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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. 8 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 10 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 16 – 17 April 2013, CityWest Hotel, Dublin www.cbrneworld.com/events Taking specialist skills into disasters: developing, training and qualifying response. International participants from such fields as CBRNE, Hazmat, disaster medicine and emergency management, will gather for a two day conference and exhibition to understand how they can broaden their skills and knowledge into other fields. With four one hour long training vignettes, ‘All Hazard Response’ will provide a hands on, learning experience. ALL HAZARD RESPONSE 16 – 17 April 2013 CityWest Hotel, Dublin, Ireland www.cbrneworld.com/events 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, ��������������� ����������������������� �������������������� ��������������� ��������������� �������������� ������������� ������������ ����������������������� ����������������������� ��������������� ������������� ������������������������������������������������������������������������������������������������ Earn your Master’s Degree in Emergency and Disaster Management Gain the strategic skills required to head emergency management response efforts, improve public policy and, most importantly, save lives. Learn from lifelike emergency management simulations, multi-location field study intensives and self-paced online studies. To learn more, visit SCS.GEORGETOWN.EDU/hazmat 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. .com 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 16 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