Download Lessons from the Bhopal Disaster: Part II

Lessons Learned – Bhopal
In the second part of the
article Dr Efraim Laor looks
at patterns in the Indian
and international response
during and after the
Bhopal disaster of 1984.
Lessons
from the
Bhopal
Disaster:
Part II
Any analysis of the response to the Bhopal tragedy will be sharpened
by an equal examination of Operation Faith, which followed the initial
disaster and aimed to detoxify the remaining 15 tons of
methylisocyanate (MIC) still stored at the Union Carbide (UCC) plant.
There are some fundamental differences between these two aspects of
the tragedy – the former entailed an unplanned reaction to a disaster
whereas the latter entailed the prevention of further damage – yet
there are some common aspects that enable a retrospective
comparison, such as the scene, the principal actors and the close
timing of the events, which took place less than a fortnight apart. The
relatively organised and successful performance of Operation Faith
highlights many of the deficiencies that characterised the initial
disaster response.
Policies
Once the Indian authorities, UCC and their Indian subsidiary
recognised the scale of the Bhopal disaster, they were faced with two
major decisions: what to do with the remaining MIC and how to
minimise the damage that resulted from the accident. The challenge
posed by the first issue was clear and relatively simple to meet: they
had to choose between (a) neutralising the MIC through the scrubber
by pushing little bursts of it through caustic soda solution, (b)
repacking the MIC into smaller containers and shipping it back to
Danbury, and (c) converting it into pesticide by using the existing
facilities. How to deal with the results of the accident required a much
more complex decision. Both the Indian government and Union
Carbide (UCC) formally declared the need for damage minimisation,
but they left the question of who or what to protect unanswered, e.g.,
the political system (barely three weeks before a general election), the
public, Union Carbide, or key individuals within the establishment such
as Arjun Singh and UCC/UCIL management?. The possibilities, it later
transpired, were mutually exclusive: saving their own political skins
precluded officials from saving the public and vice versa.
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HazMat Responder World
Autumn 2012
It is the personal opinion of the author that the Indian
authorities and Union Carbide were not only grossly negligent
before the disaster, but equally callous during their response to it.
As will be demonstrated below, the major parties involved chose an
objective which deviated from the one expected of responsible
actors in charge of a response to an LSSD. Both their actions and
inactions, aimed at advancing their own interests, contributed to
the subversion of the primary objective of such a response, which
is to save as many lives as possible and reduce damage to the
public’s health.
Policy for responding to the accident
Following the tragedy everyone who could conceivably be connected
to the Bhopal tragedy asserted, to varying degrees, that they as
individuals and as organisations were outraged, but that the fault
was not theirs and someone else was culpable. Although the events
in Bhopal were catastrophic in every sense of the word, many
officials viewed the episode, for all practical purposes, as over. The
official impression was that the administrative response had been
adequate, the damage had been less serious than was originally
feared and all that remained to be done was to resolve the legal
issues arising from the accident. In other words, officials attempted
to both play down the effects and play down the causes. The probusiness government of India found itself in a delicate position,
having to confront an American-owned multinational during an
election year.. The goal of UCC was consistent (except during the
first hours) and that was to protect their own assets at any cost. In
practical terms, this meant failing to discover what really happened
at Bhopal, justifying the reopening of the MIC plant in West Virginia
and deflecting responsibility for the disaster to its Indian subsidiary.
The reaction of the US chemical industry ran along similar lines, and
was not significantly different from that of the nuclear industry
following the Chernobyl accident.
Lessons Learned – Bhopal
The strategy
There was a qualitative difference between
the strategy of response to the tragedy and
the subsequent strategy employed during
Operation Faith. Whereas the accident itself
had not been preceded by pre-disaster
preparations, resulting in a calamity,
Operation Faith was relatively organised and
eventually achieved the desired results. It is
clear that the Indian central government did
not have a systematic, objective-oriented
strategy for saving people's lives. Officials
were shocked, disoriented and paralysed.
Ongoing activities were characterised by
indecision, discord, highly-motivated but
ineffective actions, and poor performance.
The military and medical communities
seemed to be the only official arms that
functioned with some degree of efficiency.
Technically, it was feasible to begin the
relief operation at roughly 00:30 or even
earlier, which would have significantly
reduced the health hazard to the local
population. The authorities could have
prevented a great deal of suffering just by
alerting the public to the accident,
instructing them to escape perpendicular to
the wind, cover themselves with whatever
was available, breathe through wet cloth and
keep still rather than moving around. They
could have organised mobile teams to
evacuate the sick and injured to hospitals
and clinics. Even if they were underresourced, they could have targeted efforts
at children, the elderly and pregnant women
– all of whom were put at particular risk. In
short, they could have performed simple acts
which would have had important, lifepreserving effects. Yet, nothing of the sort
was done until roughly 06:00 the next
morning. Although 15 tons of MIC remained
stored in the plant, the parent company
steadfastly refused to provide details of what
might have gone wrong at Bhopal. Their
strategy was unsound from the very start:
they insisted there was no leak, failed to
sound the public alarm, withheld vital
information on treatment for the toxic
effects of MIC and other substances, and
lastly used a media campaign to deflect the
blame onto local workers.
The main objective of Operation Faith was
to minimise exposure time, and the best way
to avoid intensive human exposure to the
poison was either by moving people away
from its path or getting rid of its source. Dr.
Vardharajan, a prominent Indian scientist,
was appointed head of the operation. After
consulting UCC representatives and
Jagannath Mukund, the plant foreman, he
decided that the safest option would be to
convert the remaining MIC into pesticides.
The Chief Minister, Arjun Singh, insisted that
every precaution would be taken: the task
would be performed only during daylight
hours, a helicopter hovering overhead would
spray water to dissolve any escaping gas and
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HazMat Responder World
families would be allowed to evacuate to the
city's schools. And, indeed, a number of
precautions and actions were taken, aimed at
increasing public safety. In addition, nine
camps were set up in schools and colleges in
the city for those wanting to leave their
homes, dedicated buses shuttled residents
from colonies to camp sites, people in the
camps were fed two meals a day and
received medical treatment, and the
government closed all local schools until the
end of the detoxification process.
Despite these precautions, the secrecy
that surrounded operations at the plant
intensified the existing tension in the city.
The people of Bhopal were not convinced
and felt that they were not being evacuated
far enough away from the poisonous gas.
Most locals locked their homes and shops,
organised bundles of clothes and food and
left the city autonomously, congesting the
Autumn 2012
railways and bus stations. Nearly 400,000
fled Bhopal under their own steam whilst
official buses transported people, their
household goods and even animals. Four
hundred buses that had arrived for standby
use were quickly packed with families
seeking to get away. On the night of Singh's
announcement, more than 5,000 people
jammed the city's railway station. One man
was killed when the rushing crowd pushed
him into the path of a train. Fleeing
residents sat on the top of the buses because
there was no space inside. The operation
lasted seven days (16-22 December) and
reached a successful conclusion.
Administration
Indian authorities lacked an organisation
specifically responsible for coping with
peacetime disasters. They had neither
contingency plans, an administrative
There was a great deal of public anger after the disaster, but it was not just Dow
that was to blame ©Greenpeace
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Lessons Learned – Bhopal
The exact death toll from Bhopal will never be known ©Greenpeace
apparatus nor a standing capability to cope
with such a situation. In practice, the
majority of the activities were improvised: at
03:30, barely three hours after the plant's
evacuation and with hundreds of dead
citizens, the health minister, Rewanath
Choubey, informed Arjun Singh of the leak
from the Union Carbide plant. Singh and his
aides were evidently stunned and did not
know how to cope with the emergency. At
05:00 the police announced that the gas leak
had ended and Singh drove to the affected
areas. When Ragiv Gandhi visited the scene,
en route to a campaign tour of Madhya
Pradesh, Singh dropped his other duties to
join the prime minister.
Local authorities did not set up a crisismanagement centre. The army was alerted by
retired Brigadier M.L. Garg, who asked for
the help of the area sub-commander,
Brigadier N. K. Mayne. The Additional District
Magistrate, H. L. Prajaphati, said that he had
spoken to Mukund, the factory foreman at
his home and given him news of the disaster.
Mukund's first reaction was reportedly one
of incredulity. Before ordering the UCC
foreman to go to the plant, Prajapathi asked
him about possible medical treatments. The
advice he gave was to splash water in the
eyes and wipe the faces and mouths of those
contaminated with a wet cloth. Prajapathi
12
HazMat Responder World
recalled Mukund saying, "it is not known to
kill". The police chief asked the plant's
security officer to identify the gas and its
antidote. The man said he did not know. In
sum, during the first critical hours, the
official response was characterised by
incredulity, indecision and inaction. It was
not until the next day that civil authorities
made concrete attempts to re-establish order
and launch a co-ordinated rescue operation.
All schools, colleges and other
establishments were closed. Teams of doctors
and paramedical personnel were rushed to
the scene from other parts of India. Military
personnel, ambulances and army trucks were
pressed into service. The army opened its
hospital to the civilian population. The local
police aided in the search efforts.
Medical services
The medical problems raised by the accident
were the most complex and consequently the
most urgent to tackle. The challenge entailed
discovering which kinds of poisonous
materials had been released, finding suitable
antidotes, treating enormous numbers of
patients at a time, finding places to
hospitalise masses of victims, minimising the
danger of an epidemic and mobilising the
necessary medical resources. It rapidly
became clear that the state of Madhya
Autumn 2012
Pradesh was incapable of coping with the
situation without external involvement. Local
medical services collapsed, under masses of
casualties, before dawn. On the morning of
3rd December, the state government sent out
appeals for medical help and drugs to
surrounding cities. Messages began to flow
between Bhopal and Delhi, among them from
Singh to Prime Minister Rajiv Gandhi. In my
view, the Indian authorities could have
responded much better by requesting
international assistance without delay.
The symptoms
The initial human symptoms following the
leak were eye irritation and coughing, which
developed into vomiting, eventually leading
to blindness and death. Most of the victims
suffered severe damage to mucous
membranes and inflammation of the
respiratory tract. The chemical action within
the lungs caused them to secrete fluids, and
in acute cases the fluids caused asphyxiation
and death. People who had run great
distances, breathed deeply and inhaled large
quantities of gas suffered severe lung
damage. Many women had peculiar
gynecological problems. Exposure to MIC
generated intense heat within the body,
followed by dehydration. Besides the lungs
and eyes, the exposure damaged the liver,
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Lessons Learned – Bhopal
kidneys and gastrointestinal tract, as well as affecting the
immunological, reproductive and central nervous systems. Within
barely two weeks of the accident, Bhopal faced a jaundice epidemic,
which doctors suspected was chemically induced, rather than viral.
Other delayed effects included intestinal bleeding, pain in the kidneys,
general debility and in some cases paralysis. In fact, most of the
deaths recorded after the third day involved a failure of the central
nervous system. The survivors of the first days fell victim to secondary
infections of the lungs and the respiratory tract. The number of people
reported to be suffering from bronchitis, pneumonia and asthmatic
complaints increased. Tuberculosis patients experienced an
exacerbation of their symptoms. The theory that the gas would not
affect those who inhaled it after 72 hours of the leakage proved
wrong. Even on the ninth day after the accident, new patients applied
to hospitals for treatment.
Diagnosis of the poisons.
The disaster proved that MIC is as lethal as hydrogen cyanide and
phosgene. The fatal effects of MIC took doctors by surprise and for
years the nature of the compound which had been released during the
accident remained an unresolved controversy. There was consensus
about MIC and phosgene, but a bitter dispute about the presence of
cyanide. Some pathological symptoms strongly suggested its presence,
though UCC maintained that isocyanates were unrelated to cyanide,
claiming that there is no known metabolic pathway that converts
isocyanate into cyanide. This argument contradicted the company's
own material safety data on MIC, section 5, which stated that
"thermal decomposition may produce hydrogen cyanide, nitrogen
oxides, carbon monoxide and/or carbon dioxide". When Awashia, UCC’s
health director, was questioned about whether MIC can release
hydrogen cyanide, his initial response was to say no. He was referred
to Carbide's own manual, to which he replied "Yes, at 437 degrees C."
Given the high temperatures generated by the exothermic reaction
between MIC and water, as well as other chemical changes in tank
E610, it is more than likely that a considerable amount of MIC yielded
decomposed products. A confidential report furnished by the Indian
Council of Medical Research (ICMR), stated: "There is evidence of
chronic cyanide poisoning operating as a result of either inhalation of
hydrogenic acid or, more probably, subsequent generation of cyanide
radical from the cyanogen pool in gas afflicted victims." This
controversy lasted long enough to prove that it is unwise to stimulate
a response based on the accumulation of scientific data. This episode
also highlights the drawbacks of previous knowledge, as well as the
problems of recognition and adequate timing, suggesting that optional
benefits can be gained from international co-operation.
Therapy dilemmas.
During the first few hours of the disaster, the medical establishment
knew virtually nothing, from a medical standpoint, about what they
were dealing with. There was very little information on MIC in any
textbook on toxicology and medical staff had insufficient experience
on how to treat victims of exposure to the gas. The only people
expected to have any prior knowledge were the doctors employed at
the UCC plant. They denied that MIC was toxic or had any long-term
effects. A chemical expert team from the WHO said that no specific
antidote to cyanate poisoning was available. The doctors at Hamidia
Hospital resigned themselves to giving symptomatic treatment only,
such that each symptom was dealt with in isolation: eye drops were
prescribed for eye irritation, antibiotics to prevent infections and
antacids for the stomach. There was no attempt to either purge the
blood of the toxin or to treat long-term consequences. Sodium
thiosulphate is considered an effective antidote to cyanide. Yet, when
its usage was proposed, the Union Carbide doctors advised against it.
In February 1985, the ICMR found that treatment by sodium
thiosulphate produced "amelioration of symptoms in a good
proportion of cases." It seems that many lives would have been saved
had the doctors known that cyanide was present.
In the early stages, patients were administered large doses of the
diuretic Lasix to relieve oedema, cortico steroids to contain
inflammation of lungs, as well as bronchodilator and oxygen
inhalation in acute cases. Oxygen inhalation proved ineffective and
the ingestion of Lasix made matters worse. What the victims needed
Simple countermeasures, such as washing the face and mouth, could have made a big difference ©Greenpeace
14
HazMat Responder World
Autumn 2012
most were massive doses of antibiotics and vitamins. But they
were treated with anything at hand: glucose, painkillers, even
stomach pills. A very simple action, useful for non-seriously
injured, was to wash the face with water. A man in Jayaprakash
Nagar ordered other locals to do so and all of them survived,
whilst entire families residing in the same area who didn’t follow
the same procedure, died.
First aid.
The first patient with burning eyes arrived at Hamidia Hospital at
01:15. Within the next two hours, Dr. Sheikh was swamped by two
thousand more. Many citizens and interns rushed to the hospital to
see what had happened, and they were instantly pressed into
service along with nurses, doctors and staff members. By early
morning, the hospitals of Bhopal were overrun by thousands of
patients, who arrived blinded, breathless and dizzy, carrying those
who had collapsed along the way. Rescue teams of the army,
police, local citizens and voluntary organisations went into homes,
pulling out corpses and the injured. They flung the living on
stretchers and vehicles that went to the city's hospitals and clinics.
The dead were sent to the main morgue at Hamidia Hospital or
straight to the Muslim graveyards at Jahangirabad and the Hindu
cremation site at Cholla.
Medical supplies.
On the first day of the disaster there were not enough oxygen
cylinders to go around. Appeals for help went out to private
clinics throughout the city. UCIL flew in cylinders, masks and
stocks of cortisone drops from Calcutta and Delhi. The Indian
government and other centres in Madhya Pradesh, as already
mentioned, air-freighted medicine and personnel. Mobile medical
units of the Indian Red Cross (IRC) distributed medical supplies,
including antibiotics, ophthalmic ointments, other medicines and
vitamins. Unfortunately for the victims, the early medical effort
was soon forgotten and replaced by bureaucratics, politics and
personality clashes.
Mental health problems were a major consequence of the
disaster. The Indian Council of Medical Research (ICMR), in New
Delhi, estimated that tens of thousands of victims suffered from
mental disorders, ranging from depression to anxiety and
adjustment reactions. Damage to the central nervous system was
evident among many survivors, especially women under the age
of 45. This was reflected in symptoms of mental deterioration,
including memory loss, personality change, lack of concentration,
insomnia, anorexia, sleep disturbance, gas-phobia and a feeling of
helplessness. Others became victims of ‘compensation neurosis’, a
mental condition in which people exhibit psychosomatic
symptoms and even self-inflicted injuries, in order to acquire
benefits and compensation. Such problems were far from the
minds of the doctors, who were more concerned with saving lives.
It was not until the middle of 1985 that Hamidia Hospital
established a separate psychiatric ward. Until then, mental stress
patients were administered symptomatic drugs. Mentally ill
patients suffered a setback, as they were treated for what were
regarded as physical problems: breathlessness, fatigue and
headache. The threat of contamination and the danger of cholera
increased, as long as animal and human corpses decomposed in
the open air. Rats scurried around the dead bodies, awakening
fears of bubonic plague.
The traditional Hindu ritual of cremation is one body per pyre.
But there were too many dead and not enough firewood. The only
solution was to place the dead, as many as five or six corpses
together, on one pyre. Muslims were also buried in groups. Rescue
workers dug graves six feet long and 15 feet wide, each holding
eleven bodies. When there was no burial ground left, old tombs
were opened and old bones were displaced, in order to make
room for the victims. Thousands of animals were also killed by the
www.
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Lessons Learned – Bhopal
gas. The army and other groups used cranes
to remove the dead animals, toss them into
trucks and dump them at Nishat Pura,
about five kilometres north of the city. This
contributed to the shortage in food supply.
Milk supply to Bhopal city was affected due
to the death of an estimated 4000 cattle.
Several dairies in the worst of the affected
areas were closed down. In addition, the
Bhopal authorities banned the sale of fish,
and advised the population to refrain from
consuming meat and meat products. In the
second week of December 1984, the
government announced the awarding of
free rations to those with ration cards. It
then issued another 21,000 cards to those
who had not procured them earlier.
The relief measures were criticised by
citizen groups on the grounds of corruption.
In practice, it was the more vocal, aggressive
and politically well-connected people who
received relief (money and food) quicker and
in larger quantities than some of the more
needy but powerless. Owners of ration stores
made a lot of money by holding back rations
and selling them on the black market.
Middlemen and local money lenders exploited
illiterate and weak victims by taking
commissions for their services in procuring
relief benefits and even confiscating the
money received. Forgeries of ration cards
were commonplace and people collected
compensation twice by impersonating others.
The prevalent corruption among officials in
charge of the relief effort eroded its efficacy.
Local, public and voluntary agencies played a
vital role throughout the emergency by
providing transportation, cooking and
distributing food, setting up tents and
disposing of the dead. For example, at the
request of the central and state governments,
the Indian Red Cross (IRC) mobilised 100
volunteers to provide aid to 5,000 disaster
victims in five relief camps for a period of 30
days. By 14th December, the IRC had
distributed 12 MT of high protein biscuits, 6.5
MT of skimmed milk, 20000 blankets, 46500
pieces of clothing and 200 tents. Water
supply tests made on the drinking water in
Bhopal a few days after the accident showed
no signs of contamination. On the other hand,
tests conducted in 1990 (six years later) on
the drinking water at the community adjacent
to the former UCIL site in Bhopal revealed
high levels of dichlorobenzene, an extremely
toxic substance. Dichlorobenzenes are
known to damage the liver, kidneys and
respiratory system.
Conclusion
It is the contention of this article that
companies involved in hazardous production
should insist upon locating their plants,
whenever possible, in isolated areas (islands,
the bush, the desert), rather than in
conurbations. Concurrently, the appropriate
authorities have to block the subsequent
development of neighboring shanty towns
such as Jayaprakash Nagar and Cholla. These
measures are necessary to avoid the
emergence of elements 1 and 2 of the
Disaster Triad -- namely the proximity of
large-scale populations to a disaster
agent..The relevant concern in this context is
also whether or not this type of error can
recur elsewhere in the world. The mistakes
One of the most iconic images of Bhopal - but what is its legacy? ©Greenpeace
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HazMat Responder World
Autumn 2012
are repeatable, with marginal variations. The
main lesson that must be derived from this
case is that major accidents may happen,
despite a wide range of technical and
manual safeguards, and they will happen
more frequently if these safeguards are
disregarded. Given that accidents of this sort
are likely, the desirable course of action
should be to know how to respond to such a
situation. The analysis in this chapter has
revealed that each of the four major
participants in the Bhopal drama - Union
Carbide, UCIL, the government of India and
that of Madhya Pradesh - were jointly
responsible for both the disaster and the
improper relief. Lack of pre-crisis
preparations to face a major accident led to
improvised responses to a complex problem.
In the face of a rapidly escalating crisis and
a speedily deteriorating response, ad hoc
improvisations either failed to meet concrete
needs or led to unsatisfactory reactions to
moments of opportunity. A successful
response to large-scale disasters depends on
a comprehensive, multidimensional and
systematic course of action. That mechanism
neither existed in 1984 in India, nor was it
available to the Indians from abroad.
Lessons learned
The Indian government has established
several agencies such as the "Standing
Central Crisis Group", "Standing State
Crisis Groups", and "Standing District Level
Co-ordination Committees" to co-ordinate
rescue and relief efforts on the national,
state and district levels. The Central Crisis
Group (CCG), set up by the Ministry of
Environment and Forests, comprises senior
officials of the central government and
technical experts. Its goals are to tackle
problems caused by major chemical
accidents, to suggest a course of action
aimed at minimising the effect of the
accident, to co-ordinate the activities of
various agencies and departments, and to
provide expert guidance for handling major
chemical accidents. The Government of
India has also launched a research
program, comprising nine projects (as of
February, 1994), to formulate disaster
management plans in nine out of the 540
most hazardous districts of the country.
Manuals to assist owners of hazardous
chemicals to prepare on-site and off-site
emergency plans have been published, such
as the "Manual on Emergency
Preparedness for Chemical Hazards". The
Government of India expects these
activities to improve its readiness to tackle
future major chemical accidents.. Yet, it
has been observed that preparation of offsite and on-site emergency plans, in
general and all over the country, still
leaves much to be desired. In a number of
cases either the plans do not exist, or even
if prepared, are not comprehensive. HRW