IMCB submission to the empowered committee
IMCB recommendations regarding the Bhopal Hospital Trust given to concerned officials of the Indian Government on the 11th March 1996

1. Pattern of diseases amongst victims of Bhopal gas disaster
The existing complaints of the individuals are due to longterm affects of diseases due to gas exposure, and relate to the chronic stage of the persistent respiratory disease and possibly neurological and ophthalmic too. Although this leads to incapacity in many ways, there is rarely a need for hospitalisation. As far as we know, the respiratory disease almost certainly irreversible and not amenable directly to simple medication. The community clinic can provide the general chest care that people with chronic respiratory disease would benefit from - early treatment of infections with antibiotics (and perhaps short course of steroids) and prevention of others with say regular flu and pneumococcal vaccinations. A further role for these clinics would be the discouragement of expensive and potentially harmful treatments (especially longterm steroids and theophyllins) and investigation of the appropriate role of simple treatments such as inhaled bronchodilators, inhaled steroids and even respiratory rehabilitation.

2.Cardiac disease
There is no reason to suppose that cardiac disease would be an outcome of exposure to MIC - or indeed other respiratory irritants. The suggestion that cardiac disease may result in intrinsically IMPLAUSIBLE. Furthermore, the sort of respiratory (thoracic in cardio-thoracic terms) disease that resulted from MIC exposure, is of an obstructive and irreversible type; which is not amenable to surgery. On these grounds the establishment of cardio-thoracic surgical centre would be INEFFECTIVE.

3. Current provision of hospital beds in Bhopal
The central and local government has primarily concentrated over the past years on increasing the hospital based services for gas victims. At present at least 950 beds are available for the gas affected areas (wards) near to the Union Carbide plant over and above the health facilities available for the general population of Bhopal.

Total number of beds has substantially increased since 19994:

I.   Pulmonary medicine centre - 30 beds
II.  Indira Gandhi Women and Children's Hospital - 100 beds
III. Kamla Nehru Hospital - 540 beds
IV. Mali Khedi Hospital - 20 beds
V.  Kotra Sultanabad Eye Hospital - 30 beds

There is enough physical infra-structure without sufficient staff to cover or run them at full capacity. The total number of beds (well over 2100 now) in Bhopal per capita, if corrected for demographic composition of the population, is probably higher than Europe now. This is certainly much higher than the World Bank recommendations. Further expansion of the number of beds either in hospital or in primary/secondary care units, as in Bhopal Hospital Trust plans, is inappropriate and not required.

4. Development of community and primary care
There are however, many complaints of overcrowding at the hospital OPD's. Absence of community and primary care in any situation would cause great problems for adequate health care delivery. This results in doctors feeling overburdened and unable to satisfy consumer demands. We conclude that the overcrowding at the hospitals will not be relieved unless the provision of community and primary care services is developed.

Patients with common ailments should be seen at the community level and those needing more specialised care could then be treated at the less crowded hospitals. To create confidence amongst consumers and reduce dissatisfaction, hospital based doctors should provide outreach services on the community on rotational basis.

5. IMCB Model
- the establishment of 140 small community care centres
- 16 new primary care centres without beds and refurbish 14 existing primary care centres
- focus on research and clinical monitoring on longterm effects of MIC exposure as already mentioned

The plan therefore recommends a bottom-up approach: development of the community care FIRST,  before any further hospital care is developed.

Phase 1: National conference to achieve consensus on PHC concept in urban setting to give necessary political push to establish MPW cadre in urban setting.
Phase 2: Refurbish existing 14 clinics and start training programme for MPWs. Possible mobile clinics as interim solution to additional primary health care clinics.
Phase 3: Implement community health centres as a working site for MPWs
Phase 4: Build extra 16 primary health care clinics.

6. Management of the proposed plan
- The plans have been developed without the necessary details and practicalities required for successful implementation.
- The input from medical professionals, particularly those with experience in having worked with MIC-exposed patients and those with knowledge of comprehensive and primary care, is lacking.
- The consumer views are not incorporated in the plan as it exists.

We believe that a permanent representation of the above mentioned medical professionals and consumer groups on the empowered committee and future Boards and Trusts is essential for effective implementation of plans to meet the changing needs of the consumers.

The IMCB, with its multi-disciplinary nature proposes the establishment of a National Medical Commission on Bhopal, to oversee the successful implementation of the proposed plan. The Commission would comprise of government representatives, respected and independent medical professionals, with no vested interests and representatives of the consumers. The IMCB itself would also be represented, through a member, and be ready to advise where necessary

Dr. Sushma Acquilla
Dr. Marinus Verweij
On behalf of the International Medical Commission on Bhopal