Nov 29, 2014

The Ghosts Of Bhopal - Part Three

Part Three: Post Mortem

Dr. Satpathy ordered that each unclaimed body be photographed and identified by number.
Dec. 3, 1984.

Stones tapping at the window.

What time is it?

Certainly past midnight.

The sound is loud enough and persistent enough to rouse Dr. D.K. Satpathy from his slumbers.

Fie. The man throwing these stones is a known drunkard. This is what the pathologist thinks to himself. The doctor cannot be bothered with such nonsense at this hour.

Dr. Satpathy was certainly not lazy. He would want the world to understand this. Though his workweeks were long, he prided himself on his readiness to conduct a post-mortem at a moment’s notice. Sundays. Holidays. Diwali. Such occasions mean nothing to a true professional. Suppose a mother has lost her son and it is Good Friday. (This is how he would phrase it.) If he were not to conduct a post-mortem in the instant, the body could not then be prepared for burial and the whole day will be a black day for her.

How long does an autopsy take? To incise a Y formation, from the clavicle, coming to a single rill down the torso to the pubis, an examination of viscera. One hour? Two at most. And then, the pathologist may resume his private affairs. His day remains to be enjoyed. (This is also how he would phrase it.)

Satpathy can make the task sound no more onerous, nor time-consuming, than reading the morning newspaper. He will conduct 70,000 necropsies in his career. This he will say proudly.

How much sleep follows the arrival of the disruptive drunkard?

Time flies past. Satpathy does not stir. One a.m. Two a.m. In the helter-skelter of J.P. Nagar, and the bus depot and the railway station and along Union Carbide Road and the bustee they call Kazi Camp, hordes of panicked Bhopalis are dropping in place. Blinded. Puking. Their bowels discharging. Ox carts and trucks begin picking up the ailing, placing the dead into piles. It is too soon yet for the cranes that will start lifting the cumbersome dead oxen.

Feroza, the wife of Afzal the painter, is placed upon a funeral pyre, from which she rises like a ghost.

Sunil Verma is a boy of 13. Running willy-nilly from his home, he stops to pee and passes out. Presumed dead he is piled into a vehicle to join the company of corpses. Later, he will wake up. Later, he will learn that three of his sisters have died. And two of his brothers. And both of his parents.

Dr. Heeresh Chandra, Satpathy’s supervisor, is now at the pathologist’s door, urgently rapping. Roused, Satpathy struggles to absorb Chandra’s earth-shattering message: “There has been a human toll beyond our imagination.”

Satpathy rushes to Hamidia Hospital, off the major artery of Berasia Road. The government hospital is crowded with bodies. The grounds that Satpathy had walked through the prior afternoon have turned into a morgue. White sheets cover human forms, as if the clouds themselves had collapsed onto the ground.

The wind chimes gently stir in Dr. Satpathy’s home on Kolar Road. To the west rise the Shyamla Hills, the lake-view enclave where Union Carbide kept its gated guest house. The pathologist’s home is on a busy thoroughfare, and thus doesn’t bar the insistent cacophony of evening life in Bhopal — the constant revving of motorcycles, the rattle of tuk-tuks; the bell-ringing of the vegetable sellers, their pushcarts laden with cauliflower and eggplant.

Satpathy pads through the French doors of his living room, offering a hygienic elbow tap by way of greeting. His snow-white sideburns, set against a surprisingly rich brown head of hair, are the most visible acknowledgement of the decades that have passed.

He is retired now — no longer the director of the Medicolegal Institute for the government of Madhya Pradesh. The institute was the first of its kind in India, established in the late ’70s to set a new standard in forensic analysis. At the time of the Bhopal disaster, the institute was still new, still groundbreaking.

Satpathy recalls the grisly sight he came upon the morning of Dec. 3. Hundreds of men, women and children had been laid out on the hospital grounds. Being at a loss for space, bodies had been stacked, one atop the other, in a washroom. “There was no space!” he exclaims. “None! The whole veranda, the whole campus, was packed with victims.”

Bodies lay in a makeshift morgue in Bhopal, India.
 Sondeep Shankar/AP
The chaos was grimly matched by the chaotic messaging from Union Carbide. A co-worker of Satpathy’s spoke directly with Dr. L.S. Loya, the Union Carbide plant physician. In Satpathy’s account, Loya replied, “Believe me, doctor, I don’t know anything about this gas. I have never been told about the toxicity of this gas. Neither have I been told the antidote, the safety precaution about this gas. Nor has any worker been informed about that.”

Loya did have one piece of advice: “Just wash your face and all this and it will be washed away.”

Satpathy assesses the dearth of information this way: “While the company was installing this factory, suppose he would have disclosed: ‘Look, gentlemen, I am installing a factory where this MIC gas will be used and even if a single puff of it will be so toxic that death may precipitate.’ Then no worker would have employed at that factory.”

MIC was produced at the Bhopal plant by reacting phosgene, the poison gas that was used as a chemical agent in the First World War, with monomethylamine. The phosgene was made on site by reacting chlorine with carbon monoxide, both of which were trucked in to the Union Carbide site. The end product, the pesticide, was produced by reacting MIC with the organic compound 1-naphthol.

By the autumn of 1984, the Bhopal plant was a chronic money loser, the size of staff had been chopped in half and safety management systems, such as they were, had been badly compromised. The MIC production unit had been shut down. Between two tanks, 610 and 611, the MIC inventory stood at 83 tonnes, which were to be stored at a target temperature of zero degrees Celsius. The MIC in both tanks exceeded recommended capacity by roughly 30 per cent. Conversion of the MIC to carbaryl, or Sevin, was deemed the soundest approach to disposing of the remaining material.

MIC is colourless, has a sharp, detectable odour, and is highly reactive with water. According to employee accounts, on the evening of Dec. 2, Rahaman Khan, also known as Rehman Khan, commenced the process of washing four lines of piping in the unit. The composition of the unit included a relief valve vent header, designed to flip open under pressure and release excess gases as required to the vent gas scrubber, the apparatus that would neutralize the gas with a caustic soda solution. Clearing such discharge pipes when blocked was common practice. But a slip blind, which would have contained the water flow and prevented it from entering the tank and contaminating the MIC, was not in place.

Tank 610, the tank that leaked methyl isocyanate (MIC) in the Union Carbide plant
As the water invaded the tank it reacted with the MIC. The temperature in the tank rapidly rose, unleashing an acute exothermic reaction. Two Indian scientists would later conclude that a temporary pipe, installed between previously unconnected parts of the MIC equipment, was the conduit for the contamination. The scientists surmised that this “bypass system” had been devised to compensate for those parts of the facility that were undergoing repair.

Union Carbide’s own investigation rejected the water washing explanation. Months after the disaster the company would finger, though not name, a “disgruntled” worker “who had ample opportunity to deliberately inject the large amount of water into the storage stank which caused the massive gas release.”

The company did not state what the worker might have to gain. M.L. Verma, a UCIL employee, would later say that it was clear the American corporation was fingering him. Verma himself addressed the central issue — that such an act would be undertaken at the enormous risk of the saboteur becoming victim. “Everyone knows that a MIC and water reaction is very dangerous.”

In addition to the nonfunctioning flare tower (which would have burned off the released gas) and the non-operational refrigeration system, the temperature gauge was malfunctioning. The exothermic reaction of the MIC with the water caused the temperature to spike, though how high it rose is unknown. A later investigation by Union Carbide would surmise that the temperature in the tank exceeded 200 degrees Celsius. How far it may have exceeded that temperature the company did not postulate. Workers noted that the day following the disaster, the tank was “hot to the touch.”

Though the idled vent gas scrubber was restarted the night of the disaster it proved no match for the explosive release: the scrubber was built to handle a low-pressure flow of 85 kilograms per hour. Instead, the gas was emitted through the scrubber at 18,000 kilograms per hour.

The runaway chemical reaction was violent.

No evacuation plans had been established for the adjacent communities. No emergency preparedness information had been transmitted as to how to respond to exposures of any kind.

The laxity around safety was not known to Dr. Satpathy. Nor the rapidly deteriorating state of the facility. The urgent medical question was simply: What is this gas?

If the temperature of the MIC at release that night was unknown in the moment, how could its chemical components be accurately assessed? At extreme heat, could the MIC have been degraded? What contaminants may have sloughed off the corroded tank walls? Union Carbide would later determine that iron compounds contributed to the catalytic reaction.

It was Dr. Chandra, Satpathy’s superior, who first ordered sodium thiosulphate injections. “In the autopsies, we were having this conception that the gas, whatever it is, that a cyanide element was the much stronger element,” Satpathy says. “During the autopsies we observed that the blood was not cyanosed. It was very cherry red ... because the oxygen was not utilized.” The presumption was cyanide poisoning.

Lending further credence to this theory, the presence of sodium thiocyanate in the urine of gas-affected patients injected with thiosulphate confirmed that detoxification was taking place.

Yet within days of the catastrophe, Union Carbide’s medical director at its operations in West Virginia, who had flown to Bhopal, asserted at a press conference that there could be no cyanide poisoning. Early in 1985, New Scientist magazine quoted from a Union Carbide statement: “Methyl isocyanate is not a cyanide. In no way should it be confused as such.”

While sodium thiosulphate is virtually harmless in and of itself, the instructions around the injections were further confused by the director of health services for the state of Madhya Pradesh, who ordered that “under no circumstances should sodium thiosulphate be given unless it is correctly and conclusively proved in the laboratory that it is cyanide poisoning.”

In fact, if the temperature had risen high enough, the MIC could have degraded into hydrogen cyanide. No systematic study was undertaken to solve this piece of the riddle, a fact that grieves Satpathy greatly. The ultimate toxicant at Bhopal has never been determined.

Union Carbide control room safety sign.

Union Carbide control room safety sign.
Those who had acutely inhaled the gas, those who ran with the wind, those who did not place a wet cloth to their faces, those who were unfortunate and young enough to be fully exposed, perhaps those who ran fastest, presented a problem — there were simply too many to autopsy.

Practical decisions were taken. All bodies were photographed and numbered. A random sample of autopsies was conducted. External examinations were undertaken for the rest. “There were no visible injuries. There were no burns. There were no ...” Satpathy’s voice drifts off. A delicate froth, often pink in tone, can be viewed emerging from the noses and mouths of many of the deceased, a sign of pulmonary edema. In those that were autopsied, the fluid-filled lungs were found to be voluminous, as much as three times their normal weight.

Thirty years ago, photographs of the unclaimed dead were affixed to a large placard. Satpathy held it up to show the media. Residents were urged to identify the bodies with haste, else they would be disposed of. There were rumours that some victims had been dumped in the river.

And what of those left behind?

Satpathy is sharply critical of the Indian Council of Medical Research, which started, then aborted or closed, a series of projects on the disaster. “These studies should have been continued for years.... There is no study. There is no project going on,” he says, brushing the palms of his hands together to emphasize the dismissive stance that has been taken.

The ICMR did undertake a number of what the council deemed long-term studies. By example, the children of J.P. Nagar aged 5 in 1986 were monitored for four years. In 1990, 44 to 56 per cent of children were found to be still suffering the consequences of gas exposure, with such reported ailments as upper respiratory infections. Case closed.

The council did record some powerful statistics. Spontaneous abortion in the immediate aftermath of the tragedy was five times higher than in a control group. Neonatal deaths, from birth to seven days, were three times higher. Congenital malformations were twice as high.

Further findings suggested that MIC “and its breakdown products” — whatever they may be — had entered the bloodstream.

Satpathy says fetal post-mortems proved beyond a doubt that the toxic gas crossed the placental barrier. “In the future, it can also affect the genes. Say after 10 years, after 20 years, after 30 years. We don’t know!”

Holes are often punched in the wall of the factory grounds, just across the road from J. P. Nagar. Children often play at the contaminated site until police chase them off.

Here’s a riddle: A corporation espouses a product as safe when safely used, but fails to enforce the standards required to ensure that safe use.

Satpathy offers a stern yet plaintive message to America. “There should be an international rule that whatever the substance might be, it may be a diamond, and if it is toxic, unless and until its treatment, its effect, its antidote is available, if it has not been told to all the persons, it should not be used in any country.”

An advantage was taken. “A developed country, they should not misuse the poorness of the undeveloped country. Why are they not installing the facility in their own country?” And no resolution has been reached. “It is a man-made disaster. It is not nature. The international community, they should come forward.”

Satpathy does not let his home country off the hook. “Where is the labour department? Where is the industry department? Where is the health department who have visited the factory and who have given the certificate, this factory is all right? They should be hanged.”

It is a sunny day and Nadra Bi is hanging her laundry along a line she has strung opposite her doorway. Her goat is tethered in the shade and the stone steps to her home are wet from the morning’s labours.

Nadra’s address is deemed to be on Road Number 1 in J.P. Nagar, though if you were to enter the community from its opposite end, you would be informed that that too is Road Number 1. This leads to some confusion. Nadra’s avenue is the closest to Union Carbide Road, closest to the corroded remnants of the factory. On the grounds of the factory, a small knot of boys play gilli-danda, a game that requires nothing more than two sticks and rambunctiousness. The police will chase them off, as it is forbidden to play there. As they scatter one of the boys offers a quote for the reporter’s notebook: “The gas has leaked from hell,” he says.

Around the corner, Jebur Nisha’s husband, Mohammed, is at work in his barber shop. Down the way is the mournful statue erected in tribute to the disaster. A featureless woman covers her face with one hand, carrying a limp, swaddled infant in the other.

Nadra will allow a few moments to talk. Her fuchsia scarf has drifted back from her brow, revealing a receding hennaed stain that no longer disguises her grey hair. She appears to be in her late 50s. She places one hand on her hip, and speaks directly.

In the early hours of Dec. 3, 1984, she ran from her home. In this her story bears no distinction. But in taking the decision to flee Nadra also took the decision to leave behind her 7-year-old son, Manna. Manna could not walk. He would drag himself to get about, and Nadra had no means by which to get him out of her little hovel on Road Number 1 in J.P. Nagar. And so she fled. Manna died two months later.

Nadra Bi. Jennifer Wells/Toronto Star
The first baby Nadra gave birth to after the disaster was stillborn. He was blue, she tells us, quite matter-of-factly, before returning to her chores.

Entering the Medicolegal Institute today, visitors are met right off with a large mural along one wall in the entranceway. “Bhopal — City of Death” is the painted banner, as if this were the city’s trademark. An artist has rendered a simple representation of the Union Carbide factory process: the MIC tanks, the release of gas to the atmosphere, the toxic inhalation by a lone male figure, crudely rendered, and a mortuary with bodies lined up like dominoes.

Adjacent are shelves of large specimen jars, including a display of fetuses autopsied after the disaster. Satpathy says they used to be identified as such. They are no longer.

Dr. D.S. Badkur is the current director of the institute and he appears to harbour no small resentment toward his predecessor, dismissively referring to Satpathy as a “media-loving person.”

Badkur then launches into an hour-long, stomach-churning PowerPoint of the suicides and murders that have challenged his forensics crew. He pauses for a detailed explanation of the young woman who could not have hanged herself from a tree with her dupatta, as the ligature marks in the images make clear. He alights upon the case of the auto-eroticism gone wrong. As he delves into the dismemberment of a little girl in a yellow dress, Badkur appears to be testing us: will we turn away?

Primary research on the gas tragedy is what we’re after. He waves his fingers in the air. “That gives the wrong message to society,” he says, flipping a hand in the air. “This is a teaching institution. The people who worked on the gas are all retired.”

There are no records here.

And justice?

“It is a great social issue. It is a great judicial issue. It is an issue related to multinational companies. I don’t find myself fit to say anything.”

Part One: Wedding Season

Part Two: Building a New India 

Part Four: Mass Tort

Story by Jennifer Wells. Photos by Spencer Wynn.

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