IN THE SUPREME COURT OF INDIA
CIVIL ORIGINAL JURISDICTION
WRIT PETITION (CIVIL) NO. ______OF 2020
[Under Article 32 of the Constitution of India]
In the Matter of:
Munni Bee &Anr. …Petitioners
VERSUS
Union of India &Ors. …Respondents
I N D E X
Sl No. Particulars Copies Court Fee
3. List of Dates 1+3 4. Impugned Orders dated.23.03.2020 and dated.24.03.2020 (Imp Orders) 5. Writ Petition with affidavit 1+3 Rs. 6. Annexure-P-1 to P-18 1+3 Rs. 5. App. for Interim Directions 1+3 Rs.
6. Application for Exemption From Filing
Official Translation Of Annexure P-1. 1+3 Rs.
7. Application for exemption from filing of court
Fees. 1+3 Rs.
8. Vakalatnama with Memo of Appearance. Rs.
Place: New Delhi FILED BY
Date: 01.04.2020 (APARNA BHAT)
ADVOCATE ON RECORD FOR THE PETITIONERS
CHAMBER NO 206 NEW LAWYER CHAMBER SUPREME COURT OF INDIA
NEW DELHI
IN THE SUPREME COURT OF INDIA
CIVIL ORIGINAL JURISDICTION
WRIT PETITION (CIVIL) NO. ______OF 2020
[Under Article 32 of the Constitution of India]
In the Matter of:
Munni Bee &Anr. …Petitioners
VERSUS
Union of India &Ors. …Respondents
With
I.A. No. of 2020
APPLICATION FOR INTERIM DIRECTIONS
AND
I.A. No. of 2020
APPLICATION FOR EXEMPTION FROM FILING OFFICIAL TRANSLATION OF ANNEXURE P-1.
PAPER BOOK
FOR INDEX KINDLY SEE INSIDE
ADVOCATE FOR THE PETITIONER: APARNA BHAT
INDEX
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
INDEX Page No. of part to which Re it belongs Sl. No. Particulars of Document mar ks Part Part II I (i) (ii) (iii) (iv) (v) Court Fee 1. Listing Proforma A-A1 A-A1 2. Cover Page of Paperbook A3 3. Index of record of Proceedings. A4 Limitation Report prepared by the 4. A5 Registry 5. Defect List A6 6. Note Sheet NS-1 7. Synopsis & List of Dates A-M
8. Writ Petition with Affidavit 1-26 Annexure P-1 True Translated Copy of the order 27- 9. dated.23.03.2020 passed by the Health 29 and Family Department, Government of M.P. Annexure P-2 10. True copy of the office order dated 30 24.03.2020 passed by Director, BMHRC. Annexure P-3 31- 11. . True copy of the medical record of the 34 Petitioner No.1 Annexure P-4 35- 12. True copy of the order dated 03.10.1991 36 passed by the Hon’ble Supreme Court. Annexure P-5 37- 13. True copy of the order dated 14.02.1994 41 passed by the Hon’ble Supreme Court. Annexure P-6 42- 14. True copy of the “Bhopal Memorial 57 Hospital Trust” deed dated 11.08.1998. Annexure P-7 58- 15. True copy of the “Safety Consideration 62 Report” prepared by UCC Annexure P-8 True copy of the ATSDR, U.S Dept. of 63- 16. Health, sheet on toxicity of Methyl 80 Isocyanate. Annexure P-9 True copy of the 2010 Action Plan 81- 17. prepared by the Department of Bhopal 119 Gas Tragedy Relief & Rehabilitation. Annexure P-10 18. True copy of the article written by 120 medical researcher, Polly Ghazi. Annexure P-11 True copy of the medical research study paper titled: “Comorbidity and its impact 121- 19. on 1,590 patients with COVID-19 in 162 China: A Nationwide Analysis” published by Guangzhou Medical University, China. Annexure P-12 True copy of the table containing the 163- 20. data on various diseases suffered by gas 165 affected patients. Annexure P-13 True copy of the Records from the Office 21. 166 of the Welfare Commissioner, Bhopal Gas Victims Annexure P-14 167- 22. 175 True copy of the letters written to Central and State Government of M.P. by survivors’ organizations. Annexure P-15 True copy of the notification 176- 23. dated.24.03.2020 issued by Director, 178 BMHRC. Annexure P-16 True copy of the circular 179- 24. dated.25.03.2020 issued by Coordinator, 180 Health Service, BMHRC. Annexure P-17 True copy of the article 181- 25. dated.25.03.2020 published in “The 182 Hindu”. Annexure P-18 Truecopy of the “Corona Action Plan of 183- 26. Bhopal, M.P” formulated by the Govt. of 184 Madhya Pradesh. Application for Interim Directions. 185- 27. 190 Application for Exemption from Official 194- 28. Translation of Annexure P-1 196
29. F/M V/A 197- 30. 198
A
SYNOPSIS
That the Petitioner No.1 is a 68-year old woman, a survivor of the Bhopal gas disaster, who belongs to very poor socio economic background. She is presently on a ventilator in the ICU at BMHRC, Bhopal.That she has been in the ICU for the last 24 days as she had suffered a heart attack, she has also previously suffered a stroke and has diabetes and hypertension.
These respiratory and other diseases have now become a hallmark for the Bhopal gas disaster victims.
That she faces a threat of being denied this treatment in view of certain directives of the state to provide support and treatment to patients of COVID 19. The present petition is being filed challenging those actions which are not only denying treatment to patients like the
Petitioner no.1 but is also exposing them to further dangers of the novel corona virus as their condition is already extremely vulnerable.
That on December 2/3 1984, Munni Bee along with approx. 5,74,000 people living near the
Union Carbide factory site inhaled Methyl Isocyanate (MIC), the vast majority had their lung function chronically damaged. The “Safety Consideration Report” for the Methyl Isocyanate
(MIC) Unit prepared by the Union Carbide Corporation, for breathing gave MIC the maximum dangerous rating of 5 which means that “major residual injury is likely despite prompt treatment due to the other exposure routes:
“Breathing-Methyl isocyanate is a recognized poison by inhalation and is
intensely irritating to breathe. It causes severe broncho-spasm and asthma-like
breathing. Major residual injury is likely in spite of prompt treatment.”
A
B
That the present Petition concerns diversion of the Bhopal Memorial Health and Research
Centre (BMHRC), contrary to the terms of its Trust Deed, set up under orders of this Hon’ble
Court passed between from 1991- 1998 annexed herein below. That further the Bhopal
Group for Information and Action, Petitioner No. 2 herein has approached this Hon’ble Court in a number of cases w.r.t. the health care and right to life of Bhopal’s gas victims. On the plea of Petitioner No. 2 in Writ Petition 50 Of 1998, this Hon’ble Court was pleased to pass strong orders strengthening the functioning of the Bhopal Memorial Health and Research
Centre (BMHRC); In Writ Petition 33 of 2012, this Hon’ble Court was pleased to pass orders regarding clinical trials conducted on Bhopal Gas victims inter alia in the BMHRC; In Writ
Petition 657 OF 1995 this Hon’ble Court has been pleased to pass orders to bring safe water to Bhopal gas survivors who are being forced to drink water laced with toxic waste dumped by Union Carbide. As such the present Petitioners seek to approach this Hon’ble Court directly for emergency directions.
That, on May 15, 1988, this Hon’ble court first directed the State of M.P to constitute Bhopal
Memorial Hospital and Research Centre (BMHRC) and Bhopal Memorial Hospital Trust
(BMHT) to look after the health of the affected gas victims.
That,in furtherance of its earlier order dated. 15.05.1988, the Hon’ble Supreme Court on
October 3, 1991, had directed the Union Carbide Corporation to build a 500- bed hospital with the best services and equipment for treatment of the survivors of the disaster and the provision of medical surveillance and expert medical care for them pursuant to the settlement with Union Carbide Corporation and Union Carbide India Ltd.
“..it will be proper that expert medical facility In the form of the
establishment of a full-fledged hospital of at least 500 bed strength with the best of
B
C
equipment for treatment of MIC related affliction should be provided for medical
surveillance and for expert medical treatment……It shall be equipped as a Specialist
Hospital for treatment and research of MIC related afflictions and for medical
surveillance of the exposed population. [367D-F]
27. The Capital outlays on the hospital and its operation expenses for
providing free treatment and services to the victims should, both on humanitarian
considerations and in fulfilment of the offer made before the Bhopal Court, be borne
by the UCC and UCIL.”
That, in accordance with the said orders of the Supreme Court of India, the Bhopal Memorial
Hospital Trust was set up on August 11, 1998, one of the prime objectives of which was, “(i)
The construction, staffing, equipping, management, operation and maintenance of the
Hospital and the provision therein of medical and other appropriate facilities (including facilities for medical surveillance by periodic medical checkups) for the benefit in the first instance of the victims of the Bhopal Gas Tragedy of 1984 and their dependents, and subject thereto for the people of Bhopal and the public at large.”
That according to a number of studies published in national and international scientific journals and official records, it has come to light that long term health damage has most likely been caused to 5,74,375 individuals as a result of their exposure to Methyl isocyanate.
That, the epidemiological research by the ICMR indicates that the rate of illness (morbidity) in the affected areas is 2.5 times higher than the unaffected areas and that 95% of the affected population is suffering from some physical or mental illness.
C
D
That, as per the 2010 action plan of Department of Bhopal Gas Tragedy Relief &
Rehabilitation, the number of gas victims with exposure induced chronic respiratory disorders alone is 100,000.
That, the Department of Public Health and Family Welfare, Government of Madhya Pradesh issued an order dated. March 22, 2020, to convert the Bhopal Memorial Hospital & Research
Centre (BMHRC), super specialty hospital into a hospital for exclusive treatment of COVID-
19 patients.
That, on March 24, 2020 Director, BMHRC issued an order to its staff stating “health care services will be provided now only for COV-19 patients at BMHRC, Bhopal. All other health care services to be stopped with immediate effect till further orders.”
That, on 24th March, 2020 BMHRC started discharging all the patients, over 80 % of which were those with history of acute exposure to Union Carbide’s poisonous gas from the
Intensive Care, Surgical and Medical wards in the hospital and succeeded in discharging 86 patients therefrom.
That, effectively from the midnight of March 24, 2020 all the Emergency Services of the
Casualty Ward of BMHRC have been closed. That, all the Dialysis facilities have been stopped from March 25, 2020. There are about 30 gas victims who undergo dialysis twice a week at the hospital, whose lives, without timely and quality dialysis, are in perennial danger.
D
E
That, more than 40 gas victims who have undergone kidney transplant require life-saving drugs and appropriate medicines from the hospital. As such hundreds of thousands of gas victims are being denied treatment and supply of life saving medicines for serious ailments like Chronic Obstructive Pulmonary Disease, Diabetes, Hypertension, Renal Failure, etc.
That, the Respondent No.3 has also closed the OPD in the main hospital. OPD plays a crucial role in providing medical consultation, supplying medicines and carrying out pathological and other investigations.
That, in addition to the main hospital, BMHRC also operates additionally with 8 community mini units (dispensaries) situated in different parts of the gas affected areas. All these 8 units, when taken together, have a total OPD footfall of 500-600 gas victims/day. However, on March 25, 2020, Coordinator, Health Services, BMHRC, issued a circular to the effect that:
“One Health Centre (i.e mini unit) to be operational every day. The same team of two Senior
Medical Officers, one nurse, two pharmacists, two computer operators to move from one
Health Centre to the other.”
The same is causing a crowd and a rush on this health centre, increasing vulnerability to the coronavirus.
That, in order to treat COVID-19 patients from the general population, the entire BHMRC hospital is being closed down, which will affect more than half a million of the most vulnerable population of the city whose health status has been decimated by the Bhopal gas leak and will be amongst the populations most vulnerable to coronavirus.
E
F
This especially when this Hon’ble Court has accorded their right to adequate and proper healthcare, a status of the constitutional Right to Life.
That it is also pertinent to mention that the Respondent No.2, in furtherance of its earlier impugned order dated.23.03.2020, has now taken over the management and administration of the Respondent No.3 and has vested the same with the concerned District Magistrate.
That, in the first and largest study conducted by First Affiliated Hospital of Guangzhou
Medical University, titled “Comorbidity and its impact on 1,590 patients with COVID-19 in
China: A Nationwide Analysis”, it was revealed that people with any Cardio- vascular and
Pulmonary problems, Diabetes, Cancers and most importantly compromised immune systems are 79% more at risk of being infected by the Corona virus, becoming critically ill and dying due to COVID-19. Further, for a person with any of the two above health problems, the risk of the above outcomes is 2.5 times in comparison to the general population. The co-morbidities mentioned above are a fallout of breathing the MIC for the
Bhopal victims, as such they are at a massively heightened risk also to COVID 19.
That, on 11.03.2020, Petitioner No.1, Munni Bee underwent a tracheostomy in the ICU and since then, has been in the General ICU under critical medical care – as such the ventilator is effectively performing her breathing function. However, the Respondent No. 3 is now pressuring her family to take her back home to make the bed available for potential coronavirus patients. That it is most relevant to state that, if she is forced out from the
Hospital, then, she would not have access to any super specialty hospital that has experience and high level competence in dealing with the peculiar morbidities of Bhopal gas
F
G survivors. Further, Munni Bee and other victims would not have the means or resources to afford private medical care and treatment.
That many other Bhopal victims’s health status is deteriorating due to the BMHRC being requisitioned. In addition, they are much more likely to contract and die from COVID-19 unless they are adequately treated, indeed international medical experts have described the reduced immunity of Bhopal gas victims as “chemically induced AIDS”. As such ensuring that the BMHRC remains true to the purpose for which it was set up under the Trust Deed, following the orders of this Hon’ble Court thus saving the lives of some of India’s most vulnerable citizens is urgent.
Hence the present Writ Petition.
List of Dates & Events
2/3 Dec,1984 Petitioner No.1, Munni Bee, along with approx. 5,74,000
people living near the Union Carbide factory site inhaled
Methyl Isocyanate (MIC), as a result of which, a vast
majority of victims had their lung function chronically
damaged. The “Safety Consideration Report” for breathing
Methyl Isocyanate (MIC) prepared by the Union Carbide
Corporation, for gave MIC the maximum danger rating of 5:
G
H
“Breathing-Methyl isocyanate is a recognised poison by
inhalation and is intensely irritating to breathe. It causes
severe broncho-spasm and asthma-like breathing. Major
residual injury is likely in spite of prompt treatment.”
15.05.1988 This court first directed the State of M.P to constitute Bhopal
Memorial Hospital and Research Centre (BMHRC) and
Bhopal Memorial Hospital Trust (BMHT) to look after the
health of the affected gas victims.
03.10.1991 In furtherance of its earlier order dated. 15.05.1988, the
Hon’ble Supreme Court ordered Union Carbide Corporation
to build a 500-bed hospital with the latest equipment for
treatment of Bhopal Gas victims, pursuant to the settlement
with Union Carbide Corporation and Union Carbide India
Ltd.
“..it will be proper that expert medical facility In the
form of the establishment of a full-fledged hospital of at
least 500 bed strength with the best of equipment for
treatment of MIC related affliction should be provided
for medical surveillance and for expert medical
treatment. The State of Madhya Pradesh shall provide
suitable land free of cost…It shall be equipped as a
H
I
Specialist Hospital for treatment and research of MIC
related afflictions and for medical surveillance of the
exposed population.
27. The Capital outlays on the hospital and its
operation expenses for providing free treatment and
services tothe victims should, both on humanitarian
considerations and in fulfilment of the offer made
before the Bhopal Court, be borne by the UCC and
UCIL.”
11.08.1998 That, in accordance with the order of the Supreme Court of
India dated October 3, 1991, the Bhopal Memorial Hospital
Trust was set up on August 11, 1998, one of the prime
objectives of which was, “(i) The construction, staffing,
equipping, management, operation and maintenance of the
Hospital and the provision therein of medical and other
appropriate facilities (including facilities for medical
surveillance by periodic medical checkups) for the benefit in
the first instance of the victims of the Bhopal Gas Tragedy of
1984 and their dependents, and subject thereto for the
people of Bhopal and the public at large.”
I
J
April 2002 The Agency for Toxic Substances and Disease Registry
(ATSDR), is a federal public health agency of the U.S.
Department of Health and Human Services. It is concerned
with the effects of hazardous substances on human health.
The ATSDR study on Methyl Isocyanate (MIC) states that Acute exposure to higher vapor concentrations may cause
severe pulmonary edema and injury to the alveolar walls of
the lung and death. Children may be more vulnerable to
corrosive agents than adults because of the smaller
diameter of their airways. Survivors of acute exposures may
exhibit long-term respiratory and ocular effects. ..The
exposure to MIC in Bhopal was acute in nature and there is enough evidence to suggest that exposure to it can cause
death and long term permanent injury.”
That, in the first and largest study conducted by First
Feb 27, 2020 Affiliated Hospital of Guangzhou Medical University, titled
“Comorbidity and its impact on 1,590 patients with COVID-
19 in China: A Nationwide Analysis”, it was revealed that
people with any Cardio-vascular and Pulmonary problems,
Diabetes, Cancers and most importantly compromised immune systems are 79% more at risk of being infected by
the Corona virus, becoming critically ill and dying due to
COVID-19. Further, for a person with any of the two above
health problems, the risk of the above outcomes is more
than double - 2.5 times in comparison to the general
J
K
population.
16.03.2020- That in this period 180 gas victims were admitted in different
wards including Munni Bee, Petitioner No. 1. 20.03.2020
23.03.2020 Department of Public Health and Family Welfare, Madhya
Pradesh Govt. issued an order to turn Bhopal Memorial
Hospital & Research Centre (BMHRC), super specialty
hospital into a hospital for treatment of COVID-19 patients,
exclusively.
24.03.2020 Director, BMHRC issued an order to all staff stating “health
care services will be provided now only for COVID-19
patients at BMHRC, Bhopal. All other health care services to
be stopped with immediate effect till further orders.”
24.03.2020 BMHRC started discharging all the patients with history of
acute exposure to Union Carbide’s poisonous gas from the
Intensive Care, Surgical and Medical wards in the hospital.
24.03.2020 All Emergency Services of the Casualty Ward of BMHRC
were closed.
K
L
24.3.2020 BMHRC issued a notification on the Constitution of a
Committee to prepare a Protocol for Disinfection &
Management for COVID-19 patients (quote exact title).
Doctors, Nurses and other Paramedical and Technical staff
have been divided into 9 Committees who have been asked
to prepare protocols for management of all COVID-19
patients.
25.03.2020 That, the entire Outpatient Department of BMHRC was
closed. BMHRC had recorded OPD registration of more than
5000 patients during the seven day period between March
16th-21st, 2020.
25.03.2020 That, all emergency dialysis facilities have been stopped
since March 25, 2020.
That, Coordinator, Health Services,BMHRC issued a circular 25.03.2020 to the effect:
“One Health Centre to be operational every day and the
same team of two Senior Medical Officers, one nurse, two pharmacists, two computer operators to move from one
health centre to the other.”
The BMHRC are now pressuring Munni Bee’s family to take
L
M her back home and off the ventilator to make the bed available for potential coronavirus patients. Many other
Bhopal victims’s health status is deteriorating due to the
BMHRC being requisitioned. In addition, they are much more likely to contract and die from COVID-19 unless they are adequately treated, indeed international medical experts have described the reduced immunity of Bhopal gas victims as “chemically induced AIDS”.
Hence, the present writ petition.
M
1
IN THE SUPREME COURT OF INDIA
CIVIL ORIGINAL JURISDICTION
WRIT PETITION (CIVIL) NO. ______OF 2020
[Under Article 32 of the Constitution of India]
IN THE MATTER OF:
1. Munni Bee W/o: Abdul Salam 68 years, H. No. 397, Near Old Naka Nala, North Area Congress Nagar, Bhopal, Tehsil Huzur Madhya Pradesh-462001 …Petitioner No 1
2. Bhopal Group for Information and Action Through its Member, Ms. RachnaDhingra D/o: MeeraKhubchandani 42 Years, 44 SantKanwar Ram Nagar Bersia Road Bhopal, Madhya Pradesh-462001 …Petitioner No.2
VERSUS
1. Union of India Through Secretary, Ministry of Law ShastriBhavan Rajendra Prasad Road New Delhi-110001 …Respondent No.1
2
2. State of Madhya Pradesh, Through its Principal Secretary, Health Department Bhopal Madhya Pradesh- 462004 ….Respondent No.2
3. Bhopal Memorial Hospital and Research Centre Through Its Director, Raisen Rd, BMHRC Campus, Karond, Bhopal, Madhya Pradesh 462038 ….Respondent No.3
A WRIT PETITION UNDER ARTICLE 32, 21 and 14 OF THE CONSTITUTION OF INDIA PRAYING INTER ALIA FOR THE ISSUANCE OF APPROPRIATE WRIT/ORDER OR DIRECTION THAT BHOPAL MEMORIAL HOSPITAL AND RESEARCH CENTRE RESUME IMMEDIATELY AND PRIORITISE AT THE FIRST INSTANCE TO SURVIVORS OF BHOPAL GAS TRAGEDY INCUDING FOR COVID-19
TO
THE HON’BLE THE CHIEF JUSTICE OF INDIA AND HIS HON’BLE COMPANION JUSTICES
OF THE SUPREME COURT OF INDIA
THE HUMBLE PETITION OF THE PETITIONER ABOVENAMED
MOST RESPECTFULLY SUBMITS AS UNDER:
1. The Petitioners herein have been constrained to invoke the Writ
Jurisdiction of this Hon’ble Court under Article 32 of the Constitution of 3
India in order to protect their fundamental rights, specifically those
enshrined in Articles 14 and 21 of the Constitution of India.
1A. That the present Petition concerns diversion and interruption of the
Bhopal Memorial Health and Research Centre (BMHRC) contrary to
the terms of its Trust Deed set up under orders of this Hon’ble Court
passed between from 1991- 1998 annexed herein below. That further
the Bhopal Group for Information and Action, Petitioner No. 2 herein
has approached this Hon’ble Court in a number of cases w.r.t. the
health care and Right to life of Bhopal’s gas victims. On the plea of
Petitioner No. 2 in Writ Petition 50 Of 1998, this Hon’ble Court was
pleased to pass strong orders strengthening the functioning of the
Bhopal Memorial Health and Research Centre (BMHRC); In Writ
Petition 33 of 2012, this Hon’ble Court was pleased to pass orders
regarding clinical trials conducted on Bhopal Gas victims inter alia in
the BMHRC; In Writ Petition 657 OF 1995 this Hon’ble Court has been
pleased to pass orders to bring safe water to Bhopal’s gas survivors
who are being forced to drink water laced with toxic waste dumped by
Union Carbide. As such the present Petitioners seek to approach this
Hon’ble Court directly for emergency directions.
2. That the Petitioners herein seek to challenge the order dated 23.03.2020
of the Department of Public Health and Family Welfare, Government of
the State of Madhya Pradesh whereby decision was taken to convert the
Bhopal Memorial Hospital & Research Centre (BMHRC), super specialty 4
hospital into a hospital for exclusive treatment of COVID-19 patients
thereby shutting all of its other medical services and treatment for the
victims of the Bhopal Gas disaster.
3. That, the Dept. of Public Health and Family Welfare, Madhya Pradesh
Govt. issued an order on 23rd March, 2020, to convert the Bhopal
Memorial Hospital & Research Centre (BMHRC), super specialty
hospital into a hospital for exclusive treatment of COVID-19 patients.
The same was carried out under S.52 of the MP Public Health Act, 1949.
A true copy of the order dated.23.03.2020 passed by Dept. of Health
and Family Welfare, Government of M.P is annexed hereto and marked
as Annexure P-1. (Page Nos. 27-29)
4. That the Petitioners, inter alia, have also challenged order
dated.24.3.2020 passed by Director, BMHRC, whereby direction was
issued to all its staff stating: “health care services will be provided now
only for COV-19 patients at BMHRC, Bhopal. All other health care
services to be stopped with immediate effect till further orders.” A true
copy of the order dated.24.03.2020 passed by Director, BMHRC, is
annexed hereto and marked as Annexure P-2. (Page No. 30)
5. That as an effect of the said order, the medical care and treatment of the
victims of the Bhopal Gas Tragedy despite the emergency status on
many, has been severely compromised and even extremely serious
patients have been forcibly discharged from the hospital. Medical advice 5
regarding Munni Bee is that she is improving and moving her to another
hospital would jeopardize her treatment.
6. That the Petitioners have also sought directions from this Hon’ble Court
in directing the Respondent No.3 to restart and reopen all Emergency
Services of its Casualty Ward.
7. That the petitioners have further sought directions of this Hon’ble Court
in directing the Respondent No.3 to reopen and resume all its OPD and
Dialysis facilities, which have been stopped since March 25, 2020.
8. That the Petitioner No.1 is a 68-year old woman who belongs to very
poor socio economic background. That she is presently on a Ventilator
in the ICU at BMHRC, Bhopal. That she has been in the ICU for the last
24 days after a myocardial infarction (heart attack), she has also
suffered a stroke in the past, and has diabetes and hypertension, the
diseases which have now become a characteristic feature of those
exposed to Union Carbide’s poisonous gas.
9. It is also pertinent to mention that on 11.03.2020, Petitioner No.1
underwent a tracheostomy in ICU and since then has been in the
General ICU under critical medical care, she is breathing with support of
a ventilator. However, the Respondent No.3 is now asking her family to
take her back home to make the bed available for potential coronavirus
patients. That it is most relevant to state that, if she is forced out from
the Hospital, then, she would not have any means or resources to afford 6
private medical care and treatment. A true copy of the medical report of
the Petitioner No.1 is annexed hereto and marked as Annexure P-3.
(Page Nos. 31-34)
FACTS OF THE CASE:
10. The brief facts that led to the filing of the present petition are as under:
(a) That, on October 3, 1991 as part of the settlement pursuant to the
Union Carbide gas disaster, this Hon’ble Court had directed the
Union Carbide Corporation to build a 500 - bed hospital with the best
services and equipment for treatment of the victims of MIC (Methyl
Isocyanate – the poisonous gas that leaked from Union Carbide’s
factory) related affliction. The provision of medical surveillance and
expert medical treatment were also ordered. Further, it was also
directed that the said hospital would be a Specialist Hospital for
treatment and research of MIC related afflictions and for medical
surveillance of the exposed population. This is required as these
diseases and their epidemiology wreak unique morbidity on their
survivors and other hospitals are unable to deal with such patients in
a medically informed manner.
A true copy of the order dated 03.10.1991 passed by the Hon’ble
Supreme Court is annexed hereto and marked as Annexure P-4.
(Page Nos. 35-36)
7
(b) That in pursuance of the said order, Union Carbide Corporation, on
March 20, 1992, established a charitable trust called “The Bhopal
Hospital Trust”.
(c) That, later, in its order dated 14 February 1994, the Hon’ble
Supreme Court directed inter-alia that the Government of India shall
constitute an appropriate committee to take steps for the planning,
construction, equipping and commissioning of the Hospital, for the
treatment of Bhopal gas victims
A true copy of the order dated.14.2.1994 passed by the Hon’ble
Supreme Court is annexed hereto and marked as Annexure P-5.
(Page Nos. 37-41)
(d) That, in accordance with the orders passed from time to time by this
Hon’ble Court, the Bhopal Memorial Hospital Trust was finally set up
on 11 August 1998.
A true copy of the “Bhopal Memorial Hospital Trust” deed
dated.11.08.1998 is annexed hereto and marked as Annexure P-6.
(Page Nos. 42-57)
(e) That it is pertinent to mention that the main objective of the Trust
was, “(i) The construction, staffing, equipping, management,
operation and maintenance of the Hospital and the provision therein
of medical and other appropriate facilities (including facilities for
medical surveillance by periodic medical checkups) for the benefit in
the first instance of the victims of the Bhopal Gas Tragedy of 1984 8
and their dependents, and subject thereto for the people of Bhopal
and the public at large.”
AFTERMATH OF THE DISASTER AND CONTINUING NEED FOR
TREATMENT
(f) That, the large number of studies published in national and
international scientific journals and official records of government run
hospitals in the last three and half decades have documented that
long term health damage has been caused to 5,74,375 individuals
as a result of their exposure to Methyl isocyanate, the damage to
many is extreme.
(g) That, “Safety Consideration Report” for the Methyl Isocyanate (MIC)
Unit prepared by the Union Carbide Corporation, gave MIC the most
dangerous rating of 5 which means that “major residual injury is likely
despite prompt treatment due to the other exposure routes viz.
“breathing”.
“Breathing-Methyl isocyanate is a recognised poison by inhalation
and is intensely irritating to breathe. It causes severe broncho-spasm
and asthma-like breathing. Major residual injury is likely in spite of
prompt treatment. Avoid breathing vapors of methyl-isocyanate.”
A true copy of the “Safety Consideration Report” prepared by UCC
is annexed hereto and marked as Annexure P-7. (Page Nos. 58-62)
9
(h) That, the Agency for Toxic Substances and Disease Registry
(ATSDR), is a federal public health agency of the U.S. Department
of Health and Human Services. It is concerned with the effects of
hazardous substances on human health. The ATSDR on Methyl
Isocyanate (MIC) states that Acute exposure to higher vapor
concentrations may cause severe pulmonary edema and injury to the
alveolar walls of the lung and death.
(i) That children may be more vulnerable to corrosive agents than adults
because of the smaller diameter of their airways. Survivors of acute
exposures may exhibit long-term respiratory and ocular effects.
Genotoxicity testing in animals indicates that methyl isocyanate may
have the capacity to affect chromosome structure. The exposure to
MIC in Bhopal was acute in nature and there is enough evidence to
suggest that exposure to it can cause death and long term
permanent injury. A true copy of the ATSDR, U.S Dept. of Health
dated April 2002, report is annexed hereto and marked as Annexure
P-8. (Page Nos. 63-80)
(j) That, the epidemiological research by the ICMR indicates that the
rate of illness in the affected areas is 2.5 times higher than the
unaffected areas and that 95% of the affected population- 5,74,375
persons who were near the Carbide factory site the night of the gas
leak is suffering from some physical or mental illness.
10
(k) That, as per the 2010 action plan of Department of Bhopal Gas
Tragedy Relief & Rehabilitation, the number of gas victims with
exposure induced chronic respiratory disorders alone is 100,000.
Also, 25-30% of the survivors have neurological & mental illnesses
as a consequence of the disaster. Even 23 years after the disaster,
incidence of Lung, Eye, Gastrointestinal and general morbidities was
4 to 5 times higher than a matched unexposed population. A true
copy of the 2010 action plan prepared by the Department of Bhopal
gas Tragedy Relief & Rehabilitation is annexed hereto and marked
as Annexure P-9. (Page Nos. 81-119)
(l) That, the toxic exposure has damaged the immune systems of such
a large population in Bhopal that the situation was described as
chemically induced AIDS by a medical researcher. A true copy of an
article written by Polly Ghazi (medical researcher) dated Nil is
annexed hereto and marked as Annexure P-10. (Page No. 120)
(m)That, in view of the reasons above stated from Para (a) to (l), it is a
fact that multi systemic damage is one of the characteristic features
of the health impact of the gas disaster in Bhopal upon the victims
thereof.
VICTIMS VULNERABILITY TO THE (CORONA) VIRUS
(n) That, in the first and largest study conducted by First Affiliated
Hospital of Guangzhou Medical University, titled “Comorbidity and its 11
impact on 1,590 patients with COVID-19 in China: A Nationwide
Analysis”, it was revealed that people with any Cardio- vascular and
Pulmonary problems, Diabetes, Cancers and most importantly
compromised immune systems are 79% more at risk of being
infected by the Corona virus, becoming critically ill and dying due to
COVID-19. Further, for a person with any of the two above health
problems, the risk of the above outcomes is 2.5 times in comparison
to the general population. A true copy of the research study titled:
“Comorbidity and its impact on 1,590 patients with COVID-19 in
China: A Nationwide Analysis” published by Guangzhou Medical
University is dated Feb 27, 2020 and annexed hereto and marked as
Annexure P-11. (Page Nos. 121-162)
(o) That, the data gathered from 8 community health units of the ICMR
run Bhopal Memorial Hospital & Research Centre (BMHRC) in
Bhopal from 1998 to 2016, which is available on their official website
(www.bmhrc.org on 21/01/2020), shows that 50.4% of gas affected
patients suffer from Cardiovascular problems, 59.6% of them suffer
from Pulmonary problems and 15.6% of them suffer from Diabetes.
A true copy of the table containing the data of various diseases
suffered by gas affected patients is annexed hereto and marked as
Annexure P-12. (Page Nos. 163-165)
(p) That, as per the records of the Office of the Welfare Commissioner,
Bhopal Gas Victims, 10,550 (1.84% of the gas exposed population) 12
have been granted ex gratia compensation as Cancer patients. A
true copy of the data extract from the office of the Welfare
Commissioner is annexed hereto and marked as Annexure P-13.
(Page No. 166)
(q) That, on 21st March, 2020 the representatives of the 4 organizations
working with the survivors of the Union Carbide Disaster wrote to all
concerned officials of the state and central government regarding
vulnerability of Bhopal gas victims in contracting COVID-19. The
people exposed to Union Carbide’s gases are at least 5 times more
vulnerable to COVID-19 than a general population and many will die
if urgent attention is not paid towards their medical care. A true copy
of the letters written to Central and State Government of M.P is
annexed hereto and marked as Annexure P-14. (Page Nos. 167-
175)
(r) That, the people exposed to Union Carbide’s gases are at least 5
times more vulnerable to COVID-19 than a general population and
many will die if urgent attention is not paid towards their medical care.
GOVERNMENT MIS (ACTION)
(s) That, the Dept. of Public Health and Family Welfare, Madhya
Pradesh Govt. issued an order on 23rd March, 2020, to convert the
Bhopal Memorial Hospital & Research Centre (BMHRC), super
specialty hospital into a hospital for exclusive treatment of COVID- 13
19 patients. The same was carried out under S.52 of the MP Public
Health Act, 1949.
(t) Also, as per the provisions of MP Disease COVID-19 Regulation,
2020 in Point 3 & 4:
3. “Authorised persons under this Act are Principal Secretary
(Health & Family Welfare) at the State Level, District Magistrate,
Commissioner of Municipal Corporation, Sub Divisional
Magistrate (SDM), Chief Medical & Health officer and Civil
Surgeon cum Hospital Superintendent in the districts.”
4. “Staff of all Government Department and Organization of
the concerned area will be at the disposal of the District
magistrate, Sub Divisional Magistrate (SDM) and officers
authorized by the Department of Public health & family welfare,
for discharging the duty of containment measures in the districts.
If required, District Magistrate may order requisition of services
and facilities of any other person/institution. “
(u) On March 24, 2020, Director, BMHRC, issued an order to all its staff
stating “health care services will be provided now only for COV-19
patients at BMHRC, Bhopal. All other health care services to be
stopped with immediate effect till further orders.”
14
(v) That, on March 24, 2020 BMHRC started discharging all the patients
including those with previous history of acute exposure to Union
Carbide’s poisonous gas, from the Intensive Care, Surgical and
Medical wards in the hospital.
(w) The following Table summarizes the total number of discharges
made by the Respondent No.3 on March 24, 2020 from 8 AM to 5
PM:
No of Date of Still in Ward Name patients Remark Discharge Hospital discharged Gastro-medicine 4 March 24, 2020 March 24, 3 1 3 patients had Cardio Thoracic 2020 undergone Vascular Surgery Thoracic (CTVS) surgery 2 days before CTVS -ICU 1 March 24, 2020 Cardiac Care March 24, 5 Family Unit (CCU) 2020 members of all 5 patients, including 3 on Ventilator support, were pressured to take patients home or to shift them somewhere else Gastro Surgery 10 24 March Post-operative 2020 surgeries 15
Urology 24 March 7 1 Tremendous 2020 pressure on the patient who was operated on 24th March to leave the hospital Pulmonary March 24, 28 Some of these 2020 patients were in very serious condition. 2 of them were sent to Hamidia hospital where the staff asked the family members to take the patient home due to COVID-19 scare Nephrology 1 24 March, 2020 Neurology 2 24 March
2020 Neurosurgery March 24 11 4 had been 2020 operated, 7 were supposed to undergo surgery in next few days Psychiatry 15 March 24, 2020 Ophthalmology 6 March 24, 2020
TOTAL 86 8 16
(x) That, effectively from the midnight of March 24, 2020, all Emergency
Services of the casualty ward of BMHRC have been closed.
However, it is relevant to point out that the records of the BMHRC
show that 60 to 70 gas victims in need of Emergency services such
as Nebulization and Oxygen support, defibrillation for cardiac arrests,
uncontrolled Blood Pressure & Diabetes are being daily registered at
the casualty ward.
(y) That, on March 24, 2020 BMHRC issued a notification on the
Constitution of a Committee to prepare a Protocol for Disinfection &
Management for COVID-19 patients. Doctors, Nurses and other
Paramedical and Technical staff have been classified into 9
Committees who have been tasked to prepare protocols for
management of all COVID-19 patients irrespective of whether they
were victims of the Union Carbide Disaster or not. A true copy of the
notification dated 24.03.2020 by BMHRC is annexed hereto and
marked as Annexure P-15. (Page Nos. 176-178)
(z) That, on March 25, 2020, entire Outpatient services of BMHRC have
been closed. BMHRC recorded OPD of upwards of 5000 patients for
the duration of March 16 – 21, 2020.
17
(aa) That, 180 gas victims were admitted during the six day period
between 16.03.2020 and 21.3.2020 in different wards of the
Respondent No.3 hospital.
(bb) That during the said period, a number of surgical procedures were
conducted in the hospital in its different departments as follows:
S No. Department No. of Surgical
procedures
1. Cardiology 48
2. Neurosurgery 7
3. Urology 12
4. Gastrosurgery 7
5. Ophthalmology 27
(cc) That, all the Dialysis facilities have been stopped from March 25,
2020. There are about 30 gas victims who undergo dialysis twice a
week at the hospital, whose lives, without timely and quality dialysis,
are in perennial danger. That, more than 40 gas victims who have
undergone kidney transplant require life-saving drugs and
appropriate medicines from the hospital.
(dd) That, hundreds of thousands of gas victims are being denied their
regular supply of life saving medicines for serious ailments like 18
Chronic Obstructive Pulmonary Disease, Diabetes, Hypertension,
Renal Failure, Coronary Heart Disease, Stroke etc.
(ee) That, in addition to the main hospital, BMHRC also has 8
community mini units situated in different parts of the gas affected
area. All these units play a crucial role in supplying medicines,
carrying out pathological & other crucial investigations. All these 8
units, when taken together, see a total footfall of 500-600 gas victims
per day in their Out Patient Departments.
(ff) That, on March 25, 2020, Coordinator, Health Services, BMHRC
issued a circular to the effect that:
“One Health Centre to be operational every day. The same
team of two Senior Medical Officers, one nurse, two pharmacists,
two computer operators to move from one health centre to the
another.”
A true copy of the circular dated.25.03.2020 issued by Coordinator,
Health Service is annexed hereto and marked as Annexure P-16.
(Page Nos. 179-180)
(gg) That, due to the closure of OPD in the main hospital and also in
the mini units, there will be a surge of survivors who will show up at
mini units thereby making it impossible for the already low staff to 19
manage the crowd and to provide treatment and medicines to the
gas victims, in such a situation.
(hh) That, gas victims are panicking as the Outpatient & Inpatient
services, Casualty services and daily OPD in the main hospital as
well as in the mini units (which are only opened for a day in the whole
week) have been shut down only for the purpose of accommodating
a 7 bed isolation centre for COVID-19 patients at BMHRC. A true
copy of the article dated.25.03.2020 published in “The Hindu” is
annexed hereto and marked as Annexure P-17. (Page Nos. 181-
182)
(ii) That, the “Corona Action Plan of Bhopal, MP” issued by the Govt. of
Madhya Pradesh has designated the following places as Isolation
Centres.
AIIMS Bhopal 6 bed
Hamidiya Hospital 6 Bed
BMHRC Hospital 7 bed (TBC)
A true copy of the “Corona Action Plan of Bhopal, MP” formulated by
the Govt. of Madhya Pradesh is annexed hereto and marked as
Annexure P-18. (Page Nos. 183-184)
20
(jj) That, it is unclear why the only super-specialty hospital set up for and
with the ability to treat Bhopal gas victims should be identified as one
exclusively for COVID-19 patients. If the entire BHMRC hospital is
being closed down, it will affect more than half a million of the most
vulnerable population of the city.
(kk) That it is also pertinent to mention that the Respondent No.2, in
furtherance of its earlier impugned order dated.23.03.2020, has now,
on dated.28.03.2020, taken over the management and
administration of the Respondent No.3 and has vested the same in
the concerned District Magistrate.
(ll) That, the petitioners herein, humbly submit that it is of the utmost
urgency that this Hon’ble Court to take cognizance of the magnitude
and complexity of the health condition of the Bhopal gas victims,
during the present times, for whom this Hon’ble Court has accorded
their right to adequate and proper healthcare, a status of the
constitutional Right to life (in WP 50/98).
MEASURES TO ADOPT
(mm) That, a system needs to be put in place for community
surveillance, identification & testing of gas victims for COVID-19
disease. That, ambulances need to be allocated in every gas relief
hospital to transport critical cases affected by COVID-19 patients.
21
(nn) That, a comprehensive system for community education with the
help of community health worker and social workers needs to be
immediately introduced in the gas affected communities to educate
& spread awareness on COVID-19.
(oo) That, a system for caring of critical cases needs to be, forthwith,
put in place by setting up of a transitory arrangement consisting of
one hospital with ICU, isolation wards, ventilators, with adequate
supply of relevant medicines & consumables such as oxygen &
Personal Protection Equipment (PPE) for doctors & nurses to take
proper care of gas victims suffering from COVID-19.
(pp) That, the 50 bed Pulmonary Medicine Centre, gas relief hospital
situated in Jahangirabad could be used for the purpose of isolating
the patients of Covid-19 – with priority to gas relief patients- as the
same is well-equipped and near-by located and therefore is best-
suited for the said purpose.
11. Petitioners pray that this Hon’ble Court may intervene and protect the
fundamental rights of the Bhopal gas disaster survivors as enshrined
under Articles 14 and 21 of the Constitution of India.
12. GROUNDS
22
(A) BECAUSE the terms of the Trust Deed under which the Bhopal
Memorial Hospital and Research Centre operates are clear, so are
the orders of this Hon’ble Court dated 1992-1998 which directed the
said Hospital to be set up as part of the purported settlement of Union
Carbide w.r.t the Bhopal victims: A super specialty hospital was
required as diseases emerging from inhalation of MIC and their
epidemiology wreak unique morbidity on victims. Other hospitals are
unable to deal with such patients in as medically informed a manner.
That the Trust Deed requires Bhopal victims to be medically treated
“at the first instance” at BMHRC.
(B) BECAUSE the vulnerability of the Bhopal Gas survivors to CoVID-19
is far greater than that of the rest of the population and therefore it is
necessary to extend the medical services required by them, rather
than limiting the same by passing such stringent orders and
directives, as aforestated.
(C) BECAUSE the proposal of an isolation centre to be set up for
treatment of the CoVID-19 patients by shutting down the entire
hospital to Bhopal gas victims in need of Intensive and urgent care is
arbitrary and unreasonable as the BMHRC hospital has total capacity
of 350 beds. That it is also pertinent to mention that other hospitals
such as the Pulmonary Medicine Centre, Gas Relief Hospital, located
in near-by Jahangirabad, could be used for the purpose of isolating 23
the patients of Covid-19 as the same is proximate and well-equipped
and therefore is best-suited for the said purpose.
(D) BECAUSE the right to life and health of the survivors of the Bhopal
Gas disaster has already been sacrificed to a great degree to the
corporate malfeasance and state apathy. The proposed measures
will only further contribute to their misery by making their health
deteriorate in the absence of medical care and treatment from the
hospital which alone has the capability of addressing their specific
healthcare requirements. Such a deprivation of their medical needs
and treatment will be in direct conflict with their right to life and health
under Article 21 of the constitution of India, thereby warranting the
intervention of this Hon’ble Court.
(E) BECAUSE the order dated.23.03.2020 passed by the Respondent
No.2, whereby decision was taken to convert its Bhopal Memorial
Hospital & Research Centre (BMHRC), super specialty hospital into
a hospital for exclusive treatment of COVID-19 patients has in effect
infringed and violated the right to substantive equality under Article
14 of the Constitution, of the Bhopal Gas survivors by shutting down
all of the medical services and treatment as required by them due to
their peculiar condition. It is humbly submitted that it amounts to
treating unequals as equals.
(F) BECAUSE the order dated.24.3.2020 passed by the Respondent
No.3, whereby it was directed that all the health care services and 24
facilities will now be provided only for CoVID-19 patients at BMHRC,
Bhopal and that all other health care services to be stopped with
immediate effect till further orders, is violative of Article 14 and 21 of
the constitution. That as a result of this order, the survivors, most of
whom were already struggling for their lives due to the ghastly effect
of the disaster, are left in lurch without any medical treatment and
support, thereby violating their right to life under Article 21 of the
Constitution of India. It is respectfully submitted that it that it amounts
to treating dissimilarly situated people as similar, thereby also
violating Article 14 of the Constitution.
(G) The Petitioners crave leave of this Hon’ble Court to add to, alter,
amend and/or modify any of the grounds aforestated.
(H) That no identical or similar Petition has been filed by the petitioners
before this Hon’ble Court or any High Court. The Petitioner states
that the present petition is being filed bonafide and in the interests of
justice.
PRAYER
It is therefore most respectfully prayed that this Hon’ble Court be
pleased to issue:
a) A Writ in the nature of certiorari quashing the order dated 23.03.2020 passed by the Respondent No.2as being violative of Articles 14 and 21 of the Constitution of India and,
25
b) A Writ in the nature of certiorari quashing order dated 24.3.2020 passed by the Respondent No.3 as being violative of Articles 14 and 21 of the Constitution of India and,
c) A Writ in the nature of mandamus directing the Respondents to shift the isolation centre for Covid-19 patients to the Pulmonary Medicine Centre, Gas Relief Hospital, Jehangirabad and/or any other appropriate hospital and,
d) A Writ in the nature of mandamus directing the Respondents to develop and update clinical protocols with particular regard to victims of the Bhopal gas disaster for COVID-19 related morbidity for treatment in other hospitals with isolation facilities;
e) And pass such other order or orders as this Hon’ble Court may deem fit in the facts and circumstances of the case.
AND FOR THIS ACT OF KINDNESS THE PETITIONER AS IN DUTY BOUND
SHALL EVER PRAY
DRAFTED BY:
Karuna Nundy, Advocate
Abhay Chitravanshi, Advocate
Filed on: 01.04.2020 FILED BY
Place: New Delhi
(APARNA BHAT)
ADVOCATE ON RECORD FOR THE PETITIONERS
26
Annexure P-1 27 28
Dept of Health & Family Welfare Govt of Madhya Pradesh Mantralaya, Vallabh Bhawan, Bhopal
No/IDSP/2020/270 Bhopal, Date: 23/3/2020
Order
COVID-19 (Novel Corona Virus) Disease has been declared infectious diseases
under Section 51 of MP Public health Act, 1949.
As per the Provisions of “The Madhya Pradesh Disease COVID-19 Regulation,
2020” for prevention of Novel Corona Virus diseaase, Point No. 3 and 4 states:-
3. “Authorised person under this Act are Principal Secretary (Health & Family
Welfare) at the State Level, District Magistrate, Commissioner of Municipal
Corporation, Sub Divisional Magistrate (SDM), Chief Medical and Health officer and Civil Surgeon cum Hospital Superintendent in the districts.”
4. “Staff of all Government Departments and Organisation of the concerned area will be at the disposal of the District Magistrate, Sub Divisional Magistrate (SDM), and officers authorised by the Department of Public Health and Family welfare, for discharging the duty of containment measures in the districts. If required
District Magistrate may order requisitionof services and faciliteis of any other person/institution.”
Bhopal Memorial Hospital & Research Center is an established Super Speciality
Hopsital. As per the above provisions. Under the above act, the said insitution 29 has been identified as a treatment centre in public interest at the state level for
COVID-19 Disease. This hospital will only treat COVID-19 patients.
Above order to be brought in effect with immediate effect.
Signature Pallavi Jain Govil Principal Secretary, Govt of Madhya Pradesh Dept of Public Health & Family Welfare Bhopal, MP Annexure P-2 30 Annexure P-3 31 32 33
BHOPAL MEMORIAL HOSPITAL & RESEARCH CENTRE DEPARTMENT OF HEALTH RESEARCH, MINISTRY OF HEALTH & FAMILY WELFARE, GOVERNMENT OF INDIA Raisen By Pass Road, Bhopal, 462038 (MP) Tel: 0755-2742212-16, Fax: +91-755 2748309, Website: www.bmhrc.org
Name: Munni Age: 61 Sex: F DOA: 17/2/2020 DOD: Address: Mangalwara, Bhopal Diagnosis: CVA C/o HTN & DM-2, CAD/LRTI
Chief C/o: Patient presented C/o Cervical Radiocuolopathy on 17/02/2020. HTN/DM-2. On 3/3/2020 patient went unresponsive & gasping. Urgen ICU call done-Intubated. Cardiology call done. S/O NSTEMI (Non ST elevated Myocardial Infraction) . At present GCS E Em V1- MB H/o Present Illness: following verbal conversations. Tracheostomy done on 13/02/2020
Clinical Features: P-108 /mt BP: 150/54 /fg mm of HG Pallor: + JVP Cyanosis Ogy Clubbing Icterus : - R/S: B/2 AE + P/A: Soft CVS: S1, S2 CNS: GCS-E4 VT MH Course during stay
Homage & Hope- In the Services of Bhopal Gas Victims 34
Investigations: Pleural Fluid Collected: Hb: 10.4 Pus Cells- 0-1/H/F WBC: 8300 RBC-0-1/O/F Plt: 2.39 No organism seen Urea: 118 AFB-no AFB Creatnine: 1.06 Gram Stain-No org seen Na-B1 CN NAAT-MTB not detected K-4.25
ECHO 5/3/2020: NAC
16/3/2020 PML: Calcified and restricted Blood: C/S: Sterile LA dialted BAC: Acute Bacterial Species Mild R/M Urine: C/S-Candida Species LVEF 60%
NEET Brain: 26/02/2020: Area of encepholomalacio with gliosis and occipital lobe, likely to be sequele of Old CVA.
Advice : Current Medication Patient is being refered for Inj Colistin critical care management Inj Tiegecycline Inj Pantop Inj Mexturd Inj Lasix Inj Albumium TabClopitab Tab Howas Tab Mucomix Tab Deriphyline Syp Lactulose
Signature Doctor Incharge
Homage & Hope- In the Services of Bhopal Gas Victims SCC Online Web Edition, Copyright © 2020 Page 1 Tuesday, March 31, 2020 Printed For: Ms. Karuna Nundy Annexure P-4 35 SCC Online Web Edition: http://www.scconline.com
------SCC Online Web Edition, Copyright © 2020 Page 2 Tuesday, March 31, 2020 Printed For: Ms. Karuna Nundy 36 SCC Online Web Edition: http://www.scconline.com
------SCC Online Web Edition, Copyright © 2020 Page 1 Tuesday, March 31, 2020 Printed For: Ms. Karuna Nundy Annexure P-5 37 SCC Online Web Edition: http://www.scconline.com TruePrint™ source: Supreme Court Cases ------SCC Online Web Edition, Copyright © 2020 Page 2 Tuesday, March 31, 2020 Printed For: Ms. Karuna Nundy 38 SCC Online Web Edition: http://www.scconline.com TruePrint™ source: Supreme Court Cases ------SCC Online Web Edition, Copyright © 2020 Page 3 Tuesday, March 31, 2020 Printed For: Ms. Karuna Nundy 39 SCC Online Web Edition: http://www.scconline.com TruePrint™ source: Supreme Court Cases ------SCC Online Web Edition, Copyright © 2020 Page 4 Tuesday, March 31, 2020 Printed For: Ms. Karuna Nundy 40 SCC Online Web Edition: http://www.scconline.com TruePrint™ source: Supreme Court Cases ------SCC Online Web Edition, Copyright © 2020 Page 5 Tuesday, March 31, 2020 Printed For: Ms. Karuna Nundy 41 SCC Online Web Edition: http://www.scconline.com TruePrint™ source: Supreme Court Cases ------Annexure P-6 42
BHOPAL MEMORIAL HOSPITAL TRUST
TRUST DEED
THIS DEED OF TRUST is made at New Delhi on this The 11th Day of August 1998 by
1.Shri Dipak Chatterjee, Secretary,Dcpartment of Chemicals & PetrochemicaIs, New Delhi (Chairman, Empowered Committee).
2.Shri K.S. Sharma, Chief Secretary, Government of Madhya Pradesh, Vallabh Bhavan, . Bhopal. 3. Dr. S. P. Aggarwal, Director Gencra1, Health Services, Ministry of Health & Family Welfare, Nirman Bhavan, New Dclhi. 4. Dr.B. K. Sharma, Director, Postgraduate Institute of Medical Education and research , Chandigarh. . . 5. Dr. J. N. Pande, Professor & Head, Dcpartment of Mcdicine, All India Institute of Medical Sciences, Ansari Nagar. New De!hi. 6. Shri Shantanu Consul, Joint Secretary , Department of Chemicals & Petrochemicals, Shastri Bhavan, New Delhi.
7. Smt.Renu Sahni Dhar , Joint Secretary, Ministry of health & Family Welfare, Nirman Bhavan, New Dclhi.
8. Shri S. Kabilan , Joint Secretary & Financial Adviser, Ministry of Chemicals &. Fertilizcrs, Shastri Bhavan, New Delhi.
9. Shri D. P. Sharma, Joint Secretary & Legal Adviser, Department of Legal Affairs, Shastri Bhavan. New Dclhi. 10. Dr. Bela Shah, Deputy Director General , Indian Council of Medical Research , Ansari Nagar Post Box 4508, New Dclhi. 11 . Dr. Bhagirath Prasasd , Secretary , Government of Madhya Pradesh, Bhopal Gas Tragedy & Relief & Rehabilitation Department, Valabh Bhavan, Bhopal.
the members of the Empowered Committee, constituted in accordance with the orders of the Hon’ble` Supreme Court of India dated 14 February’ 94, and Government of India’s order No.21/2O/94 Ch.I.B dated 12th August, 1994 and 18th April, 1996; and Mr Robert Eldon Percival, Barrister-at law, Bhopal Hospital Trust, 5, Paper Buildings , Temple, London, EC4Y 7HB and Mr. Edward Geroge Nugee, QC, Wilberforce Chambers, 8, New Square, Lincolin’s Inn, London WC2A 3QP, England, the two Trustees of the Bhopal Hospital t,rust, London (BHT) hereinafter called “the Settlors”, in pursuance of the Supreme Court order dated I5th May, 1998.
Recitals 43
WHEREAS
As a result of the Bhopal Gas Tragedy of 1984 where in thousands of people were affected by the leakage of toxic gas from the plant of Union Carbide India Limited (UCIL) in Bhopal in the State of Madhya Pradesh , India , the Supreme Court of India In its Judgement delivered on 3rd October 1991 in Civil AppeaI Number 3187-88 of 1988 in the matter of Union Carbide Corporation (UCC) -V –Union of India concluded, found and directed that on humanitarian considerations and in fulfillment of an offer made earlier (which the Supreme Court hoped and trusted they would abide by) the UCC and UCIL should agree to bear the financial burden for the establishment and equipment of a hospital, and its oprationa1 expenses for a period of 8 years and further concluded, found and directed that the State Government should provide suitable land free of cost for the hospital facilities. . . .
(2) By a Trust Deed dated 20th March 1992 (hereinafter called “the Original Trust Deed) made between Union Carbide Corporation (hereinafler called “UCC”) of the first part, Union Carbide Chemicals and Plastics Company Inc.(UCCP) of the second part and Late Sir Ian Percival, of the third part, UCC established a charitable trust called “The Bhopal Hospital Trust”, for the purpose of providing (inter-alia), the Government of India up to Rs. 51 crores for a hospital to be built and operated by the Government of India in Bhopal and operating the said hospital in pursuance of the above judgement and paid to the Sole Tustee, a sum of Pound 1000/-(one thousand Pound Sterling only) to be held by him as Sole trustee of the Bhopal Hospital Trust upon the trusts of the Original trust Deed and provided that by a security Agreement UCCP under directions of UCC would charge 16,585,000 Ordinary Shares of Rs 10/- each in UCIL with the payment to the Sole Trustee as Trustee of the Trust thereby constituted of a sum not exceeding Rs.51 crores. By a Trust Deed of 3 April, 1998, the Sole Trustee retired and Mr. Robert Eldon Peiciva1 and Mr. Edward. George Nugee were appointed by Union Carbide Corporation as Bhopal Hospital Trustees By another Deed of 4th April, Sir Ian Percival was reappointed as a Trustee but he expired on the same day.
(3) ‘The Supreme Court of India in its order dated 14. 2 .94 directed, inter-alia that the Government of India shall constitute an appropriate committee to take steps for the planning, construction, equipping and commissioning of the Hospital and that Sir Ian Percival, the Sole Trustee of the Bhopal Hospital Trust may be invited to be a co- Chairman of this committee. The Court further directed that Sir Ian Percival in discharge of his obligations as the Sole Trustee shall release such sums for the hospital project as may be indicated by the Hospital Committee.
(4) The Empowered Committee in its meeting held on 21 .2.95. in exercise of the powers vested in it by the Govcrnment of India order No21/20/94-Ch.I B dated , 12th August, 1994, resolved that Sir Jan Percival, Sole Trustee of BHT be requested , to enter into such contracts and agreements for the construction of the Hospital, its equipment and its running and to pay all sums which may become payable under such contracts and agreements. Sir Ian Percival, in turn, wanted it to be recorded that he would enter into such contracts only when requested by the Committee so to do and that it was for the Empowered Committee to decide what is to b done and what is not to be done.
(5) In pursuance of the order of the Supreme Court dated 3rd October, 1991, the Government of the Stale of Madhya Pradesh has provided land at Bhopal, free of cost, for the site of the said Hospital and has provided or intends to provide further land and buildings at Bhopal free of cost for a number of mini units to be operated in conjunction with the said Hospita1. 44
(6) The Supreme Court of India, in its Order dated 15 May, 1998, directed ,in the view of the death of Sir Ian Percival, the bank account which was earlier being operated by him, as Sole Trustee, of the Bhopal Hospital Trust, will henceforth be operated jointly by two persons, one of whom would be nominated by the Empowered Committee and the other would be nominated by the Trustees of the Bhopal Hospital Trust as an arrangement for construction of the hospital till the Trust is constituted. Accordingly, the Empowered Committee nominated Shri. Shantanu Consul, Joint Secretary, Department of Chemicals & Petrochemicals and the Bhopal Hospital Trustees nominated Mr. Robert Percival to jointly operate the accounts.
(7) The Hon’ble Supreme Court in its above Order directed that the number the Trustees should be confined to 11 and in order to have a fine mix of experts, Government representatives as well as public participation in the Trust, the Trustees be appointed from amongst persons falling in the following categories:
(1) A retired Chief Justice of India who would be the Chairman. (2) A nominee of the Bhopal Hospital Trust, if such nominee lives in a foreign country, the expenses of the said Trustee for attending the meetings of the Trust would be borne by the Bhopal Hospital Trust. 3) A nominee of the Government of India 4) Director General of Indian Council Medical Research. 5) Director of All India Institute of Medica1 Sciences New Delhi or the Director, Post Graduate Institute for Medical Research, Chandigarh. 6) A nominee of the Government Madhya Pradesh. 7) A person to represent the interests of the victims of Bhopal Gas Tragedy. 8) A person having experience in the matters of finance and commerce . (9) A person of eminence in the field of Medicine. (10) A person having experience in the field of Public Administration, (preferably from the State of Madhya Pradesh.) (11) A person known for his contribution in the field of social Welfare.
(8) In accordance with the order of the Supreme Court of India dated. 15.5.98, the list of Trustees has been finalised and is annexed as Schedule I to this ‘Trust Deed. The Trustees (hereinafter called the Original Trustees) have given their consent to act as such Trustees.
(9) The Settlors are desirous of establishing a trust for the purpose of ensuring the effective and proficient management of the Bhopal Memorial Hospital.
(10) The Settlors have paid the sum of Rs. 1,000/-(One Thousand Rupees) to the Original Trustees to be held by them upon the trusts of this Deed.
NOW THIS DEED W1TNESSETH as follows:
Transfer of the Trust and name of the Trust 45
1. In order to effectuate the said desire of the Settlors in consideration of the premises the Settlors doth hereby assign unto the Trustees all that the said sum of Rs.1000/- (One Thousand Rupees), full benefits and advantage thereof AND ALL the right, title, interest, property claim and demand what so ever of the Settlors into and upon the said sum TO HAVE AND TO HOLD the said sum of Rs. 1,000/-(One thousand Rupees ) and all the income thereof hereby assigned or expressed so to be and the investments for the time being and from time to time representing the same upon the trusts and subject to the powers, provisions, covenants, agreements and declarations hereinafter appearing and contained of and concerning the same.
The Trust established by this Deed shall be called ‘ The Bhopal memorial Hospital Trsust’.
Confirmation of the Settlors’ Intention
2. The Settlors confirm that soon after the new trust is constituted, they will transfer the balance of the funds ordered by the Supreme Court in its order of 14 February 1994, and the 14 February 1997, and the grant given by the Government of India together with interest accrued thereon to the Original Trustees and vest in them the site of the Hospital and the dispensaries converted or to be converted to Mini Units together with the buildings erected thereon and the equipments, fittings and fixtures attached there to be held by them upon the trusts of this Deed
Definitions
3. In this Deed; the following expressions where the context admits have the following meanings respectively:
(i) “the Trust” means The Bhopal Memorial Hospital Trust.
(ii) “the Hospital means The Bhopal Memorial Hospital and the facilities therein for medical treatment, research and teaching.
(iii) “the Trustees means the Original Trustees and the survivors or survivor of them or the other Trustees or Trustee for the time being of these presents.
(iv)“the Trust property’’ means a) the said sum of Rs 1000/-( One Thousand Rupees)
(b) so much of the Hospital and the dispensaries converted to be converted to Mini Units, together with equipment, fittings fixtures etc. as is from time to time vested in or under the control of the Trustees .
(c) all other property which may at any time be added to the Trust Property by way accumulation of income capitol accretion or otherwise 46
d) the investments, Property (movable and immovable) and other assets from time to time representing the premises respectively.
(v) “the Governors means the members of the Governing Body constituted by clause 7 of this Deed.
Objects of the Trusts
4. The Trustees shall stand possessed of the Trust Property and the income there of, - upon trust both during and after the termination of the said period, of eight years, for the following purposes:
(i) The construction, staffing, equipping, management, operation and maintenance of the Hospital and the provision therein of medical and other appropriate facilities (including facilities for medical surveillance by periodic medical checkups) for the benefit in the first instance of the victims of the Bhopal Gas Tragedy of 1984 and their dependents, and subject thereto for the people of Bhopal and the public at large.
(ii) The owning, acquiring, constructing, equipping, staffing, managing running, developing, organising, improving, promoting and subsidising in Bhopal (whether in or in connection or association with the Hospital or otherwise) of one or more other hospitals, dispensaries, clinics, diagnostic centres,’ polyclinics, pathology, laboratories, research centres, operation theatres, blood banks, eye banks, kidney banks, nursing homes, physiotherapy centres, investigation centres and other similar . establishments whether on land provided by the Government of the State of Madhya Pradesh and forming part of the Trust Property or otherwise and including mobile clinics, ambulances and other mobile facilities.
(iii) The establishment, construction, maintenance, equipment, staffing, management and support of sanatoriums, convalescent homes and maternity homes and the making of contributions to the support of such institutions (whether or not , managed by the Trustees)
(iv) The establishment, construction, maintenance, equipment, staffing, management aid support of institutions (includuig schools and colleges whether or not forming an integral part of the Hospital) for the spread of education in the field of medicine, medical research and other allied fields, and hostels for the accommodation of students at such institutions,’ and the grant of scholarships, bursaries and other financial support to students studying at such institutions(whether or not managed by the Trustees) and support of facilities providing accommodation to the staff of the hospitals and other institutions the patients and the attendants of such patients.
(v) The provision of treatment and medical relief for such fees or confessional fees or free of charge as the Trustees think fit.. 47
(vi) The grant of medical aid to the poor and needy without distinction of race and caste or creed and the grant of such medical , financial and other help as the Trustees think fit during times of epidemic, famine, flood or unforeseen or warlike operations.
(vii) Such other charitable purposes in connection with the operation and maintenance of the Hospital and of such other institutions and facilities as aforesaid as the Trustees shall from time to time determine to be appropriate having regard to the hope and trust expressed, conclusions reached, findings made and directions given by the Supreme Court of India aforesaid. (viii) If at any time, hereafter none of the foregoing objects is capable of being achieved then such other charitable medical purposes in or in the neighbourhood of Bhopal as the Trustees think fit.
(ix) All the incomes, earnings, movable or immovable properties of the Trust shall be solely utilised and applied towards the Object of the Trust and no profit thereof shall be paid or transferred directly or indirectly by way of dividends, bonus, profits or in any manner whatsoever to the present or past Trustees or to any person claiming through any one or more of the present or past Trustees. No Trustee shall have any personal claim on any movable or immovable properties of the Trust or make any profit whatsoever by virtue of his have any personal claim on any movable or immovable properties of the Trust or any profit whatsoever by virtue of his being a Trustee.
Powers of the Trustees in relation to the Trust Property
5. In furtherance of the objects of the Trust ( but not further or otherwise ) the Trustees shall have all the powers of investment, management, sale, exchange, mortgage, leasing, insurance, protection, improvement , equipment, dealing and,disposition ( and all other powers ) of an absolute beneficial owner of the Trust Property and in particular ( but without prejudice to the generality of the foregoing powers ) as Trustees shall have over and in respect of the Trust Property and every part thereof the following powers :
(i) To invite and receive or without such invitation receive any voluntary contribution in cash or kind whether consisting of movable or immovable property either from the Settlors or from any of the Trustees or from the Central or State Governments and other institutions, domestic or otherwise or from any member or members of the public including any firm, company or institution by way of donation, legacy, trust or otherwise for all or any of the purposes mentioned above PROVIDED THAT they are, not inconsistent with the provisions contained in this Deed. The Trustees may allow any such donor to erect a building or buildings on any land belonging to the Trust for use for any of the purposes of the Trust. Any such donation may be accepted either with or without any special conditions as may be : agreed between the donor and the Trustee PROVIDED THAT such conditions are : not inconsistent with t intent and purposes and provisions of this Deed. All such donations shall be utilised in accordance with the terms and conditions of the donation and subject thereto shall be treated as forming part of the Trust Property. PROVIDED FURTHER that it shall be lawful for the Trustees in their absolute discretion to refuse to accept any donation offered to them without giving any reason for such refusal.. 48
(ii) To retain the Trust Property or any part thereof in its actual state and condition for any period and to vary or transpose the mode of investment of the Trust Property within the range herein after authorised.
(iii) To accumulate the income of the Trust Property so far as is permissible , under the law, with a view to better enabling them to utilise the Trust Property including such accumulations for carrying out the purposes of the Trust. (iv) To invest Trust Moneys in the acquisition by purchase or otherwise of or at interest upon the security of such stocks, funds, shares, securities or other investments or property of whatsoever nature and wheresoever situate as the Trustees think fit to the intent that the Trustees shall have the same full and unrestricted powers of investing and transposing investments in all respects as if they were beneficially entitled to the Trust Property. (v) To permit any investments or property forming part of the Trust Property to be held in the name or the names of any nominee or nominees of the Trustees on such terms ( if any) as to the execution of blank transfers or declarations of trust and as to the custody of documents of title relating to such investments or property and otherwise as the Trustees think fit. (vi) Without prejudice to any other power of delegation hereby or by law conferred upon the Trustees, to delegate upon such terms and at such reasonable remuneration as the Trustees think fit to professional investment managers ( hereinafter called “the Managers”) the exercise of all or any of their powers of investment PROVIDED ALWAYS that –
(a)the Managers shall be persons who are entitled by law to carry on investment business (b)the delegated powers shall be exercisable only within clear policy guidelines drawn up in advance by the Trustees and within the powers of investment conferred by this Deed. (c)the Managers shall be under a duty to report promptly to the Trustees any exercise of the delegated powers and in particular to report every transaction carried out by the Managers to the Trustees within 14 days and to report on the performance of investments managed by them at least every six months. (d)the Trustees shall be entitled at any time to review alter or determine the delegation or its terms (e)the Trustees shall be bound to review the arrangements for delegation at intervals not ( in the absence of special reasons ) exceeding 12 months but so that any failure by the Trustees to undertake such reviews within the period of 12 months shall not invalidate the delegation. .
(vii) To open and maintain a banking account or accounts ( either by way of fixed deposit or current or savings account or any other account ) in the name of the Trust or in the name of the Trustees or Bhopal Memorial Hospital at such bank or banks as they may from time to time decide and to pay or cause to be paid any sum forming part of the Trust Property or the income thereof to the credit of any such account. Any such account may be operated by any two or more persons as the Trustees shall from time to time determine. (viii) To borrow and raise money on the security of the Trust Property for the sole purpose of defraying the costs and expenses of the Trust and to mortgage charge or pledge 49
any part of the Trust Property as security for any monies so raised, and for the same purpose to guarantee the payment of money and the performance of obligations in respect of the borrowings of any company wholly owned or controlled by the Trustees and in connection with such guarantees to enter into such indemnities as the Trustees think fit. (ix) To lend and advance money to any person or persons, firm, company, association or body corporate upon such security and on such terms as to repayment and payment of interest as the Trustees think fit, and to give guarantees in respect of the fulfilment of any contract or obligations and to become surety for any person or persons on such terms and conditions as the Trustees think fit. (x) To permit any movable property forming part of the Trust Property or otherwise in the possession of the Trustees to be used or enjoyed by any other person or persons for any of the purposes of the Trust on such terms as the Trustees think fit.
(xi) to permit any immovable property forming part of the Trust Property or otherwise in the possession or occupation of the Trustees to be used or occupied as an office of the Trust by any officials or employees of the Trust or for the residence of any officials of the Trust or by any other person or persons for any of the purposes of the Trust and either free from payment of rent or on such terms as to payment of rent, fees, charges and otherwise as the Trustees from time to time consider proper. (xii) To pull down, renovate, rebuild, alter, adapt, improve, add to, develop or repair any immovable property forming part of the Trust Property whether the same is used or to be used for the objects of the Trust or not and to expend thereon such moneys out of the Trust Property or the income thereof as the Trustees think fit and to enter into agreements or covenants with the owners of or other persons interested in any other properties and whether restrictive or otherwise and whether for the ‘benefit of the properties forming part of the Trust Property or such other properties as they from time to time think fit.. (xiii) To insure the Trust Property or any part thereof( whether used for any of the charitable purposes of the Trust or not ) or other property used in connection with the Trust as the Trustees from time to time think fit against loss or damage by fire, lightning, civil commotion or other risks or losses as the Trustees from time to time think proper ( but no liability shall attach to the Trustees or any of them by reason of any property remaining or at any time being uninsured) (xiv) To set aside from time to time such sums of money as the Trustees consider proper to meet the expenses of major repairs or by way of provision for depreciation or a sinking fund and to utilise the same and the income thereof for major repairs to or the rebuilding or reinstating of immovable properties or for erecting new buildings or for renewing replacing or acquiring major items of equipment and in the meantime to invest the same in any manner authorised by this Deed (xv) In the name of the Trustees or in the names of one or more of them to become members of any co-operative society or like institution for the protection, benefit or improvement of the Trust Property or any part thereof and to enter into such contracts and take such proceedings as they think proper for the purpose of such protection, benefit or improvement and to pay all fees and subscriptions and defray all charges and expenses in connection therewith as they consider proper (xvi) To sell by public auction or private contract or exchange or transfer, assign or grant leases or sub-leases for any term however long or otherwise dispose of all or any part of the Trust Property, movable or immovable, whether such property is used for the purpose of the Trust or of any other charitable institution or otherwise and on such terms and conditions relating to title or otherwise in all respects as they think proper and to buy in, rescind or vary any contract, sale, exchange, mortgage, 50
transfer, assignment or other disposition without being answerable for any loss occasioned thereby and for such purpose to execute all necessary. conveyances, deeds of exchange, assignments, transfers, mortgages, leases, sub-leases, counterparts and other assurances, and to pass, give and execute all necessary receipts, releases and discharges for the consideration moneys or otherwise relating to the said instruments and assurances. All moneys arising from any such transfer or other assurance shall be deemed to be part of the Trust Property and shall be applicable according to the terms : of this Deed. Upon any sale or other transfer by the Trustees under the power aforesaid the purchaser or purchasers) transferee or transferees dealing in good faith with the Trustees shall not be concerned to see or enquire whether the occasion for executing or exercising such power has arisen or whether the provisions as to the appointment and retirement of Trustees herein contained have been properly and regularly observed and performed nor to the application of the purchase moneys or other consideration or be answerable for any loss misapplication or non-application thereof. (xvii) To purchase all such equipment,. apparatus, medicines, drugs and other pharmaceutical products and all other machinery and accessories as the Trustees consider proper for the purpose of attaining the objects of the Trust. (xviii)To deposit any documents held by them relating to the Trust Property or any part thereof with any bank or banks and to pay any sum payable in respect of such deposit (xix) To settle all accounts and to compromise, compound, abandon or refer to arbitration any action, proceedings, claim, demand or thing relating to the Trust (xx) To transfer and hand over by way of donation, trust or in any other manner the Trust Property or any part thereof to any other charitable trust or institution having among its objects the objects of the Trust or any of them to be used such trust or institution for the objects of the Trust or such of them as may be directed by the Trustees (xxi) To merge or amalgamate with any other charitable trust or institution having objects altogether or in part similar to the objects of the Trust (xxii) To delegate such powers and authorities in favour of such person or persons as the Trustees may from time to time deem fit and proper so as to ensure smooth administration and working of the administration of the Trust and/or the Hospital. .(xxiii)To do all such other lawful acts or things as shall in the opinion of the Trustees further the attainment of the objects of the Trust and so far as may be necessary or convenient to do such acts or things in collaboration with any person, body, institution, authority or otherwise PROVIDED THAT no part of. the Trust Property or the income thereof shall be applied for any purpose which is not a charitable purpose.
Powers of the Trustee in relation to the management of the Hospital
6. For the better achievement of the objects of the Trust (but not further or otherwise ) the Trustees shall have all the powers of management and administration of the Hospital and of all other facilities and institutions for the time being in their ownership or under their control or any and absolute beneficial owner of the Trust Property and the business of the Trust and in particular (but without prejudice to the generality of the foregoing powers ) the Trustees shall have the following powers :
(i) To make and from time to time add to, vary or rescind such rules, regulations, statutes and bye-laws for the management and administration of the Trust 51 as they think fit Provided that such rules, regulations, statutes and bye-laws shall not be inconsistent with the terms of this Deed. Without Prejudice to the generality of the above such rules, regulations, statues and bye-laws may include provisions with respect to the manner in which any charitable statutes conducted by or under the control of the Trustees is to be used or permitted to be used as also in respect of any other matter within the objects of the Trust and in respect of the consideration and management and the executing of the trusts and powers contained in this Deed as the Trustees may from time to time think fit (ii) To determine and regulate the procedure at meetings of the Trustees and to fix the quorum for such meetings. A meeting of the Trustees at which a quorum is present shall be competent to exercise by a majority all or any of the powers vested in the Trustees by this Deed or otherwise exercisable by them. (iii) To appoint managers, treasurers and secretaries for looking after the day to day activities of the Trust, and to remove such managers, treasurers and secretaries and appoint others in their stead. Such managers, treasurers and secretaries shall be directly responsible and answerable to the Trustees. . . (iv) To employ a Director-General, Finance Director and such other officers, clerks and other persons for the purpose of the effective and efficient running of the . Trust as may be necessary on such terms as the employment an remuneration as the Trustees think proper, and to vary such terms from time to time, and to remove such employees and appoint others in their stead. . (v) To employ doctors specialists, consultants and practitioners from any field of medicine or any allied fields whatsoever, to employ nurses, paramedical staff , maintenance staff, research assistants and other personnel and staff and to pay them such fees or salaries as the Trustees think fit (vi) To employ and pay agents ( including any banks ) to transact any business or do any act whatsoever in relation to the Trust including the receipt and payment of moneys without being liable to pay their reasonable fees and charges vii) To appoint lawyers, accountants, tax consultants, auditors and other professionals to do any legal or tax or other professional work in relation to the Trust and to pay their reasonable fees and charges. (viii) To establish and maintain provident funds, gratuity funds, pension funds and other funds for any employee of the Trust and to make and from time to time add to, vary rescind rules and regulations for the conduct thereof (ix) To reimburse to the Trustees or any of the in and pay and discharge out of the Trust Property ‘or the income thereof all reasonable expenses incurred by them in or about the execution of the trusts or powers of this Deed (x) Without prejudice to the provisions of Clause 8 hereof to delegate to any person or to any board of management or committee of persons ( whether or not being or including one or more Trustees ) the exercise of all or any of the powers conferred on the Trustees by this Deed or by law notwithstanding the fiduciary nature of such power or powers and the Trustees shall be entitled to determine the constitution of any such board or committee and the duration of the period for which such person, board or committee is to act and to make and from time to time add to, vary or rescind rules and regulations for the management and conduct of the business so delegated and the meetings of any such board or committee . (xi) To form and register one or more societies with such objects as the Trustees think fit for the purpose of the more efficient management of the Trust Property or the affairs of the Trust or any part thereof respectively and the Trustees shall entitled to determine and from time to time vary the constitution of each such 52 society. .
The Governing Body
7.(a) The Trustees shall ‘establish a Governing Body of the Hospital, consisting of, . not less than 7 and not more than 9 persons, subject to the condition that one nominee, each of the Government of the Union of India and the Government of the State of Madhya Pradesh shall always be members of the Governing Body. b). Executive head of the Hospital should be entitled to attend the meetings of the Governing Body except for such items of private business as the Governing Body shall determine
(c)The quorum for the meetings of the Governing Body shall be five.
(d) The members of the Governing Body shall hold office for a period of three years subject only to the right of the nominating body to remove its nominee and replace him with another at its discretion. The members of the Governing Body may be renominated,
8. The Trustees shall make and may from time to time add to, vary or rescind statutes, rules, regulations and bye-laws touching the mode of convening meetings of the Governors, the conduct of the business to be transacted at such meetings (including the appointment of a Chair person and a Vice-Chairperson of the Governors) and all matters relating to the management of the Hospital, and shall confer on the Governors and delegate to them the exercise of all such powers as are by this Deed or by law conferred on the Trustees and as are in the opinion of the Trustees necessary or expedient to enable, the Governors to conduct the affairs of the Hospital (including the research and educational functions of the Hospital) and of such other institutions and facilities referred to in Clause 4 of this Deed as the Trustees shall from time to time consider can conveniently be carried on in conjunction with the Hospital and the Trustees shall have power from time to time to revoke or vary the extent of such delegation with a view to ensuring the efficient management by the Governors of the affairs of the Hospital and of such other institutions or facilities.
The Trustee.
9. The Trustees shall be eleven in number but shall be competent to act in the trusts of this Deed at any time when there are not less than five Trustees.
10. Save as provided by clause 17 hereof in case of a difference of opinion existing among the Trustees and in all matters wherein the Trustees shall have discretionary powers the votes of the majority of the Trustees present at a duty convened meeting of the Trustees shall prevail and be binding on the minority as well as on those Trustees who are absent or have not voted and if the Trustees shall be equally divided in opinion the 53 matter shall be decided according to the casting vote of the Chairperson of the meeting.
11. The Trustees shall make and from time to time add, vary or rescind regulations touching the mode of convening meetings of the Trustees, the quorum for such meetings and (so far as not provided for by the forgoing provisions of this Deed)’the conduct of the business to be transacted at such meetings
12. If the nominee of the Bhopal Hospital Trust, London is residing in a foreign country the expenses of the said Trustee, for attending the meetings of the Trust, shall be borne by the Bhopal Hospital Trust, London.
13. Any Trustee upon giving three calendar months notice to the other Trustees may retire and shall be duly discharged from the trusts hereof at the expiry of such notice.
14. If and so often as any one of the Trustees, other than the government nominees and the Chairman shall die or vacate office for any other reason, the Trustees shall appoint a new Trustee in place of the Trustee who has so died or vacated office. In the event of a vacancy occurring in the office of the Chairman of the Trust, the Trustees shall obtain suitable direction form the Hon’ble Supreme Court of India. In the case of a Trustee nominated by the Government of India or the Government of Madhya Pradesh, the nominating government will have the right to appoint/change/ replace the person so nominated.
15. In the execution of the trusts and powers of this Deed no trustee shall be liable for/any loss to the Trust Property arising by reason of any improper investment made in good faith or for the negligence or fraud of any agent or other person employed by the trustees or by such Trustee or any other Trustee although the employment of such agent or other person was not strictly necessary or expedient or by reason of any mistake or omission made in good faith by the Trustees or by such Trustee or any other Trustee or by reason of any matter or thing except willful and individual fraud or dishonesty on the part of the Trustee who is sought to be made liable.
16.The Trustees shall be indemnified out of the Trust Property from and against all claims and demands and from and against all actions, suits, proceedings and from and against all costs, charges, expenses, penalties, fines, prosecutions and other charges that the Trustees may suffer, incur ‘or be put to by reason of any claim, notice, demand, proceedings or suits that may be made or adopted against the Trustees by any person or party on account of any act or omission, default or negligence of any staff member/ employee of the Hospital, or any doctor, surgeon, specialist, technician, consultant or any other person working for the Hospital, in the performance of their duties or for any reason whatsoever; and any loss and/or damage that the Trustees may suffer , incur or be put to on account thereof shall be made good out of the Trust property 54
General
17. The Trustees (being eleven in number and unanimous or acting by a majority of not less than seven of their number) may at any time or times during the continuance of the Trust by deed) amend add to or revoke any of the provisions of this Deed other than the provisions of clausc 4 hereof but so no part of the Trust Property or the income there of shall in any circumstances become applicable for any purpose that is not a charitable purpose PROVIDED THAT, NO AMENDMENT, which is not consistent with the Supreme Court Order of 15 May, 1998 shall be made.
18. These trusts shall be and remain irrevocable for all time.
19. This Deed shall be construed and have effect in accordance with Indian law. IN WITNESS whereof the parties hereto have hereunto set their respective hands and seals on the day and year first herein above written.
SIGNED AND SEALED AND DELIVERED
by the within named Settlors.
1. Shri Deepak Chatterjee, Secretary,Dcpartment of Chemicals & PetrochemicaIs, New Delhi (Chairman, Empowered Committee).
2. Shri K.S. Sharma, Chief Secretary, Government of adhya Pradesh,Vallabh Bhavan, . Bhopal. 3. Dr. S. P. Aggarwal, Director Gencra1, Health Services, Ministry of Health & Family Welfare, Nirman Bhavan, New Dclhi. 4. Dr.B. K. Sharma, Director, Postgraduate Institute of Medical Education and research , Chandigarh. . . 5. Dr. J. N. Pande, Professor & Head, Dcpartment of Mcdicine, All India Institute of Medical Sciences, Ansari Nagar. New Delhi. 6. Shri Shantanu Consul, Joint Secretary , Department of Chemicals & Petrochemicals, Shastri Bhavan, New Delhi.
7. Smt.Renu Sahni Dhar , Joint Secretary, Ministry of health & Family Welfare, Nirman Bhavan, New Dclhi.
8. Shri S. Kabilan , Joint Secretary & Financial Adviser, Ministry of Chemicals &. Fertilizcrs, Shastri Bhavan, New Delhi.
9. Shri D. P. Sharma, Joint Secretary & Legal Adviser, Department of Legal Affairs, Shastri Bhavan. New Dclhi. 10. Dr. Bela Shah, Deputy Director General , Indian Council of Medical Research , Ansari Nagar Post Box 4508, New Dclhi. 55
11 . Dr. Bhagirath Prasasd , Secretary , Government of Madhya Pradesh, Bhopal Gas Tragedy & Relief & Rehabilitation Department, Valabh Bhavan, Bhopal. 12. Mr Edward George Nugee, QC , 8 New square, Lincoln’s Inn , London, WC2A3QP.
13. Mr Robert Eldon Percival; Barrister at Law, 5 paper Building Temple , London EC4YHB.
SCHEDULE I To TRUST THE TRUST DEED
ORIGINAL TRUSTEES OF THE BHOPAL MEMORIAL HOSPITAL TRUST
Category Trustee
1. A retired Chief justice of India who would Mr, Justice AM.Ahmadi C-3,Kant be chairman EnclaveNear Dr.Karnail Singh Shooting Range, Anangpur, Faridabad District,Haryana 121003.
2. A nominee of Bhopal Hospital Trust, Mr.Robert Eldon Percival London Barister at Law, 5 paper buildings, temple , London ,EC4Y7HB
3.A nominee the Government of India Shri K.K. Bakshi, Secretary
Health , Min. of Health & Family Welfare, Nirman Bhavan , New Delhi- 110011
4.Director General of Indian Council of Dr N.K. Ganguly, Director general, Indian medical Research Council of medical Research, Ansari Nagar PO Box No 4911, New Delhi- 10029 56
5 Director of All India institute of Medical Dr P.K. Dave, Director, All India Institute of Sciences, New Delhi or the Director, Post Medical Sciences , Ansari Nagar, New Delhi - Graduate Institute for Medical Research, 110029 Chandigarh .
6. A nominee of Government of Madhya Shri K.S Sharma, Chief Secretary, Govt. of Pradesh M.P. , Vallabh Bhavan, Bhopal- 462004
7.A person to represent the interest of the Shri Aziz Ahmed Siddiqui, D- sector Kohe victims of Bhopal Gas Tragedy fiza, Bhopal- 462001
8. A person having experience in the matters of Shri S.H. Khan, 61 – Jolly Marker –2, Cuffe finance and commerce Parade, Opposite world trade center , Mumbai- 40005
9. Aperson of eminence in the field of Dr madan Mohan , 73, Ring Road, Lajpat medicine nagar, New Delhi- 110003
10. A Person having experience in the field of Shri M.N. Buch , E-4/17, arera colony Bhopal- Public Administration preferably from the state 462016 of Madhya Pradesh
11. A person known for his contribution in the Smt Ela R. Bhat, Self employed Association ( field of social welfare SEWA), Sewa reception center , opposite Victoria Garden Vhadra , Ahemdabad -280001
ADDRESSES OF ALL Present TRUSTEES OF BMHT
1. Hon’ble Shri Justice A.M. Ahrnadi,, Chairman, BMHT, C-3 Kant Enclave, Anangpur, Haryana 121 003Tele Fax: 915-251755
2. Shri Mohd. Shafi Qureshi, Vice Chairman, Governing Body, Bhopal Memorial Hospital Trust, Q-3, Tara Apartment, Alaknanda, New Delhi -- 110019 57
3.Smt. Vimla Sharma Former First Lady of India, 23. Safdarjung Road, NewDeihi— 110011 Ph.301993, 3792092
4 Mr Robert Percival, 5 Paper Building, Temple, London,EC4Y7I-1B, Ph:0044-20785132O1,Fax-0044-207-8153200.
5.Smt Bagwani Tayagrajan , IA.S. Joint Secretary, (Health),Min. Health & Family welfare GO.I. Nirman NewDeihi- 110001. Ph:3018863, Fax: 3012544’301 252
6. Dr N. K. Ganguly, Director General, ICMR, Ansari Nagar, New Delhi — 110029. Ph:6517204/6962794 Fax :01 1-686662.
7. Dr. K.K. Talwar, Director Post Graduate Institute of India, Chandigarh, 160012
8.Shri Vijay Singh, I.A.S. Chief secretarv, Govt. of M.P. Vallabh Bhavan, Bhopal -462004 Ph: 0755-551848, Fax:0755-55 1521,551751
9. Shri Aziz Ahmad Siddiqui, Working Trustee, BMHT, Ashiyana Compound, D Sector,Koh-e-fi.za, Bhopal- 462001 Ph: 0755-540605/540606
10.Shri S.H.Khan,181, “ANTARIKSHA” 95,96, Kaka Saheb Gadgil Marg, Prabhadcvi, Mumbai 400018 Ph.022-4975575(O)022-4223002 (Res)
11. Dr Madan Mohan, House No.D-338, Defence Co1on’, NeA Pu: (FCs.) Clinic. 29 Link Road, Lajpat Nagar,New Deihi— 110003. Ph: 6847800 (Clinic) Fax: 6847600 . Annexure P-7 58
UNION CARBIDE INDIA LIMITED INDIA MIC-BASES PESTICIDE PROJECT BHOPAL (M.P.) INDIA
PHOSGENE UNIT AND METHYL ISOCYANATE UNIT
SAFETY CONSIDERATION REPORT
W.O. 930-4533 930-4534
DECEMBER 16, 1974
ENGINEERING DEPARTMENT CHEMICALS AND PLASTICS UNION CARBIDE CORPORATION SOUTH CHARLESTON, WEST VIRGINIA 59
INDIA MIC-BASED PESTICIDE PLANT
Engineering Order 938-6795 Work Orders (UCIL) 930-4533-4534
PHOSGENE UNIT AND METHYL ISOCYANATE UNIT
SAFETY CONSIDERATION REPORT
DECEMBER 16, 1974
COMPILED AND EDITED BY
J.F. DOOD - PROCESS GROUP LEADER G.E. RUTZEN PROCESS ENGINEER
CONTRIBUTORS:
PROCESS ENGINEER E.F. HORYL PROCESS SAFETY AND FIRE PROTECTION ENGINEER D.L. HIERMAN SAFETY REVIEW ENGINEERS E.F. MORYL P.E. NARASIMHAN CONTROL SYSTEMS ENGINEER J.V. FISHER INDUSTRIAL HYGIENIEST R.G. ZAHN OPERATION DEPARTMENT CONSULTANTS W.K. NORTON, JR W.K. GRAMPTON R.L. FOSTER R & D REPRESENTATIVE D.W. PECK
ENGINEERING DEPARTMENT CHEMICALS AND PLASTICS UNION CARBIDE CORPORATION TECHNICAL CENTER SOUTH CHARLESTON, WEST VIRGINIA
UCC 21451 60
11 TABLE OF CHEMICALS (Continued)
NOTES: (a) Air sampling and analysis for this chemical is recommended (b) Established by American Conference of Governmental Industrial Hygienists (AWGIH), 1973 (c) Promulgated by Occupational Safety and Health Act (OSHA) in the United States as limit allowed by law. (d) Repeated contact is more hazardous (e) Sensitization may result. (f) Irritation of the nose, eyes, and throat.
Health Hazard Rating Symbols
1 No residual injury is to be expected from accidental exposure even if no treatment is applied.
2 Minor residual injury may result from some accidental exposures if no treatment is applied.
3 Minor residual injury may result in spite of prompt treatment.
4 Major residual injury may result in spite of prompt treatment.
5 Major residual injury is likely in spite of prompt treatment. 61
METHYL ISOCYANATE
Methyl isocyanate is a hazardous material by all means of contact. Its odor or tearing effects cannot be used to alert personnel to an unsafe concentration of vapor. The Threshold Limit Value (TLV) is 0.02ppm by volume in air for average 6-hours exposures, but no odor or tearing is perceived by humans even at concentrations as high as 0.4ppm. Mild irritation to the nose, throat and eyes (with no odor) is noticeable at 2.0ppm; this irritation becomes more intense at a concentration level of 4.0ppm. Methyl isocyanate is a poison to humans by inhalation as defined by UCC regulations and should be regarded as a poison by swallowing or skin contact.
Methyl isocyanate is assigned a health hazard rating of 4 in the UCC hazard signal system. WARNING: Use stringent precautions to eliminate any possibility of human contact with methyl isocyanate.
Eye Hazards- Methyl isocyanate liquid will seriously injure the eyes even when it is diluted with a non-toxic liquid to a 1 percent concentration. Avoid eye contact with vapors or liquid by wearing vapor-proof goggles or full face mask. Eyes exposed to methyl isocyanate liquid or concentrated vapor should be treated by copious irrigation with water for 15 minutes. Then obtain medical attention.
Breathing-Methyl isocyanate is a recognised poison by inhalation and is intensely irritating to breathe. It causes severe broncho-spasm and asthma-like breathing. Major residual injury is likely in spite of prompt treatment. Avoid breathing vapors of methyl-isocyanate.
Air-supplied, full face masks should be used when necessary to work in vapors of methyl isocyanate. If accidental exposure occurs remove the patient to fresh air, give artificial respiration if needed, and take the patient to the medical department immediately.
Skin Contact: Liquid methyl isocyanate can cause skin burns and absorption through skin can be harmful. Minor to major residual injury may result by contact with the skin in spite of prompt treatment. In case of skin contact, flush contaminated area thoroughly with water for 15 minutes after removing contaminated clothing. Remove the patient to the medical department as as soon as possible
Swallowing- Methyl isocyanate is a serious poison if swallowed. Major residual injury may result in spite of prompt treatment. DO NOT SWALLOW METHYL 62
ISOCYANATE. In case of accidental swallowing of methyl isocyanate, get medical attention at once Annexure P-8 Methyl Isocyanate63
Methyl Isocyanate (C2H3NO) CAS 624-83-9; UN 2480
Synonyms include isocyanomethane, isocyanatomethane, methylcarbylamine, and MIC.
• Persons exposed only to methyl isocyanate gas pose no risk of secondary contamination. Persons whose skin or clothing is contaminated with liquid methyl isocyanate can secondarily contaminate rescuers by direct contact or through off- gassing of vapor.
• At temperatures below 39 °C (102 °F), methyl isocyanate is a very flammable colorless liquid that readily evaporates when exposed to air. Gaseous methyl isocyanate is slightly heavier than air.
• Although methyl isocyanate has a pungent odor, adverse health effects have been reported at or below the human odor threshold; therefore, odor detection is not a reliable indicator of exposure.
• Methyl isocyanate is readily absorbed through the upper respiratory tract. Methyl isocyanate can also be absorbed through the digestive tract or skin.
Description At temperatures below 39 °C (102 °F), methyl isocyanate is a very flammable liquid that readily evaporates when exposed to air. Gaseous methyl isocyanate is approximately 1.4 times heavier than air. Methyl isocyanate liquid is colorless with a pungent odor. Most people can smell methyl isocyanate vapors at levels as low as 2 to 5 ppm. Methyl isocyanate is handled and transported as a very flammable and explosive liquid.
Routes of Exposure
Inhalation Inhalation is the major route of exposure to methyl isocyanate. The vapors are readily absorbed through the lungs. The odor threshold is approximately 100 to 250 times higher than the OSHA PEL TWA (0.02 ppm). Significant exposures to methyl isocyanate occur primarily in occupational settings. Acute exposure to methyl isocyanate vapors below the odor threshold can be irritating to the eye and respiratory epithelium. Acute exposure to higher vapor concentrations may cause severe pulmonary edema and injury to the alveolar walls of the lung and death. Survivors of acute exposures may exhibit long-term respiratory effects. Odors of methyl isocyanate may not provide adequate warning of hazardous concentrations because the Immediately Dangerous to Life or
ATSDR • General Information 1 Methyl Isocyanate 64 Health (IDLH) limit is only 3 ppm and the threshold for detection of methyl isocyanate vapors ranges from 2 to 5 ppm in humans. Significant exposure to methyl isocyanate vapors would most likely be the result of accidental release of methyl isocyanate to the air such as occurred in Bhopal, India in 1984, where the primary effect was pulmonary edema with some alveolar wall destruction. Methyl isocyanate is heavier than air; therefore, exposure in poorly ventilated, enclosed, or low-lying areas could result in asphyxiation.
Children exposed to the same levels of methyl isocyanate as adults may receive larger doses because they have relatively greater lung surface area:body weight ratios and higher minute volume:weight ratios. In addition, they may be exposed to higher levels than adults in the same location because of their short stature and the higher levels of methyl isocyanate found nearer to the ground. Children may be more vulnerable to corrosive agents than adults because of the smaller diameter of their airways.
Skin/Eye Contact Direct contact with liquid or concentrated vapors of methyl isocyanate may cause irritation of the skin or eyes and severe ocular damage. Direct skin contact may result in dermal absorption. Significant dermal exposure to methyl isocyanate would not likely occur outside an occupational environment in which methyl isocyanate is stored or used.
Because of their relatively larger surface area:weight ratio, children are more vulnerable to toxicants absorbed through the skin.
Ingestion Although unlikely, ingestion of liquid methyl isocyanate could produce severe gastrointestinal irritation.
Sources/Uses Methyl isocyanate is made by reacting methylamine with phosgene. The primary use of methyl isocyanate is as a chemical intermediate in the production of pesticides. It is also used to produce polyurethane foams and plastics. Standards and Guidelines OSHA PEL (permissible exposure limit) = 0.02 ppm (averaged over an 8-hour workshift) with a skin notation
NIOSH IDLH (immediately dangerous to life or health) = 3 ppm
AIHA ERPG-2 (maximum airborne concentration below which it is believed that nearly all persons could be exposed for up to 1 hour without experiencing or developing irreversible or other serious
2 General Information • ATSDR Methyl Isocyanate65 health effects or symptoms that could impair their abilities to take protective action) = 0.5 ppm
Physical Properties Description: Colorless liquid at room temperature; volatile, flammable, explosive in air Warning properties: Pungent odor of methyl isocyanate may not be adequate to warn of acute exposure. Most people can detect methyl isocyanate at levels of 2 to 5 ppm (1 ppm is equivalent to 2.35 mg/m3) Molecular weight: 57.05 daltons Boiling point (760 mm Hg): 102 °F (39.1 °C) Freezing point: -49 °F (-45 °C) Vapor pressure: 348 mm Hg at 68 °F (20 °C) Vapor density: 1.42 (air = 1.00) Water solubility: 6.7% at 68 °F (20 °C) Flammability: highly flammable Flammable Range: 5.3 % to 26 % (concentration in air)
Incompatibilities Methyl isocyanate reacts violently with water. Methyl isocyanate is incompatible with oxidizers, acids, alkalis, amines, iron, tin, and copper.
ATSDR • General Information 3 Methyl Isocyanate66 Health Effects
• Methyl isocyanate is irritating and corrosive to the eyes, respiratory tract, and skin. Acute exposure to high vapor concentrations may cause severe pulmonary edema and injury to the alveolar walls of the lung, severe corneal damage, and death. Survivors of acute exposures may exhibit long-term respiratory and ocular effects. Methyl isocyanate may be a dermal and respiratory sensitizer.
• Mechanisms of methyl isocyanate-induced toxicity are not known. Persistent respiratory and ocular effects may reflect methyl isocyanate-induced immunologic effects. Methyl isocyanate may cross the placenta and enter a developing fetus. Individuals especially susceptible to the toxic effects of methyl isocyanate include those with existing disorders of the respiratory system or eyes.
Acute Exposure Mechanisms of toxicity have not been clearly elucidated for methyl isocyanate; however, carbamylation of globin and blood proteins may play a role. Persistent respiratory and ocular effects may reflect methyl isocyanate-induced immunologic effects since antibodies specific to methyl isocyanate have been demonstrated in the blood of exposed patients. Methyl isocyanate is highly reactive; therefore, it is not metabolized in the classical sense. The onset of respiratory effects following acute exposure to methyl isocyanate can be immediate in some cases. In others, respiratory injury can evolve over periods of hours or days. Exposure-related deaths sometimes can occur as late as 30 or more days post-exposure, due in part to the development of pneumonia.
Children do not always respond to chemicals in the same way that adults do. Different protocols for managing their care may be needed.
Respiratory Methyl isocyanate vapors are severely irritating and corrosive to the respiratory tract. Symptoms may include cough, chest pain, dyspnea, coma, and death. Irritative respiratory symptoms such as pulmonary edema and bronchial spasms may occur in immediate response to exposure. Methyl isocyanate-induced pulmonary edema may progress to effects such as alveolar wall destruction and pneumonia, which may ultimately lead to respiratory failure and death. Some respiratory effects may progress in severity over a period of hours to days post-exposure. Asthmatic reactions and long-term respiratory effects have been reported.
ATSDR • Health Effects 5 Methyl Isocyanate 67 Children may be more vulnerable to corrosive agents than adults because of the smaller diameter of their airways. Children also may be more vulnerable to gas exposure because of relatively higher minute ventilation per kg and failure to evacuate an area promptly when exposed.
Ocular/Ophthalmic Severe eye irritation can result from exposure to methyl isocyanate vapors or direct contact with the liquid. Symptoms may include immediate eye pain, lacrimation, photophobia, profuse lid edema, and corneal ulcerations. Ocular exposure may result in long-term or permanent eye damage.
Dermal Methyl isocyanate is a skin irritant and may cause chemical burns upon dermal contact at high exposure levels.
Because of their relatively larger surface area: body weight ratio, children are more vulnerable to toxicants that affect the skin.
Gastrointestinal Nausea, vomiting, abdominal pain, and defecation have been reported after acute exposure to methyl isocyanate vapors.
Potential Sequelae Initial irritative symptoms of the respiratory tract may progress to more serious respiratory injury over a period of hours to days following exposure to methyl isocyanate vapors. Compromised lung tissue may be susceptible to bacterial pneumonias. Exposure may result in permanent eye damage. Methyl isocyanate may also be a respiratory and dermal sensitizer. Renal tubular necrosis, reduced liver function, and miscarriage were associated with methyl isocyanate exposure in the Bhopal, India incident.
Chronic Exposure Chronic exposure to methyl isocyanate may result in chronic obstructive lung disease.
Carcinogenicity Methyl isocyanate has not been classified for carcinogenicity. Reproductive and Developmental Effects Methyl isocyanate is not included in the list of Reproductive and Developmental Toxicants, a 1991 report published by the U.S. General Accounting Office that lists 30 chemicals of concern because of widely acknowledged reproductive and developmental consequences. Increased rates of spontaneous abortions and neonatal deaths among victims of the Bhopal accident were observed for months following exposure. However, the precise role of methyl isocyanate in developmental toxicity is difficult to determine. Poor oxygenation resulting from compromised lung
6 Health Effects • ATSDR Methyl Isocyanate68 function may nr involved. Animal studies indicate that inhalation exposure during gestation may result in decreased numbers of live births and decreased survival during lactation. There was no evidence of a dominant lethal effect in exposed male mice. Genotoxicity testing in animals indicates that methyl isocyanate may have the capacity to affect chromosome structure, but it apparently does not induce gene mutations.
ATSDR • Health Effects 7 Methyl Isocyanate69 Prehospital Management
• Persons exposed only to methyl isocyanate gas pose no risk of secondary contamination to rescuers. Persons whose skin or clothing is contaminated with liquid methyl isocyanate can secondarily contaminate response personnel by direct contact or through off-gassing of vapor.
• Methyl isocyanate is irritating to the eyes, respiratory tract, and skin. Early symptoms may include eye irritation, coughing, and shortness of breath. In cases of severe exposure, later symptoms may include vomiting and diarrhea. Acute exposure to high vapor concentrations may cause relatively rapid and severe pulmonary edema, alveolar wall injury, and corneal damage. Initial signs of irritation may progress to vomiting, diarrhea, and death. Survivors of acute exposures may exhibit long-term respiratory and ocular effects. Methyl isocyanate may be a dermal and respiratory sensitizer.
• There is no antidote for methyl isocyanate. Treatment consists of removal of the victim from the contaminated area and support of respiratory and cardiovascular functions.
Hot Zone Rescuers should be trained and appropriately attired before entering the Hot Zone. If the proper equipment is not available, or if the rescuers have not been trained in its use, call for assistance from a local or regional hazardous materials (HAZMAT) team or other properly equipped response organization.
Rescuer Protection Inhaled methyl isocyanate is a severe respiratory tract irritant. Contamination of the skin can cause irritation or chemical burns. Contamination of the eyes can cause irritation and serious or long- term damage. Methyl isocyanate is absorbed through the skin.
Respiratory protection: Positive-pressure, self-contained breathing apparatus (SCBA) with a full facepiece and operated in a positive pressure mode is recommended in response to situations that involve exposure to potentially unsafe levels of methyl isocyanate gas.
Skin protection: Chemical protective clothing is recommended because methyl isocyanate can cause skin irritation and burns. Protective eye equipment is recommended to prevent eye contact.
ABC Reminders Quickly establish a patent airway, ensure adequate respiration and pulse. Maintain adequate circulation. Provide supplemental oxygen if cardiopulmonary compromise is suspected. If trauma is suspected, maintain cervical immobilization manually and apply a cervical collar
ATSDR • Prehospital Management 9 Methyl Isocyanate 70 and a backboard when feasible. Apply direct pressure to stop any heavy bleeding.
Victim Removal If victims can walk, lead them out of the Hot Zone to the Decontamination Zone. Victims who are unable to walk should be removed on backboards or gurneys. If these are not available, carefully carry or drag victims to safety.
Consider appropriate management of anxiety in victims with chemically-induced acute disorders, especially childrenwho may suffer separation anxiety if separated from a parent or other adult.
Decontamination Zone Patients exposed only to methyl isocyanate gas who have no eye or skin irritation do not need decontamination. They may be transferred immediately to the Support Zone. Other patients will require decontamination as described below.
Rescuer Protection If exposure levels are determined to be safe, decontamination may be conducted by personnel wearing a lower level of protection than that required in the Hot Zone (described above).
ABC Reminders Quickly establish a patent airway, ensure adequate respiration and pulse. Maintain adequate circulation. Provide supplemental oxygen if cardiopulmonary compromise is suspected. If trauma is suspected, maintain cervical immobilization manually and apply a cervical collar and a backboard when feasible. Administer supplemental oxygen as required. Assist ventilation with a bag-valve-mask device if necessary. Apply direct pressure to control any heavy bleeding.
Basic Decontamination Rapid skin decontamination is critical. Victims who are able may assist with their own decontamination. Remove contaminated clothing and personal belongings and place them in double plastic bags.
Wash exposed skin thoroughly with soap and water. Use caution to avoid hypothermia when decontaminating victims, particularly children or the elderly. Use blankets or warmers after decontamination as needed.
Irrigate exposed eyes with copious amounts of tepid water for at least 15 minutes. Remove contact lenses if they are easily removable without additional trauma to the eye. If pain or injury is evident, continue irrigation while transferring the victim to the Support Zone.
10 Prehospital Management • ATSDR Methyl Isocyanate71 In cases of ingestion, do not induce emesis. If the victim is not symptomatic, consider administering activated charcoal at a dose of 1 g/kg (infant, child, and adult dose). A soda can and straw may be of assistance when offering charcoal to a child. However, the effectiveness of activated charcoal in binding methyl isocyanate has not been demonstrated.
If the victim is conscious and able to swallow, consider giving 4 to 8 ounces of water.
Consider appropriate management of chemically contaminated children at the exposure site. Also, provide reassurance to the child during decontamination, especially if separation from a parent occurs.
Transfer to Support Zone As soon as basic decontamination is complete, move the victim to the Support Zone.
Support Zone Be certain that victims have been decontaminated properly (see Decontamination Zone, above). Victims who have undergone decontamination or have been exposed only to methyl isocyanate gas pose no serious risk of secondary contamination to rescuers. In such cases, Support Zone personnel require no specialized protective gear.
ABC Reminders Quickly establish a patent airway. If trauma is suspected, maintain cervical immobilization manually and apply a cervical collar and a backboard when feasible. Ensure adequate respiration and pulse. Administer supplemental oxygen as required and establish intravenous access if necessary. Place on a cardiac monitor, if available.
Additional Decontamination Continue irrigating exposed skin and eyes, as appropriate.
In cases of ingestion, do not induce emesis. If the victim is not symptomatic, consider administering charcoal at a dose of 1 g/kg (infant, child, and adult dose). A soda can and straw may be of assistance when offering charcoal to a child. However, the effectiveness of activated charcoal in binding methyl isocyanate has not been demonstrated.
If the victim is conscious and able to swallow, consider giving 4 to 8 ounces of water if it has not been given previously.
ATSDR • Prehospital Management 11 Methyl Isocyanate 72 Advanced Treatment Treat cases of respiratory compromise with respiratory support using protocols and techniques available and within the scope of training. Some cases may necessitate procedures such as endotracheal intubation or cricothyrotomy by properly trained and equipped personnel.
Treat patients who have bronchospasm with oxygen, aerosolized bronchodilators such as albuterol, and/or steroids according to established protocol.
In cases of non-cardiogenic pulmonary edema, which may be delayed in onset, maintain adequate ventilation and oxygenation. Early use of mechanical ventilation and positive-end-expiratory pressure (PEEP) may be required. To minimize barotrauma and other complications, use the lowest amount of PEEP possible while maintaining adequate oxygenation. Consider drug therapy for pulmonary edema.
Patients who are comatose, hypotensive, or having seizures or cardiac arrhythmias should be treated according to advanced life support (ALS) protocols.
If evidence of shock or hypotension is observed begin fluid administration. For adults with systolic pressure less than 80 mm Hg, bolus perfusion of 1,000 mL/hour intravenous saline or lactated Ringer’s solution may be appropriate. Higher adult systolic pressures may necessitate lower perfusion rates. For children with compromised perfusion administer a 20 mL/kg bolus of normal saline over 10 to 20 minutes, then infuse at 2 to 3 mL/kg/hour. Consider vasopressors if patient is hypotensive with a normal fluid volume.
Transport to Medical Facility Only decontaminated patients or patients not requiring decontamination should be transported to a medical facility. “Body bags” are not recommended.
Report the condition of the patient, treatment given, and estimated time of arrival at the medical facility to the base station and the receiving medical facility.
If methyl isocyanate has been ingested, prepare the ambulance in case the victim vomits toxic material. Have ready several towels and open plastic bags to quickly clean up and isolate vomitus.
12 Prehospital Management • ATSDR Methyl Isocyanate73 Multi-Casualty Triage Consult with the base station physician or the regional poison control center for advice regarding triage of multiple victims.
Patients who have histories or evidence suggesting significant exposure (e.g., altered behavior, respiratory distress, or chemical burns) should be transported to a medical facility for evaluation. Patients who have a history of chronic pulmonary disease should be clinically evaluated for airflow obstruction.
Patients who have mild symptoms of respiratory or eye irritation should be clinically evaluated because onset of pulmonary edema may be delayed for up to 72 hours post-exposure and eye injury may need to be treated topically for inflammation or secondary infection. Patients who have symptoms of transient skin, nose, or eye irritation may be discharged from the scene after their names, addresses, and telephone numbers are recorded. They should be advised to rest and to seek medical care promptly if symptoms develop or recur (see Patient Information Sheet below).
ATSDR • Emergency Department Management 13 Methyl Isocyanate74 Emergency Department Management
• Persons exposed only to methyl isocyanate gas pose no risk of secondary contamination to rescuers. Persons whose skin or clothing is contaminated with liquid methyl isocyanate can secondarily contaminate response personnel by direct contact or through off-gassing of vapor.
• Methyl isocyanate is irritating to the eyes, respiratory tract, and skin. Acute exposure to high vapor concentrations may cause severe pulmonary edema and injury to the alveolar walls of the lung, severe corneal damage, and death. Survivors of acute exposures may exhibit long-term respiratory and ocular effects. Methyl isocyanate may be a dermal and respiratory sensitizer.
• There is no antidote for methyl isocyanate. Treatment consists of removal of the victim from the contaminated area and support of respiratory and cardiovascular functions.
Decontamination Area Previously decontaminated patients and those exposed only to methyl isocyanate gas who have no skin or eye irritation may be transferred immediately to the Critical Care Area. Others require decontamination as described below.
Be aware that use of protective equipment by the provider may cause anxiety, particularly in children, resulting in decreased compliance with further management efforts.
Because of their relatively larger surface area:body weight ratio, children are more vulnerable to toxins absorbed through the skin. Also emergency room personnel should examine children’s mouths because of the frequency of hand-to-mouth activity among children.
ABC Reminders Evaluate and support the airways, breathing, and circulation. Provide supplemental oxygen if cardiopulmonary compromise is suspected. Treat cases of respiratory compromise with respiratory support using protocols and techniques available and within the scope of training. Some cases may necessitate procedures such as endotracheal intubation or cricothyrotomy by properly trained and equipped personnel.
Treat patients who have bronchospasm with oxygen, aerosolized bronchodilators such as albuterol, and/or steroids according to established protocol.
ATSDR • Emergency Department Management 15 Methyl Isocyanate 75 Children may be more vulnerable to corrosive agents than adults because of the smaller diameter of their airways.
Consider racemic epinephrine aerosol for children who develop stridor. Dose 0.25–0.75 mL of 2.25% racemic epinephrine solution, repeat every 20 minutes as needed, cautioning for myocardial variability.
In cases of non-cardiogenic pulmonary edema, which may be delayed in onset, maintain adequate ventilation and oxygenation. Mechanical ventilation and positive-end-expiratory pressure (PEEP) may be required. To minimize barotrauma and other complications, use the lowest amount of PEEP possible while maintaining adequate oxygenation. Consider drug therapy for pulmonary edema. Keep in mind that the use of steroids to prevent or treat chemical pneumonitis and pulmonary edema is controversial.
Patients who are comatose, hypotensive, or are having seizures or cardiac arrhythmias should be treated in the conventional manner.
Basic Decontamination Patients who are able may assist with their own decontamination.
Because methyl isocyanate can cause burns, ED staff should don chemical-resistant jumpsuits (e.g., of Tyvek or Saranex) or butyl rubber aprons, rubber gloves, and eye protection if the patient’s clothing or skin is wet. After the patient has been decontaminated, no special protective clothing or equipment is required for ED personnel.
Quickly remove contaminated clothing while gently washing the skin with soap and water. Double-bag the contaminated clothing and personal belongings. Handle burned skin with caution.
Wash exposed skin thoroughly with soap and water. If pain or injury is evident, continue irrigation while transferring the victim to the Critical Care Area. Use caution to avoid hypothermia when decontaminating children or the elderly. Use blankets or warmers when appropriate.
Flush exposed or irritated eyes with copious amounts of tepid water for at least 15 minutes. Remove contact lenses if easily removable without additional trauma to the eye. If pain or injury is evident, continue irrigation while transferring the victim to the Critical Care Area.
16 Emergency Department Management • ATSDR Methyl Isocyanate76 In cases of ingestion, do not induce emesis. If the victim is not symptomatic, consider administering activated charcoal at a dose of 1 g/kg (infant, child, and adult dose). A soda can and straw may be of assistance when offering charcoal to a child. However, the effectiveness of activated charcoal in binding methyl isocyanate has not been demonstrated.
If the victim is conscious and able to swallow, consider giving 4 to 8 ounces of water.
Critical Care Area Be certain that appropriate decontamination has been carried out.
ABC Reminders Evaluate and support the airways, breathing, and circulation as in ABC Reminders above. Establish intravenous access in seriously ill patients. Continuously monitor cardiac rhythm.
Patients who are comatose, hypotensive, or are having seizures or cardiac arrhythmias should be treated in the conventional manner.
Inhalation Exposure Administer supplemental oxygen by mask to patients who have respiratory complaints. Treat patients who have bronchospasm with aerosolized bronchodilators such as albuterol and/or steroids.
In cases of non-cardiogenic pulmonary edema, which may be delayed in onset, maintain adequate ventilation and oxygenation.
Monitor arterial blood gases and/or pulse oximetry. If a high FIO2 is required to maintain adequate oxygenation, mechanical ventilation and positive-end-expiratory pressure (PEEP) may be required. To minimize barotrauma and other complications, use the lowest amount of PEEP possible while maintaining adequate oxygenation. Consider drug therapy for pulmonary edema. Keep in mind that the use of steroids to prevent or treat chemical pneumonitis and pulmonary edema is controversial. Antibiotics should be used as indicated to control infection. Damaged lower respiratory tissue might be more susceptible to infection.
Skin Exposure If concentrated methyl isocyanate is in contact with the skin, chemical burns may result; treat as thermal burns.
Because of their relatively larger surface area:body weight ratio, children are more vulnerable to toxicants that affect the skin.
Eye Exposure Continue irrigation for at least 15 minutes. Test visual acuity. Examine the eyes for corneal damage and treat appropriately.
ATSDR • Emergency Department Management 17 Methyl Isocyanate 77 Immediately consult an ophthalmologist for patients who have suspected severe corneal injuries.
Ingestion Do not induce emesis. Consider endoscopy to evaluate the extent of gastrointestinal-tract injury. Extreme throat swelling may require endotracheal intubation or cricothyrotomy. Gastric lavage is useful in certain circumstances to remove caustic material and prepare for endoscopic examination. Consider gastric lavage with a small nasogastric (NG) tube if: (1) a large dose has been ingested; (2) the patient’s condition is evaluated within 30 minutes; (3) the patient has oral lesions or persistent esophageal discomfort; and (4) the lavage can be administered within 1 hour of ingestion. Care must be taken when placing the gastric tube because blind gastric-tube placement may further injure the chemically damaged esophagus or stomach.
Because children do not ingest large amounts of corrosive materials, and because of the risk of perforation from NG intubation, lavage is discouraged in children unless intubation is performed under endoscopic guidance.
If the victim is not symptomatic, consider administering activated charcoal at a dose of 1 g/kg (infant, child, and adult dose). A soda can and straw may be of assistance when offering charcoal to a child. However, the effectiveness of activated charcoal in binding methyl isocyanate has not been demonstrated.
Consider giving 4 to 8 ounces of water to alert patients who can swallow, if not done previously.
Antidotes and Other Treatments There is no antidote for methyl isocyanate. Treatment is supportive of respiratory and cardiac functions.
Laboratory Tests Routine laboratory studies include chest radiography and pulse oximetry (or ABG measurements). Disposition and Follow-up Consider hospitalizing symptomatic patients who have evidence of respiratory or cardiac distress or significant chemical burns.
Delayed Effects Acute exposure to high concentrations of methyl isocyanate may result in delayed onset of pulmonary edema and risk of secondary infection of the lungs or eyes.
18 Emergency Department Management • ATSDR Methyl Isocyanate78 Patient Release Patients who become totally asymptomatic in terms of pulmonary complaints in a 72-hour observation period are not likely to develop complications. They may be released and advised to rest and to seek medical care promptly if symptoms develop (see the Methyl Isocyanate—Patient Information Sheet below). Cigarette smoking can exacerbate pulmonary injury and should be discouraged for 72 hours after exposure.
Follow-up Obtain the name of the patient’s primary care physician so that the hospital can send a copy of the ED visit to the patient’s doctor.
Follow-up evaluation of respiratory function should be arranged for severely exposed patients. Patients who have skin or corneal lesions should be reexamined within 24 hours.
Reporting If a work-related incident has occurred, you might be legally required to file a report; contact your state or local health department.
Other persons might still be at risk in the setting where this incident occurred. If the incident occurred in the workplace, discussing it with company personnel might prevent future incidents. If a public health risk exists, notify your state or local health department or other responsible public agency. When appropriate, inform patients that they may request an evaluation of their workplace from the Occupational Safety and Health Administration (OSHA) or the National Institute for Occupational Safety and Health (NIOSH). See Appendix III for a list of agencies that may be of assistance.
ATSDR • Emergency Department Management 19 Methyl Isocyanate79
Methyl Isocyanate (C2H3NO ) Patient Information Sheet
This handout provides information and follow-up instructions for persons who have been exposed to methyl isocyanate.
What is methyl isocyanate? Methyl isocyanate is a very flammable liquid that readily evaporates when exposed to air. Methyl isocyanate liquid is colorless with a pungent odor. The primary use of methyl isocyanate is as a chemical intermediate in the production of pesticides. It is also used to produce polyurethane foams and plastics. It is shipped and handled as a flammable and explosive liquid in a special container.
What immediate health effects can be caused by exposure to methyl isocyanate? Methyl isocyanate vapors are severely irritating and corrosive to the respiratory tract and eyes. Symptoms may include cough, chest pain, shortness of breath, watery eyes, eye pain (particularly when exposed to light), profuse lid edema, and corneal ulcerations. Respiratory symptoms such as pulmonary edema and bronchial spasms may occur in immediate response to exposure or develop and progress in severity over a period of hours to days post-exposure. Acute exposure to very high concentrations may be quickly fatal due to respiratory failure. Methyl isocyanate is a skin irritant and may cause chemical burns upon dermal contact.
Can methyl isocyanate poisoning be treated? There is no antidote for methyl isocyanate, but its effects can be treated. Persons who have inhaled large amounts of methyl isocyanate would most likely need to be hospitalized. Persons who have come into direct skin or eye contact with methyl isocyanate liquid or vapors may need to be treated for chemical burns or serious eye injury.
Are any future health effects likely to occur? A single exposure from which a person recovers quickly may not result in long-term health effects. However, some respiratory and eye damage may persist for a long time after exposure to methyl isocyanate. The chemical may also be a dermal and respiratory sensitizer, causing reactive responses upon subsequent exposures.
What tests can be done if a person has been exposed to methyl isocyanate? Specific tests for the presence of methyl isocyanate in blood or urine are not generally useful. If a severe exposure has occurred, blood analyses, x-rays, and breathing tests might show whether the lungs have been injured.
Where can more information about methyl isocyanate be found? More information about methyl isocyanate can be obtained from your regional poison control center; your state, county, or local health department; the Agency for Toxic Substances and Disease Registry (ATSDR); your doctor; or a clinic in your area that specializes in occupational and environmental health. If the exposure happened at work, you might be required to contact your employer and the Occupational Safety and Health Administration (OSHA), or the National Institute for Occupational Safety and Health (NIOSH). Ask the person who gave you this form for help locating these telephone numbers.
ATSDR • Patient Information Sheet 21 Methyl Isocyanate 80 Follow-up Instructions Keep this page and take it with you to your next appointment. Follow only the instructions checked below.
[ ] Call your doctor or the Emergency Department if you develop any unusual signs or symptoms within the next 24 hours, especially: ? eye, nose, throat irritation ? coughing or wheezing ? difficulty breathing or shortness of breath ? chest pain or tightness ? nausea, vomiting, diarrhea, or stomach pain
[ ] No follow-up appointment is necessary unless you develop any of the symptoms listed above. [ ] Call for an appointment with Dr. in the practice of . When you call for your appointment, please say that you were treated in the Emergency Department at Hospital by and were advised to be seen again in days. [ ] Return to the Emergency Department/ Clinic on (date) at AM/PM for a follow-up examination. [ ] Do not perform vigorous physical activities for 1 to 2 days. [ ] You may resume everyday activities including driving and operating machinery. [ ] Do not return to work for days. [ ] You may return to work on a limited basis. See instructions below. [ ] Avoid exposure to cigarette smoke for 72 hours; smoke may worsen the condition of your lungs. [ ] Avoid drinking alcoholic beverages for at least 24 hours; alcohol may worsen injury to your stomach or have other effects. [ ] Avoid taking the following medications: [ ] You may continue taking the following medication(s) that your doctor(s) prescribed for you:
[ ] Other instructions:
• Provide the Emergency Department with the name and the number of your primary care physician so that the ED can send him or her a record of your emergency department visit.
• You or your physician can get more information on the chemical by contacting: or , or by checking out the following Internet Web sites: ; .
Signature of patient Date
Signature of physician Date
22 Patient Information Sheet • ATSDR 81 Annexure P-9 Proposal 2010
Summary
This document attempts to establish the critical nature of the corpus fund worth Rs 500 Crore needed by GoMP from GoI for meeting the cost of further strengthening and augmenting the medical facilities currently being provided by GoMP to those individuals and their dependents that were affected by the Bhopal Gas Tragedy. The need for this fund is necessitated on both moral and legal grounds. On one hand GoMP stands committed to provide medical facilities to the Bhopal Gas Victims to the maximum extent possible while on the other hand it needs to meet legal obligation on behalf of GoI of catering to the medical needs of the victims and their dependents, free of cost, for all times to come and for any ailment whether or not they arise owing to inhalation of MIC. The need for the corpus funds is necessitated not only because of the burgeoning number of patients but also due to the resources required to provide medical care for serious ailments like Cancer, Renal failure, congenital diseases etc. Cost of providing both one- time treatment and the consequent follow-up for most of these diseases is exorbitant and needs to be met urgently.
GoMP intends to use the income from corpus funds to meet only the productive expenditure that directly meets the diagnostic and treatment needs of the patients, rather than meeting the administrative cost of providing the services.
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1. Background
A. The Bhopal Gas Disaster
The Bhopal Gas disaster is one of the world’s worst industrial catastrophe. It occurred on the night of December 2-3, 1984 at the Union Carbide India Limited (UCIL) pesticide plant in Bhopal, which was the Indian subsidiary of Union Carbide Corporation, USA. This tragedy occurred due to leak of Methyl Iso Cynate (MIC) and other chemicals from tank No. 610 where MIC was stored, due to ingression of water, and the resulting reaction. The medical professionals at Bhopal faced a situation which was unparalleled in the annals of medical history. Huge numbers of affected persons thronged the corridors of the hospitals; gasping for breath, frothing at mouth, congested watery eyes, unable to see clearly, retching and vomiting with fear and panic written large on their face. The ICMR estimated that out of a total 832904 population of Bhopal, 5, 21, 262 (62.58%) suffered from inhalational toxicity while 311642 (37.42%) escaped the effect of toxic gas. It was estimated that approximately 2000 exposees died in the first 72 hours and large proportion of the survivors suffered acute multi system morbidities- eyes and lungs being the main target organs. An estimate suggested that approximately 1, 00,000 persons residing in areas close to the Union Carbide Factory would have been exposed to relatively higher concentration of the potentially lethal toxic gas than the areas farther away. Predictably, a large proportion of population which survived this tragedy developed morbidity of varying degrees over the last 25 years.
B. Impact
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Spatial Impact
In terms of spatial distribution, out of the total 56 municipal wards in Bhopal, 36 wards were affected by the gas MAP OF BHOPAL SHOWING 56 MUNCIPAL WARDS AS ON 1984 UCIL tragedy. Of these 2 wards were J.P. NAGAR severely affected, 5 were RAILWAY STATION moderately affected and 29 were mildly affected. The remaining 20 wards were largely unaffected by the gas UCIL leak. A total of 5.74 lac persons
------GAS AFFECTED AREA were affected as a result of the tragedy. . 4
A brief profile of these wards is presented in the annexure.
Health Impact
The following initial observations1 were made with respect to the impact of Gas Tragedy on the population; The observed mortality and morbidity pattern clearly indicated that the toxic gas was potentially lethal and may cause many more deaths and diseases in the near and distant future. It was most disturbing that nothing was known about the exact composition of the toxic gas or its antidotes.
1 Synopsis of Technical Report on Population Based Long Term Clinical Studies, ICMR.
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MIC being a highly reactive chemical may adversely affect the pregnancy outcome, causing abortion, still births or congenital anomalies. There was also the possibility of incidence of cancer going up. A large number of exposees may suffer from chronic, progressive multi system morbidities and disabilities for a long time or entire life, it was feared! It was necessary to conduct clinical and epidemiological research studies to understand the etiopathogenesis and natural history of the morbidities caused, so that the rational method of therapy and prevention of serious disabilities could be evolved. There was an urgent need to strengthen, upgrade or create new medical and epidemiological research facilities in Bhopal.
C. Government Response
As an immediate relief, the state government provided financial support to affected families. To this effect, Rs. 12.80 crores was distributed amongst the affected families as immediate relief. In addition to this Rs. 19.20 crore worth of milk and grain was distributed free of cost amongst the affected families. Rs. 0.25 crore was spent as compensation for livestock lost and Rs. 37.8 crore was given to 3.78 Lac families of a deceased as compensation.
Till 1990, the state government spent Rs. 67.24 crores on the rehabilitation of the gas affected families from its own resources. Out of this Rs. 26.76 crores was spent on medical rehabilitation.
In the year 1990, first five year action plan worth Rs. 258 crores was sanctioned with a 75:25 share between centre and the state. This action plan was later extended till 1999. BGTRRD, GoMP Page4 85 Proposal 2010
This plan provided for Rs. 150.35 crore for medical rehabilitation in addition to economic rehabilitation (Rs. 21.18 crore), social rehabilitation (Rs. 49.72 crore) and environmental rehabilitation (23.76 crore).
After 1999 all the necessary expenditures related with rehabilitations have been borne by the state government. It has made expenditure to the tune of Rs. 321.22 (as on October 2010) from its own resources. Of the total expenditure made towards rehabilitation, about 85% (i.e. Rs. 273.78 crores) has been spent on medical rehabilitation.
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2. Status of Medical Rehabilitation
The following section details the present status of infrastructure available to the gas patients. The section also presents an insight into the pressure on services being provided to the group.
A. Infrastructure
In the year 1985, the Bhopal Gas Relief and Rehabilitation Department was set up. The department subsequently established 6 big multi specialty hospitals and 9 day care centre;
Specialty Hospitals The following table presents a list of hospitals providing specialty medical care to the affected population. These hospitals have been recording 100% occupancy against the bed strength. Additionally, in OPDs a doctor sees about 100-150 patients a day against a standard of 30 patients per day per doctor. This indicates towards a heavy patient pressure in these hospitals.
Also, with the given patient pressure and need for catering to changing disease profile, increasing strength of ICU and ICCU has been proposed.
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Table: List of Hospitals S. No. Hospitals Specialty No. of Bed 1 Kamla Nehru Hospital Super Specialty 219 2 Indira Gandhi Women & Children Hospital Women and Children 150 3 Jawaharlal Nehru Hospital Multi- Specialty 125 4 RAS Pulmonary Medicine Centre Respiratory Diseases 50 5 Khan Shanker Ali Khan Hospital General Hospital 60 6 Master Lal Singh Hospital General Hospital 30 Total 634
Day Care Units The following table presents the list of day care units. These units have been placed in the gas affected localities to provide them with local centers for primary medical care. These centers require improved diagnostic and treatment facilities. Due to the limitation of the same, the patients have to visit the secondary and tertiary medical facilities leading to increasing pressure on the specialized facilities. This limitation in diagnostic facility at the primary centers also has an adverse effect on the early detection and treatment of serious ailments amongst the gas affected families.
Table: List of Day Care Units S. No. Day Care Unit S. No. Day Care Unit 1 K.N. Pradhan 6 Ibrahimganj 2 Putligarh 7 Rukma Bai 3 Bag Umrao Dulha 8 Ashoka Garden 4 Karond 9 Lal Bahadur Shastri 5 Kushabau Thakre, Narela Shankari
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Indian System of Medicine Dispensaries In addition to the above, 9 institutions of Indian system of medicines including 3 dispensaries each of Ayurvedic, Homeopathic and Unani have been set up as indicated below:
Table: List of Dispensaries S. No. Location S. No. Location S. No. Location Ayurvedic Dispensaries 1 Lalghati 2 Tila Jamalpura 3 Chandbad Homeopathy Dispensaries 1 Kabitpura 2 Nariyalkheda 3 Tila Jamalpura Unani Dispensaries 1 Chhavni 2 Rafiquia 3 Kazi Camp
Bhopal Memorial Trust along with 8 mini unit was also set up to cater to the primary as well as specialty needs of the gas affected population of the city of Bhopal. These 33 medical units which provide medical assistance from primary to super specialty levels to the gas victims form a chain of hospitals whose density is one of the highest of government hospitals in any city outside the metros in the country.
B. Services
The total number of patients in attendance in OPDs in various gas related hospitals comes to over a million in a year. The average daily attendance in the OPD in the various units of Bhopal Gas Rehabilitation Hospitals is 3600. The average indoor attendance over the last 15 years has been approximately 32784. The annual total investigations carried by these hospitals of the Bhopal Gas Rehabilitation Department are approximately 2, 69, 355. The BGTRRD, GoMP Page8 89 Proposal 2010
following sub section presents the pressure on various services provided by the medical institutions.
Patient Pressure The patient data of Gas Relief Medical Institutions is presented below. The table suggests an annual total OPD patients of around 12.5 Lacs with a daily average of about 3500 patients and In- patients of around 30, 000.
Table: Patient Data of Gas Relief Medical Institutions S. Year Number of OPDs Daily No. of In No. New Patients Old Patients Total Patients Average Patients 1 2009 734963 368050 1103013 3628 28342 2 2010* 690018 367019 1057037 3477 23774
*Up to October 2010.
Medical Investigations The facilities and the number of key medical investigations done at the centers are presented in the tables below. However, a lot of equipments and machineries require further editions in terms of numbers, maintenance and replacement. Also, there is a strong need
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to further develop capacities in areas where an early detection can help in reducing the overall cost of treatment such as cancer etc.
Table: Medical Investigations done at the Hospitals in FY 2009-10 up to October 2010. PFT Ultra- E.C.G. Echo- X-Ray Endosc Dialysis C.T. Sonography Cardiograph opy Scan 148 10294 9003 815 24218 1110 624 2088
The following table presents the pathology investigations undertaken in the hospitals.
Table: Pathology Investigations done at the Hospitals in FY 2009-10 up to October 2010. Blood Urine Stool Sputum Bio- Serology Bacteriology chemistry 106366 53553 543 4248 55817 6254 -
C. Research
In the initial period after the gas tragedy, there was very little information available about the effect of the gas on human body. This posed the treatment of patients as a major challenge. GoMP took the initiative and invited ICMR, New Delhi which in collaboration with Gandhi Medical College initiated about 24 research projects. The financial support for the research was provided by ICMR. After the scientific research the panel of scientists produced a working manual and the same is being utilized for treatment of the patients.
The Indian Council for Medical Research (ICMR) launched a series of long term Epidemiological and Clinical studies in the year 1985 and this went on till December, 1994. These ICMR studies were on 22 different subjects regarding long term effect and
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impact of the gas leakage. ICMR also established a population based cancer registry in the department of Pathology, Gandhi Medical College, Bhopal, to estimate the instances of cancer to the affected population and also the population of rest of Bhopal.
After May 1995, the Government of Madhya Pradesh set up a separate research centre under Gas Relief Department named as Center for Rehabilitation Studies for carrying out medical research and to coordinate other research activities with other institutions on the subject.
Broadly, research has been taken up on the following aspects under the Center for Rehabilitation Studies; a. Research on ailments in new born children. b. Epideomological studies related with alleged water pollution around the factory. c. Analysis of statistics related with the hospitals. d. Studies related with pubertal growth e. Study of persons severely affected by gas f. Cancer Survey g. Study related with eye ailments h. Study related with newly born children
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3. Disease Profile and Trends
This section presents the disease profile amongst the gas victims as evident in the short term and the changing trends in the disease profile in the long run.
A. Disease Profile and Trends
As discussed before, ICMR conducted several population based long term technical clinical studies between 1985 and 1994. The key findings of these reports are presented below; i. In the acute phase of toxic gas exposure, 99% of the severely exposed patients suffered from breathlessness, cough, ocular symptoms and abnormal chest radiographs. They improved with time. ii. Lung histopathology in 3 open lung biopsies after 3-4 months showed alveolar, bronchial and peri-bronchial lesions in the form of inflammation, destruction and fibrosis. iii. In the sub-acute phase, impairment of lung function could also be demonstrated. iv. A single one time inhalation of MIC/ toxic gas in a group of 119 severely exposed patients produced acute inflammation of airways and alveoli. The healing of acute lung injury resulted in alveolo-pleural fibrosis and airway constricting lesions much more in the peripheral / small airways less than 2 mm internal diameter than the central airways. Pulmonary disability was caused due by reduced FEV, psychogenic factors, physiological de-conditioning and malnutrition. In the future, such patients with evidence of residual lung damage might run a clinical course similar to COPD, with recurrent respiratory illnesses. v. Acute exposure to MIC/ toxic gas resulted in alveolar and interstitial pulmonary oedema, inflammatory, bronchial and peri-bronchial lesions in chest radiographs- the BGTRRD, GoMP Page12 93 Proposal 2010
extent of lesions apparently was determined by severity of exposure. Following the exposure the chest radiographs started showing evidence of clearance. However, in the chronic phase, a proportion of cases were left with residual lesions, consisting of alveolar, interstitial, peri bronchial inflammation, destruction, fibrosis and airway narrowing. vi. Study of a large sample of toxic gas exposed subjects compared with unexpected subjects suggested the following clinical diagnosis: Exposed vs Controls: chronic bronchitis – 17% vs 7%; bronchial asthama- 12% vs 5% classified as “Reactive airway dysfunction syndrome (RADS)”; unspecified lung disease including small airway disease- 57% vs 0.2%; pulmonary tuberculosis- 2% vs 1%. vii. In the immediate post exposure period, nearly 50% of the population including children suffered from mental health problems. Most of them recovered. Five years follow-up studies revealed that the prevalence rates of psychiatric disorders were several times higher in the exposed areas than the control areas. These were higher in women than men, as also in higher than lower age groups. Though reduced, prevalence rates were still 3 times higher in exposed areas than control areas. viii. The long term ocular morbidity studies showed that the toxic gas exposed resulted in ocular changes namely trachoma, chronic irritative conjunctivitis, corneal opacities, cataract – complicated in some cases with poly chromatic lustre and fundus abnormalities.
B. Change in Disease Profile
Based on the various epidemiological and clinical studies which have been carried out in the past 25 years as well as evidences that is emerging on a continuous basis, is briefly presented below;
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i. Long term population based cancer registry has shown that there are over 3000 cancer patients who have developed this disease as a result of the gas tragedy. Similarly there are nearly 2000 patients of chronic renal failure who require specialized and high cost medical assistance. ii. The MIC leak has its greatest impact on the respiratory systems. The number of people suffering from respiratory related diseases is more than 1, 00,000. This is supported by the studies carried out by the ICMR and various other research agencies and NGOs operating in the field in Bhopal. These patients require continuous monitoring treatment due to their reduced physical capacity because of permanent pulmonary problems. iii. Continuous research has shown neurological deficiencies and Psychiatric disorders of almost 20 to 25% of the gas victims which exists as a concomitant co-morbidity amongst the gas affected population. iv. Gastroenteritis, renal failure and cardiac diseases are rampant amongst the gas affected population. The incidence of these non-communicable diseases is much higher amongst the Bhopal Gas affected population than those of the normal population. v. The studies done by the Centre for Rehabilitation Studies, Bhopal, in a report submitted in August, 2006 indicates that incidence of Lung Eye, GIT and General morbidities is 4 to 5 times more amongst the gas affected population than that of the people living in a control area in the city of Bhopal. vi. Recent studies carried out by several NGOs and that of similar medical research has shown that due to toxic waste dumped by the Union carbide factory within the campus, the water around the carbide factory has got polluted and this has resulted in a large number of congenital malformation and this requires continuous and specialized treatment to these children. There is a plan to establish a congenital
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malformation registry so that this category of children can be looked after, scientifically.
In addition to the above facts, it is also appreciated that even the general immunity status of the affected population has been comprised causing very high infection rate and therefore, medical rehabilitation on a continuous basis needs to be carried out over the next several years.
The detail of morbidity pattern and disease profile is presented in the annexure.
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4. Latest Action Plan
This section details the recent support provided, resource allocation by the state government and resource gap for medical rehabilitation to the extent that is appropriate and desired for the gas affected population. The Chemical and Petro-Chemical Department of the GoI sanctioned an action plan in 2008 submitted by BGTTRRD, GoMP. The detail of the sanctioned amount is as follows;
Table: Details of the Latest Action Plan S. No. Item Amount (in Rs Crore) 1 Medical Rehabilitation 33.55 2 Social Rehabilitation 85.20 3 Economic Rehabilitation 104.00 4 Water Supply 50.00 Total 272.75
Out of the 272.55 crores, 33.55 crores were provided under the medical rehabilitation head.
Details of the Medical Rehabilitation Plan The following sub-section provides details of the estimates under the medical rehabilitation head and primarily covers the different equipments proposed under the action plan. The following table presents the hospital-wise sanctioned budget. (Figures in Rs. Crore) S Name of Hospital Specialty Building Furniture Equipments Total N & Fixture
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1 Rasool Ahmed Respiratory 0.40 0.10 2.05 2.55 Siddiqui P.M.C Disease 2 Indira Gandhi Women & Child 0.10 0.50 0.74 1.34 Hospital 3 Jawaharlal Nehru Multi-Speciality 0.40 0.10 3.62 4.12 Hospital 4 Shakir Ali Khan General Hospital 0.40 0.15 2.00 2.55 Hospital 5 Master Lal Singh General Hospital 0.10 0.20 0.69 0.99 Hospital 6 Kamla Nehru Super Speciality 0.50 1.15 19.12 31.27 Hospital Hospital Total 1.90 1.15 28.22 31.27 Medical Research 2.28 Grand Total 33.55
Out of the Rs. 33.55 crores, Rs. 28.22 crores will be spent on medical equipment only for improving the medical services at the hospitals. The hospital-wise department-wise list of equipments is presented as follows;
Kamla Nehru Hospital i. Nephrology Department (Figures in Rs Lacs) S.N Name of Equipment Cost 1 New Dialysis machines 32.00 2 Dialysis Chairs – 4 4.00 3 Blood Gas Analyser with Hb. Electrolyte attachment – 1 7.00 4 R.O. Plant 500 Ltrs./Hr. with tullu pump – 1 2.00 5 Multiparameter Cardiac Monitors – 4 12.00 6 Autoprocessor clean dialysis – 2 8.00
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7 Computer System with printer – 1 0.50 8 One separate power backup/generator for dialysis unit 5.00 Total 70.50 ii. Pathology Department (Figures in Rs. Lakhs) S.N. Name of Equipment Cost 1 Blood Cell Counter 5 part 12.50 2 Automatic Bacteria detection instrument 23.00 3 Identification & Sensitivity of Bacteria 14.00 4 Semiautomatic kemi-illumination instrument 5.00 5 Laminar Air Flow, Autoclave (Vertical- Double drum) 2.00 Microscope ( non- ocular & Binocular Both) Total 56.50 iii. I.C.U. (Figures in Rs. Lakhs) S.N. Name of Equipment Cost 1 Ventilators – 10 100.00 2 Fowler’s Bed with cardiac ventilation support- 10 10.00 3 Cardiac Monitors SPO2 NIBP, Resp & CVP 30.00 4 Central Monitor – 1 5.00 5 Cardiac Colour Doppler machine with USG attachment & Vascular 100.00 & S4, S* Flat & other probes 6 Defibrillator cum Monitor - 2 6.00 7 Aortic Balloon Pump - 1 10.00 8 Blood Gas Analyzer with Hb. & Electrolyte attachment 8.00 9 Pulmonary Function Test 2.00 10 Holtor Monitoring system – 1 3.00 11 TMT machine 3.00 12 Central Oxygen System (all wards & units) 100.00 13 C-arm 20.00 14 Portable X-ray 2.00 15 Syringe & IV Infusion Pump - 10 4.00 16 Autoclave – 1 0.20 17 Minor Equipment such as BP instruments etc. 5.00 BGTRRD, GoMP Page18
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18 Computer with Printer, scanner etc. 1.00 19 Hospital and General Furniture 5.00 20 Recurring expenses on consumable & other Supplies 21 Ambulance Support One – Cardiac Ambulance having Ventilator & 50.00 Defibrillator 22 Central Air- conditioning 5.00 Split A.C. System 20 Tons Total 469.20 iv. Radiology Department (Figures in Rs. Lakhs) S.N. Name of Equipment Cost New Equipment 1 MRI 1-5 system with accessories 500.00 2 Digital Radiography system with IITV & Standing Buck with 80.00 accessories 3 4-D Colour Doppler unit with Biopsy attachment to convex linear & 60.00 TV/ TR porbes & Colour printer 4 Digital mammography unit with Sterotactic Biopsy attachment 80.00 5 Orthopurtotomogram 40.00 6 Mobilt 100 mA X-ray Unit- 2 10.00 Upgradation 7 C.R. System existing 300 mA X-ray units 50.00 8 P.C. with printer 0.40 9 Recent Text Books and International journals on CT/MRI/ Ultrasound/ 15.00 Doppler/ Radiology/ Intervention Radiology (lacs per year) 25.00 Total 860.40 v. Opthalmology Department (Figures in Rs. Lakhs) S.N. Name of Equipment Cost 1 Digital Fluorescein Angiography unit with fundus camera of Carl/ 50.00 Zeiss make or equivalent 2 O.C.T. ( optical coherence tomography 25.00 3 Operating Microscope with zoom magnification with x-y compiling 50.00 with post segment attachment lens BIOME
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4 Posterior Vitrectomy machine 6.00 5 Cold Phaco machine unit or legacy/ oertelli 25.00 6 INOR’s surgical instrument for ophthalmic surgeries (list attached) 5.00 7 Endolaser for sac surgery 5.00 8 Direct ophtalmoscope 6 units (B 200) with rechargeable batteries 0.70 9 Synaptophore (Keeler) 2.00 10 Goniscope- single mirror- 2, Pan fundus lens- 2 1.00 11 Corneal Topography 10.00 12 Lasik Laser for refractive surgery (complete unit) 200.00 Total 379.70
Indra Gandhi Hospital
Department wise estimate- (Figures in Rs. Lakhs) Item/ Department Approximate cost Centralized Oxygen supply 25.00 Two Elevators 60.00 Establishment of Microbiology Lab Equipment 0.94 Reagents 0.55 Up-gradation of Biochemistry Lab Equipment 7.00 Radiology 56.00 Operation Theatre 24.00 Labor Room 05.00 Pediatrics 5.50 Total 183.00 i. Microbiology Lab, Operation Theatre and Radiology Department (Figures in Rs. Lakhs) S.No. Name of Equipment Cost
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1 Incubator 37 degree centigrade – 2 0.20 2 Hot Air oven- two 0.20 3 Autoclave – 2 0.10 4 Terminal Flow 0.20 5 Gas Stove with cylinder- 2 0.10 6 Almirah – 3 0.05 7 Reagents Glass wares and other disposable 0.54 8 Semi Auto analyzer – 2 4.00 9 Calorimeter – 1 0.20 10 Air Cooler – 2 0.12 11 Inverter with battery – 2 0.40 12 A.C. – 4 1.00 13 Honda Generator electric 1.25 14 O. T. Table Hydrolic-2 6.20 15 Boyles apparatus – 2 0.10 16 Resuction Unit – 1 1.20 17 Formaline Vapour Box, Suction machine, revolving stool, 0.81 steel basin, patient monitor system, surgical drum, steel bucket, 18 Shadow less light 0.70 19 Hydrolic door closer – 4 0.04 20 New Born Ambu bag – 4, Aqua guard, desert cooler, 1.04 refrigerator, Split A.C., Window A.C. Kooker Curved Code No. 6 21 Pulse Oxymeter – 2 1.00 22 Defibrillator 2.00 23 Colour Doppler with TVS probe with Printer 30.00 24 Digital X-ray Machine – 1 15.00 25 Almirah &Furniture including sonography tables 5.00 Total 71.45
ii. Pulmonary Medicine Center (Figures in Rs. Lakhs) BGTRRD, GoMP Page21
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S.No. Name of Equipment Cost List of Obsolete Equipments and Cost of Replacement 1 TMT Machine 25.00 2 PFT Machine 25.00 3 Color Doppler with all prove & Biopsy attachment with 30.00 digital camera 4 Five multipara monitors(Oxygen saturation, ECG 6.75 tracings, Heart rate, Noninvasive blood pressure 5 Arterial blood gas analyzer 3.00 6 Trade mill with monitors for heart rate, calorimeter and 1.25 milometer 7 Ergo meter(cycle) with monitor 1.25 Total 92.25 Purchase of Equipments 1 Ambu bag 0.21 2 Portable X-Ray machine 1.30 3 Digital X-Ray machine with IITV & with Accessories 48.00 4 Laryngoscopes 0.24 5 Central Oxygen Supply 25.00 6 Pulse oxymeter – 4 0.82 7 ECG machine with computerized interpretation Model 2.20 No. 8408 BPL 8 Adjustable ICU beds-12 0.60 9 One portable spirometer 0.05 10 Generator for continuous power supply 5.00 11 Haemotology Analyser 1.50 12 Vibrator 0.06 13 Short wave diathermy 0.21 14 Shoulder wheel 0.06 15 Respiratory Exerciser Electronic 0.38 16 Digital photo Kelorimeter 0.25 17 Intercom (12 line) 0.20 18 Inverter 1500 watt – 10 No 2.00 19 AC 1.5 Ton – 10 & AC 2.0 Ton – 6 8.00 20 Tubewell 1.50 21 Almirah -12 No. 0.60 22 Photocopier Machine 1.50 23 Furniture/fixtures including chairs, tables, cabinates 20.00 etc. for all the rooms. BGTRRD, GoMP Page22
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Total 113.86
Jawaharlal Nehru Hospital (Figures in Rs. Lakhs) S.No. Name of Equipment Cost 1 Chemistry analyzer 2.00 2 Microscope- 2 0.40 3 Opthalmoscope 0.15 4 C-Arm 2.00 5 Dental Chair 5.00 6 Colour Doppler 18.00 7 Digital X-ray Machine 20.00 8 Portable X-ray machine 1.30 9 C.T. Scan 200.00 10 Ventilator 10.00 11 Monitor with Central Station 25.00 12 Pulse Oxymeter 1.00 13 Bayles apparatus 2.00 14 Twins Ceiling Light (O.T. Light ) 1.00 15 O.T. Table Hydrolic 2.00 16 Ambulance- 2 5.40 17 ICU beds 3.00 18 Oxygen Cylinder 0.45 19 Stretcher 0.10 20 Diathermy machine 1.00 21 Computer 1.20 22 Photocopy machine 1.00 23 Fax Machine 0.07 24 Fridge- 3 0.60 25 De-Freezer 0.45 26 Generator-2 2.00 27 Fire Extinguisher- 40 1.00 28 Furniture for Canteen, Patients waiting hall, Library, 50.00 enquiry room, meeting hall etc. 29 Lift- 2 ( construction and installation 5.00 Tolal 361.12
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Master Lal Singh Hospital (Figures in Rs. Lakhs) S.No. Name of Equipment Cost 1 Digital x-ray machine including furniture and 20.00 fixtures 2 Colour Doppler including furniture and fixtures 16.00 3 Spectro meter including furniture and fixtures 1.00 4 Computerized Cell counter 2.50 5 Culture Auto clave 2.50 6 Pathology Lab including furniture and fixtures 1.50 7 16 Channel ECG Machine 2.50 8 Pulse Oxymeter 2.50 9 Multi channel Cardiac monitor with accessories 0.60 10 Mechanical Syringe with other accessories 1.50 11 Portable Defibrillator with accessories 3.50 12 Blood Gas Monitor 3.50 13 Electrolyte monitor 2.50 14 Central Oxygen Supply 2.50 15 Generator 3.50 16 Furniture and repair of furniture 1.00 Total 66.60
Khan Shakhir Ali Khan Hospital (Figures in Rs. Lakhs) S.N Name of Equipment Cost 1 A.C. – 6 2.00 2 Intercomm Telecom Service 1.00 3 Generator set – 1 1.00 4 Elevator – 1 30.00 5 TMT Machine – 1 3.00 6 Color Doppler – 1 with accessories 16.00 7 ECG Machine – 1 0.30 8 Glucometer 0.25 9 Central O2 supply system ICU Beds – 1, Beds – 4, Defibrillator, 40.00 Nebulizer, Ventilator 10 Digital X-ray Machine – 1 70.00
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11 O.T. Table-2 shadow less lamp, suction machine 3.00 12 Boyles Apparatus Major – 2 0.10 13 Shadow less Lamp – 2 1.40 14 Suction Machine – 2 0.10 15 Pulse Oximeter – 2 1.00 16 Paediatric Circuit Jackson REES – 1 0.10 17 Nitrous Oxide Cylinder – 3 0.15 18 Direct Opthalmoscope – 2 0.07 19 Indirect Opthalmoscope – 1 0.02 20 A Scan – 1 1.50 21 B Scan – 2 1.50 22 Phakco emulsification – 1 0.10 23 Microsurgical Instrument 0.05 24 Diamond Knife – 6 0.15 25 Angle Keratome+crescent blade – 6 0.10 26 Patients Examination Chair – 2 0.30 27 Automated Vision Drum – 2 0.05 28 Fundus Camera – 1 0.30 29 Low vision aid set – 1 0.02 30 Humpreys Automated Perimeter – 1 0.03 31 Applanation Tono meter 0.03 32 Specular Microscope 0.15 33 Digital Camera 0.30 34 Automatic Analyser 1.50 35 Automated Coagulation Analyser 1.00 36 Elisa Reader 0.50 37 Microbiology, Bacteriology culture 0.80 38 Plaster cutter 0.03 39 Physiotherapy wax bath 0.30 40 Shorter wav diathermy 1.00 41 Ultravav diathermy 3.00 42 Orthpedic table 1.00 43 Image intensifier 1.00 44 Endoscope for upper GI, Colonoscope 4.00 45 Cautery Machine 0.50 46 Double Drum Autoclave 0.30 47 Surgical Drum 9x9 0.12 48 Flexible Fibreoptic Laryngoscope 1.00 49 Electric drill with micromotor, hand piece and Burr points for ear 1.00 BGTRRD, GoMP Page25 106 Proposal 2010
50 Nasal Endoscope 2.00 51 Computer with printer 0.70 52 Ambulance(ICU and Trauma Unit) 5.00 Total 200.32
Genetic Lab i. Washing Room
(Figures in Rs. Lakhs) S.N. Item Cost 1 Autoclave 1.50 2 Hotair oven 0.50 3 Water purification system (Millipore) 5.00 4 Water distillation assembly 1.50 5 Ice maker machine 2.50 Total 11.00 ii. Cytogenetic Laboratory
(Figures in Rs. Lakhs) S.N. Item Cost 1 Laminar flow Rs. 1.25 2 Centrifuge(2) Rs. 0.75 3 CO2 incubator Rs. 3.75 4 Refrigerator (4) Rs. 1.25 5 Deep freeze – 20 degree centrigate Rs. 3.50 6 Ph meter (2) Rs. 1.25 7 Magnetic Stirrer(4) Rs. 1.25 8 Weighing balance Rs. 2.00 9 LPG Connection Rs. 0.25 10 Microscope with microphography and cytovision software (for Rs. 15.75 chromosome sorting) Total Rs. 31.00 lacs iii. Nucleic Acid Preparation Lab
BGTRRD, GoMP Page26 107 Proposal 2010
(Figures in Rs. Lakhs) S. No. Item Cost 1 -20 and 80 degree centrigate deep freezer Rs. 10.00 2 Refrigerated Centrifuge Rs. 4.00 3 Vortex machine cum centrifuge (3) Rs. 2.00 4 Water bath (2) Rs. 0.40 5 Shaker incubator Rs. 5.00 6 Horizontal gel electrophoresis apparatus with power pack(4 to 5) Rs. 2.50 7 UPS 8 Spectrophotometer/nandrop Rs. 5.60 9 Microwave(2) Rs. 0.20 10 Dry heating block Rs. 1.30 Total Rs. 31.00 iv. Genome Analysis Lab
(Figures in Rs. Lakhs) S.N Item Cost 1 Thermal cycler – 2 (PCR machine) Rs. 7.50 2 Automated DNA sequencer Rs. 31.00 3 Gel documentation system Rs. 6.00 4 Horizontal gel electrophoresis apparatus Rs. 2.50 5 Centrifuge/mini spin/ cooling centrifuge Rs. 5.00 6 Real time PCR Rs. 19.00 7 Thermo mixer Rs. 4.00 8 Laminar flow Rs. 5.00 9 UPS(10,5,3 and 2 KV on line) Rs. 6.00 Total Rs. 86.00
BGTRRD, GoMP Page27 108 Proposal 2010
5. Rationale for the Corpus
The provisions for the Bhopal Gas Rehabilitation Hospitals under different heads for the year 2010-11 compared to the increased annual requirement form 2011 -12 on account of extra facilities being provide through the procurement of new equipment is presented in the table below. The table indicates a total deficit of Rs. 42.5 crores. (Figures in Rs. Crore) S. No. Head Funds Funds Funds Deficit/ Allotted Requirement Requirement a. Medicine 8.95 45.00 36.05 b. Hospital Equipment Replacement 3.07 5.00 1.93 c. Equipment Maintenance and 3.13 6.00 Consumables 2.87 d. Computerization, Networking and 3.35 5.00 Smart Card 1.65 e. Electricity and Water Supply 2.00 2.00 0 f. Building Maintenance 1.29 1.29 0 g. Professional Services 1.45 1.45 0 h. Human Resource 26.82 26.82 0 i. Alteration/ Renovation of Buildings 5.93 5.93 0 Total 56.00 98.49 42.5
There may be an increase in the human resource, professional services, building maintenance and alteration / renovation of buildings head. These would be completely borne by the state.
Justification for Corpus Fund Here it would be meaningful to explain some factors which would also add to the need for the corpus / annual additional requirement of funds. Firstly, there is no reduction in number of patients over the years. The data from the hospitals suggest that the number of OPDs and inpatients have been gradually rising. Secondly, the hospitals under the department are expected to provide investigation and treatment facilities to non gas BGTRRD, GoMP Page28 109 Proposal 2010
patients as well. In cases of BPL families or members of families of ex-servicemen, the same has to be provided free of cost. With increasing facilities at these hospitals, it is expected that the number of such patients would also increase. This would require recurring additional resources.
A detailed explanation for the additional amount, by budget head, is presented as follows; a. Medicine i. Routine Medical Treatment There are 6 gas relief multi specialty hospitals and 9 day care centre where about 13 lakh outdoor and 33000 indoor patients are being treated per year. The routine treatment includes both routine investigations as well as medications. At present the hospitals are not equipped to offer some of the facilities being requested under the latest action plan and the same is also not being outsourced due to paucity of funds. Once these facilities are established, the number of patients will increase leading to additional expenditure on medicines.
Each indoor patient requires medical support ranging between Rs. 500 and Rs. 1000. As the hospitals cater to between 30000 and 33000 indoor patients annually, for routine medical indoor treatment this would be costing about Rs. 3 crores
Some investigation facilities, however, would not be available in these hospitals, including inter alia, all kinds of hormonal assays, microbiological investigations and MRI requiring dependence on external agencies. It has been estimated that the cost of routine medical investigation and treatment varies from Rs. 100 to Rs. 150 per patient. With availability of BGTRRD, GoMP Page29 110 Proposal 2010
funds, outsourcing of some of the facilities would also become possible. Therefore, catering to approximately 13 lakh OPD patients cost (including the cost of investigation outsourced) of routine medical treatment would be around 14 crores.
In addition the hospitals also carry out a range of routine surgical interventions entailing an expenditure ranging from Rs. 500 to Rs. 1000 per patient which rises to Rs. 3, 000 to Rs. 10,000 per patient in case of major surgeries. With increase in facilities, there is expected to be a resulting increase in patients. The increasing number of surgeries will require additional expenditure on medicines and investigations. The estimated expenditure for about 3000 major surgeries (like general, orthopaedic, ophthalmic, gynecological surgery etc) in the department would be requiring Rs. 2-2.5 crores. Similar number of minor cases would require Rs. 50 Lakhs. Therefore, the total estimated cost for surgeries would come to approximately Rs. 3 crore per year.
To provide routine medical facilities for outdoor patient, indoor medical patients and indoor surgical patients would require about 20 crores per annum. ii. Specialized treatment for severely ill patients It is estimated that 10-15% of the gas affected population are suffering from chronic illness. Hence, there are about 2 lakh gas victims who have been suffering from chronic ailments like the COPD (Chronic Obstructive Pulmonary Diseases), Cardiac diseases, Cerebro Vascular Accidents, Respiratory failure, Pulmonary tuberculosis, Paralysis, Chronic Gastro Intestinal Disorders, BGTRRD, GoMP Page30 111 Proposal 2010
Chronic Arthritis, Chronic Skin Disease, Psychiatric cases etc. This type of patients require long term admission, investigation etc.
Out of these 2 lakh chronic ill patients, about 5000 patients belong to the critical category. These patients are treated in ICU or ICCU or in continuous supervision mechanism. As the Gas Rahat Hospitals’ ICU/ICCU have been recording 100% occupancy, continuous treatment and follow up is not possible due to lack of beds and recurring expenses. The department is in the process of operationalizing a separate 10 bedded ICCU. Once this become operational, there will be an additional burden of investigation and treatment for such patients which will entail substantially high recurring cost.
Further, the department runs a dedicated hospital for respiratory diseases. The number of chronic respiratory cases amongst the gas exposed population is very high and calls for additional super specialty treatment. The gas relief department has established separate dedicated hospital for such kind of patients named as pulmonary medicine center. Looking at the requirement, the department plans to establish an additional 8 bedded ICU.
The cost of establishing these 18 beds is Rs. 2.75 crores which has been provided under the new action plan mentioned before. Once these 18 beds are operationalized, the investigation and treatment cost will increase due to increase in patient size. Such critically ill 5000-6000 patients require long term treatment round the year and the estimated cost incurred per patient is about 25000- 35000 per year. Therefore, with increased number of patients there will be a requirement of almost 15 crore iii. Super specialty treatment for cancer and renal patients
BGTRRD, GoMP Page31 112 Proposal 2010
Renal Patients There are 4 dialysis machines available in the department out of which only 3 machines are in working condition. Of the three machines only two machines are being used for one shift only because of budgetary constraints. The number of renal patients being catered by the institution is definitely less as compared to their actual numbers due to limited availability of facilities. With the 4 machines in place, it will be possible to render the services round the clock. With increased facilities, the number of patients catered to would increase resulting in to increase in cost of treatment.
In addition to this, there is a plan to establish a separate 25 bedded nephrology wing where the patient before dialysis and after dialysis would be managed. The cost of medicines for treatment of such patients would be an additional burden on the institution and is expected to be high.
With the increased availability of funds, the hospitals would be able to render services to 200 patients (2 times a week, 104 times a year) at Rs. 1800 per patient per dialysis including medicines. This would require an allocation of Rs. 3. 75 crores.
Further, many of the renal failure patients need to be referred for renal transplantation. Each renal transplantation costs about 10-15 lakhs. Moreover, there are a few transplant cases which need special medicines costing about Rs. 15, 000 to Rs. 20, 000 per month. It BGTRRD, GoMP Page32 113 Proposal 2010
is estimated that the department would be catering to about 5-6 patients for renal transplantation and post transplantation care. For this an estimated allocation of Rs. 1 crore is required. As these patients are very susceptible to other ailments (co-morbidity), the treatment of these patients and follow up of transplanted kidney would require an additional allocation of Rs. 25 Lakhs.
Given the cost of dialysis (including admission and treatment), renal transplanting and post transplanting follow up and care would require an allocation of Rs. 5 crores.
Cancer patients The department now has facility of early diagnosis of cancer. However, it has to depend completely upon external agencies for providing treatment facilities. Some severe cases may require patients to be referred to institutions outside the state.
As there is no facility for cancer treatment in gas relief hospitals, most of the cancer patients are being treated at Jawaharlal Nehru Cancer Hospital & Research Centre, Bhopal for which the department has to incur the actual expenditure for the specialized investigations, surgery, chemotherapy and radio therapy etc for gas victim cancer patients. Up till now payments have been made to the tune of Rs. 14.78 crores to Jawaharlal Nehru Cancer Hospital and Research Centre. At present there are about 2463 registered cancer patients. As a result of the early diagnosis facility, it is expected that more patients would be referred to external institutions, thereby, increasing the burden on resources.
Till now, due to paucity of resources, the department was unable to provide referrals to severe patients requiring referrals to outside the state. However, with the resources in hand the department would be able to refer these patients to super specialized BGTRRD, GoMP Page33 114 Proposal 2010
institutions outside the state for proper treatment. The present budget provision for cancer patients is about 3 crores. Once the referral cases are allowed to receive treatment from outside the state, the cost would increase substantially. It is estimated that annually about 20 patients would be referred out of state at the rate of Rs. 5 Lakhs per patient cost of treatment.
Therefore, a budgetary provision of Rs. 4 crore has been estimated for the cancer patients.
Congenital Malformation Cell The department does not have any facility for congenital malformed children in any of the hospitals. The department will establish a congenital malformation registry to enumerate the number of malformed children among the gas exposed families of Bhopal. It will also create a specialized diagnostic and management facility for such children. The latest action plan has provided 6 lac for the cell. All these patients would be referred to an external agency for diagnosis and treatment which would require additional allocation of resources. Among the congenital malformed children there is a possibility of cardiac anomaly and some may also belong to the neurologically deficit group which would require higher resource allocation and long term support in terms of physiotherapy facilities for these children. The annual target of the group has been placed at 300 children per year.
Out of 300 there is a possibility of congenital malformation of heart in 2-3% children who would require surgical intervention costing about Rs. 10 Lakhs including medication. Earlier gas relief department used to refer such cases to Indrprastha Apolo Hospital, New Delhi.
BGTRRD, GoMP Page34 115 Proposal 2010
There is a possibility of 2-5% children having congenital malformation related to lip and palate which would again require surgical intervention. There are other different types of anomalies which would require surgical corrections. Once the Congenital malformation cell starts functioning and registration of patient is done actual requirement can be enumerated. At present we are allocating funds at the minimum for treatment, investigation etc at Rs. 1 crore per year.
The summary of fund requirement for various kinds of medical treatment is as follows; S. No. Items Fund Requirement (in Rs. crore) 1 Routine medical treatment 20 2 Specialized treatment for severely ill patients ailments 15 3 Super specialty treatment for cancer and renal patients 10 Total 45 b. Hospital Equipment Replacement The specialized nature of hospitals under the department requires replacement of dysfunctional equipments and addition of new equipments as per the requirement. The average recommended life of equipment varies between 7 and 10 years. Therefore, regular replacement becomes a necessity for their continued functional availability. A lot of equipments have already crossed their expiry date or are reaching expiry. The department has classified them as per their functioning. The latest action plan, for now, provides for replacement of equipments. However, there would be a regular requirement for resource making necessary replacements and addition of new equipments as per requirement in the future.
As per the medical audit findings equipments including Body Plethysuograph, Vitatograph, Ultrasonic Nabuloser, Glucometer, Semi- Automatic Photometer, MMR with X-ray, USG, Blood Gas analyzer, Yag Laser, Haemodialysis machine, Multipara Cardiac BGTRRD, GoMP Page35 116 Proposal 2010
Monitor, Semi Automatic Analyzer, 5- Part Blood Cell Counter, Carbon dioxide Monitor and Ventilator have qualified for immediate replacement. The same would be met through resources provided under the latest action plan. However, the future and some current needs for replacement of old equipments would require a provision of Rs. 5 crore, annually. c. Equipment Maintenance and Consumables It is expected that the hospitals under the department would have equipments estimated worth Rs. 45 crores. This would include new equipments and replaced equipments procured under the latest action plan for Rs. 28.22 crores and equipments already in place. This would entail an annual maintenance cost in the range of 4.25 crore per annum.
The cost of spare parts is not covered under annual maintenance contract. This cost is variable and an allocation of Rs. 75 Lakhs has been budgeted. The spare parts of some of the equipments are very costly and its timing cannot be ascertained. For others the cost is relatively low but is required on a regular basis. The average recommended life of spare part is about 7 to 10 years. For example, CT-Scan needs replacement of X-ray tube every alternate year which is costing about Rs. 25 Lakhs. Similarly, other equipments like MRI, X-ray machine, Dialysis machine etc require replacement of some part(s) at specific intervals.
In terms of consumables, a major requirement is for dialysis. At present the number of dialysis is around 700 per year. The requirement as per patient load is around 3000 dialysis per year. Therefore the total cost of dialysis would be in the range of Rs. 36 Lacs.
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In addition to this, the department is carrying out about 25000 X-rays per years, 300 CT scans and 9000 ECGs, 800 Echocardiography, 11000 ultra-sonography, 150 PFT and other pathological investigations and all these investigations require disposables. At present the cost of these disposables is about Rs. 50 Lakhs. With expected increase in number of patients, the allocation has been increased to Rs. 75 Lakhs.
Given the fund requirement for maintenance, spare parts and consumables an allocation of Rs. 6 crore is absolutely necessary. d. Computerization, Networking and Smart Card
It has become a long pending issue for the gas relief hospitals. Presently, all the hospitals are computerized in terms of OPD facilities and mainly support the registration of patients. As per the recommendation of honorable Supreme Court and advisory committee constituted by honorable Supreme Court of India all the hospital functioning under gas relief department should be fully computerized to establish HIMS. In addition to this, all the gas victims should be provided smart card to facilitate easy access to individual’s medical history to ensure proper medical management of gas victim. Moreover, there is need to analyze the hospital data so that any improvisation in the treatment facilities can be operationalized quickly.
A proper HIMS would also help in tracking of individual patient across all the medical institution under the department and ensure proper usage of medicines. The system can also help distribute patients amongst the different medical institutions based on their location of residence and kind of medical facility required. This would help in optimizing patient pressure on each institution.
BGTRRD, GoMP Page37 118 Proposal 2010
The department has reached the final stage of approval of computerization with a provision of a smart card for each gas victim (estimated at 5 lakhs). The estimated cost of computerization would be Rs.3 crore per hospital which would be met by GoMP. NIC has to build the network and operate it in a build- operate mode. An allocation of Rs. 5 crore has been made here which would be provided to NIC on an annual maintenance contract.
The gap of Rs. 42.5 crores in the fund allocation is expected to be filled through the interest from corpus of Rs. 500 crore requested from the GoI. GoMP intends to use the income from corpus funds to meet only the productive expenditure that directly meets the diagnostic and treatment needs of the patients and would be bearing the administrative costs pertaining to human resources and construction on their own.
However, it is also realized that the interest from the corpus might not be sufficient to cover the annual expenses required over the years. In that case, the state would manage the shortfall from its own resources.
BGTRRD, GoMP Page38 119 Proposal 2010
5. Conclusion
The surviving victims of Bhopal Gas Tragedy, their dependants and dependants of those who lost their lives, make demands on the medical rehabilitation set-up for meeting their diagnosis and treatment needs. Their situation is made difficult by the strong impact of the gas which has lead to minor to severe to multiple ailments in the victims and has also affected their children.
The effort made by the state government has been to provide them with basic and advanced services throughout the past 25 years. However, the gaps in services have been realized due to want for basic investigation and treatment service for the increasing patient numbers, advanced infrastructure and funds for providing referral services.
GoMP for the past 25 years has been providing the services from primarily its own resources. A financial support was provided to the state in the form of first action plan by the GoI in 1990. After 1999, there has been no support from the center. The present request for the corpus of Rs. 500 crore from GoI would take care of the much needed recurring costs to ensure proper and continuous provision of services for the gas patients.
Bhopal Gas Tragedy Memorial Statue
BGTRRD, GoMP Page39 Annexure P-10 120
BHOPAL STRUCK BY WAVE OF ‘CHEMICAL AIDS’, POLLY GHAZI, THE OBSERVER 20TH NOVEMBER 1994 TEN years after the world's worst industrial disaster made the central Indian city of Bhopal a household name, the daily lives of ·its inhabitants are still dictated by the tragedy- as if it happened yesterday. Every day hundreds of people suffering from the effects of acute gas poisoning queue daily at government hospitals. Their symptoms include breathing problems, streaming eyes, ulcers, unstoppable menstrual bleeding, tuberculosis caused by the poison-induced collapse of their immune systems. Tens of thousands of inhabitants are pleading with the Indian authorities for compensation. And Warren Anderson, former president of Union Carbide, whose factory's gas leak killed 2,000 people in a few hours, is still being sought to answer criminal charges of culpable homicide. At the time we couldn't believe it was really happening, it was like a terrible dream,' said Rehana Begum, a leading campaigner for the survivors' rights, on a visit to London last week. 'Ten years later we are still living the same nightmare.' Rehana is in Britain to raise international awareness of the city's continuing plight. Survivors' groups claim the numbers of people coming forward with long-term, gas induced symptoms have risen substantially in recent years. International medical experts have coined a new phrase; 'chemically induced Aids', to explain the unusual proneness of Bhopal's population to diseases such as tuberculosis. A report by the first team of international medical experts to be allowed to examine 'victims will be published shortly in London to coincide with the tenth anniversary of the disaster on 2 December 1984 which killed at least 6,000 people and injured up to half a million. The report concludes that 'a substantial proportion of Bhopal's population' is suffering from 'genuine long-term morbidity' and falling prey to a variety of diseases and nervous disorders. Detailed examinations of 63 survivors found, for example, that 43 were suffering from gas-induced breakdown of the immune system similar to that suffered by carriers of the HIV virus, making victims particularly susceptible to tuberculosis and respiratory problems. The authors condemn the 'disturbing absence' of any systematic strategy either for assessing victims' injuries or for their long term medical care and eventual rehabilitation. But, to add a Kafkaesque twist to the nightmare, the Indian government instead plans next month to wind up all 25 of the official monitoring programmes into the many complex symptoms suffered by survivors. 'We feel betrayed,' said Rehana, who has suffered ulcers, breathlessness and eye diseases for 10 years. 'We have been fighting all this time for proper treatment, rehabilitation and compensation. But the Indian government just wants to forget about Bhopal. Rehana's daughter Rizwana, 14, has suffered repeated bouts of tuberculosis and has lost much of her schooling. Rehana's brother-in-law is now dying in hospital of the same disease. But the campaign groups claim hospital doctors are often fearful of attributing patients' illnesses to Union Carbide for fear of pushing the total compensation bill too high. In the, tragedy's aftermath, the Indian government initially pressed for S3 billion from Union Carbide, but eventually settled for S470 million. The Indian Supreme Court then ruled that, if the total compensation agreed was higher, the Indian government should make up the shortfall. To date, $90m has been paid out to about a tenth of almost 700,000 claimants. The average payments are S870 for injury and $3,000 to the families of victims who died. At this rate campaigners estimate it will take a further 13 years until all the victims receive recompense. ‘By then,’ says Rehana, ‘many will probably be dead.' Bhopal's survivor groups are also bitter that Union Carbide, as part of the compensation settlement, has renounced any liability for the accident, and that Anderson has never been extradited from the United States to face criminal charges. Instead, Rehana and other survivors will present evidence at a week-long trial in absentia of Union Carbide and its president at a Permanent People's Tribunal on Industrial Hazards and Human Rights which begins in London a week tomorrow. medRxiv preprint doi: https://doi.org/10.1101/2020.02.25.20027664. The copyright holder for this preprint (which was not peer-reviewed) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . Annexure P-11 121
Original article
Comorbidity and its impact on 1,590 patients with COVID-19 in China: A Nationwide Analysis
Wei-jie Guan1,#, Ph.D., Wen-hua Liang2,#, M.D., Yi Zhao2,#, M.Med., Heng-rui Liang2,#, M.Med., Zi-sheng Chen2,3,#, M.D., Yi-min Li 4, M.D., Xiao-qing Liu 4, M.D., Ru-chong Chen 1, M.D., Chun-li Tang 1, M.D., Tao Wang 1, M.D., Chun-quan Ou 5, Ph.D., Li Li 5, Ph.D., Ping-yan Chen 5, M.D., Ling Sang 4, M.D., Wei Wang 2, M.D., Jian-fu Li 2, M.D., Cai-chen Li 2, M.D., Li-min Ou 2, M.D., Bo Cheng 2, M.D., Shan Xiong 2, M.D., Zheng-yi Ni 6, M.D., Jie Xiang 6, M.D., Yu Hu 7, M.D., Lei Liu 8,9, M.D., Hong Shan 10, M.D., Chun-liang Lei 11, M.D., Yi-xiang Peng 12, M.D., Li Wei 13, M.D., Yong Liu 14, M.D., Ya-hua Hu 15, M.D., Peng Peng 16, M.D., Jian-ming Wang 17, M.D., Ji-yang Liu 18, M.D., Zhong Chen 19, M.D., Gang Li 20, M.D., Zhi-jian Zheng 21, M.D., Shao-qin Qiu 22, M.D., Jie Luo 23, M.D., Chang-jiang Ye 24, M.D., Shao-yong Zhu 25, M.D., Lin-ling Cheng 1, M.D., Feng Ye 1, M.D., Shi-yue Li 1, M.D., Jin-ping Zheng 1, M.D., Nuo-fu Zhang 1, M.D., Nan-shan Zhong 1,*, M.D., Jian-xing He 2,*, M.D., on behalf of China Medical Treatment Expert Group for COVID-19
1 State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
2 Department of Thoracic Oncology and Surgery, China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.
3 The sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan, Guangdong, China
4 Department of Pulmonary and Critical Care Medicine, China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
5 State Key Laboratory of Organ Failure Research, Department of Biostatistics, Guangdong Provincial Key Laboratory of Tropical Disease Research, School of Public Health, Southern Medical University, Guangzhou, China
6 Wuhan Jin-yintan Hospital, Wuhan, Hubei, China
7 Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
1 medRxiv preprint doi: https://doi.org/10.1101/2020.02.25.20027664. The copyright holder for this preprint (which was not peer-reviewed) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 122
8 Shenzhen Third People’s Hospital, Shenzhen, China
9 The Second Affiliated Hospital of Southern University of Science and Technology, National Clinical Research Center for Infectious Diseases, Shenzhen, China
10 The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, China
11 Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
12 The Central Hospital of Wuhan, Wuhan, Hubei, China
13 Wuhan No.1 Hospital, Wuhan Hospital of Traditional Chinese and Western Medicine, Wuhan, Hubei, China
14 Chengdu Public Health Clinical Medical Center, Chengdu, Sichuan, China
15 Huangshi Central Hospital of Edong Healthcare Group, Affiliated Hospital of Hubei Polytechnic University, Huangshi, Hubei, China
16 Wuhan Pulmonary Hospital, Wuhan, 430030, Hubei, China
17 Tianyou Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, Hubei 430065, China
18 The First Hospital of Changsha, Changsha 410005, Hunan, China
19 The Third People's Hospital of Hainan Province, Sanya, 572000, Hainan, China
20 Huanggang Central Hospital, Huanggang, Hubei, China
21 Wenling First People's Hospital, Wenling, Zhejiang, China
22 The Third People's Hospital of Yichang, Yichang, 443000, Hubei Province, China
23 Affiliated Taihe Hospital of Hubei University of Medicine, Shiyan, China
24 Xiantao First People's Hospital, Xiantao, China
25 The People's Hospital of Huangpi District, Wuhan, China
# Wei-jie Guan, Wen-hua Liang, Yi Zhao, Heng-rui Liang and Zi-sheng Chen are joint first authors.
2 medRxiv preprint doi: https://doi.org/10.1101/2020.02.25.20027664. The copyright holder for this preprint (which was not peer-reviewed) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 123
Correspondence to: Jian-xing He MD, PhD, FACS, FRCS, AATS active member, ESTS member. Department of Thoracic Surgery, the First Affiliated Hospital of Guangzhou Medical University; China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, Guangzhou, China. Tel: +86-20-8337792; Fax: +86-20-83350363; Email: [email protected]; or Nan-Shan Zhong. State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Guangzhou, Guangdong, China. Tel.: +86-20-83062729; Fax: +86-20-83062729; E-mail: [email protected]
Conflict of interest: There is no conflict of interest.
Ethics approval: This study is approved by the ethics committee of the First Affiliated Hospital of Guangzhou Medical University.
3 medRxiv preprint doi: https://doi.org/10.1101/2020.02.25.20027664. The copyright holder for this preprint (which was not peer-reviewed) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 124
Abstract
Objective: To evaluate the spectrum of comorbidities and its impact on the clinical outcome in
patients with coronavirus disease 2019 (COVID-19).
Design: Retrospective case studies
Setting: 575 hospitals in 31 province/autonomous regions/provincial municipalities across China
Participants: 1,590 laboratory-confirmed hospitalized patients. Data were collected from November
21st, 2019 to January 31st, 2020.
Main outcomes and measures: Epidemiological and clinical variables (in particular, comorbidities)
were extracted from medical charts. The disease severity was categorized based on the American
Thoracic Society guidelines for community-acquired pneumonia. The primary endpoint was the
composite endpoints, which consisted of the admission to intensive care unit (ICU), or invasive
ventilation, or death. The risk of reaching to the composite endpoints was compared among patients
with COVID-19 according to the presence and number of comorbidities.
Results: Of the 1,590 cases, the mean age was 48.9 years. 686 patients (42.7%) were females. 647
(40.7%) patients were managed inside Hubei province, and 1,334 (83.9%) patients had a contact
history of Wuhan city. Severe cases accounted for 16.0% of the study population. 131 (8.2%)
patients reached to the composite endpoints. 399 (25.1%) reported having at least one comorbidity.
269 (16.9%), 59 (3.7%), 30 (1.9%), 130 (8.2%), 28 (1.8%), 24 (1.5%), 21 (1.3%), 18 (1.1%) and 3
(0.2%) patients reported having hypertension, cardiovascular diseases, cerebrovascular diseases,
diabetes, hepatitis B infections, chronic obstructive pulmonary disease, chronic kidney diseases,
4 medRxiv preprint doi: https://doi.org/10.1101/2020.02.25.20027664. The copyright holder for this preprint (which was not peer-reviewed) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 125
malignancy and immunodeficiency, respectively. 130 (8.2%) patients reported having two or more
comorbidities. Patients with two or more comorbidities had significantly escalated risks of reaching
to the composite endpoint compared with those who had a single comorbidity, and even more so as
compared with those without (all P<0.05). After adjusting for age and smoking status, patients with
COPD (HR 2.681, 95%CI 1.424-5.048), diabetes (HR 1.59, 95%CI 1.03-2.45), hypertension (HR
1.58, 95%CI 1.07-2.32) and malignancy (HR 3.50, 95%CI 1.60-7.64) were more likely to reach to
the composite endpoints than those without. As compared with patients without comorbidity, the HR
(95%CI) was 1.79 (95%CI 1.16-2.77) among patients with at least one comorbidity and 2.59 (95%CI
1.61-4.17) among patients with two or more comorbidities.
Conclusion: Comorbidities are present in around one fourth of patients with COVID-19 in China,
and predispose to poorer clinical outcomes.
FUNDING: Supported by National Health Commission, Department of Science and Technology of
Guangdong Province. The funder had no role in the conduct of the study.
Key words: SARS-CoV-2; comorbidity; clinical characteristics; prognosis
Main text: 2,354 words; abstract: 365 words
Short title: Comorbidity of COVID-19 in China 5 medRxiv preprint doi: https://doi.org/10.1101/2020.02.25.20027664. The copyright holder for this preprint (which was not peer-reviewed) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 126
Author’s contributions: W. J. G., W. H. L., J. X. H., and N. S. Z. participated in study design and
study conception; W. H. L., Y. Z., H. R. L., Z. S. C., C. Q. O., L. L., P. Y. C., J. F. L., C. C. L., L. M.
O., B. C., W. W. and S. X. performed data analysis; R. C. C., C. L. T., T. W., L. S., Z. Y. N., J. X., Y.
H., L. L., H. S., C. L. L., Y. X. P., L. W., Y. L., Y. H. H., P. P., J. M. W., J. Y. L., Z. C., G. L., Z. J. Z.,
S. Q. Q., J. L., C. J. Y., S. Y. Z., L. L. C., F. Y., S. Y. L., J. P. Z., N. F. Z., and N. S. Z. recruited
patients; W. J. G., J. X. H., W. H. L., and N. S. Z. drafted the manuscript; all authors provided critical
review of the manuscript and approved the final draft for publication.
Highlights
What is already known on this topic?
- Since November 2019, the rapid outbreak of coronavirus disease 2019 (COVID-19) has recently
become a public health emergency of international concern. There have been 79,331
laboratory-confirmed cases and 2,595 deaths globally as of February 25th, 2020
- Previous studies have demonstrated the association between comorbidities and other severe acute
respiratory diseases including SARS and MERS.
- No study with a nationwide representative cohort has demonstrated the spectrum of comorbidities
and the impact of comorbidities on the clinical outcomes in patients with COVID-19.
What this study adds?
- In this nationwide study with 1,590 patients with COVID-19, comorbidities were identified in 399
6 medRxiv preprint doi: https://doi.org/10.1101/2020.02.25.20027664. The copyright holder for this preprint (which was not peer-reviewed) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 127
patients. Comorbidities of COVID-19 mainly included hypertension, cardiovascular diseases,
cerebrovascular diseases, diabetes, hepatitis B infections, chronic obstructive pulmonary disease,
chronic kidney diseases, malignancy and immunodeficiency.
- The presence of as well as the number of comorbidities predicted the poor clinical outcomes
(admission to intensive care unit, invasive ventilation, or death) of COVID-19.
- Comorbidities should be taken into account when estimating the clinical outcomes of patients with
COVID-19 on hospital admission.
Introduction
Since November 2019, the rapid outbreak of coronavirus disease 2019 (COVID-19), which arose
from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, has recently become
a public health emergency of international concern [1]. COVID-19 has contributed to an enormous
adverse impact globally. Hitherto, there have been 79,331 laboratory-confirmed cases and 2,595
deaths globally as of February 25th, 2020 [2].
The clinical manifestations of COVID-19 are, according to the latest reports [3-8], largely
heterogeneous. On admission, 20-51% of patients reported as having at least one comorbidity, with
diabetes (10-20%), hypertension (10-15%) and cardiovascular and cerebrovascular diseases (7-40%)
being most common [3,4,6]. Previous studies have demonstrated that the presence of any
comorbidity has been associated with a 3.4-fold increased risk of developing acute respiratory
distress syndrome in patients with H7N9 infection [9]. Similar with influenza [10-14], Severe Acute
7 medRxiv preprint doi: https://doi.org/10.1101/2020.02.25.20027664. The copyright holder for this preprint (which was not peer-reviewed) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 128
Respiratory Syndrome coronavirus (SARS-CoV) [15] and Middle East Respiratory Syndrome
coronavirus (MERS-CoV) [16-24], COVID-19 more readily predisposed to respiratory failure and
death in susceptible patients [4]. Nonetheless, previous studies have been certain limitations in study
design including the relatively small sample sizes and single center observations. Studies that address
these limitations is needed to explore for the factors underlying the adverse impact of COVID-19.
Our objective was to compare the clinical characteristics and outcomes of patients with
COVID-19 by stratification according to the presence and category of comorbidity, thus unraveling
the subpopulations with poorer prognosis.
Methods
Data sources and data extraction
This was a retrospective cohort study that collected data from patients with COVID-19 throughout
China, under the coordination of the National Health Commission which mandated the reporting of
clinical information from individual designated hospitals which admitted patients with COVID-19.
After careful medical chart review, we compiled the clinical data of laboratory-confirmed
hospitalized cases from 575 hospitals between November 21st, 2019 and January 31st, 2020. The
diagnosis of COVID-19 was made based on the World Health Organization interim guidance [25].
Confirmed cases denoted the patients whose high-throughput sequencing or real-time
reverse-transcription polymerase-chain-reaction (RT-PCR) assay findings for nasal and pharyngeal
swab specimens were positive [3]. See Online Supplement for details.
8 medRxiv preprint doi: https://doi.org/10.1101/2020.02.25.20027664. The copyright holder for this preprint (which was not peer-reviewed) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 129
The clinical data (including recent exposure history, clinical symptoms and signs, comorbidities,
and laboratory findings upon admission) were reviewed and extracted by experienced respiratory
clinicians, who subsequently entered the data into a computerized database for further
cross-checking. Manifestations on chest X-ray or computed tomography (CT) was summarized by
integrating the documentation or description in medical charts and, if available, a further review by
our medical staff. Major disagreement of the radiologic manifestations between the two reviewers
was resolved by consultation with another independent reviewer. Because disease severity reportedly
predicted poorer clinical outcomes of avian influenza [9], patients were classified as having severe or
non-severe COVID-19 based on the American Thoracic Society guidelines for community-acquired
pneumonia because of its global acceptance [26].
Comorbidities were determined based on patient’s self-report on admission. Comorbidities were
initially treated as a categorical variable (Yes vs. No), and subsequently classified based on the
number (Single vs. Multiple). Furthermore, comorbidities were sorted according to the organ
systems (i.e. respiratory, cardiovascular, endocrine). Comorbidities that were classified into the same
organ system (i.e. coronary heart disease, hypertension) would be merged into a single category.
The primary endpoint of our study was a composite measure which consisted of the admission
to intensive care unit (ICU), or invasive ventilation, or death. This composite measure was adopted
because all individual components were serious outcomes of H7N9 infections [9]. Secondary
endpoints mainly included the mortality rate, and the time from symptom onset to reaching to the
composite endpoints.
Statistical analysis
9 medRxiv preprint doi: https://doi.org/10.1101/2020.02.25.20027664. The copyright holder for this preprint (which was not peer-reviewed) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 130
Statistical analyses were conducted with SPSS software version 23.0 (Chicago, IL, USA). No formal
sample size estimation was made because there has not been any published nationwide data on
COVID-19. Nonetheless, our sample size was deemed sufficient to power the statistical analysis
given its representativeness of the national patient population. Continuous variables were presented
as means and standard deviations or medians and interquartile ranges (IQR) as appropriate, and the
categorical variables were presented as counts and percentages. Independent t-test, Kruskal-Wallis
test and chi-square test were applied for the comparisons between the two groups as appropriate. Cox
proportional hazard regression models were applied to determine the potential risk factors associated
with the composite endpoints, with the hazards ratio (HR) and 95% confidence interval (95%CI)
being reported.
Patient and public involvement
No patients were directly involved in our study design, setting the research questions, the
interpretation of data, or asked to advise on writing up of the report.
Results
Demographic and clinical characteristics
The National Health Commission has issued 11,791 patients with laboratory-confirmed COVID-19
in China as of January 31st, 2020. At this time point for data cut-off, our database has included 1,590
cases from 575 hospitals in 31 province/autonomous regions/provincial municipalities (see Online
Supplement for details). Of these 1,590 cases, the mean age was 48.9 years. 686 patients (42.7%)
10 medRxiv preprint doi: https://doi.org/10.1101/2020.02.25.20027664. The copyright holder for this preprint (which was not peer-reviewed) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 131
were females. 647 (40.7%) patients were managed inside Hubei province, and 1,334 (83.9%) patients
had a contact history of Wuhan city. The most common symptom was fever on or after
hospitalization (88.0%), followed by dry cough (70.2%). Fatigue (42.8%) and productive cough
(36.0%) were less common. At least one abnormal chest CT manifestation (including ground-glass
opacities, pulmonary infiltrates and interstitial disorders) was identified in more than 70% of patients.
Severe cases accounted for 16.0% of the study population. 131 (8.2%) patients reached to the
composite endpoints during the study (Table 1).
Presence of comorbidities and the clinical characteristics and outcomes of COVID-19
Of the 1,590 cases, 399 (25.1%) reported having at least one comorbidity. The most common
comorbidities encompassed hypertension (269 [16.9%]), diabetes (130 [8.2%]), and cardiovascular
diseases (59 [3.7%]). Chronic obstructive pulmonary disease (COPD) was identified in 24 cases. At
least one comorbidity was seen more commonly in severe cases than in non-severe cases (32.8% vs.
10.3%). Patients with at least one comorbidity were older (mean: 60.8 vs. 44.8 years), were more
likely to have shortness of breath (41.4% vs. 17.8%), nausea or vomiting (10.4% vs. 4.3%), and
tended to have abnormal chest X-ray manifestations (29.2% vs. 15.1%) (Table 1).
Clinical characteristics and outcomes of COVID-19 stratified by the number of comorbidities
We have further identified 130 (8.2%) patients who reported having two or more comorbidities. Two
or more comorbidities were more commonly seen in severe cases than in non-severe cases (40.0% vs.
29.4%, P<0.001). Patients with two or more comorbidities were older (mean: 66.2 vs. 58.2 years),
were more likely to have shortness of breath (55.4% vs. 34.1%), nausea or vomiting (11.8% vs.
9.7%), unconsciousness (5.1% vs. 1.3%) and less abnormal chest X-ray (20.8% vs. 23.4%) compared 11 medRxiv preprint doi: https://doi.org/10.1101/2020.02.25.20027664. The copyright holder for this preprint (which was not peer-reviewed) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 132
with patients who had single comorbidity (Table 2).
Clinical characteristics and outcomes of COVID-19 stratified by organ systems of comorbidities
A total of 269 (16.9%), 59 (3.7%), 30 (1.9%), 130 (8.2%), 28 (1.8%), 24 (1.5%), 21 (1.3%), 18
(1.1%) and 3 (0.2%) patients reported having hypertension, cardiovascular diseases, cerebrovascular
diseases, diabetes, hepatitis B infections, COPD, chronic kidney diseases, malignancy and
immunodeficiency, respectively. Severe cases were more likely to have hypertension (32.7% vs.
12.6%), cardiovascular diseases (33.9% vs. 15.3%), cerebrovascular diseases (50.0% vs. 15.3%),
diabetes (34.6% vs. 14.3%), hepatitis B infections (32.1% vs. 15.7%), COPD (62.5% vs. 15.3%),
chronic kidney diseases (38.1% vs. 15.7%) and malignancy (50.0% vs. 15.6%) compared with
non-severe cases. Furthermore, comorbidities were more common patients treated in Hubei province
as compared with those managed outside Hubei province (all P<0.05) as well as patients with an
exposure history of Wuhan as compared with those without (all P<0.05) (Table 3).
Prognostic analyses
The composite endpoint was documented in 77 (19.3%) of patients who had at least one comorbidity
as opposed to 54 (4.5%) patients without comorbidities (P<0.001). This figure was 37 cases (28.5%)
in patients who had two or more comorbidities. Significantly more patients with hypertension
(19.7% vs. 5.9%), cardiovascular diseases (22.0% vs. 7.7%), cerebrovascular diseases (33.3% vs.
7.8%), diabetes (23.8% vs. 6.8%), COPD (50.0% vs. 7.6%), chronic kidney diseases (28.6% vs.
8.0%) and malignancy (38.9% vs. 7.9%) reached to the composite endpoints compared with those
without (Table 3).
12 medRxiv preprint doi: https://doi.org/10.1101/2020.02.25.20027664. The copyright holder for this preprint (which was not peer-reviewed) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 133
Patients with two or more comorbidities had significantly escalated risks of reaching to the
composite endpoint compared with those who had a single comorbidity, and even more so as
compared with those without (all P<0.05, Figure 1). After adjusting for age and smoking status,
patients with COPD (HR 2.68, 95%CI 1.42-5.05), diabetes (HR 1.59, 95%CI 1.03-2.45),
hypertension (HR 1.58, 95%CI 1.07-2.32) and malignancy (HR 3.50, 95%CI 1.60-7.64) were more
likely to reach to the composite endpoints than those without (Figure 2). As compared with patients
without comorbidity, the HR (95%CI) was 1.79 (95%CI 1.16-2.77) among patients with at least one
comorbidity and 2.59 (95%CI 1.61-4.17) among patients with two or more comorbidities (Figure 2).
Discussion
Our study is the first nationwide investigation that systematically evaluates the impact of
comorbidities on the clinical characteristics and prognosis in patients with COVID-19 in China.
Circulatory and endocrine comorbidities were common among patients with COVID-19. Patients
with at least one comorbidity, or more even so, were associated with poor clinical outcomes. These
findings have provided further objective evidence, with a large sample size and extensive coverage
of the geographic regions across China, to take into account baseline comorbid diseases in the
comprehensive risk assessment of prognosis among patients with COVID-19 on hospital admission.
Overall, our findings have echoed the recently published studies in terms of the commonness of
comorbidities in patients with COVID-19 [3-7]. Despite considerable variations in the proportion in
individual studies due to the limited sample size and the region where patients were managed,
circulatory diseases (including hypertension and coronary heart diseases) remained the most 13 medRxiv preprint doi: https://doi.org/10.1101/2020.02.25.20027664. The copyright holder for this preprint (which was not peer-reviewed) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 134
common category of comorbidity [3-7]. Apart from circulatory diseases, endocrine diseases such as
diabetes were also common in patients with COVID-19. Notwithstanding the commonness of
circulatory and endocrine comorbidities, patients with COVID-19 rarely reported as having
comorbid respiratory diseases (particularly COPD). The reasons underlying this observation have
been scant, but could have arisen from the lack of awareness and the lack of spirometric testing in
community settings that collectively contributed to the underdiagnosis of respiratory diseases [27].
Consistent with recent reports [3-7], the percentage of patients with comorbid renal disease and
malignancy was relatively low. Our findings have therefore added to the existing literature the
spectrum of comorbidities in patients with COVID-19 based on the larger sample sizes and
representativeness of the whole patient population in China.
A number of existing literature reports have documented the escalated risks of poorer clinical
outcomes in patients with avian influenza [10-14], SARS-CoV [15] and MERS-CoV infections
[16-24]. The most common comorbidities associated with poorer prognosis included diabetes [21,24],
hypertension [24], respiratory diseases [15,24], cardiac diseases [15,24], pregnancy [12], renal
diseases [24] and malignancy [15]. Our findings suggested that, similar with other severe acute
respiratory outbreaks, comorbidities such as COPD, diabetes, hypertension and malignancy
predisposed to adverse clinical outcomes in patients with COVID-19. The strength of association
between different comorbidities and the prognosis, however, was less consistent when compared
with the literature reports [12,15,21,24]. For instance, the risk between cardiac diseases and poor
clinical outcomes of influenza, SARS-CoV or MERS-CoV infections was inconclusive [12,15,21,24].
Except for diabetes, no other comorbidities were identified to be the predictors of poor clinical
outcomes in patients with MERS-CoV infections [21]. Few studies, however, have explored the 14 medRxiv preprint doi: https://doi.org/10.1101/2020.02.25.20027664. The copyright holder for this preprint (which was not peer-reviewed) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 135
mechanisms underlying these associations. Kulscar et al showed that MERS-CoV infections resulted
in prolonged airway inflammation, immune cell dysfunction and an altered expression profile of
inflammatory mediators [23]. A network-based analysis indicated that SARS-CoV infections led to
immune dysregulation that could help explain the escalated risk of cardiac diseases, bone diseases
and malignancy [28]. Therefore, immune dysregulation and prolonged inflammation might be the
key drivers of the poor clinical outcomes in patients with COVID-19 but await verification in more
mechanistic studies.
There has been a considerable overlap in the comorbidities which has been widely accepted. For
instance, diabetes [29] and COPD [30] frequently co-exist with hypertension or coronary heart
diseases. Therefore, patients with co-existing comorbidities are more likely to have poorer baseline
well-being. Importantly, we have verified the significantly escalated risk of poor prognosis in
patients with two or more comorbidities as compared with those who had no or only a single
comorbidity. Our findings implied that both the category and number of comorbidities should be
taken into account when predicting the prognosis in patients with COVID-19.
Our findings suggested that patients with comorbidities had greater disease severity compared
with those without. A greater number of comorbidities correlated with greater disease severity of
COVID-19. The public health implication of our study was that proper triage of patients should be
implemented in out-patient clinics or on hospital admission by carefully inquiring the medical
history because this will help identify patients who would be more likely to develop serious adverse
outcomes during the progression of COVID-19. A multidisciplinary team with specialists would be
needed to manage the comorbid conditions in a timely fashion. Moreover, patients with COIVD-19
15 medRxiv preprint doi: https://doi.org/10.1101/2020.02.25.20027664. The copyright holder for this preprint (which was not peer-reviewed) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 136
who had comorbidities should be isolated immediately upon confirmation of the diagnosis, which
would help provide with this susceptible population better personal medical protection.
The main limitation of our study was the self-report of comorbidities on admission.
Underreporting of comorbidities, which could have stemmed from the lack of awareness and/or the
lack of diagnostic testing, might contribute to the underestimation of the true strength of association
with the clinical prognosis. However, significant underreporting was unlikely because the spectrum
of our report was largely consistent with existing literature [3-7] and all patients were subject to a
thorough history taking after hospital admission. Moreover, the duration of follow-up was relatively
short and some patients remained in the hospital as of the time of writing. More studies that explore
the associations in a sufficiently long time frame are warranted. As with other observational studies,
our findings did not provide direct inference about the causation or reverse causation of
comorbidities and the poor clinical outcomes.
Conclusions
Comorbidities are present in around one fourth of patients with COVID-19 in China, and predispose
to poorer clinical outcomes. A thorough assessment of comorbidities may help establish risk
stratification of patients with COVID-19 upon hospital admission.
Acknowledgment: We thank the hospital staff (see Supplementary Appendix for the full list) for 16 medRxiv preprint doi: https://doi.org/10.1101/2020.02.25.20027664. The copyright holder for this preprint (which was not peer-reviewed) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 137
their efforts in collecting the information. We are indebted to the coordination of Drs. Zong-jiu
Zhang, Ya-hui Jiao, Bin Du, Xin-qiang Gao and Tao Wei (National Health Commission), Yu-fei
Duan and Zhi-ling Zhao (Health Commission of Guangdong Province), Yi-min Li, Zi-jing Liang,
Nuo-fu Zhang, Shi-yue Li, Qing-hui Huang, Wen-xi Huang and Ming Li (Guangzhou Institute of
Respiratory Health) which greatly facilitate the collection of patient’s data. Special thanks are given
to the statistical team members Prof. Zheng Chen, Drs. Dong Han, Li Li, Zheng Chen, Zhi-ying Zhan,
Jin-jian Chen, Li-jun Xu, Xiao-han Xu (State Key Laboratory of Organ Failure Research,
Department of Biostatistics, Guangdong Provincial Key Laboratory of Tropical Disease Research,
School of Public Health, Southern Medical University). We also thank Li-qiang Wang, Wei-peng Cai,
Zi-sheng Chen (the sixth affiliated hospital of Guangzhou medical university), Chang-xing Ou,
Xiao-min Peng, Si-ni Cui, Yuan Wang, Mou Zeng, Xin Hao, Qi-hua He, Jing-pei Li, Xu-kai Li, Wei
Wang, Li-min Ou, Ya-lei Zhang, Jing-wei Liu, Xin-guo Xiong, Wei-juna Shi, San-mei Yu, Run-dong
Qin, Si-yang Yao, Bo-meng Zhang, Xiao-hong Xie, Zhan-hong Xie, Wan-di Wang, Xiao-xian Zhang,
Hui-yin Xu, Zi-qing Zhou, Ying Jiang, Ni Liu, Jing-jing Yuan, Zheng Zhu, Jie-xia Zhang, Hong-hao
Li, Wei-hua Huang, Lu-lin Wang, Jie-ying Li, Li-fen Gao, Jia-bo Gao, Cai-chen Li, Xue-wei Chen,
Jia-bo Gao, Ming-shan Xue, Shou-xie Huang, Jia-man Tang, Wei-li Gu, Jin-lin Wang (Guangzhou
Institute of Respiratory Health) for their dedication to data entry and verification. We are grateful to
Tecent Co. Ltd. for their provision of the number of certified hospitals for admission of patients with
COVID-19 throughout China. Finally, we thank all the patients who consented to donate their data
for analysis and the medical staffs working in the front line.
17 medRxiv preprint doi: https://doi.org/10.1101/2020.02.25.20027664. The copyright holder for this preprint (which was not peer-reviewed) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 138
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Tables
Table 1: Demographics and clinical characteristics of patients with or without any comorbidities.
Variables Any comorbidity
Total No Yes P Va lue (n=1590) (n=1191) (n=399)
Age (years) 48.9±16.3 44.8±15.2 60.8±13.4 <0.001
Incubation period (day) 3.6±4.2 3.7±4.3 3.5±3.9 0.329
Temperature on admission ( ) 37.4±0.9 37.4±0.9 37.3±0.9 0.034
Respiratory rate on admission (breath/min) 21.2±12.0 21.2±13.7 21.3±4.7 0.876
Heart rate on admission (beat/min) 88.7±14.6 88.5±14.7 89.2±14.4 0.402
Systolic pressure on admission (mmHg) 126.1±16.4 123.5±15.2 133.2±17.5 <0.001
Diastolic pressure on admission (mmHg) 79.5±25.6 79±28.9 80.9±12.6 0.22
Highest temperature ( ) 38.3±1.6 38.3±1.1 38.2±2.6 0.634
Sex 0.241
Male 904/1578 (57.3) 667/1182 (56.4) 237/396 (59.8)
Female 674/1578 (42.7) 515/1182 (43.6) 159/396 (40.2)
Smoking status <0.001
Never/unknown 1479/1590 (93) 1127/1191 (94.6) 352/399 (88.2)
Former/current 111/1590 (7) 64/1191 (5.4) 47/399 (11.8)
Symptoms
Fever 1351/1536 (88) 1002/1148 (87.3) 349/388 (89.9) 0.176
Conjunctival congestion 10/1345 (0.7) 7/1014 (0.7) 3/331 (0.9) 0.715
Nasal congestion 73/1299 (5.6) 59/979 (6) 14/320 (4.4) 0.328
Headache 205/1328 (15.4) 151/1002 (15.1) 54/326 (16.6) 0.537
24 medRxiv preprint doi: https://doi.org/10.1101/2020.02.25.20027664. The copyright holder for this preprint (which was not peer-reviewed) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 145
Dry cough 1052/1498 (70.2) 775/1116 (69.4) 277/382 (72.5) 0.271
Pharyngodynia 194/1317 (14.7) 148/999 (14.8) 46/318 (14.5) 0.928
Productive cough 513/1424 (36) 363/1064 (34.1) 150/360 (41.7) 0.011
Fatigue 584/1365 (42.8) 435/1031 (42.2) 149/334 (44.6) 0.446
Hemoptysis 16/1315 (1.2) 9/991 (0.9) 7/324 (2.2) 0.084
Shortness of breath 331/1394 (23.7) 185/1041 (17.8) 146/353 (41.4) <0.001
Nausea/vomiting 80/1371 (5.8) 44/1025 (4.3) 36/346 (10.4) <0.001
Diarrhea 57/1359 (4.2) 39/1023 (3.8) 18/336 (5.4) 0.213
Myalgia/arthralgia 234/1338 (17.5) 174/1007 (17.3) 60/331 (18.1) 0.739
Chill 163/1333 (12.2) 129/1006 (12.8) 34/327 (10.4) 0.285
Signs
Throat congestion 21/1286 (1.6) 16/973 (1.6) 5/313 (1.6) 1
Tonsil swelling 31/1376 (2.3) 22/1024 (2.1) 9/352 (2.6) 0.678
Enlargement of lymph nodes 2/1375 (0.1) 1/1027 (0.1) 1/348 (0.3) 0.442
Rash 3/1378 (0.2) 2/1032 (0.2) 1/346 (0.3) 1
Unconsciousness 20/1421 (1.4) 11/1063 (1) 9/358 (2.5) 0.064
Abnormal chest image
Radiograph 243/1590 (15.3) 236/1566 (15.1) 44036 (29.2) 0.079
Computed tomography 1130/1590 (71.1) 1113/1566 (71.1) 17/24 (70.8) 1
Hubei <0.001
Yes 647/1590 (40.7) 434/1191 (36.4) 213/399 (53.4)
No 943/1590 (59.3) 757/1191 (63.6) 186/399 (46.6)
Wuhan-contacted 0.012
Yes 1334/1590 (83.9) 983/1191 (82.5) 351/399 (88)
25 medRxiv preprint doi: https://doi.org/10.1101/2020.02.25.20027664. The copyright holder for this preprint (which was not peer-reviewed) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 146
No 256/1590 (16.1) 208/1191 (17.5) 48/399 (12)
Severity 254/1590 (16) 123/1191 (10.3) 131/399 (32.8) <0.001
Composite endpoint 131/1590 (8.2) 54/1191 (4.5) 77/399 (19.3) <0.001
Death 50/1590 (3.1) 15/1191 (1.3) 35/399 (8.8) <0.001
Data are mean ± standard deviation, n/N (%), where N is the total number of patients with available data. p values are calculated by χ² test, Fisher’s exact test, or Mann-Whitney U test. COPD=chronic obstructive pulmonary disease.
Data in bold indicated the statistical comparisons with significance.
Table 2: Demographics and clinical characteristics of patients with 1 or ≥2 comorbidities.
Variables 1 comorb id(n=269ity ) ≥2 comorbidities (n=130) P Value
Age (years) 58.2±13.1 66.2±12.2 <0.001
Incubation period (days) 3.2±3.1 4.0±5.2 0.124
Temperature on admission ( ) 37.4±0.9 37.1±0.9 <0.001
Respiratory rate on admission (breath/min) 21.4±4.6 21.2±5 0.977
Heart rate (bit/minute) 90.2±14.6 87.2±13.7 0.134
Systolic pressure on admission (mmHg) 132.2±16.5 135.3±19.4 <0.001
Diastolic pressure on admission (mmHg) 81.7±12.5 79.5±12.9 0.350
Highest temperature ( ) 38.2±3.0 38.4±0.8 0.424
26 medRxiv preprint doi: https://doi.org/10.1101/2020.02.25.20027664. The copyright holder for this preprint (which was not peer-reviewed) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 147
Sex 0.430
Male 158/268 (59.0) 79/128 (61.7)
Female 110/268 (41.0) 49/128 (38.3)
Smoking status <0.001
Never/unknown 234/269 (87.0) 118/130 (90.8)
Former/current 35/269 (13.0) 12/130 (9.2)
Symptoms
Fever 241/263 (91.6) 108/125 (86.4) 0.126
Conjunctival congestion 3/222 (1.4) 0/109 (0) 0.374
Nasal congestion 5/213 (2.3) 9/107 (8.4) 0.046
Headache 34/220 (15.5) 20/106 (18.9) 0.589
Dry cough 195/258 (75.6) 82/124 (66.1) 0.088
Pharyngodynia 33/218 (15.1) 13/100 (13.0) 0.872
Productive cough 101/241 (41.9) 49/119 (41.2) 0.036
Fatigue 97/227 (42.7) 52/107 (48.6) 0.444
Hemoptysis 4/219 (1.8) 3/105 (2.9) 0.149
Shortness of breath 79/232 (34.1) 67/121 (55.4) <0.001
Nausea/vomiting 23/236 (9.7) 13/110 (11.8) <0.001
Diarrhea 11/229 (4.8) 7/107 (6.5) 0.359
Myalgia/arthralgia 45/227 (19.8) 15/104 (14.4) 0.457
Chill 25/222 (11.3) 9/105 (8.6) 0.400
Signs
Throat congestion 4/216 (1.9) 1/97 (1) 0.868
Tonsil swelling 5/234 (2.1) 4/118 (3.4) 0.685
28 medRxiv preprint doi: https://doi.org/10.1101/2020.02.25.20027664. The copyright holder for this preprint (which was not peer-reviewed) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 148
Enlargement of lymph nodes 1/232 (0.4) 0/116 (0) 0.441
Rash 0/231 (0) 1/115 (0.9) 0.249
Unconsciousness 3/240 (1.3) 6/118 (5.1) 0.002
Abnormal chest image
Radiograph 63/269 (23.4) 27/130 (20.8) <0.001
Computed tomography 200/269 (74.3) 96/130 (73.8) 0.283
Hubei <0.001
Yes 120/269 (44.6) 93/130 (71.5)
No 149/269 (55.4) 37/130 (28.5)
Wuhan-contacted 0.003
Yes 229/269 (85.1) 122/130 (93.8)
No 40/269 (14.9) 8/130 (6.2)
Severity 79/269 (29.4) 52/130 (40.0) <0.001
Composite endpoint 40/269 (14.9) 37/130 (28.5) <0.001
Deaths 15/269 (5.6) 20/130 (15.4) <0.001
Data are mean ± standard deviation, n/N (%), where N is the total number of patients with available data. p values are calculated by χ² test, Fisher’s exact test, or Mann-Whitney U test. COPD=chronic obstructive pulmonary disease.
Data in bold indicated the statistical comparisons with significance.
29 149 medRxiv preprint doi: https://doi.org/10.1101/2020.02.25.20027664
Table 3: Demographics and clinical characteristics of patients stratified by different comorbidities. author/funder, whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
COPD Diabetes Hypertension Cardiovascular disease Cerebrovascular disease It ismadeavailableundera
No Yes ( n =2 4) P No Yes P No Yes P No Yes (n=59) P No Yes ( n =3 0) P
(n=1566) Value (n=1460) (n=130) Value (n=1321) (n=269) Value (n=1531) Value (n=1560) Value
Age (year) 48.5±16.0 74.7±6.8 <0.001 47.8±16.1 61.2±13.4 <0.001 46.2±15.6 62.1±12.5 <0.001 48.2±15.9 66.3±15.1 <0.001 48.5±16.1 70.4±8.9 <0.001
Incubation period (day) 3.6±4.2 4.5±3.2 0.331 3.6±4.1 3.8±5 0.619 3.6±4.2 3.6±4.1 0.958 3.7±4.2 3.3±3.7 0.564 3.6±4.2 3.8±3.4 0.867 CC-BY-NC-ND 4.0Internationallicense . Thecopyrightholderforthispreprint Temperature on admission ( ) 37.4±0.9 37.3±0.9 0.921 37.4±0.9 37.2±1 0.048 37.4±0.9 37.2±0.9 0.013 37.4±0.9 37.3±1 0.570 37.4±0.9 36.9±0.8 0.007
Respiratory rate on admission 21.2±12.1 21.8±5.2 0.843 21.2±12.4 21.4±5.4 0.869 21.2±13.1 21.3±4.5 0.887 21.2±12.2 21.4±6.2 0.911 21.3±12.1 19.9±3.3 0.537
(breath/min)
Heart rate (bit/minute) 88.6±14.6 90.2±12.8 0.631 88.6±14.6 89.1±14.3 0.730 88.6±14.7 89±14.3 0.729 88.8±14.6 86.4±14.9 0.250 88.8±14.6 84.5±11.4 0.127
Systolic pressure on admission 126±16.4 131±17.5 0.16 125.3±15.9 134.4±19.1 <0.001 123.9±15.2 135.4±18.2 <0.001 125.8±16.3 132.3±18.8 0.005 125.9±16.4 132.9±16 0.026
(mmHg) (which wasnotpeer-reviewed) .
Diastolic pressure on admission 79.6±25.7 77±11.9 0.640 79.4±26.4 80.9±13.2 0.551 79.2±27.7 81±12.5 0.298 79.6±25.9 78.4±13.6 0.746 79.6±25.8 77.4±9.6 0.655
(mmHg)
Highest temperature ( ) 38.3±1.6 38.5±0.6 0.543 38.3±1.7 38.4±0.8 0.338 38.3±1.3 38.2±2.7 0.678 38.3±1.7 38.5±0.8 0.482 38.3±1.6 38.2±1 0.892
30 isthe 150 medRxiv preprint doi: Sex 0.011 0.711 0.635 0.500 0.039 https://doi.org/10.1101/2020.02.25.20027664
Male 884/1554 20/24 828/1449 76/129 748/1312 156/266 868/1520 36/58 881/1548 23/30 author/funder, whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
(56.9) (83.3) (57.1) (58.9) (57) (58.6) (57.1) (62.1) (56.9) (76.7) It ismadeavailableundera Female 670/1554 4/24 (16.7) 621/1449 53/129 564/1312 110/266 652/1520 22/58 667/1548 7/30 (23.3)
(43.1) (42.9) (41.1) (43) (41.4) (42.9) (37.9) (43.1)
Smoking status 0.232 0.002 0.430 0.298 0.152
Never/unknown 1458/1566 21/24 1368/1460 111/130 1232/1321 247/269 1426/1531 53/59 1453/1560 26/30
(93.1) (87.5) (93.7) (85.4) (93.3) (91.8) (93.1) (89.8) (93.1) (86.7) CC-BY-NC-ND 4.0Internationallicense . Thecopyrightholderforthispreprint
Former/current 108/1566 3/24 (12.5) 92/1460 19/130 89/1321 22/269 105/1531 6/59 (10.2) 107/1560 4/30 (13.3)
(6.9) (6.3) (14.6) (6.7) (8.2) (6.9) (6.9)
Symptoms
Fever 1331/1513 20/23 (87) 0.751 1239/1412 112/124 0.473 1113/1273 238/263 0.177 1308/1482 43/54 0.051 1328/1507 23/29 0.150
(88) (87.7) (90.3) (87.4) (90.5) (88.3) (79.6) (88.1) (79.3)
Conjunctival congestion 10/1325 0/20 (0) >0.999 9/1237 1/108 (0.9) 0.568 9/1120 1/225 (0.4) >0.999 10/1299 0/46 (0) >0.999 10/1320 0/25 (0) >0.999 (which wasnotpeer-reviewed) .
(0.8) (0.7) (0.8) (0.8) (0.8)
Nasal congestion 72/1281 1/18 (5.6) >0.999 66/1195 7/104 (6.7) 0.655 62/1079 11/220 (5) 0.750 67/1253 6/46 (13) 0.040 73/1275 0/24 (0) 0.394
(5.6) (5.5) (5.7) (5.3) (5.7)
31 isthe 151 medRxiv preprint doi: Headache 202/1309 3/19 (15.8) >0.999 187/1225 18/103 0.317 166/1106 39/222 0.359 197/1283 8/45 (17.8) 0.674 197/1303 8/25 (32) 0.043 https://doi.org/10.1101/2020.02.25.20027664 (15.4) (15.3) (17.5) (15) (17.6) (15.4) (15.1) author/funder, whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
Dry cough 1038/1474 14/24 0.259 972/1378 80/120 0.405 854/1238 198/260 0.021 1018/1442 34/56 0.135 1035/1469 17/29 0.217
(70.4) (58.3) (70.5) (66.7) (69) (76.2) (70.6) (60.7) (70.5) (58.6) It ismadeavailableundera
Pharyngodynia 189/1300 5/17 (29.4) 0.091 182/1219 12/98 0.555 165/1102 29/215 0.674 185/1272 9/45 (20) 0.288 192/1296 2/21 (9.5) 0.757
(14.5) (14.9) (12.2) (15) (13.5) (14.5) (14.8)
Productive cough 502/1400 11/24 0.391 462/1309 51/115 0.055 403/1178 110/246 0.002 499/1373 14/51 0.235 504/1397 9/27 (33.3) 0.842
(35.9) (45.8) (35.3) (44.3) (34.2) (44.7) (36.3) (27.5) (36.1) CC-BY-NC-ND 4.0Internationallicense . Thecopyrightholderforthispreprint Fatigue 573/1347 11/18 0.15 529/1257 55/108 0.085 488/1143 96/222 0.882 564/1318 20/47 >0.999 574/1344 10/21 0.663
(42.5) (61.1) (42.1) (50.9) (42.7) (43.2) (42.8) (42.6) (42.7) (47.6)
Hemoptysis 15/1296 1/19 (5.3) 0.209 12/1214 (1) 4/101 (4) 0.029 12/1096 4/219 (1.8) 0.323 15/1268 1/47 (2.1) 0.443 16/1292 0/23 (0) >0.999
(1.2) (1.1) (1.2) (1.2)
Shortness of breath 316/1371 15/23 <0.001 277/1279 54/115 (47) <0.001 223/1154 108/240 <0.001 310/1342 21/52 0.007 319/1366 12/28 0.023
(23) (65.2) (21.7) (19.3) (45) (23.1) (40.4) (23.4) (42.9) (which wasnotpeer-reviewed) Nausea/vomiting 77/1350 3/21 (14.3) 0.119 69/1264 11/107 0.051 55/1134 25/237 0.002 73/1321 7/50 (14) 0.023 79/1348 1/23 (4.3) >0.999 .
(5.7) (5.5) (10.3) (4.9) (10.5) (5.5) (5.9)
Diarrhea 57/1338 0/21 (0) >0.999 48/1255 9/104 (8.7) 0.035 46/1129 11/230 0.590 53/1313 (4) 4/46 (8.7) 0.123 57/1336 0/23 (0) 0.621
32 isthe 152 medRxiv preprint doi: (4.3) (3.8) (4.1) (4.8) (4.3) https://doi.org/10.1101/2020.02.25.20027664
Myalgia/arthralgia 231/1320 3/18 (16.7) >0.999 218/1234 16/104 0.687 188/1112 46/226 0.213 227/1294 7/44 (15.9) >0.999 233/1317 1/21 (4.8) 0.153 author/funder, whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
(17.5) (17.7) (15.4) (16.9) (20.4) (17.5) (17.7) It ismadeavailableundera Chill 159/1313 4/20 (20) 0.294 151/1230 12/103 1.000 140/1111 23/222 0.432 161/1290 2/43 (4.7) 0.156 162/1310 1/23 (4.3) 0.347
(12.1) (12.3) (11.7) (12.6) (10.4) (12.5) (12.4)
Signs
Throat congestion 21/1269 0/17 (0) >0.999 20/1189 1/97 (1) >0.999 18/1075 3/211 (1.4) >0.999 21/1245 0/41 (0) >0.999 21/1266 0/20 (0) >0.999
(1.7) (1.7) (1.7) (1.7) (1.7) CC-BY-NC-ND 4.0Internationallicense . Thecopyrightholderforthispreprint
Tonsil swelling 31/1355 0/21 (0) >0.999 28/1265 3/111 (2.7) 0.734 25/1133 6/243 (2.5) 0.811 29/1326 2/50 (4) 0.312 31/1348 0/28 (0) >0.999
(2.3) (2.2) (2.2) (2.2) (2.3)
Enlargement of lymph nodes 2/1355 0/20 (0) >0.999 2/1267 0/108 (0) >0.999 2/1135 0/240 (0) >0.999 1/1325 1/50 (2) 0.071 2/1347 0/28 (0) >0.999
(0.1) (0.2) (0.2) (0.1) (0.1)
Rash 3/1357 0/21 (0) >0.999 2/1270 1/108 (0.9) 0.217 2/1141 1/237 (0.4) 0.433 3/1327 0/51 (0) >0.999 3/1351 0/27 (0) >0.999
(0.2) (0.2) (0.2) (0.2) (0.2) (which wasnotpeer-reviewed) .
Unconsciousness 18/1400 2/21 (9.5) 0.034 18/1309 2/112 (1.8) 0.668 12/1175 (1) 8/246 (3.3) 0.013 17/1371 3/50 (6) 0.031 19/1392 1/29 (3.4) 0.340
(1.3) (1.4) (1.2) (1.4)
Abnormal chest image
33 isthe 153 medRxiv preprint doi: Radiograph 236/1566 7/24 (29.2) 0.079 218/1460 25/130 0.203 178/1321 65/269 <0.001 231/1531 12/59 0.269 231/1560 12/30 (40) 0.001 https://doi.org/10.1101/2020.02.25.20027664 (15.1) (14.9) (19.2) (13.5) (24.2) (15.1) (20.3) (14.8) author/funder, whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
Computed tomography 1113/1566 17/24 >0.999 1034/1460 96/130 0.545 926/1321 204/269 0.065 1090/1531 40/59 0.561 1111/1560 19/30 0.416
(71.1) (70.8) (70.8) (73.8) (70.1) (75.8) (71.2) (67.8) (71.2) (63.3) It ismadeavailableundera
Hubei 0.094 <0.001 <0.001 <0.001 <0.001
Yes 633/1566 14/24 568/1460 79/130 491/1321 156/269 609/1531 38/59 623/1560 24/30 (80)
(40.4) (58.3) (38.9) (60.8) (37.2) (58) (39.8) (64.4) (39.9)
No 933/1566 10/24 892/1460 51/130 830/1321 113/269 922/1531 21/59 937/1560 6/30 (20) CC-BY-NC-ND 4.0Internationallicense . Thecopyrightholderforthispreprint (59.6) (41.7) (61.1) (39.2) (62.8) (42) (60.2) (35.6) (60.1)
Wuhan-contacted 0.408 0.025 0.003 0.471 0.210
Yes 1312/1566 22/24 1216/1460 118/130 1092/1321 242/269 1282/1531 52/59 1306/1560 28/30
(83.8) (91.7) (83.3) (90.8) (82.7) (90) (83.7) (88.1) (83.7) (93.3)
No 254/1566 2/24 (8.3) 244/1460 12/130 229/1321 27/269 (10) 249/1531 7/59 (11.9) 254/1560 2/30 (6.7)
(16.2) (16.7) (9.2) (17.3) (16.3) (16.3) (which wasnotpeer-reviewed) .
Severity 239/1566 15/24 <0.001 209/1460 45/130 <0.001 166/1321 88/269 <0.001 234/1531 20/59 <0.001 239/1560 15/30 (50) <0.001
(15.3) (62.5) (14.3) (34.6) (12.6) (32.7) (15.3) (33.9) (15.3)
Composite endpoint 119/1566 12/24 (50) <0.001 100/1460 31/130 <0.001 78/1321 53/269 <0.001 118/1531 13/59 (22) 0.001 121/1560 10/30 <0.001
34 isthe 154 medRxiv preprint doi: (7.6) (6.8) (23.8) (5.9) (19.7) (7.7) (7.8) (33.3) https://doi.org/10.1101/2020.02.25.20027664
Deaths 44/1566 6/24 (25) <0.001 37/1460 13/130 (10) <0.001 22/1321 28/269 <0.001 42/1531 8/59 (13.6) <0.001 44/1560 6/30 (20) <0.001 author/funder, whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
(2.8) (2.5) (1.7) (10.4) (2.7) (2.8) It ismadeavailableundera Hepatitis B infection Malignancy Chronic kidney disease Immunodeficiency
No Yes ( n =2 4) P No Yes P No Yes P No Yes (n=59) P
(n=1566) Value (n=1460) (n=130) Value (n=1321) (n=269) Value (n=1531) Value
Age (year) 48.9±16.3 50.8±14.8 0.559 48.7±16.2 63.1±12.1 <0.001 48.8±16.2 63.7±14 <0.001 48.9±16.3 51±21.7 0.824 CC-BY-NC-ND 4.0Internationallicense . Incubation period (day) 3.7±4.2 3±2.8 0.417 3.7±4.2 3.1±3.1 0.633 3.6±4.1 3.3±7.5 0.750 3.6±4.1 12.7±16.3 0.437 Thecopyrightholderforthispreprint
Temperature on admission ( ) 37.4±0.9 37.3±0.8 0.864 37.4±0.9 37.3±0.9 0.597 37.4±0.9 37.2±1 0.353 37.4±0.9 36.6±0.2 0.147
Respiratory rate on admission 21.2±12.1 21.2±3 0.995 21.3±12.1 20.2±1.6 0.701 21.3±12.1 19±2.8 0.425 21.3±12 19±1 0.746
(breath/min)
Heart rate (bit/minute) 88.7±14.6 86.3±13.2 0.405 88.7±14.6 89.4±13.1 0.834 88.7±14.6 89.1±12.5 0.909 88.7±14.6 91±18.5 0.782
Systolic pressure on admission 126.1±16.4 124.8±14.7 0.708 126±16.4 128.3±14.5 0.557 125.9±16.3 135.4±20.5 0.012 126.1±16.4 127.3±7.4 0.895 (which wasnotpeer-reviewed) . (mmHg)
Diastolic pressure on admission 79.6±25.7 78.3±13 0.817 79.5±25.7 81.2±8.8 0.784 79.5±25.7 79.8±14 0.967 79.5±25.6 84.7±15 0.728
(mmHg)
35 isthe 155 medRxiv preprint doi: Highest temperature ( ) 38.3±1.5 37.6±4.4 0.457 38.3±1.6 38.5±0.9 0.516 38.3±1.6 38.5±0.5 0.586 38.3±1.6 38±0.5 0.789 https://doi.org/10.1101/2020.02.25.20027664
Sex 0.336 0.814 0.361 0.078 author/funder, whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
Male 885/1550 19/28 893/1560 11/18 891/1559 13/19 904/1575 0/3 (0) It ismadeavailableundera (57.1) (67.9) (57.2) (61.1) (57.2) (68.4) (57.4)
Female 665/1550 9/28 (32.1) 667/1560 7/18 (38.9) 668/1559 6/19 (31.6) 671/1575 3/3 (100)
(42.9) (42.8) (42.8) (42.6)
Smoking status 0.440 0.032 >0.999 0.195 CC-BY-NC-ND 4.0Internationallicense .
Never/unknown 1454/1562 25/28 1465/1572 14/18 1459/1569 20/21 1477/1587 2/3 (66.7) Thecopyrightholderforthispreprint
(93.1) (89.3) (93.2) (77.8) (93) (95.2) (93.1)
Former/current 108/1562 3/28 (10.7) 107/1572 4/18 (22.2) 110/1569 1/21 (4.8) 110/1587 1/3 (33.3)
(6.9) (6.8) (7) (6.9)
Symptoms
Fever 1326/1508 25/28 >0.999 1335/1519 16/17 0.711 1334/1516 17/20 (85) 0.725 1348/1533 3/3 (100) >0.999
(87.9) (89.3) (87.9) (94.1) (88) (87.9) (which wasnotpeer-reviewed) .
Conjunctival congestion 9/1323 1/22 (4.5) 0.153 10/1330 0/15 (0) >0.999 10/1328 0/17 (0) >0.999 10/1343 0/2 (0) >0.999
(0.7) (0.8) (0.8) (0.7)
36 isthe 156 medRxiv preprint doi: Nasal congestion 73/1277 0/22 (0) 0.631 71/1285 2/14 (14.3) 0.184 73/1282 0/17 (0) 0.619 73/1297 0/2 (0) >0.999 https://doi.org/10.1101/2020.02.25.20027664 (5.7) (5.5) (5.7) (5.6) author/funder, whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
Headache 202/1306 3/22 (13.6) >0.999 203/1314 2/14 (14.3) >0.999 203/1311 2/17 (11.8) >0.999 205/1326 0/2 (0) >0.999
(15.5) (15.4) (15.5) (15.5) It ismadeavailableundera
Dry cough 1037/1472 15/26 0.193 1039/1481 13/17 0.791 1037/1479 15/19 0.614 1050/1495 2/3 (66.7) >0.999
(70.4) (57.7) (70.2) (76.5) (70.1) (78.9) (70.2)
Pharyngodynia 188/1294 6/23 (26.1) 0.134 193/1303 1/14 (7.1) 0.707 191/1300 3/17 (17.6) 0.728 193/1315 1/2 (50) 0.273
(14.5) (14.8) (14.7) (14.7) CC-BY-NC-ND 4.0Internationallicense . Thecopyrightholderforthispreprint Productive cough 508/1401 5/23 (21.7) 0.190 504/1408 9/16 (56.3) 0.115 505/1407 8/17 (47.1) 0.446 512/1421 1/3 (33.3) >0.999
(36.3) (35.8) (35.9) (36)
Fatigue 570/1340 14/25 (56) 0.221 577/1349 7/16 (43.8) >0.999 581/1350 3/15 (20) 0.113 583/1363 1/2 (50) >0.999
(42.5) (42.8) (43) (42.8)
Hemoptysis 16/1293 0/22 (0) >0.999 15/1299 1/16 (6.3) 0.179 16/1300 0/15 (0) >0.999 16/1313 0/2 (0) >0.999
(1.2) (1.2) (1.2) (1.2) (which wasnotpeer-reviewed) Shortness of breath 321/1370 10/24 0.05 323/1377 8/17 (47.1) 0.039 321/1375 10/19 0.006 330/1392 1/2 (50) 0.419 .
(23.4) (41.7) (23.5) (23.3) (52.6) (23.7)
Nausea/vomiting 78/1349 2/22 (9.1) 0.371 78/1355 2/16 (12.5) 0.239 79/1351 1/20 (5) >0.999 80/1369 0/2 (0) >0.999
37 isthe 157 medRxiv preprint doi: (5.8) (5.8) (5.8) (5.8) https://doi.org/10.1101/2020.02.25.20027664
Diarrhea 55/1337 2/22 (9.1) 0.235 57/1343 0/16 (0) >0.999 56/1339 1/20 (5) 0.578 56/1356 1/3 (33.3) 0.121 author/funder, whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
(4.1) (4.2) (4.2) (4.1) It ismadeavailableundera Myalgia/arthralgia 232/1316 2/22 (9.1) 0.403 231/1322 3/16 (18.8) 0.75 233/1323 1/15 (6.7) 0.491 233/1336 1/2 (50) 0.319
(17.6) (17.5) (17.6) (17.4)
Chill 161/1310 2/23 (8.7) >0.999 162/1318 1/15 (6.7) >0.999 161/1317 2/16 (12.5) >0.999 163/1331 0/2 (0) >0.999
(12.3) (12.3) (12.2) (12.2)
Signs CC-BY-NC-ND 4.0Internationallicense . Thecopyrightholderforthispreprint
Throat congestion 21/1264 0/22 (0) >0.999 20/1271 1/15 (6.7) 0.220 21/1271 0/15 (0) >0.999 20/1284 1/2 (50) 0.032
(1.7) (1.6) (1.7) (1.6)
Tonsil swelling 30/1353 1/23 (4.3) 0.410 30/1359 1/17 (5.9) 0.323 30/1356 1/20 (5) 0.368 31/1373 0/3 (0) >0.999
(2.2) (2.2) (2.2) (2.3)
Enlargement of lymph nodes 2/1352 0/23 (0) >0.999 2/1359 0/16 (0) >0.999 2/1355 0/20 (0) >0.999 2/1372 0/3 (0) >0.999
(0.1) (0.1) (0.1) (0.1) (which wasnotpeer-reviewed) .
Rash 3/1355 0/23 (0) >0.999 3/1361 0/17 (0) >0.999 3/1360 0/18 (0) >0.999 3/1376 0/2 (0) >0.999
(0.2) (0.2) (0.2) (0.2)
Unconsciousness 19/1397 1/24 (4.2) 0.290 20/1404 0/17 (0) >0.999 20/1401 0/20 (0) >0.999 20/1418 0/3 (0) >0.999
38 isthe 158 medRxiv preprint doi: (1.4) (1.4) (1.4) (1.4) https://doi.org/10.1101/2020.02.25.20027664
Abnormal chest image author/funder, whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
Radiograph 240/1562 3/28 (10.7) 0.79 239/1572 4/18 (22.2) 0.504 240/1569 3/21 (14.3) >0.999 243/1587 0/3 (0) >0.999 It ismadeavailableundera (15.4) (15.2) (15.3) (15.3)
Computed tomography 1111/1562 19/28 0.679 1113/1572 17/18 0.033 1116/1569 14/21 0.634 1127/1587 3/3 (100) 0.561
(71.1) (67.9) (70.8) (94.4) (71.1) (66.7) (71)
Hubei 0.439 0.030 0.001 0.570 CC-BY-NC-ND 4.0Internationallicense .
Yes 638/1562 9/28 (32.1) 635/1572 12/18 631/1569 16/21 645/1587 2/3 (66.7) Thecopyrightholderforthispreprint
(40.8) (40.4) (66.7) (40.2) (76.2) (40.6)
No 924/1562 19/28 937/1572 6/18 (33.3) 938/1569 5/21 (23.8) 942/1587 1/3 (33.3)
(59.2) (67.9) (59.6) (59.8) (59.4)
Wuhan-contacted 0.436 0.097 >0.999 >0.999
Yes 1312/1562 22/28 1316/1572 18/18 (100) 1316/1569 18/21 1331/1587 3/3 (100)
(84) (78.6) (83.7) (83.9) (85.7) (83.9) (which wasnotpeer-reviewed) .
No 250/1562 6/28 (21.4) 256/1572 0/18 (0) 253/1569 3/21 (14.3) 256/1587 0/3 (0)
(16) (16.3) (16.1) (16.1)
39 isthe 159 medRxiv preprint doi: Severity 245/1562 9/28 (32.1) 0.032 245/1572 9/18 (50) 0.001 246/1569 8/21 (38.1) 0.012 253/1587 1/3 (33.3) 0.407 https://doi.org/10.1101/2020.02.25.20027664 (15.7) (15.6) (15.7) (15.9) author/funder, whohasgrantedmedRxivalicensetodisplaythepreprintinperpetuity.
Composite endpoint 128/1562 3/28 (10.7) 0.498 124/1572 7/18 (38.9) <0.001 125/1569 6/21 (28.6) 0.005 130/1587 1/3 (33.3) 0.227
(8.2) (7.9) (8) (8.2) It ismadeavailableundera
Deaths 49/1562 1/28 (3.6) 0.594 47/1572 (3) 3/18 (16.7) 0.017 45/1569 5/21 (23.8) <0.001 50/1587 0/3 (0) >0.999
(3.1) (2.9) (3.2)
Data are mean ± standard deviation, n/N (%), where N is the total number of patients with available data. p values are calculated by χ² test, Fisher’s exact test, or Mann-Whitney U test. COPD=chronic obstructive pulmonary disease. CC-BY-NC-ND 4.0Internationallicense . Thecopyrightholderforthispreprint (which wasnotpeer-reviewed) .
40 isthe medRxiv preprint doi: https://doi.org/10.1101/2020.02.25.20027664. The copyright holder for this preprint (which was not peer-reviewed) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . 160
Figure legends
Figure 1. Comparison of the time-dependent risk of reaching to the composite endpoints
Figure 1-A, The time-dependent risk of reaching to the composite endpoints between patients with (orange curve) or without any comorbidity (dark blue curve);
Figure 1-B, The time-dependent risk of reaching to the composite endpoints between patients without any comorbidity (orange curve), patients with a single comorbidity (dark blue curve), and patients with two or more comorbidities (green curve).
Figure 2. Predictors of the composite endpoints in the proportional hazards model
Shown in the figure are the hazards ratio (HR) and the 95% confidence interval (95%CI) for the risk factors associated with the composite endpoints (admission to intensive care unit, invasive ventilation, or death). The comorbidities were classified according to the organ systems as well as the number.
The scale bar indicates the HR.
The model has been adjusted with age and smoking status
41 medRxiv preprint doi: https://doi.org/10.1101/2020.02.25.20027664. The copyright holder for this preprint (which was not peer-reviewed) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license .
161 medRxiv preprint doi: https://doi.org/10.1101/2020.02.25.20027664. The copyright holder for this preprint (which was not peer-reviewed) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license .
162 Annexure P-12 163
ICD wise summary of disease burden in 1,19,865 Gas Victims and 1536 dependents seen at 8 Health Centres of BMHRC (1998-2016 (April))
S No. ICD Code ICD Group ICD Description No of Patient 1 S1102 CARDIO VASCULAR SYSTEM ACUTE LVF/CHF 16 2 S1104 CARDIO VASCULAR SYSTEM CAD WITH ANGIOPLASTY 743 3 S1107 CARDIO VASCULAR SYSTEM CARDIAC SURGERY - POST VALVE REPLACEMENT 99 4 S1109 CARDIO VASCULAR SYSTEM CONGENITAL HEART DISEASE 37 5 S1110 CARDIO VASCULAR SYSTEM CORONARY ARTERY DISEASE (CAD) 9631 6 S1113 CARDIO VASCULAR SYSTEM CAD - UNSTABLE ANGINA 25 7 S1116 CARDIO VASCULAR SYSTEM DISEASE OF MYOCARDIUM 28 8 S1123 CARDIO VASCULAR SYSTEM OTHERS - CVS 178 9 S1119 CARDIO VASCULAR SYSTEM HYPERTENSION 39122 10 S1124 CARDIO VASCULAR SYSTEM CARDIOMYOPATHY 83 11 S1106 CARDIO VASCULAR SYSTEM CARDIAC SURGERY - POST CABG 1633 12 S1108 CARDIO VASCULAR SYSTEM CARDIAC SURGERY - MVB 30 13 S1111 CARDIO VASCULAR SYSTEM CAD - MI 219 14 S1114 CARDIO VASCULAR SYSTEM CAD - VARIANT ANGINA 31 15 S1117 CARDIO VASCULAR SYSTEM DYSLIPIDEMIA 4176 16 S1121 CARDIO VASCULAR SYSTEM PVD 259 17 S1122 CARDIO VASCULAR SYSTEM RHD 608 18 S1103 CARDIO VASCULAR SYSTEM ARRHYTHMIAS 345 19 S1105 CARDIO VASCULAR SYSTEM CARDIAC SURGERY 75 20 S1112 CARDIO VASCULAR SYSTEM CAD - ANGINA 3172 21 S1115 CARDIO VASCULAR SYSTEM DISEASE OF PERICARDIUM 1 22 S1118 CARDIO VASCULAR SYSTEM ENDOCARDITIS 2 23 S1120 CARDIO VASCULAR SYSTEM HYPERTENSION WITH COMPLICATION 549 24 S1101 CARDIO VASCULAR SYSTEM ATYPICAL CHEAT PAIN 844 25 S1210 CENTRAL NERVOUS SYSTEM SEIZURES DISORDER 1345 26 S1206 CENTRAL NERVOUS SYSTEM INFECTIVE DISEASE OF CNS - ENCEPHALITIS 6 27 S1208 CENTRAL NERVOUS SYSTEM NEUROPATHY 1313 28 S1214 CENTRAL NERVOUS SYSTEM SPONDYLOSIS 545 29 S1203 CENTRAL NERVOUS SYSTEM HEAD ACHE 6681 30 S1213 CENTRAL NERVOUS SYSTEM SPASMODIC TORTICOLLIS 2 31 S1219 CENTRAL NERVOUS SYSTEM GERD 997 32 S1201 CENTRAL NERVOUS SYSTEM CARDIO VASCULAR ACCIDENT (CVA) 1631 33 S1202 CENTRAL NERVOUS SYSTEM ESSENTIAL TREMORS/ABNORMAL MOVEMENT 21 34 S1204 CENTRAL NERVOUS SYSTEM INFECTIVE DISEASE OF CNS 14 35 S1215 CENTRAL NERVOUS SYSTEM SPONDYLOSIS - CERVICAL 1496 36 S1216 CENTRAL NERVOUS SYSTEM SPONDYLOSIS - LUMBER 124 37 S1209 CENTRAL NERVOUS SYSTEM PARKINSONS DISEASE 125 38 S1211 CENTRAL NERVOUS SYSTEM SINUS THROMBOSIS/INTRACRANIAL VENUS THROMBOSIS 25 39 S1212 CENTRAL NERVOUS SYSTEM SOL (SPACE OCCUPYING LESION) 2 40 S1217 CENTRAL NERVOUS SYSTEM OTHERS - CNS 1529 41 S1218 CENTRAL NERVOUS SYSTEM UPPER GI BLEED 17 42 S1905 ENDOCRIANOLOGY THYROID DISORDER 2960 43 S1901 ENDOCRIANOLOGY ADRENAL GLAND DISORDER 10 44 S1902 ENDOCRIANOLOGY DIABETES MELLITUS 15857 45 CAR03 ENDOCRIANOLOGY DM WITH COMPLICATIONS 3054 46 S1908 ENDOCRIANOLOGY MENOPAUSAL SYNDROME 7 47 S1904 ENDOCRIANOLOGY PITUITARY GLAND DISORDER 4 48 S1301 GASTRO ENTROLOGY ACID PEPTIC DISEASE (APD) 43520 49 S1307 GASTRO ENTROLOGY FISSURE IN ANO 160 50 S1310 GASTRO ENTROLOGY HERNIA 33 51 S1311 GASTRO ENTROLOGY INFLAMMATORY BOWEL DISEASE 7 52 S1313 GASTRO ENTROLOGY LIVER DISORDER/HEPATITIS/CIRRHOSIS/LIVER FAILURE 18 53 S1303 GASTRO ENTROLOGY AMOEBIASIS 3820 54 S1306 GASTRO ENTROLOGY DYSPHAGIA 34 55 S1317 GASTRO ENTROLOGY REFLUX OESOPHAGITIS 34 56 S1305 GASTRO ENTROLOGY CONSTIPATION/DIARRHEA 12079 57 S1314 GASTRO ENTROLOGY LOWER GI BLEEDING 1 164
S No. ICD Code ICD Group ICD Description No of Patient
58 S1315 GASTRO ENTROLOGY MAL ABSORPTION SYNDROME 3 59 S1309 GASTRO ENTROLOGY HAEMORRHOIDS 2129 60 S1312 GASTRO ENTROLOGY IRRITABLE BOWEL SYNDROME 34 61 S1318 GASTRO ENTROLOGY OTHERS - GASTRO 724 62 S1308 GASTRO ENTROLOGY GASTRO ENTERITIS 4950 63 S1316 GASTRO ENTROLOGY PANCREATITIS 8 64 S1302 GASTRO ENTROLOGY ACUTE ABDOMEN 1707 65 S1304 GASTRO ENTROLOGY CHOLELITHIASIS 103 66 S1011 GENERAL OBESITY 53 67 S1016 GENERAL SKIN INFECTION / SKIN DISORDER - SEPTIC 4801 68 S1003 GENERAL APTHOUS STOMATITS 2872 69 S1006 GENERAL BODY ACHE 32663 70 S1009 GENERAL LEUCORRHOEA 46 71 S1018 GENERAL OTHERS - GN 18163 72 S1020 GENERAL DYSLIPIDEMIA 1863 73 S1007 GENERAL HIV (+)VE / HBV (+)VE 3 74 S1021 GENERAL SPONDYLOSIS - CERVICAL 317 75 S1002 GENERAL ALLERGY 8455 76 S1005 GENERAL BACK ACHE 24265 77 S1008 GENERAL INJURIES 5935 78 S1017 GENERAL WORM INFESTATION 447 79 S1019 GENERAL SKIN INFECTION / SKIN DISORDER - ANAPHYLACTIC 6260 80 S1023 GENERAL OSTEOMALACIA / OSTEPOROSIS 1152 81 S1001 GENERAL ANAEMIA 18798 82 S1004 GENERAL ARTHRITIS 8982 83 S1010 GENERAL LYMPHADENIPATHY 47 84 S1013 GENERAL PYREXIA/PUO/MALARIA/TYPHOID/VIRAL 10403 85 S1012 GENERAL PREGNANCY 44 86 S2009 MULTIPLE MULTIPLE 3544 87 S1406 NEPHROLOGY DIALYSIS 2 88 S1403 NEPHROLOGY URINARY TRACT INFECTION 8222 89 S1402 NEPHROLOGY ACUTE RENAL FAILURE 7 90 S1405 NEPHROLOGY NEPHROTIC SYNDROME 11 91 S1404 NEPHROLOGY NEPHIRITIS 8 92 S1401 NEPHROLOGY CHRONIC RENAL FAILURE 184 93 S1407 NEPHROLOGY OTHERS - NEPHRO 7 94 S2004 ONCOLOGY LUMP IN BREAST 40 95 S2002 ONCOLOGY BORNCHOGENIC CARCINOMA 15 96 S2007 ONCOLOGY RETINOBLASTOMA 1 97 S2005 ONCOLOGY LUMPS IN NECK 1 98 S2006 ONCOLOGY URINARY TRACT MALIGNANCIES 184 99 S2008 ONCOLOGY OTHERS - ONCO 5 100 S2010 ONCOLOGY OVAL / HEAD/ NECK MALIGNANCIES 1 101 S2001 ONCOLOGY LYMPHADENOPATHY 17 102 S2011 ONCOLOGY GENITO URINARY MALIGNANCY 3 103 S2003 ONCOLOGY GASTRO INTESTINAL MALIGNANCY 5 104 S1604 OPHTHALMOLOGY CORNEAL OPACITY 64 105 S1609 OPHTHALMOLOGY KERATOPATHY LID INFECTION 224 106 S1610 OPHTHALMOLOGY OCULAR INJURIES 9 107 S1611 OPHTHALMOLOGY REFRACTIVE ERROR 6947 108 S1607 OPHTHALMOLOGY FOREIGN BODY IN EYE 72 109 S1614 OPHTHALMOLOGY OTHERS - OPHT 5166 110 S1615 OPHTHALMOLOGY TRACHOMA 20 111 S1608 OPHTHALMOLOGY GLAUCOMA 187 112 S1612 OPHTHALMOLOGY RETINOPATHY 25 113 S1602 OPHTHALMOLOGY CHRONIC DACROCYSTITS 226 114 S1605 OPHTHALMOLOGY DRY EYE 1874 115 S1603 OPHTHALMOLOGY CONJUNCTIVITIS 21361 116 S1606 OPHTHALMOLOGY EPISELERITS 99 117 S1601 OPHTHALMOLOGY CATARACT 1756 118 S1613 OPHTHALMOLOGY UVEITIS 8 165
S No. ICD Code ICD Group ICD Description No of Patient
119 S1706 PSYCHAITRY FS SYNDROME 2 120 S1709 PSYCHAITRY SCHIZOPHRENIA 24 121 S1701 PSYCHAITRY ALCOHOLISM 53 122 S1703 PSYCHAITRY CONVERSION REACTION/HYSTERIA 32 123 S1702 PSYCHAITRY ANXIETY 1919 124 S1705 PSYCHAITRY DRUG ADDICTION 7 125 S1710 PSYCHAITRY OTHERS - PSYC 22 126 S1707 PSYCHAITRY INSOMNIA 1672 127 S1711 PSYCHAITRY DEMENTIA 14 128 S1704 PSYCHAITRY DEPRESSION 299 129 S1806 RESPIRATORY SYSTEM PNEUMOT HORAX 2 130 S1810 RESPIRATORY SYSTEM TROPICAL PULMONARY CONSINOPHILIA 10 131 S1807 RESPIRATORY SYSTEM PULMONARY TUBERCULOSIS 245 132 S1808 RESPIRATORY SYSTEM UPPER RESPIRATORY TRACT INFECTION 58005 133 S1803 RESPIRATORY SYSTEM INTERSTITIAL LUNG DISEASE 3 134 S1805 RESPIRATORY SYSTEM PLEURAL EFFUSION 3 135 S1801 RESPIRATORY SYSTEM BRONCHIAL ASTHAMA 4201 136 S1804 RESPIRATORY SYSTEM LOWER RESPIRATORY TRACT INFECTION 664 137 S1809 RESPIRATORY SYSTEM OTHERS - RS 53 138 S1802 RESPIRATORY SYSTEM CHRONIC OBSTRUCTIVE AIRWAY DISEASE (COAD) 9131 139 S1502 UROLOGY DISEASE OF PROSTATE 94 140 S1507 UROLOGY URINARY INCONTINENCE 50 141 S1504 UROLOGY RENAL STONE/COLIC 723 142 S1505 UROLOGY URINARY TRACT OBSTRUCTION 37 143 S1501 UROLOGY ACUTE RETENTION OF URINE 16 144 S1506 UROLOGY OTHERS - URO 22 145 S1503 UROLOGY HAEMATURIA 39 Total 442241
No of Gas Victim Patient 119865 No of Gas Victim Depandent Patient 1536 Total No of Patient 121401 Annexure 166 P-13 Annexure P-14 167
To, 1. Dr. Harsh Vardhan Union Minister Ministry of Health & Family Welfare Government of India [email protected]
2. Dr. Balram Bhargav Director General Indian Council of Medical Research Ansari Nagar, New Delhi, [email protected]
3. Mr. P. Raghevendra Rao Secretary Department of Chemicals & Petrochemicals-Bhopal Cell Ministry of Chemical & Fertilizers Shastri Bhawan, New Delhi [email protected]
4. Mr. Gopal Reddy Chief Secretary Govt of Madhya Pradesh Mantralaya, Vallabh Bhawan, Bhopal, MP [email protected]
5. Dr. Pallavi Jain Govil Principal Secretary Bhopal Gas Tragedy Relief & Rehabilitation Govt of Madhya Pradesh, Mantralaya, Vallabh Bhawan, Bhopal [email protected]
Cc: Justice VK Aggarwal Chairman, Monitoring Committee for Medical Rehabilitation of Bhopal Gas Victims [email protected] 21 March 2020
Sub: Immediate steps to be taken for identification, testing and medical care of COVID - 19 in the population affected by the Union Carbide disaster in Bhopal.
Dear Sirs & Madam,
On behalf of organisations working with the survivors of the 1984 Union Carbide Disaster, we would like to draw your attention to the fact that the little over half million people of Bhopal who 168 continue to suffer consequences of the disaster are much more vulnerable in contracting COVID-19 in comparison to the general population.
As you may be aware, several reports to the Parliament, large number of studies published in international scientific journals and records of government run hospitals in the last three and half decades have documented the long term health damage caused to hundreds of thousands of Bhopalis as a result of their acute exposure to Methyl isocyanate. At least a quarter of the 5,74,375 individuals officially acknowledged to have inhaled the poisonous gas are today battling chronic and disabling diseases.
The toxic exposure is known to have damaged the immune system of such a large population in Bhopal that the situation was described as chemically induced AIDS by a medical researcher. It will be pertinent to mention that taking cognizance of the magnitude and complexity of the health situation of the Bhopalis, the Supreme Court of India has accorded the Bhopal survivor’s right to healthcare the status of the constitutional right to life.
Through this letter, we are seeking your urgent intervention towards providing essential services of testing and critical care to the gas affected population in view of their heightened vulnerability to the COVID - 19 pandemic.
A. Data on vulnerability of the gas affected population of Bhopal to COVID-19.
The most current data on COVID-19 indicates that people with any Cardio-vascular and Pulmonary problems, Diabetes, Cancers and most importantly compromised immune systems are 79% more at risk of being infected by the Corona virus, becoming critically ill and dying due to COVID-19. Further for a person with any of 2 of the above health problems the risk of the above outcomes is 2.5 times in comparison to the general population. (Source-https://www.worldometers.info)
Data from 8 community health units of the ICMR run Bhopal Memorial Hospital & Research Centre (BMHRC) in Bhopal from 1998 to 2016 presented on their official website (www.bmhrc.org on 21/01/2020) shows that 50.4% of gas affected patients suffer from Cardiovascular problems, 59.6% of them suffer from Pulmonary problems and 15.6% of them suffer from Diabetes. Further as per the records of the Office of the Welfare Commissioner, Bhopal Gas Victims, 10,550 (1.84% of the gas exposed population) have been granted ex gratia compensation as Cancer patients.
In view of the above and considering the fact that multi systemic damage is one of the characteristic features of the health impact of the gas disaster in Bhopal, it would be safe to say that the over half a million Bhopalis exposed to Union Carbide’s gases are at least 5 times more vulnerable to COVID-19 than a general population. Accordingly, it is very much likely that unless urgent steps are taken by the concerned government authorities, too many Bhopalis will suffer from COVID - 19 and die from it. 169
B. Conditions in the hospitals meant for gas victims are possibly contributing to the spread of Corona virus.
Visits to the BMHRC and to any of its 8 community units as well as 6 gas relief hospital run by the Department of Bhopal Gas Tragedy & Rehabilitation, Govt of Madhya Pradesh currently show that the concerned authorities have not at all woken up to the urgency of spreading awareness for prevention of COVID-19.
Date of Visit Name of Hospital Signage Content Photo
19 March Jawaharlal Nehru 1, A4 size B&W 5 point brief 1 Hospital poster
19 March Shakir Ali Hospital 1, A4 size B&W Homeopathy medicine to Photo poster cure Coronavirus will be 2,3 administered
1, 4X4 poster Asking patients to greet other with Namaste
19 March Indira Gandhi 1, A4 size B&W Patient should only bring Photo 4 Women & Child poster (pasted one attendant with them Hospital on lift)
Asking patients to greet 1, 4X4 coloured other with Namaste-No poster specific mention
19 March Kamla Nehru 1,A4 size illegible advisory of MOHFW Photo5 Hospital illegible advisory on COVID-19 of MOHFW
19 March Pulmonary Medicine 1 A4 size B&W Asking patients to cover Photo6 Centre poster their face with cloth while sneezing and coughing. 1 4X4 coloured poster Asking patients to greet other with Namaste
19 March BMHRC, Main None None Hospital 1 A3 size B&W Mini Unit No2- poster Poster issued by “Jagran Photo 7 Station Bajariya Josh” on Swine Flu
In all these hospitals there is a massive crowd and no plans have been put in place to Photo8- segregate patients from each other or for hand washing 13 170
C. Additional facts in support of Special attention to Bhopal survivors
In addition to their increased vulnerability, as underlined above, the Bhopal survivors have a justified claim to special attention for protection from COVID - 19 due to the following two facts :
1. Living conditions : The technical report of the epidemiological study on Bhopal gas victims by the ICMR highlights the fact that a significant majority of the survivors population is economically disadvantaged. Most survivors live in crowded and unhygienic conditions with rooms as small as 100 sq ft and no facility of running water. Special attention needs to be paid to ensure that facilities for handwashing are available to them. Likewise special attention needs to be paid for identifying symptomatic spreaders in disadvantaged communities and arranging for their care in isolation.
2. Working conditions : According to ICMR data on Bhopal survivors over 60 % are dependent on hard manual labour for their livelihood. Many of them such as sanitation workers, vegetable and other cart vendors, drivers, police and security guards and casual labour will continue to work mainly because of economic compulsions. Such people need to be provided with the means, including PPE to keep themselves safe despite potential -contact with virus infected individuals.
In view of the above the following steps need to be taken urgently by the concerned authorities
I. Awareness Spreading in Hospitals & in Gas Affected Communities: As described above currently there are no educational material on protection from and care of COVID – 19 in the hospitals meant for Bhopal survivors. This situation needs to be remedied without delay. Given the low level of literacy in the affected population it may be imperative to include audio-visual media for effective communication on a much wider scale in the communities of survivors. Community health workers, socials workers need to be immediately deployed in the gas affected communities to educate & spread awareness on COVID 19.
ii. Identification & Testing: There is an urgent need to set up Corona OPDs in the 6 state run gas relief hospitals and in the BMHRC and its 8 community health units to identify gas victims who will require testing for COVID 19. A system needs to be put in place to ensure that testing of these identified cases happen at the earliest. It has also come to our knowledge that AIIMS Bhopal has tested less than 50 samples & currently their testing equipment is non functioning. More testing centers/sampling centers need to be established without delay. The Indian Council of Medical Research (ICMR) should develop BMHRC as a testing center for Bhopali survivors.
iii. Caring of critical cases: A hospital with ICU, isolation wards, ventilators and supply of relevant medicines & consumables such as oxygen that is fully dedicated to caring for the critically ill survivors need to be urgently established. We suggest using the 50 bed Pulmonary Medicine Centre (Rasool Ahmed Siddiqui Gas Relief Hospital) situated in Jehangirabad fo0r this purpose.
We are attaching a pamphlet on different aspects of COVID that is being distributed by NGO’s working among the gas victims. (Annexure 1-Pamphlet), Concerned officials of the state and 171 central government must move on production and distribution of educational material in the gas affected communities without delay.
We look forward to hearing from you.
Thanking You
Sincerely PHOTOGRAPHS FROM DIFFERENT GAS RELIEF HOSPITAL 1-13 172
Photo 1 JNH Hospital 1 Photo 2: Shakir Ali Hospital
Photo 4: Indira Gandhi Hospital Photo 3: Shakir Ali Hospital 1 173
Photo 6: PMC Hospital Photo 5: Indira Gandhi Hospital
Photo 8: Crowd at JNH hospital Photo 7: BMHRC Mini Unit 2 174
Photo 9: Crowd at JNH hospital Photo 10: Crowd at Indira Ganghi Women & Child hospital
Photo 11 Indira Gandhi Women & Child Hospital
Photo 12 Shakir Ali Hospital 1 175
Photo 13: Crowd at Indira Ganghi Women & Child hospital Annexure P-15 (a) 176 Annexure P-15 (b) 177 Annexure P-15 (c) 178 Annexure P-16 (a) 179 Annexure P-16 (b) 180 3/26/2020 AnxietyAnnexure grips Bhopal gas tragedy survivors asP-17 hospital designated as COVID-19 facility - The Hindu 181
NATIONAL Anxiety grips Bhopal gas tragedy survivors as hospital designated as COVID-19 facility Sidharth Yadav BHOPAL, MARCH 25, 2020 03:33 IST UPDATED: MARCH 25, 2020 01:06 IST
Several patients including critical ones were discharged to make way for virus- affected
After the Madhya Pradesh government designated the ICMR-run Bhopal Memorial Hospital and Research Centre (BMHRC) as the State-level COVID-19 treatment facility and stopped all other services there, anxiety gripped the Bhopal gas tragedy survivors who depend on it for super speciality care. “Only patients suffering from the infection will be treated there now,” read an order issued by Pallavi Jain Govil, Principal Secretary, Public Health and Family Welfare Department, on Monday. “I undergo dialysis three times a week there. Missing even one session could cost me my life,” said Aqueel Ahmad, undergoing the procedure for 10 years. “In such a condition where will I go now? Even in the OPD, they say no doctor will see us.”
On Tuesday, several patients including critical ones were discharged to make way for the special COVID-19 facility. Four patients were discharged from the gastro medicine ward, three from the cardiothoracic and vascular surgery (CTVS), one from the CTVS ICU, 10 patients from gastro surgery, seven from urology, 28 from pulmonary, one patient from nephrology, two from neurology, 15 from psychiatry, 11 from neurosurgery and six from ophthalmology, according to BMHRC sources.
https://www.thehindu.com/news/national/anxiety-grips-bhopal-gas-tragedy-survivors-as-hospital-designated-as-covid-19-facility/article31157647.ece 1/4 3/26/2020 Anxiety grips Bhopal gas tragedy survivors as hospital designated as COVID-19 facility - The Hindu 182
Giving the reassurance that alternative arrangements had been put in place for the patients, Ms. Govil told The Hindu, “The State government runs six dedicated hospitals for gas victims. They will cover all health care needs of the victims.” So far, the State has recorded nine COVID-19 cases, with six in Jabalpur and one each in Bhopal, Shivpuri and Gwalior. Rachna Dhingra of the Bhopal Group for Information and Action said, “Each day, around 4,000 survivors get their medicines from the hospitals. The government has taken away the only hospital that offers special services.” According to an order dated March 24 and issued by Dr. Prabha Desikan, BMHRC Director, all other health services were stopped there with immediate effect till further orders. Moreover, on March 21, rights groups including the Bhopal Group for Information and Action working for the welfare of the Bhopal gas tragedy survivors wrote to Union Health Minister Harsh Vardhan demanding adequate testing and critical facilities for them, in view of their heightened vulnerability to the pandemic. According to the eight community health centres of the BMHRC, which cater to the survivors, wrote the groups, from 1998 to 2016, 50.4% of gas-affected patients suffered from cardiovascular problems, 59.6% from pulmonary problems and 15.6% from diabetes. Furthermore, 10,550 (1.84% of the survivors) had been given ex gratia compensation as cancer patients. The groups pointed out that given the magnitude of the health hazard posed by the methyl isocyanate leak from a pesticide unit here in 1984, the Supreme Court had accorded the survivors’ right to healthcare the status of the Fundamental Right to Life under the Constitution.
Printable version | Mar 26, 2020 12:11:35 PM | https://www.thehindu.com/news/national/anxiety-grips-bhopal-gas-tragedy-survivors- as-hospital-designated-as-covid-19-facility/article31157647.ece
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https://www.thehindu.com/news/national/anxiety-grips-bhopal-gas-tragedy-survivors-as-hospital-designated-as-covid-19-facility/article31157647.ece 2/4 Annexure P-18 183
MP GOVT CORONA ACTION PLAN BHOPAL, MP
Help Line Facilities WhatsApp No: 9301089967 Telephone No: 0755-2570328 MP Helpline Number for Corona Virus: 0755-2527177/104 Dr. K.C. Raikwar, Bhopal: 7999926269 Dr. Rashmi Jain, Bhopal: 9424476989 AIIMS Bhopal: 18002331104 Corona Whatsapp No: 9013151515 Bhopal City Information Portal: 7415225222 Home Delivery Service for Senior Citizens: 1800 233 1253
Isolation Setup • AIIMS Hospital: 6 Beds • Hamidia Hospital-6 Beds • BMHRC Hospital – 7 Beds • Total Isolation Setup-19 beds • Upcoming Preperations: Letters written to 129 priate hosptials to reserve isolation beds • Private Medical College 05
Actions take by District Administration, Bhopal for Prevention of Corona Virus
• Quarentine Setup • TB Hospital Bhopal-60 Bed • Advance Medical College-500 bed • JP Hospital-6 Bed • Night Shelters (Bhopal Municipal Corporation) 74 bed • 3EME Centre, Army -300 Bed • Total Quarntine Setup: 1166 Bed • Forthcoming Preperations: Letter has been written to take over all Guest House, Marriage garden, Rewsidential Training Centres • If need arises Bhauri Institutional Area, Jamboori Maidan, will be taken over on need basis.
Current Status : Bhopal District
Date 23-3-2-2020 COVID-19 Positive 1 List of International travellers received 624 Residing in Bhopal 379 Monitoring Period Ended 50 Total Rapid Response Team 12 184
Future Action: Rapid response teams have been increased. Ward wise 85 teams have been set up who will work on contact tracing
Medical College Setup • People’s Medical College & Hospital • Chirayu Medical College & Hospital • Mahavir Medical & Hospital • LN Medical College & J.K Hospital • RKDF Medical College & Hospital • All private hospital have been directed to reserve isolation & ICU beds • All Medical colleges have been directed to reserve 10 Quarentine, 10 Isolation, & 5 ICU beds
COVID 19 Management Plan: Total 8 teams have been constituted
District level Steering Committee Establishment Team Data Centre Integrated Command and Control Centre Surveillance and Security Team
Procurement and Supply Management Team Rapid Response and Citizen Support Team Media Management Cell 185
IN THE SUPREME COURT OF INDIA
CIVIL ORIGINAL JURISDICTION
I.A No. of 2020
In
WRIT PETITION (CIVIL) NO. ______OF 2020
[Under Article 32 of the Constitution of India]
In the Matter of:
Munni Bee &Anr. …Petitioners
VERSUS
Union of India &Ors. …Respondents
APPLICATION FOR INTERIM DIRECTIONS
To,
The Hon’ble Chief Justice of India and
His Lordship's Companion Justices of the Hon’ble Supreme Court of India
The Humble Petition of the
Petitioner above Named
MOST RESPECTFULLY SUBMITS: 186
1. That the applicants have filed the above mentioned writ petition before this Hon’ble
Court, seeking following reliefs:
(a) A Writ in the nature of certiorari quashing the order dated 23.03.2020 passed by the Respondent No.2as being violative of Articles 14 and 21 of the Constitution of India and.
(b) A Writ in the nature of certiorari quashing order dated 24.3.2020 passed by the Respondent No.3 as being violative of Articles 14 and 21 of the Constitution of India.
(c) A Writ in the nature of mandamus directing the Respondents to shift the isolation centre for Covid-19 patients to the Pulmonary Medicine Centre, Gas Relief Hospital, Jehangirabad and/or any other appropriate hospital and.
(d) A Writ in the nature of mandamus directing the Respondents to develop and update clinical protocols with particular regard to victims of the Bhopal gas disaster for COVID-19 related morbidity for treatment in other hospitals with isolation facilities.
2. In order to avoid repetition, the applicants are not setting out the contents of the
accompanying writ petition in the present application, and seek liberty to rely on the
same and all accompanying annexures at the hearing of the present application.
3. That despite the orders dated.3.10.1991 and 14.2.1994 passed by this Hon’ble
providing for the establishment of the Hospital for the Bhopal Gas victims and provision
for medical care and treatment to them, the aggrieved persons including the present
applicants are adversely affected by the order dated.23.03.2020 passed by the
Respondent No.2, whereby decision was taken to convert it’s Bhopal Memorial
Hospital & Research Centre (BMHRC), super specialty hospital into a hospital for 187
exclusive treatment of COVID-19 patients thereby shutting all of it’s other medical
services and treatment for the victims of the Bhopal Gas disaster. That the applicants
humbly submit that the said order is in contravention of the principle of equality
enshrined under the Article 14 of the constitution.
4. That the applicants are also aggrieved by the order dated.24.3.2020 passed by the
Respondent No.3, whereby it was directed that all the health care services and facilities
will now be provided only for CoVID-19 patients at BMHRC, Bhopal and that all other
health care services to be stopped with immediate effect till further orders. The
Petitioners submit that the same is violative of Article 14 and 21 of the constitution.
That as a result of this order, the survivors, most of whom were already struggling for
their lives due to the ghastly effect of the disaster, are left stranded without any medical
treatment and support, thereby violating their right to life under Article 21 of the
Constitution of India. It is respectfully submitted that it that it amounts to treating
dissimilarly situated people as similar, thereby also violating Article 14 of the
Constitution.
5. That consequently, there is a grave and urgent danger to the life of the applicants as
all of them are left with no medical care and treatment.
6. That the applicants have a very good prima facie case on merits, and there is every
likelihood that the applicant will succeed in the present petition.
7. That irreparable extreme prejudice would be caused to the lives of Bhopal Gas
survivors, if the interim reliefs are not granted. On the contrary, no prejudice would be 188
caused to anyone as the grant of interim reliefs will medically benefit everyone in the
affected population, until the applicants’ petition is finally heard and decided.
8. That in such an eventuality, the balance of convenience lies firmly in favour of the
Petitioners. If this Hon’ble Court were to ultimately agree with the Petitioners, then
there appears to be no cogent reason as to why the interim “life-saving” reliefs should
not be granted to the survivors. That unless the aforestated reliefs are not granted to
the victims of the disaster, there would be further increase in casualties as a result of
their vulnerable and unshielded position, thereby causing great prejudice to their rights
and lives. On the other hand, no prejudice would be caused to the Respondents, if this
Hon’ble Court were to give the aforesaid reliefs to the Petitioners, pending final
disposal of the present writ petition.
9. That it is most respectfully submitted that if the present emergency reliefs are not
granted, the life and health of the Bhopal gas victims shall be in grave dangerand it is
no exaggeration to state that it is likely to contribute to a massive increase in deaths,
casualties and morbidity amongst them.
PRAYER
In the facts and circumstances stated above it is most respectfully prayed that
this Hon’ble Court be pleased to:
(i) Pending hearing and final disposal, stay the operation of order dated 23.03.2020 and order dated 24.3.2020 passed by the Respondent No.2 and by the Respondent No.3 respectively as being violative of Articles 14 and 21 of the Constitution of India.
189
(ii) Direct the Respondents, to immediately begin emergency, other urgent medical treatment, Casualty services and In Patient Department services for the victims of the Bhopal gas disaster;
(iii) (a) Direct Respondents to immediately resume OPD (Out Patient Department) facilities or
In the alternate:
(b) Direct the Respondents to keep open eight community units of the BMHRC or;
In the alternate:
(c) Direct that the respondents provide medicines for 30 days for Bhopal gas survivors with chronic conditions and telemedicine access to a cardiologist, a pulmonologist, a gastroenterologist, a neurologist and a psychiatrist.
(iv) Direct the Respondents to put a system in place for community surveillance, identification & testing of gas victims for COVID-19 disease, and allocate ambulances in every gas relief hospital to transport critical cases affected by COVID-19 patients.
(v) Direct the Respondents to begin urgent community education in gas affected communities to educate & spread awareness on COVID-19.
(vi) Direct the Respondents to put in place a system for caring of critical cases by setting up of a transitory arrangement consisting of one hospital with ICU, isolation wards, ventilators, with adequate supply of relevant medicines & consumables such as oxygen & Personal Protection Equipment (PPE) for doctors & nurses to take proper care of gas victims suffering from COVID-19.
(2) Pass ex-parte ad interim orders in terms of prayer 1. (i) to (vi) above. 190
(3) Pass such other further order(s) as this Hon’ble may deem fit in the facts and
circumstances of the present case.
AND FOR THIS ACT OF KINDNESS THE PETITIONER AS IN DUTY BOUND SHALL
EVER PRAY
DRAFTED BY:
Karuna Nundy, Advocate
Abhay Chitravanshi, Advocate
Filed on: 01.04.2020 FILED BY
Place: New Delhi
(APARNA BHAT)
ADVOCATE ON RECORD FOR THE PETITIONERS
191
IN THE SUPREME COURT OF INDIA
CIVIL ORIGINAL JURISDICTION
WRIT PETITION (CIVIL) NO. ______OF 2020
[Under Article 32 of the Constitution of India]
In the Matter of:
Munni Bee & Anr. …Petitioners
VERSUS
Union of India & Ors. …Respondents
APPLICATION FOR URGENT LISTING OF THE CAPTIONED MATTER
To,
The Hon’ble Chief Justice of India and
His Lordship's Companion Justices of the Hon’ble Supreme Court of India
The Humble Petition of the
Petitioners above Named
MOST RESPECTFULLY SUBMIT AS UNDER:
1. That the Petitioner No.1, Munni Bee, is a 68-year old lady, and is one of the Bhopal Gas survivors, who belongs to a very poor socio-economic background. That she was admitted to hospital as she had a heart attack, and underwent a Tracheostomy on 11.03.2020 at the BMHRC hospital and since then, has been on ventilator in critical condition at the General ICU thereof. However, the BMHRC management is now pressuring her family to take her back home to make the bed available for potential coronavirus patients, pursuant to the orders impugned in the accompanying writ petitions dated, inter alia, 23.3.2020. That it is most relevant to state that, if she is forced out from the Hospital, then, she would not have access to any super specialty hospital that has experience and high level competence in 192
dealing with the peculiar morbidities of Bhopal gas survivors. Further due to her economic condition she is not equipped with any means or resources to afford private medical care and treatment. The impugned orders seek to evict all the Bhopal victims from the hospital set up for them pursuant to the settlement of Union Carbide and pursuant to the orders of this Hon'ble Court from 1992-1998. This despite the fact that many of them have been operated on just a few days ago. That further, a medical study from Guangzhou, China indicates that Bhopal gas victims will be infected and die from COVID 19 at 2-3 times the rate of other patients 2. It is pertinent to State that there is another hospitaly for Pulmonary diseases also serving gas victims which may be more appropriate as it is not a multi super specialty hospital set up under the Bhopal Memorial Trust as directed by this Hon'ble Court. 3. That further the Petitioner No. 2, Bhopal Group for Information and Action, is an organization which is collectively representing the Bhopal Gas Victims and as Petitioner has assisted this Hon’ble Court, in the past, in a number of original writs concerning the Right to Life and Right to adequate and proper health care for Bhopal’s gas victims. That the Petitioner No.2 alongwith other organizations has written letters to the Union and State Governments, thereby attempting to bring the plight of the victims to the notice of the government, but to no avail. 4. That in view of the outbreak of Coronavirus epidemic, the consequent closing down of the BMHRC and limited functioning of its 8 health centres, the health condition of the victims of Bhopal disaster is deteriorating by the day due to absence of access to the medical facilities. In addition, they are much more likely to contract and be subject to casualties from COVID-19 because of their gas-affected reduced immunity, unless they are not given adequate treatment and required medicines. 5. That in the backdrop of the absence of any access to medical facilities due to the shutting down of the BMHRC and the apathy and inaction by both the State and Union Governments, the petitioners herein are constrained to hereby invoke the extraordinary jurisdiction of this Hon’ble Court. 6. That the urgency in the matter is that the Right to Life and Right to Adequate Healthcare and Proper Treatment (as recognized by this Hon’ble Court) as enshrined under Article 21 of the Constitution of India is in the gravest of danger in the toughest of the times as present and therefore needs protection of this Hon’ble Court. 7. That the accompanying writ petition is being filed in order to seek urgent and immediate relief to the victims of Bhopal Gas disaster including the Petitioner No.1 193
and the contents of same are not repeated herein for the sake of brevity and the same may be read as part and parcel of the present affidavit. 8. That if the present petition is not heard, there would be further increase in casualties of the Bhopal gas Victims as a result of their vulnerable and unshielded position, thereby causing great prejudice to their rights and lives. PRAYER
In the facts and circumstances stated above it is most respectfully prayed that
this Hon’ble Court be pleased to:
(a) allow the urgent listing of the captioned Writ petition at the earliest in the interest of justice.
(b) Pass such further orders as this Hon’ble may deem fit.
AND FOR THIS ACT OF KINDNESS THE PETITIONER AS IN DUTY BOUND SHALL
EVER PRAY
DRAFTED BY:
Karuna Nundy, Advocate
Abhay Chitravanshi, Advocate
Filed on: 01.04.2020 FILED BY
Place: New Delhi
(APARNA BHAT)
ADVOCATE ON RECORD FOR THE PETITIONERS
194
IN THE SUPREME COURT OF INDIA
CIVIL ORIGINAL JURISDICTION
Civil M.P No. of 2020
In
WRIT PETITION (CIVIL) NO. ______OF 2020
[Under Article 32 of the Constitution of India]
In the Matter of:
Munni Bee & Anr. …Petitioners
VERSUS
Union of India & Ors. …Respondents
APPLICATION FOR EXEMPTION FROM FILING OFFICAL TRANSLATION OF ANNEXURE P-1.
To,
The Hon’ble Chief Justice of India and
His Lordship's Companion Justices of the Hon’ble Supreme Court of India
The Humble Petition of the
Petitioner above Named
MOST RESPECTFULLY SUBMITS:
195
1. The petitioners have today filed the above noted writ petition. The petitioners
crave leave of this Hon’ble Court to consider the detailed facts stated therein
as part and parcel of this application as the same are not being repeated herein
for sake of brevity.
2. It is submitted that the Petitioners have filed the Annexure No. P-1 along with
the Petition which was originally in Hindi and which have been translated in
English. The Advocate has got the afore-mentioned annexure translated into
English on his own. It is submitted that the translation is true and correct
translation of the original and it is in the interest of justice that the said
translation be taken on record and the Petitioner be exempted from filing the
official translation.
3. That the present application has been filed bona fide and in the interest of justice.
PRAYER
In view of the above, it is respectfully prayed that this Hon'ble Court may be pleased to:
(a) Allow the present application and exempt the Petitioners from filing the
official translation of Annexure No. P-1; AND
(b) Pass such further and other orders as the court may deem fit in the
circumstances of the present case may require.
AND FOR THIS ACT OF KINDNESS THE PETITIONER AS IN DUTY BOUND SHALL
EVER PRAY 196
DRAFTED BY:
Karuna Nundy, Advocate
Abhay Chitravanshi, Advocate
Filed on: 01.04.2020 FILED BY
Place: New Delhi
(APARNA BHAT)
ADVOCATE ON RECORD FOR THE PETITIONERS
197
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