When Money is Not Enough -
|As Development Coordinator for an environmental health manual, the
author became interested in health care issues of survivors of the 1984 Union Carbide gas
disaster in Bhopal. In the Summer of 2000 the author spent two months in Bhopal
investigating the health care provided in the Bhopal Memorial Hospital Trust community
clinics. She was disappointed with what she found.
The Dec. 1984 gas leak in Bhopal left a cruel legacy. Today, upwards of 200,000 people suffer from debilitating chronic illnesses caused by exposure to the gas. Sixteen years after the disaster, the health care provided to gas-effected survivors is inadequate. For the most part survivors receive only medications that addresses their symptoms but are given no treatment to address their underlying health problems; there has been no development of diagnosis or treatment protocols to ensure that patients get consistent and relevant care; and there has been no systematic research into the long-term effects of the gas.
The Bhopal Hospital Memorial Trust (BHMT) was established in 1998, with money from the seizure of Union Carbide shares (Union Carbide assets in India were confiscated when they refused to appear in a criminal case) and a sizable contribution from the Indian government. Their financial resources are upwards of US $ 87 million, with which they were directed to build a 260-bed hospital and 10 community clinics. As of today, it runs only 5 community clinics and the hospital has just become operational in the last two months. Even though gas survivors suffer chronic injuries that will last the rest of their lives, the Bhopal Memorial Hospital Trust is only obliged to provide free care at these sites for 8 years.
This report is focused on the care provided in the Bhopal Memorial Hospital Trust clinics. It looks at the clinic infrastructure, patient diagnosis and treatment, and doctors' attitudes and knowledge about gas-related health problems. Findings are qualitative, and are based on individual interviews with 14 doctors representing all five clinics, and the Director of the BMHT. It analyzes the ways in which the BMHT clinics fall short of providing lasting and comprehensive care. Ultimately, the report demonstrates that simply pouring money into construction of buildings, high-tech machinery, and medical staff is not enough, particularly when the services are only provided for eight years. The report argues that other interventions, such as community health education and environmental improvements, are likely to produce more lasting impacts.
The report concentrates on three topics:
I. The survivors' current health problems
It is estimated that currently 200,000 people in Bhopal suffer from debilitating chronic illnesses resulting from gas-exposure. The majority of these people suffer from respiratory illnesses such as fibrosis, bronchial asthma, Chronic Obstructive Airways Disease, emphysema and recurrent chest infections. In addition, because the gas-effected lungs are more susceptible to infection, pulmonary tuberculosis among the exposed population is significantly higher than the national average.
Other prominent health problems attributed to the gas are damage to the cornea of the eye, reproductive problems, post-traumatic stress syndrome and neurological problems. A plethora of studies on the health effects of the gas leak have documented these specific health problems. Studies on eye damage have found corneal ulcers, chronic conjunctivitis, deficiency of tear secretion, persistent corneal opacities, increased risk of eye infections, and chronic inflammation - resulting in persistent eye watering, photophobia (aversion to light), burning, itching, redness, and pain. Studies in reproductive problems have shown an increase in menstrual cycle disruption, leucorrhea (white discharge), dysmenorrhea (pain with menstruation), pregnancy loss and infant mortality. Studies on psychological effects of the disaster report high rates of anxiety, restlessness, grief, sleep disturbances and generalized weakness and fatigue. Studies on neurological damage have shown tingling, numbness, a sensation of pins and needles in the extremities and muscle aches.
II. The treatment provided in the Bhopal Hospital Memorial Trust clinics
Each of the five BMHT clinics is located in a neighborhood near the factory that was seriously effected by the gas. At the time of the accident the majority of the affected population lived below poverty levels. Today, the majority of the survivors live in impoverished communities. To get to each of the clinics one must travel through narrow dirt roads flanked by worn-out and cramped houses. Long open tubes border the sides of the road in front of the homes, containing standing water and serving as depositories for human and kitchen waste. The BMHT clinics seem entirely out of place in these environments. Four of the five clinics are covered with glistening marble (the fifth is a dilapidated former Red Cross building) both inside and out. These brand-new opulent buildings represent a large expenditure of money.
Each clinic has a head doctor and two or three other staff doctor (three clinics have 4 doctors, two have 3 doctors.) Each clinic is staffed with an ophthalmologist and at least one general doctor. In addition, two of the clinics have Ear-Nose-Throat specialists, two have radiologists, and one has a pathologist. Each clinic is equipped with some means of laboratory diagnosis. The more sophisticated clinics have X-ray machines, machines for evaluating eyesight, spirometers and flow meters (to measure lung capacity).
Four of the clinics see 100 to 150 patients a day (one of the clinics sees only 50 patients a day). Many doctors reported that they typically see 50 patients during the 5-½ hours that the clinic is open. On average, they spend less than five minutes with each patient. This is not enough time to conduct sufficient physical examinations. Physical exams are generally considered necessary to help doctors better understand patients' complaints, and also help them pick up on illnesses that will otherwise be missed until the patient is so ill they cannot be treated. Many doctors agree that a physical exam should include taking pulse and blood pressure, palpation of the abdomen, listening to the lungs and heart, and examination of the skin.
In a study carried out over five months in 1998, health workers from Sambhavna Trust (a non-profit organization that provides health care and political advocacy for survivors) interviewed 474 patients seen in one BMHT clinic. Several patients reported that doctors at the clinic were reluctant to touch them, possibly because their bodies or clothing were viewed as dirty. In general, they found that examinations were minimal. 5.1% of patients had their pulse taken, .6% had their abdomens palpated, and 4.4.% had stethoscopic examinations. In my own interviews with BMHT clinic patients, 7 patients told me that they received absolutely no physical exams at the clinics. They told me that to get physical check-ups they must go to private doctors. Five women who complained of "white water discharge" said that they've never had a BMHT doctor ask them any questions about their symptoms, they were just given drugs.
Laboratory diagnosis is also minimal. The Sambhavna Trust health workers found that of the 474 patients seen in one BMHT clinic, only 6.1% received blood tests, 1.3% received sputum tests (to test for TB), and .4% were given urine tests (to test for diabetes). In addition to being infrequent, lab tests are limited. Doctors at the BMHT clinics told me that in their lab tests they are looking for evidence of common diseases, such as TB, asthma, diabetes and anemia. Thus, they are only paying attention to health problems that they are familiar with and are likely to miss other long-term gas related problems that even the patients may not be aware of.
In the summer of 1990, two non-profit groups, The Bhopal Group for Information and Action (Bhopal) and Socially Active Medicos (Indore) released a document entitled "Evaluation of Some Aspects of Medical Treatment of Bhopal Gas Victims". In this report, they write:
It is indeed shocking that while such a large population continues to be sick, a proper line of treatment of gas victims remains to be evolved. The prevailing symptomatic - supportive line of treatment currently being followed by doctors in Bhopal is indistinguishable from the line of treatment followed in the immediate aftermath of the disaster. As a result the gas victims can get only symptomatic temporary relief from their sufferings. While such a situation is understandable in the chaos, confusion and complete lack of information in the immediate aftermath, it is decidedly intolerable that after the passage of nearly six years, expenditure of crores of rupees and involvement of large number of professionals there is no effective improvement in the means for treating the gas victims.
Today, a decade after that statement was written, and after an even larger expenditure of money and investment of professionals' time, there has been no marked improvement in treatment provided to gas-exposed people. In a 1998 study of 502 BMHT health books, Dr. Rajiv Bhatia recognized that "Overall the drugs prescribed to the study population do not seem to be targeted to the organ system damage most likely to be consequent to the Union Carbide exposure as suggested by the available research findings .drugs are prescribed for short term symptomatic relief of non-specific symptoms." Four BMHT doctors told me that the treatments they are providing to the gas victims is no different than treatments they would provide to a non-gas-affected person with similar symptoms. This reflects that the medical community has developed no therapies to address the injuries caused by the gas.
Lack of Treatment Protocols
The BMHT clinics do not have treatment protocols for specific gas-related illnesses. Thus, doctors' treatment is based on their own understanding of the survivors' health problems. This is problematic for two reasons. First, there are large discrepancies in the understanding of health problems; some doctors who have worked the community for a long time have fairly in-depth knowledge of the body systems effected by the gas, but other doctors know very little. Thus there will be discrepancies in care; the more knowledgeable doctors will provide therapies that they has seen are most effective, the ignorant doctors will be prescribing therapies that their colleagues have already seen to be useless or harmful. Second, combinations of certain medications can have a harmful effect. Therefore it is essential to have treatment protocols so that doctors know what drugs doctors in other specialties are prescribing. This knowledge of therapies would enable doctors to develop comprehensive treatment plans, incorporating the knowledge of each specialty.
Absence of Treatment Follow-up
The clinics do not have mechanisms for following-up on their patients. One doctor put it most succinctly when he told me: "It is up to the patients to return and let the doctors know how they are responding to treatment." This is not an appropriate way to treat chronic health problems. Because the majority of the survivors will be on medication for the rest of the their lives, it is essential that they are monitored closely to ensure that the medications are effective and do not cause secondary problems. In my interviews with patients I found that if the drugs they received from the BMHT clinics did not provide immediate relief from their symptoms they went to other doctors to get "better" drugs. In the treatment of chronic problems it is common that the effects of the medication will be seen only after continual use. Patients said BMHT doctors did not explain the importance of sticking with their treatment plans. Additionally, some of the medications prescribed can have harmful effects if combined with other medication. BMHT clinic doctors told me they are aware that patients see outside doctors for other drugs, but have no way of knowing what these drugs are. Comprehensive follow-up with patients would help doctors stay informed about patients' other medications and would help them avoid prescribing drugs that will interact negatively with these medications.
Prescription of Rational Drugs
Treatment at the BMHT clinics is focused on the distribution of pharmaceuticals. Some of the medications, such as corticosteroid injections, have significant potential toxicity, and have little or no demonstrated benefit. In the summer of 2000, Dr. Atanu Sarkar of the Catholic Health Association of India analyzed 101 prescriptions issued in one BMHT clinic. He compared the drugs prescribed with descriptions of patients' symptoms in their health books. He found that 26.3% of drugs given were harmful, 48.5% were useless to address the person's complaints, 7.6% were both harmful and useless. Only 17.6% of the drugs given were properly selected. In addition, he found that in a large number of cases (45.3%) when appropriate drugs were issued, the dosage was improper - people were instructed to take the wrong number of pills per day, were given a shorter course of drugs that needed, and were less mg. per dose than needed. In some cases, he found that doctors were prescribing pediatric dosages for adults.
Doctors' Knowledge Regarding Health Effects of Gas
BMHT doctors told me that doctors were not chosen for the clinics because of any knowledge of gas-related problems, nor did doctors get any training regarding the specific health problems of the population they are serving. Therefore, it is not surprising that in my interviews doctors demonstrated little knowledge of the effect of the gas on people's health. One doctor summed up the lack of research and investigation: "We are totally in the dark. If such a disaster were to occur again we would not know what to do about it."
According to the BMHT Director, the clinics were developed to address the health problems identified in the Indian Council of Medical Research (ICMR) reports on health effects of the 1984 gas leak (the last study was terminated in 1990). Despite this, few doctors have basic knowledge of research that has been done on the health effects of the gas. In a fairly cursory search, I was able to find over 70 studies on the toxicological effects of MIC (Methyl Isocyanate was the main component of the gas released). Many of these were in prominent journals. These 70 include 26 studies of the human health effects of the Bhopal Gas Leak. 7 focus on ocular effects, 7 on respiratory effects, 4 on reproductive effects, 3 on genetic effects, 3 on immune system functioning, 1 on psychological effects, and 1on neurobehavioral effects. It appears that it would be rather easy for BMHT physicians to educate themselves about the special health problems of the population they are serving.
In an interview with the Director of the BMHT, I found him complacent about the lack of understanding among his staff about the health effects of the gas. I asked him why his staff did not know the ICMR findings. He answered that the doctors could have gotten the ICMR reports through their own efforts. He said that doctors are just treating problems as they come, and mentioned that many of the young doctors work in the clinics as a part time job (they also have private practices) and will probably leave the clinics in a couple of years.
BMHT Clinic doctors' lack of knowledge about the findings of research on long-term effects is evidenced by their disagreements about what health problems may have been caused by exposure to the gas. Regarding eye problems, one ophthalmologist told me that she did not know of any MIC related eye problems. She said most of the people she sees have allergic conditions (which she described as itching and redness), and loss of vision. She stated that there was not an unusually high incidence of eye problems among the gas-affected population. Another ophthalmologist said that watery eyes, itching and redness could possibly be a result of exposure, and that the gas caused corneal ulcers. A third ophthalmologist reported that the gas caused corneal opacities, burning, and corneal ulcers.
In regards to lung problems, one radiologist said that most patients' lungs are just fine and that there is no correlation between the increase in TB and exposure to the gas. A radiologist in a second clinic stated that the gas cased fibrosis, asthma, and bronchial asthma, and that the gas' damaging of the lungs made people more susceptible to TB. 7 other doctors mentioned specific lung damage caused by the gas, including bronchitis, emphysema, asthma, TB, fibrosis, and Obstructive Airway Disease.
Other health problems BMHT clinic doctors identified as possibly caused by the gas included: skin problems (2 doctors), cancer (1 doctor), ear infections (1 doctor), general weakness (1 doctor), psychological problems (2 doctors), gastrointestinal (2 doctors), and stunted growth of children (2 doctors).
If physicians don't have knowledge of the range of health problems that gas victims can experience, they don't know what problems to look for and cannot be effective diagnosticians. Doctors may misinterpret patients' symptoms because they are treating them like "normal" (non-gas-affected) people. Thus they lose the opportunity to catch a disease in its beginning stages.
Lack of understanding of gas-related health problems also allows doctors to down-play patients' complaints. One doctor told me that there are not necessarily more health problems as a result of exposure to gas, it is just that there are more cases of illness diagnosed because there is now more free health care for this population. He said the major problem caused the gas is that people are psychologically disturbed and think that all of their health problems are caused by the gas. This doctor calls this problem "hypochondriosis". Three other doctors also said that most symptoms are only psychologically related to exposure.
III. Suggested interventions to improve treatment in Bhopal
The inability of BMHT clinics to adequately treat survivors' health problems is due in large part to problems inherent in their health care approach. There are already a large number of health care facilities providing symptomatic treatment in Bhopal (in fact, Bhopal has more hospital beds than the World Bank recommends. ) Over sixteen years, these facilities have not been able to reduce the suffering of survivors. Thus, there is no reason to expect that through use of the same methods the BMHT doctors would have different results. There must be a change in the focus of care and a commitment to educational and environmental interventions. The BMHT, with its large budget, is in a perfect position to engage in these activities. It is not too late for the BMHT to integrate these changes into their approach; the hospital has just become operational and there are upwards of five more clinics still in the planning stages.
Restructuring of Treatment to Focus on Chronic Care
First, BMHT clinics could restructure their treatment to focus on providing chronic care. This would involve conducting in-depth diagnosis, developing rational treatment protocols and rehabilitation programs (such as breathing exercises), and providing comprehensive follow-up. Patients with chronic problems should receive regular checkups and early treatment of infections, and be provided regular vaccinations and other preventative care. The specialization in chronic gas-related problems would have the added benefit of helping doctors become more familiar with the long-term effects of the gas which could help them provide more effective treatments.
Second, BMHT clinics could have outreach teams that work with community members and officials to make environmental improvements. Many researchers have noted that organs damaged by the gas are more susceptible to environmental insults like infections, irritants, and allergens. For example, a person with airway damage may be more prone to infections or respond adversely to smoke and dust. Likewise, air pollution from automobiles and fires may exacerbate eye problems and cause irritation and infections. Many BMHT doctors noted that patients have health problems that are due to, or exacerbated by, housing conditions in the Bhopal slum areas. Common environmental problems in these areas include: lack of sanitation facilities, overcrowding, and cooking and heating with coal burners and sun-baked cow-dung which causes heavy smoke and pollution. Many health problems (notably, TB, malaria, dysentery, and typhoid) could be radically reduced with environmental improvements such as clearing areas of standing water, developing sanitation facilities, improving access to clean water, and increasing household ventilation and hygiene. These interventions can be inexpensive and effective, and will last long after the BMHT leaves the community.
Promotion of Community Health Education
Third, BMHT clinics could offer health education either through their own staff, or through community members who become trained as health educators. These people could teach the importance of reducing stress on their bodies by quitting smoking or other behaviors that exacerbate existing problems; how to manage chronic health problems; and how to make their environments more conducive to good health. Health workers could teach breathing exercises and other self-help therapies (such as yoga). They also could become case managers for survivors who are resistant to receiving care in medical facilities.
One could argue that the critiques made of the MBHT in this report are overly
judgmental and that suggestions for improvement are too ambitious. I would agree with
these arguments if the $86 million came from any other source. The money that operates the
BMHT clinics was seized from Union Carbide, and was earmarked to provide quality care to
survivors. In effect, it is the survivors' money. It is fair for them to demand that it be
invested in ways that provide them with the best possible rehabilitation for their health
problems. Because the BMHT clinics and hospital only are obliged to provide free care for
8 years, it is not reasonable for them to use all of the money on fancy buildings and
high-tech diagnostic machines that will be useless when they leave. I challenge the BMHT
staff to use the remaining money in ways that will have a more lasting impact on the
communities. If they teach people how to best care for their chronic health problems and
improve community infrastructure to reduce spread of infection, the money will be well
spent. If they continue to provide stopgap health care until all the money is gone, the
BMHT will be just another injury to be suffered by the gas survivors.
|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|