from the Disaster: Part II - Home - CBRNe World Learned – Bhopal Lessons from the Bhopal Disaster: Part II Any analysis of the response to the Bhopal tragedy will be sharpened by

Lessons Learned – Bhopal

Lessonsfrom theBhopal

Disaster:Part II

Any analysis of the response to the Bhopal tragedy will be sharpenedby an equal examination of Operation Faith, which followed the initialdisaster and aimed to detoxify the remaining 15 tons ofmethylisocyanate (MIC) still stored at the Union Carbide (UCC) plant.There are some fundamental differences between these two aspects ofthe tragedy – the former entailed an unplanned reaction to a disasterwhereas the latter entailed the prevention of further damage – yetthere are some common aspects that enable a retrospectivecomparison, such as the scene, the principal actors and the closetiming of the events, which took place less than a fortnight apart. Therelatively organised and successful performance of Operation Faithhighlights many of the deficiencies that characterised the initialdisaster response.

PoliciesOnce the Indian authorities, UCC and their Indian subsidiaryrecognised the scale of the Bhopal disaster, they were faced with twomajor decisions: what to do with the remaining MIC and how tominimise the damage that resulted from the accident. The challengeposed by the first issue was clear and relatively simple to meet: theyhad to choose between (a) neutralising the MIC through the scrubberby pushing little bursts of it through caustic soda solution, (b)repacking the MIC into smaller containers and shipping it back toDanbury, and (c) converting it into pesticide by using the existingfacilities. How to deal with the results of the accident required a muchmore complex decision. Both the Indian government and UnionCarbide (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), thepublic, Union Carbide, or key individuals within the establishment suchas Arjun Singh and UCC/UCIL management?. The possibilities, it latertranspired, were mutually exclusive: saving their own political skinsprecluded officials from saving the public and vice versa.

It is the personal opinion of the author that the Indianauthorities and Union Carbide were not only grossly negligentbefore the disaster, but equally callous during their response to it.As will be demonstrated below, the major parties involved chose anobjective which deviated from the one expected of responsibleactors in charge of a response to an LSSD. Both their actions andinactions, aimed at advancing their own interests, contributed tothe subversion of the primary objective of such a response, whichis to save as many lives as possible and reduce damage to thepublic’s health.

Policy for responding to the accident Following the tragedy everyone who could conceivably be connectedto the Bhopal tragedy asserted, to varying degrees, that they asindividuals and as organisations were outraged, but that the faultwas not theirs and someone else was culpable. Although the eventsin Bhopal were catastrophic in every sense of the word, manyofficials viewed the episode, for all practical purposes, as over. Theofficial impression was that the administrative response had beenadequate, the damage had been less serious than was originallyfeared and all that remained to be done was to resolve the legalissues arising from the accident. In other words, officials attemptedto both play down the effects and play down the causes. The pro-business government of India found itself in a delicate position,having to confront an American-owned multinational during anelection year.. The goal of UCC was consistent (except during thefirst hours) and that was to protect their own assets at any cost. Inpractical terms, this meant failing to discover what really happenedat Bhopal, justifying the reopening of the MIC plant in West Virginiaand deflecting responsibility for the disaster to its Indian subsidiary.The reaction of the US chemical industry ran along similar lines, andwas not significantly different from that of the nuclear industryfollowing the Chernobyl accident.

8 HazMat Responder World Autumn 2012

In the second part of thearticle Dr Efraim Laor looksat patterns in the Indianand international responseduring and after theBhopal disaster of 1984.


The strategy There was a qualitative difference betweenthe strategy of response to the tragedy andthe subsequent strategy employed duringOperation Faith. Whereas the accident itselfhad not been preceded by pre-disasterpreparations, resulting in a calamity,Operation Faith was relatively organised andeventually achieved the desired results. It isclear that the Indian central government didnot have a systematic, objective-orientedstrategy for saving people's lives. Officialswere shocked, disoriented and paralysed.Ongoing activities were characterised byindecision, discord, highly-motivated butineffective actions, and poor performance.The military and medical communitiesseemed to be the only official arms thatfunctioned with some degree of efficiency.

Technically, it was feasible to begin therelief operation at roughly 00:30 or evenearlier, which would have significantlyreduced the health hazard to the localpopulation. The authorities could haveprevented a great deal of suffering just byalerting the public to the accident,instructing them to escape perpendicular tothe wind, cover themselves with whateverwas available, breathe through wet cloth andkeep still rather than moving around. Theycould have organised mobile teams toevacuate the sick and injured to hospitalsand clinics. Even if they were under-resourced, they could have targeted effortsat children, the elderly and pregnant women– all of whom were put at particular risk. Inshort, they could have performed simple actswhich would have had important, life-preserving effects. Yet, nothing of the sortwas done until roughly 06:00 the nextmorning. Although 15 tons of MIC remainedstored in the plant, the parent companysteadfastly refused to provide details of whatmight have gone wrong at Bhopal. Theirstrategy was unsound from the very start:they insisted there was no leak, failed tosound the public alarm, withheld vitalinformation on treatment for the toxiceffects of MIC and other substances, andlastly used a media campaign to deflect theblame onto local workers.

The main objective of Operation Faith wasto minimise exposure time, and the best wayto avoid intensive human exposure to thepoison was either by moving people awayfrom its path or getting rid of its source. Dr.Vardharajan, a prominent Indian scientist,was appointed head of the operation. Afterconsulting UCC representatives andJagannath Mukund, the plant foreman, hedecided that the safest option would be toconvert the remaining MIC into pesticides.The Chief Minister, Arjun Singh, insisted thatevery precaution would be taken: the taskwould be performed only during daylighthours, a helicopter hovering overhead wouldspray water to dissolve any escaping gas and

families would be allowed to evacuate to thecity's schools. And, indeed, a number ofprecautions and actions were taken, aimed atincreasing public safety. In addition, ninecamps were set up in schools and colleges inthe city for those wanting to leave theirhomes, dedicated buses shuttled residentsfrom colonies to camp sites, people in thecamps were fed two meals a day andreceived medical treatment, and thegovernment closed all local schools until theend of the detoxification process.

Despite these precautions, the secrecythat surrounded operations at the plantintensified the existing tension in the city.The people of Bhopal were not convincedand felt that they were not being evacuatedfar enough away from the poisonous gas.Most locals locked their homes and shops,organised bundles of clothes and food andleft the city autonomously, congesting the

railways and bus stations. Nearly 400,000fled Bhopal under their own steam whilstofficial buses transported people, theirhousehold goods and even animals. Fourhundred buses that had arrived for standbyuse were quickly packed with familiesseeking to get away. On the night of Singh'sannouncement, more than 5,000 peoplejammed the city's railway station. One manwas killed when the rushing crowd pushedhim into the path of a train. Fleeingresidents sat on the top of the buses becausethere was no space inside. The operationlasted seven days (16-22 December) andreached a successful conclusion.

Administration Indian authorities lacked an organisationspecifically responsible for coping withpeacetime disasters. They had neithercontingency 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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apparatus nor a standing capability to copewith such a situation. In practice, themajority of the activities were improvised: at03:30, barely three hours after the plant'sevacuation and with hundreds of deadcitizens, the health minister, RewanathChoubey, informed Arjun Singh of the leakfrom the Union Carbide plant. Singh and hisaides were evidently stunned and did notknow how to cope with the emergency. At05:00 the police announced that the gas leakhad ended and Singh drove to the affectedareas. When Ragiv Gandhi visited the scene,en route to a campaign tour of MadhyaPradesh, Singh dropped his other duties tojoin the prime minister.

Local authorities did not set up a crisis-management centre. The army was alerted byretired Brigadier M.L. Garg, who asked forthe help of the area sub-commander,Brigadier N. K. Mayne. The Additional DistrictMagistrate, H. L. Prajaphati, said that he hadspoken to Mukund, the factory foreman athis home and given him news of the disaster.Mukund's first reaction was reportedly oneof incredulity. Before ordering the UCCforeman to go to the plant, Prajapathi askedhim about possible medical treatments. Theadvice he gave was to splash water in theeyes and wipe the faces and mouths of thosecontaminated with a wet cloth. Prajapathi

recalled Mukund saying, "it is not known tokill". The police chief asked the plant'ssecurity officer to identify the gas and itsantidote. The man said he did not know. Insum, during the first critical hours, theofficial response was characterised byincredulity, indecision and inaction. It wasnot until the next day that civil authoritiesmade concrete attempts to re-establish orderand launch a co-ordinated rescue operation.All schools, colleges and otherestablishments were closed. Teams of doctorsand paramedical personnel were rushed tothe scene from other parts of India. Militarypersonnel, ambulances and army trucks werepressed into service. The army opened itshospital to the civilian population. The localpolice aided in the search efforts.

Medical services The medical problems raised by the accidentwere the most complex and consequently themost urgent to tackle. The challenge entaileddiscovering which kinds of poisonousmaterials had been released, finding suitableantidotes, treating enormous numbers ofpatients at a time, finding places tohospitalise masses of victims, minimising thedanger of an epidemic and mobilising thenecessary medical resources. It rapidlybecame clear that the state of Madhya

Pradesh was incapable of coping with thesituation without external involvement. Localmedical services collapsed, under masses ofcasualties, before dawn. On the morning of3rd December, the state government sent outappeals for medical help and drugs tosurrounding cities. Messages began to flowbetween Bhopal and Delhi, among them fromSingh to Prime Minister Rajiv Gandhi. In myview, the Indian authorities could haveresponded much better by requestinginternational assistance without delay.

The symptoms The initial human symptoms following theleak were eye irritation and coughing, whichdeveloped into vomiting, eventually leadingto blindness and death. Most of the victimssuffered severe damage to mucousmembranes and inflammation of therespiratory tract. The chemical action withinthe lungs caused them to secrete fluids, andin acute cases the fluids caused asphyxiationand death. People who had run greatdistances, breathed deeply and inhaled largequantities of gas suffered severe lungdamage. Many women had peculiargynecological problems. Exposure to MICgenerated intense heat within the body,followed by dehydration. Besides the lungsand eyes, the exposure damaged the liver,


The exact death toll from Bhopal will never be known ©Greenpeace

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kidneys and gastrointestinal tract, as well as affecting theimmunological, reproductive and central nervous systems. Withinbarely 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 thedeaths recorded after the third day involved a failure of the centralnervous system. The survivors of the first days fell victim to secondaryinfections of the lungs and the respiratory tract. The number of peoplereported to be suffering from bronchitis, pneumonia and asthmaticcomplaints increased. Tuberculosis patients experienced anexacerbation of their symptoms. The theory that the gas would notaffect those who inhaled it after 72 hours of the leakage provedwrong. Even on the ninth day after the accident, new patients appliedto hospitals for treatment.

Diagnosis of the poisons. The disaster proved that MIC is as lethal as hydrogen cyanide andphosgene. The fatal effects of MIC took doctors by surprise and foryears the nature of the compound which had been released during theaccident remained an unresolved controversy. There was consensusabout MIC and phosgene, but a bitter dispute about the presence ofcyanide. 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 convertsisocyanate into cyanide. This argument contradicted the company'sown material safety data on MIC, section 5, which stated that"thermal decomposition may produce hydrogen cyanide, nitrogenoxides, carbon monoxide and/or carbon dioxide". When Awashia, UCC’shealth director, was questioned about whether MIC can releasehydrogen cyanide, his initial response was to say no. He was referredto Carbide's own manual, to which he replied "Yes, at 437 degrees C."

Given the high temperatures generated by the exothermic reactionbetween MIC and water, as well as other chemical changes in tankE610, it is more than likely that a considerable amount of MIC yieldeddecomposed products. A confidential report furnished by the Indian

Council of Medical Research (ICMR), stated: "There is evidence ofchronic cyanide poisoning operating as a result of either inhalation ofhydrogenic acid or, more probably, subsequent generation of cyanideradical from the cyanogen pool in gas afflicted victims." Thiscontroversy lasted long enough to prove that it is unwise to stimulatea response based on the accumulation of scientific data. This episodealso highlights the drawbacks of previous knowledge, as well as theproblems of recognition and adequate timing, suggesting that optionalbenefits can be gained from international co-operation.

Therapy dilemmas. During the first few hours of the disaster, the medical establishmentknew virtually nothing, from a medical standpoint, about what theywere dealing with. There was very little information on MIC in anytextbook on toxicology and medical staff had insufficient experienceon how to treat victims of exposure to the gas. The only peopleexpected to have any prior knowledge were the doctors employed atthe UCC plant. They denied that MIC was toxic or had any long-termeffects. A chemical expert team from the WHO said that no specificantidote to cyanate poisoning was available. The doctors at HamidiaHospital resigned themselves to giving symptomatic treatment only,such that each symptom was dealt with in isolation: eye drops wereprescribed for eye irritation, antibiotics to prevent infections andantacids for the stomach. There was no attempt to either purge theblood of the toxin or to treat long-term consequences. Sodiumthiosulphate is considered an effective antidote to cyanide. Yet, whenits usage was proposed, the Union Carbide doctors advised against it.In February 1985, the ICMR found that treatment by sodiumthiosulphate produced "amelioration of symptoms in a goodproportion of cases." It seems that many lives would have been savedhad the doctors known that cyanide was present.

In the early stages, patients were administered large doses of thediuretic Lasix to relieve oedema, cortico steroids to containinflammation of lungs, as well as bronchodilator and oxygeninhalation in acute cases. Oxygen inhalation proved ineffective andthe 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

most were massive doses of antibiotics and vitamins. But theywere treated with anything at hand: glucose, painkillers, evenstomach pills. A very simple action, useful for non-seriouslyinjured, was to wash the face with water. A man in JayaprakashNagar ordered other locals to do so and all of them survived,whilst entire families residing in the same area who didn’t followthe same procedure, died.

First aid. The first patient with burning eyes arrived at Hamidia Hospital at01:15. Within the next two hours, Dr. Sheikh was swamped by twothousand more. Many citizens and interns rushed to the hospital tosee what had happened, and they were instantly pressed intoservice along with nurses, doctors and staff members. By earlymorning, the hospitals of Bhopal were overrun by thousands ofpatients, who arrived blinded, breathless and dizzy, carrying thosewho 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 onstretchers and vehicles that went to the city's hospitals and clinics.The dead were sent to the main morgue at Hamidia Hospital orstraight to the Muslim graveyards at Jahangirabad and the Hinducremation site at Cholla.

Medical supplies. On the first day of the disaster there were not enough oxygencylinders to go around. Appeals for help went out to privateclinics throughout the city. UCIL flew in cylinders, masks andstocks of cortisone drops from Calcutta and Delhi. The Indiangovernment and other centres in Madhya Pradesh, as alreadymentioned, air-freighted medicine and personnel. Mobile medicalunits of the Indian Red Cross (IRC) distributed medical supplies,including antibiotics, ophthalmic ointments, other medicines andvitamins. Unfortunately for the victims, the early medical effortwas soon forgotten and replaced by bureaucratics, politics andpersonality clashes.

Mental health problems were a major consequence of thedisaster. The Indian Council of Medical Research (ICMR), in NewDelhi, estimated that tens of thousands of victims suffered frommental disorders, ranging from depression to anxiety andadjustment reactions. Damage to the central nervous system wasevident among many survivors, especially women under the ageof 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 ofhelplessness. Others became victims of ‘compensation neurosis’, amental condition in which people exhibit psychosomaticsymptoms and even self-inflicted injuries, in order to acquirebenefits and compensation. Such problems were far from theminds of the doctors, who were more concerned with saving lives.It was not until the middle of 1985 that Hamidia Hospitalestablished a separate psychiatric ward. Until then, mental stresspatients were administered symptomatic drugs. Mentally illpatients suffered a setback, as they were treated for what wereregarded as physical problems: breathlessness, fatigue andheadache. The threat of contamination and the danger of choleraincreased, as long as animal and human corpses decomposed inthe open air. Rats scurried around the dead bodies, awakeningfears 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 onlysolution was to place the dead, as many as five or six corpsestogether, on one pyre. Muslims were also buried in groups. Rescueworkers dug graves six feet long and 15 feet wide, each holdingeleven bodies. When there was no burial ground left, old tombswere opened and old bones were displaced, in order to makeroom for the victims. Thousands of animals were also killed by the

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gas. The army and other groups used cranesto remove the dead animals, toss them intotrucks and dump them at Nishat Pura,about five kilometres north of the city. Thiscontributed to the shortage in food supply.Milk supply to Bhopal city was affected dueto the death of an estimated 4000 cattle.Several dairies in the worst of the affectedareas were closed down. In addition, theBhopal authorities banned the sale of fish,and advised the population to refrain fromconsuming meat and meat products. In thesecond week of December 1984, thegovernment announced the awarding offree rations to those with ration cards. Itthen issued another 21,000 cards to thosewho had not procured them earlier.

The relief measures were criticised bycitizen groups on the grounds of corruption.In practice, it was the more vocal, aggressiveand politically well-connected people whoreceived relief (money and food) quicker andin larger quantities than some of the moreneedy but powerless. Owners of ration storesmade a lot of money by holding back rationsand selling them on the black market.Middlemen and local money lenders exploitedilliterate and weak victims by takingcommissions for their services in procuringrelief benefits and even confiscating themoney received. Forgeries of ration cardswere commonplace and people collectedcompensation twice by impersonating others.The prevalent corruption among officials incharge of the relief effort eroded its efficacy.Local, public and voluntary agencies played avital role throughout the emergency byproviding transportation, cooking and

distributing food, setting up tents anddisposing of the dead. For example, at therequest of the central and state governments,the Indian Red Cross (IRC) mobilised 100volunteers to provide aid to 5,000 disastervictims in five relief camps for a period of 30days. By 14th December, the IRC haddistributed 12 MT of high protein biscuits, 6.5MT of skimmed milk, 20000 blankets, 46500pieces of clothing and 200 tents. Watersupply tests made on the drinking water inBhopal a few days after the accident showedno signs of contamination. On the other hand,tests conducted in 1990 (six years later) onthe drinking water at the community adjacentto the former UCIL site in Bhopal revealedhigh levels of dichlorobenzene, an extremelytoxic substance. Dichlorobenzenes are known to damage the liver, kidneys andrespiratory system.

ConclusionIt is the contention of this article thatcompanies involved in hazardous productionshould insist upon locating their plants,whenever possible, in isolated areas (islands,the bush, the desert), rather than inconurbations. Concurrently, the appropriateauthorities have to block the subsequentdevelopment of neighboring shanty townssuch as Jayaprakash Nagar and Cholla. Thesemeasures are necessary to avoid theemergence of elements 1 and 2 of theDisaster Triad -- namely the proximity oflarge-scale populations to a disasteragent..The relevant concern in this context isalso whether or not this type of error canrecur elsewhere in the world. The mistakes

are repeatable, with marginal variations. Themain lesson that must be derived from thiscase is that major accidents may happen,despite a wide range of technical andmanual safeguards, and they will happenmore frequently if these safeguards aredisregarded. Given that accidents of this sortare likely, the desirable course of actionshould be to know how to respond to such asituation. The analysis in this chapter hasrevealed that each of the four majorparticipants in the Bhopal drama - UnionCarbide, UCIL, the government of India andthat of Madhya Pradesh - were jointlyresponsible for both the disaster and theimproper relief. Lack of pre-crisispreparations to face a major accident led toimprovised responses to a complex problem.In the face of a rapidly escalating crisis anda speedily deteriorating response, ad hocimprovisations either failed to meet concreteneeds or led to unsatisfactory reactions tomoments of opportunity. A successfulresponse to large-scale disasters depends ona comprehensive, multidimensional andsystematic course of action. That mechanismneither existed in 1984 in India, nor was itavailable to the Indians from abroad.

Lessons learnedThe Indian government has establishedseveral agencies such as the "StandingCentral Crisis Group", "Standing StateCrisis Groups", and "Standing District LevelCo-ordination Committees" to co-ordinaterescue and relief efforts on the national,state and district levels. The Central CrisisGroup (CCG), set up by the Ministry ofEnvironment and Forests, comprises seniorofficials of the central government andtechnical experts. Its goals are to tackleproblems caused by major chemicalaccidents, to suggest a course of actionaimed at minimising the effect of theaccident, to co-ordinate the activities ofvarious agencies and departments, and toprovide expert guidance for handling majorchemical accidents. The Government ofIndia has also launched a researchprogram, comprising nine projects (as ofFebruary, 1994), to formulate disastermanagement plans in nine out of the 540most hazardous districts of the country.Manuals to assist owners of hazardouschemicals to prepare on-site and off-siteemergency plans have been published, suchas the "Manual on EmergencyPreparedness for Chemical Hazards". TheGovernment of India expects theseactivities to improve its readiness to tacklefuture major chemical accidents.. Yet, ithas been observed that preparation of off-site and on-site emergency plans, ingeneral and all over the country, stillleaves much to be desired. In a number ofcases either the plans do not exist, or evenif prepared, are not comprehensive. HRW


One of the most iconic images of Bhopal - but what is its legacy? ©Greenpeace

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from the Disaster: Part II - Home - CBRNe World Learned – Bhopal Lessons from the Bhopal Disaster: Part II Any analysis of the response to the Bhopal tragedy will be sharpened by