, only a trickle resulted.

These transnational political and legal ramifications threw a veil of secrecy around the disaster and obstructed the discovery of vital medical and toxicologic information. The medical community was often frustrated in its attempts to understand the links between gas exposure and health and devise appropriate treatment strategies. As an example, ignorance about whether the main poison, methyl isocyanate, could decompose to deadly cyanide gas, led to years of acrimonious debate on the merits of treating the gas victims for cyanide poisoning.

Recognizing the dire need of the gas victims, the Permanent Peoples’ Tribunal met in 1992 and recommended that an international medical commission provide an in-depth independent assessment of the situation in Bhopal. The International Medical Commission on Bhopal (IMCB) was thus constituted with 14 professionals from 12 countries who were chosen on the basis of their medical expertise and experience in environmental health, toxicology, neurology, immunology, and respiratory medicine. Drs. Rosalie Bertell and Gianni Tognoni serving as the co-chairpersons of the IMCB. At the request of Carbide gas victim organizations, the IMCB conducted a humanitarian visit to India in January 1994 to contribute in any way possible to the relief of the victims and to suggest ways to in which such catastrophic accidents could be prevented in the future or their effects mitigated. During their stay, the IMCB met with government officials, various disaster experts, hospitals, research teams, local private physicians, biochemists, botanists, various survivor groups, environmental activists and veterinarians.

The main goals of the IMCB were:

1. Betterment of the lives of the victims with rational diagnostic methods and treatment 2. Clarification of the place and form of international medical assistance and documentation after a catastrophic accident 3. Recommending legislation to protect humans from military and industrial pollution 4. Mobilization of international assistance in response to the request of survivors rather than waiting for government invitation. 5. Provide guidelines for planning health research on the impact of major accidents 6. Establishment of a precedent for international protection for medical research against interference from vested interests or corporations or governments 7. Legitimization of the voices of survivor organizations and their participation in relevant decisions 8. Promoting ethical and scientific standards for information collection and communication to victims 9. Coordination of medical, research, and legal information to assist victims in claims 10. Alerting the Govt. of India to the need for full disclosure of potential hazards and environmental impact studies prior to allowing any hazardous industry to set up in India

The commissioners divided their work in various groups: a) Community & clinical studies: survey of the population followed by clinical testing of selected groups b) Assessment of availability and quality of medical care, including level of medical resources available. c) Examination of the adequacy and equity of laws and regulations relating to claims and the distribution of compensation; d) Evaluation of drug therapy by examination of prescriptions routinely given to survivors; e) Accident analysis; f) Review of studies and published literature on the disaster.

The IMCB had committed itself to a) provide a full report of its findings and recommendations to the Governments of India and Madhya Pradesh, victims’ organizations, and all other interested parties, b) stand ready to assist the government of India and medical colleagues to implement the recommendations of the commission, c) enlist the National Advisory Committee to follow up the initiatives of the commission, d) recommend research studies to be undertaken in India on the long-term effects of the gas exposure, and e) assure the wide circulation of its experience and findings in the professional literature.

Findings

The IMCB publicly condemned Union Carbide and reiterated the company’s full liability not only for responsibility in causing the deadly gas leak, but also for the confounding role of its behavior with respect to pre-accident preventive and exposure mitigating efforts, and the timely and effective application of the appropriate medical measures at the time of the accident. This included the lack of transparency about the composition of the gases released, resulting in the absence of rational methods of care and planning resulting in loss of sight and in some cases life, and creation of suspicion and conflict among professionals and the population. There was also a lack of emergency preparation which would have made the public and professionals aware of the potential toxins inside the plant and how to respond to an accident.

The government of India also was faulted since no clear guidelines were laid down to determine compensation to the victims resulting in undue delays and aggravation of their health status and/or economic survival. The secrecy surrounding the health studies undertaken by the Indian Council for Medical Research may initially have been instituted to protect the litigation process, but in reality made the rational medical treatment and establishment of claims almost impossible. In hindsight, it is clear that the secrecy served no purpose whatsoever and has resulted in non-publication of the information. Moreover, because of the secrecy about the accident itself and the chemicals released, it was difficult for the survivors to document their claims. We also noted an excessive fear among government personnel of bogus claims.

In fulfilling its commitment, results of the community studies conducted by the IMCB have been communicated to the affected population in the form of public meetings, which provided a forum for the victims to ask questions and provide comments. The studies have also been published in various national and international journals so that the scientific community has access to this information.

Recommendations of the IMCB:

1. Reorganization of the health system to establish a network of community-based primary Care clinics; 2. The gas-related disease categories need to be broadened to include central nervous system and psychological (PTD) injury; 3. A conference to determine best practice rehabilitation medicine, including both Western and Indian expertise, must be undertaken to develop rational treatments and prescription medicines for survivors. 3. Health data collected by the ICMR should be communicated to the population and submitted for publication in professional journals. 4. Gas victims have the right of access to their medical records; 5. Victim organizations should be adequately represented in the national and state commissions dealing with the disaster; 6. Criteria for compensation should include medical, economic and social damage to the victims 7. Allocation of resources for economic and social rehabilitation of people and their communities should be made. 8. Thorough examination of the impact of the toxic waste buried on the Union Carbide site and its potential for further damage to public health needs to be researched.

It is now well known that persistent and chronic gas-related health effects are present in the Bhopal population. However, the full spectrum of effects is yet to be defined, especially in those exposed as children, in utero, or subsequent to the disaster, due to the lack of systematic collection of relevant information. Recent investigations have shown that local well water has become contaminated by the improper storage of a large amount of hazardous waste in the facility, some of which is carcinogenic. Twenty two years later, the prospects for learning from this disaster do not appear to be bright. What is sorely needed is an independent body to coordinate the heath care, research, rehabilitation of gas victims, and care for potential effects in their offspring. Instead of the free-for-all approach to medical treatment that currently exists, clear guidelines and criteria need to be formulated for specific medical conditions. Such an effort could be implemented through India's existing heath care pyramid. Community-level health units should be developed to serve a maximum of 5000 people each. Local hospitals with multiple departments can be used to provide secondary care. A specialized medical center dedicated to treatment and research of the more serious problems arising from the gas leak should be established. The IMCB believes it is a mistake to increase the number of hospital beds in Bhopal. The community has need for more neighborhood clinics, non-drug respiratory therapy and sheltered workshops, not for more hospital beds.

The IMCB has recommended that long-term monitoring of the community for illness and response to treatment be done for several decades. This would include the study of exposed and unexposed areas to observe patterns of illness and death as well as to detect the occurrence of related chronic diseases and the appearance of new diseases. Such an approach needs to one in which the health professionals involve the community of gas victims as active partners in investigation, provide them with feedback on community health, ensure that their health risks are properly communicated, and thereby enabling an increase in their consciousness, autonomy and self-determination.

Recognizing that Bhopal is a tragic model of an industrial epidemic, the IMCB has expressed willingness to organize international teams when requested, to provide technical assistance and evaluation of other environmental disasters. Rather than the provision of emergency relief functions, for which there are other organizations such as Medecines sans Frontieres and the Red Cross/Red Crescent, the IMCB envisions its role at three levels: 1) response to communities who appeal on the basis of chronic disability due to a disaster, 2) represent victims at the international level for legislative needs required to implement the International Bill of Rights relevant to health and safety, and 3) working to define the appropriate public health investigations to serve the needs of the community rather than use the victim community to serve the needs of science. The International Bill of Rights includes: The Universal Declaration of Human Rights, proclaimed on Dec 10, 1948; The International Covenant on Economic, Social, and Cultural Rights (1976), and the International Covenant on Civil and Political Rights, 1976.

The steps to be taken to achieve the full realization of this right shall include: - provision for the reduction infant deaths and for healthy development of the child; - improvement of all aspects of environmental and industrial hygiene; - prevention, treatment, and control of epidemic, endemic, occupational and other diseases; - creation of conditions which would assure to all people medical service and medical attention in the event of sickness

To protect these rights, an international body, free of industry and government pressures, and competent to advise on health and safety standards, is required to be able to mediate just and equitable resolution and compensation of damage in the case of unanticipated disasters.

Members of the International Medical Commission on Bhopal: Rosalie Bertell (Canada), Gianni Tognoni (Italy), Thomas Callendar, Jerry Havens, V. Ramana Dhara (USA), Birger Heinzow (Germany), Marinus Verweij (Netherlands), Sushma Acquilla, Paul Cullinan (U.K.), Wang Zhengang (China), Jerzy Jaskowski (Poland), Leonid Titov (Belarus), Ingrid Eckerman (Sweden), and C. Sathyamala (India).

L to R: Drs. Ingrid Eckerman, Gianni Tognoni, Rosalie Bertell, Sushma Acquilla, Birger Heinzow, Ramana Dhara Image File history File links Download high-resolution version (1408x1024, 237 KB)L to R: Drs. ...

IMCB members (L to R) Ramana Dhara, Jerry Havens, Birger Heinzow calibrate a spirometer Jan 1994 Image File history File links Download high-resolution version (1408x1024, 158 KB)IMCB members Ramana Dhara, Jerry Havens & Birger Heinzow calibrate a spirometer; Jan 1994 I, the creator of this work, hereby release it into the public domain. ...

Carbide gas victims’ organizations: Bhopal Gas Peedith Mahila Udyog Sanghatana, Gas Peedith Stationary Karamchari Sangh, Zahreeli Gas Kand Sangharsh Morcha, Nirashvrit Pension Bhogi Karamchari Sangh, and the Bhopal Group for Information & Action.

References: 1. Bertell R, Tognoni G. International Medical Commission, Bhopal: A model for the future. National Medical Journal of India. 1996; 9(2):86-91 2. Dhara VR. What Ails the Bhopal Disaster Investigations? Int J Occup Environ Health; 2002;8:371-379. 3. Dhara VR. Findings of the International Medical Commission on Bhopal. The Hindu – Survey of Environment; 2003