Inside Sambhavna

The Sambhavna clinic curves a white wall around the corner of two quiet streets, half a kilometre from the disused Union Carbide factory and 100 yards from Berasia Road, a main Bhopal artery. The two floor clinic, a converted house, is clean, leafy and of modest size. In contrast to government hospitals there are no paan (betel leaf) stains on the walls. Such a tranquil exterior doesn't really prepare you for the diversity and dedication of the work inside - though it does reveal something of Sambhavna's integrative approach to the health care of Bhopal gas survivors.

For instance, the shrubs, trees and climbing plants surrounding Sambhavna, while contributing to a soothing environment for gas-affected visitors, are also deceptively functional. Many have a specific use in Ayurvedic medicine, the traditional Indian system employed at Sambhavna. Entering the clinic's courtyard, for example, you pass under a mesh archway of the heart shaped leaves of Tinospora cordifolia, a plant used in Ayurvedic medicine to dispel different kinds of fever. Immediately to the right is a small medicinal garden containing, amongst others, a small tree of Ricinus communis, good for relieving pain in the chest, abdomen, limbs and joints - all key symptoms of gas exposure.

Visitors waiting in this courtyard can find ample shade beneath a tall mango tree that also cools the first floor roof garden. Up here, people coming for Panchakarma treatment or Yoga can sit surrounded by a variety of other medicinal plants. Especially so when some of the plants are flowering, the garden produces a sweet vegetative aroma under the heat of the sun. This is mixed with the smells from the medicines being prepared by Biju, one of the Panchakarma therapists, in a small room off the roof garden. More than 30 medicines are prepared at the clinic from locally collected or purchased herbs. These medicines, based on standard Ayurvedic texts, are three to five times cheaper than market preparations and of much better in quality.

Possibilities for care
Built onto the garden terrace is the airy Yoga room where in the morning visitors are taught to use a number of different Yoga exercises  [('Asanas' (body postures), 'Shodhana kriyas' (cleansing actions) and Pranayama (breathing discipline)] by Sushmita and Amita, both fully qualified instructors. The therapeutic effects of practicing Hatha Yoga - the over two thousand year old science of uniting and coordinating the physical and mental aspects of one’s being through consciously attempted discipline of the body - have been successfully applied at the Sambhavna. Chronic respiratory disorders are the most prevalent complaints among gas survivors: two years of research at Sambhavna using spirometry testing has demonstrated that regular Yoga produces significant and sustained improvement in lung function, decreases airway restriction and greatly lowers dependence on drug-based therapies.

According to Sushmita, early Yoga classes were poorly attended - "for one year it was difficult to get people to understand. Many people thought relief only came in the form of a pill. We faced cultural barriers too: lots of our patients are Muslim, they thought Yoga was only for Hindus. Yoga's remarkable efficacy as a drug free therapy is possibly the principle reason for its growing popularity among a people understandably sickened by the idea of taking medicines all their life. In the study mentioned above, more than half of the people taking Yoga therapy for persistent breathlessness were able to remain completely off drugs they have had to take everyday for the last 10-12 years. Naturally, Yoga costs nothing and once learned can be practiced outside of the clinic. Additionally, Yoga calls for the individual to be an active participant in his or her own healing.

In the afternoon, after sessions have finished, the four community health workers (the only four in all of gas-affected Bhopal) gather in the Yoga room to discuss their work. Their role is to visit people in their homes everyday: following up on 1,000 people who have received care at the clinic every month; collecting information on health and healthcare in the community; and through health education, involving people in taking control of their community's health. For example, women and men who, with support from the health workers, have recovered from TB (which is three times higher among gas-exposed Bhopalis) in turn provide information and inspiration to other sufferers.

As in the case of Yoga, certain obstacles had to be overcome before results could be achieved. Aziza explains: "early on, I talked to one woman and said she should take her sputum for a test. She went and hid under her bed. TB brought shame with it and people did not want to get tested in case they got 'found out'. Now people come up to us and ask for tests. TB was a taboo, now it’s more open." According to Ramesh, lack of education is the main problem: "the most important thing is to educate people. To know that the disease is actually curable and that treatment for TB is available free of cost is a revelation for most untreated patients". Even when somebody starts a six-month course of treatment there is no guarantee they’ll finish it, meaning that community monitoring and follow up visits are vital. "We have to do our best in communication so that people are regular with the treatment for the full course."

The health workers also collect information on current deaths in the community; the clinic has pioneered the use of Verbal Autopsy, a scientific and internationally validated technique for ascertaining probable cause of death. The work of the official government agency for documenting exposure-related deaths was prematurely abandoned eight years ago. Sambhavna’s ongoing data indicate that in this sixteenth year of the disaster people continue to die of diseases related to their exposure to Union Carbide's gases. Verbal Autopsy data shows many exposure-related deaths are caused by cancer, among which 49% are cancers of the respiratory system.

Just along the terrace is the fragrant Panchakarma room where a fivefold detoxification treatment is provided, including massage, enema and medicinal sauna. Panchakarma has been found to be particularly beneficial in the treatment of chronic back and joint pains. Also Shirodhara - pouring a steady stream of medicine on different parts of the head, is most effective for insomnia and anxiety. A few yards from the roof garden is the Documentation Centre: here visitors can read about all aspects of the December '84 Union Carbide disaster from books, magazines, newspapers and a considerable number of documents. Visitors benefiting from this resource include researchers, journalists and activists.

Downstairs is a fourth waiting area. Just along from the hatch of the Ayurvedic and Allopathic medical dispensary is the pathology laboratory where clinical samples of blood, sputum, urine, and PAP smears are analysed by Amita (who is also a biochemist) and Mahendra, a qualified medical laboratory technician. On the other side is the computer room where clinical data, Verbal Autopsy data and registration details are inputted by Pranay and Sushmita; and the office, where a small collection of international volunteers is likely to be seen. This waiting area, the hub of so many of the clinic’s activities, symbolises the prevailing ethos of Sambhavna: that the person coming for treatment is placed squarely at the centre of concern. Off along a small corridor are the Registration area, the Allopathic surgery of Dr Mohammed Ali Quaiser and the clinical examination room.

Herbal medicine
Also next to the main waiting area is the surgery of Sambhavna's Ayurvedic specialist, Dr Deshpande, who first applied Ayurvedic medicine to the problems of gas exposure in 1985. He has been at Sambhavna since it began nearly four years ago, facing familiar difficulties early on: "the first problem was that we had to create an awareness of herbal medicines. In the beginning people did not think so highly of Ayurvedic medicines. Then the patients who tried Ayurveda quickly found they were getting much and sustained relief."

The clinic’s use of Ayurveda - as a counterpart to Allopathic treatment - along with Panchakarma and Yoga, presents a direct challenge to the methods of treatment that have prevailed in Bhopal since the gas leak. These methods have largely been directed towards providing symptomatic relief without having any effect on the chronic disease process. Steroids antibiotics and psychotropic drugs continue to be the mainstay of treatment through modern (Allopathic) medicine in the hospitals and clinics run by the state government, the Bhopal Memorial Hospital Trust and private doctors. It is quite common to find people in Bhopal who say they have taken more than five or ten kilograms of Allopathic pills and have had only temporary relief, if at all. There is substantial evidence that indiscriminate prescription of symptomatic drugs is compounding injuries caused by the disaster on a large scale. On the other hand the continuing disaster is a windfall for drug manufacturers. A study carried out by Sambhavna in '96 showed that a dozen transnational pharmaceutical companies in control of the drug market in Bhopal were the chief beneficiaries of the situation following the disaster.

Ayurveda, an over 3000 years old system of indigenous medicine works on the principle of helping, with mostly herbal medicines, the body/mind heal itself. Disease, according to this system, occurs as a result of dis-equilibrium of the vata (air), pitta (fire) and kapha (water) humours and healing is effected through restoring this equilibrium. Ayurvedic toxicology (Agada tantra) mentions the vitiation of "doshas" (humours) and loss of vitality (Ojas) as a result of poisons entering the body and the treatment recommended includes detoxification through Panchakarma along with medicines for restoring vitality, immunity and the natural equilibrium of the body. With the realization of Ayurveda's potential for healing Bhopal victims, the clinic has generated much interest among Ayurveda practitioners and researchers in the country towards use of this ancient system in the healing of modern industrial diseases. Unlike allopathic drugs many of the Ayurvedic medicines can be prepared locally and inexpensively.

Appropriate medicine
Most visitors walk to the clinic from the severely-affected communities. Newcomers are welcomed, registered (which allows for accurate recording of medical data and follow ups on those who drop out in the middle of treatment) at a rate of 5-10 per day, given a Health Book, and after consultation are offered a choice of systems of care. Those choosing Allopathy are offered care by a general practitioner, a gynaecologist and a psychiatrist. Dr Ali Quaiser, the GP, explains that visitors are not made to feel like patients at Sambhavna, "We try to have a friendly atmosphere. People are frank, apart from relating their health problems they also report their frustrations, their home lives. As well as looking after the physical health of those who come here, we are also taking care of their spirit."

Great care is taken to ensure that any drugs that are prescribed do not add to the damage already caused. As a matter of principle the clinic buys its medicines from the only non-profit collective in India producing quality medicines. A thorough medical examination is one of the salient features of Allopathic care at the clinic. Because it is usual for people coming to Sambhavna to be accustomed to neglect, mistreatment and queues in dismal government and other hospitals first-time visitors have broken down in tears, explaining that in 15 years no doctor had ever listened to their chests or felt their pulse during examination.

Since little is known about the efficacy of different drugs in treating exposure-related injuries, special efforts are made to monitor effects of both Allopathic and Ayurvedic therapies. Doctors and other therapists have evolved a system of grading severity of different symptoms so that relief obtained in each symptom can be documented with some degree of precision. Clinical data of each person is entered into a database with analysis of data being presented on a monthly basis for assessment of efficacy of different therapies.

Women's health
Given the official neglect towards monitoring and care of gynaecological complications caused by the disaster, special attention is paid by Sambhavna in this area. While officials continue to deny any exposure-related gynaecological health consequence, data collected at Sambhavna shows that of 190 females, aged between 13 and 19, who came to the clinic between 1st June 1999 and 31st March 2000, 113 reported menstrual problems, including painful and irregular menses, heavy bleeding and excessive vaginal secretions.

The secretions, locally as ‘safed pani’ (literally white water), are not often openly discussed because of social taboos. Community health worker Aziza explains, "Women do talk about it more now but are often confined to their houses and can’t talk to their husbands about their problems or get education." Worryingly, Sambhavna’s pathologist has found a high proportion of abnormal PAP smears among women survivors, increasing fears for a connection between cervical cancer and gas exposure. Already in India, cervical cancer is the highest occurring cancer for women, but there is no provision for routine cervical screening in Bhopal. Women who are referred to local hospitals after producing abnormal smears have been reluctant to attend, given that the most common medical procedure for cervical abnormalities is an immediate hysterectomy. This is referred to as a "blind hysterectomy" because no one including the doctor knows how far or how little the malignancy is.

In response to this situation Sambhavna has initiated a cervical screening project. The project involves educational work in gas-affected communities to help surmount taboos concerning gynaecological health; a thorough programme of PAP smears coupled with cytological work (smear analysis); and where necessary the employment of up-to-date colposcope diagnosis and excision by LLETZ large loop excision of transformation zone of suspect cervical tissue. At each stage of the project the role of the community health worker is crucial to guiding the women past social obstacles. And Sambhavna’s screening project shows that there is a place for the latest technology as well as 3,000 year old therapy when seeking the most rational treatment for gas survivors.

How Sambhavna runs
Mid-morning is the busiest time at the clinic. Women wearing colourful saris and shalwar-kameez, or the more sombre burkhas, numerous children and men of differing ages and backgrounds mingle together, quickly filling up the four main waiting areas. The gas hasn't been able to mold the disposition of the people affected. Without exception visitors wait calmly and respectfully, talking quietly with each other or swapping jokes and stories with the clinic staff. Sometimes small gifts are brought in as expressions of gratitude. By their conduct, visitors reveal a sense of the clinic existing for them. And the vast majority of newcomers to Sambhavna arrive on the recommendation of those already attending.

Collective decision-making and individual responsibility taking distinguishes the particular the style of working at the clinic. The highest staff salary is not more than three times the lowest, and opportunities for improving skills are offered to all in equal measures. The staff bring a broad range of age, experience and educational qualifications to the collective efforts. Seven of the staff are women. Six of the 17 staff are victims themselves: Aziza and Diwakar the community health workers, Amita the pathologist and Yoga instructor, Alka the Panchakarma therapist and Shinde and Manu, both registration workers.

There is no formal hierarchy of jobs at Sambhavna; every member of staff is free to give suggestions on every aspect of the clinic’s work; meaning, for example, that the health workers contribute as much to the evolution of appropriate medical care as do the doctors. Poornima, who runs the Documentation Centre, finds a lot of advantages in this approach: "knowing that we can apply our ideas gives us more confidence, develops our thinking and makes us more willing to take on responsibility. Because we have to make work plans for staff meetings, because managerial skills are developed on a rotation basis, with everyone being a co-ordinator for two months, it means everybody has to take responsibility for themselves and everybody else." Consensus is arrived at in weekly meetings, where the typical quiet and calm of the clinic can occasionally be shaken. The meetings determine the day-to-day and long-term activities of the clinic.

The staff perspective
On the matter of working at the clinic, the staff of Sambhavna express very similar feelings. "Working in a social organisation you have a completely different relationship with those who come for care. And in a non-hierarchical workplace you also have a different relationship with your co-workers," says Biju. Ritesh, another of the community health workers, adds that "it’s like being in a family – there’s no difference, we feel like one big family. When I worked in the National Insurance Agency people always left the minute their work hours finished: here we stay until we are satisfied that our work is finished for the day." Pranay, who does Verbal Autopsy and data management at the clinic, echoes Ritesh: "if my career had followed my studies I’d be a civil engineer. Here I feel we all benefit from the collective spirit, the sharing of ideas. If I worked somewhere else I think I’d be trying to escape…"

Kamal, the medical dispenser, is evidently proud of the clinic's ethos: "the clinic staff treat people like fellow human beings. We do a real social service here. Other clinics are vocational; everything is oriented around salaries. I get a lot of satisfaction from being able to help people in their problems." Mr Chaudhary, who manages and administrates the finances of the clinic, used to be an officer of the Finance Department for the State government: "I’m retired and so have no need to work. You could say I’m making up for my previous work, because in that there was no attempt to serve the people." And for Dr Deshpande, "it is a very good time, a very precious time in my life. It is a privilege to work here."

In many ways the four health workers at Sambhavna get the deepest, most extensive contact with those the clinic has been set up to help. Says Diwakar, "when we first started it was like a dream come true because we set up the clinic exactly how we wanted it. Even though money is very scarce we offer four kinds of treatment, six days a week. No government hospital provides so many things: in other hospitals there is only Allopathy." Ramesh’s daytime health work is combined with being Sambhavna’s sleep-in security guard: "I’m never scared of hard work here because I know that it’s for other people’s benefit. Once I got to know my exact role in Sambhavna I was totally committed – I’m very happy with my work."

Last words go to Aziza. "This work is different for me. My family is gas affected. I didn’t start working here for a salary, but for the opportunity to do humanitarian work with the poor who needed helping. After 4-5 months, after fully realising the kind of work I am doing, I was so happy for my profession. Once we were doing a survey and we met a woman, 55 years old, who had an infection of the cervix – she had been bleeding for three months. We brought her to the clinic. If we hadn’t done this she would have died. Every time we see her now she smiles and gives us good wishes.

We have many big dreams but our hands are tied because we have to work within limitations. Because all the money is donated we have to be very careful how we spend it. We want to go to the root cause and real pains, so we can help people to the core. If we got proper funds we would be able to do so much more, to reach out to them and touch them – there are lots of dreams."

Sambhavna’s beliefs

  • The disaster in Bhopal is not an isolated event. Workers and communities are routinely poisoned all over the world.
  • Reduction and eventual elimination of hazardous chemicals from the planet and our daily lives is the only solution to the growing number of slow and silent Bhopals in our midst.
  • Till that happens, the safety of our health and lives depends on watchful monitoring, strict enforcement of regulations and exemplary punishment to offending agencies. In this respect, ensuring justice in Bhopal can be seen as a public health initiative with potential for significant and widespread change.
  • 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 all of us worldwide.
  • It is possible to combine traditional and western systems of health care when evolving appropriate care intended to provide sustained relief to chronically ill survivors of Bhopal.
  • It is possible for an individual to be an active participant in the process of healing and the community to be involved in all aspects of public health.
  • It is possible to evolve systems of health surveillance and environmental monitoring through active participation of the community of survivors. Our work in documenting long term consequences of exposure is part of the survivor’s 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.

Tim Edwards, Sambhavna volunteer