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The
Sambhavna Trust Clinic
Herbal
medicine
Appropriate
treatment
Women's
health
How
the clinic runs
The
staff perspective
Sambhavna’s
beliefs
Sambhavna is a Sanskrit / Hindi word which means "possibility".
Read as "sama" and "bhavna" it means:
"similar feelings" or "compassion".
The Sambhavna Trust is a charitable trust run by a group of
eminent doctors, scientists, writers and social workers who
have been involved with various aspects of the Union Carbide
disaster ever since its occurrence in December 1984. The Chairperson
of Sambhavna, Dr. PM Bhargava, was awarded the "Padma
Bhushan" by the President of India in 1986 and the "Legion
d'Honneur" in 1998 by the French government for his scientific
and social contributions. Dr. H H Trivedi, former Professor
at the Gandhi Medical College and Satinath Sarangi are the
two Bhopal based trustees of Sambhavna.
Many are unaware that the disaster in Bhopal continues to
this day. An estimated 120,000-150,000 survivors of the disaster
are still chronically ill. Over 20,000 have died of exposure-related
illnesses and more are dying still. Tens of thousands of children
born after the disaster suffer from growth problems and far
too many teenaged women suffer from menstrual disorders. TB
is several times more prevalent in the gas-affected population
and cancers are on the rise.
The failure of the official system of health care contributes
largely to the medical disaster in Bhopal. All research and
monitoring of the long-term health effects of Union Carbide's
gases have been abandoned since 1994. So far no treatment
protocols for symptom complexes associated with toxic exposure
have been established and symptomatic treatment remains the
mainstay of medical response. The indiscriminate prescription
of steroids, antibiotics and psychotropic drugs is compounding
the damage caused by the gas exposure. Despite the expenditure
of hundreds of crores of rupees by the government and the
Bhopal Memorial Hospital Trust [BMHT] towards medical relief,
the health status of the survivors and their children continues
to deteriorate.
In the prevailing situation of despair, the Sambhavna Trust
believes in creating possibilities by generating compassion.
The work carried out by the Sambhavna Trust over the last
five years has shown that it is possible to evolve simple,
safe, effective, ethical and participatory ways of treatment
monitoring and research for the survivors of Bhopal. However,
Sambhavna is small compared to the magnitude and complexity
of the disaster. While an estimated 120,000-150,000 survivors
of the disaster are today chronically ill, the clinic run
by this trust has provided direct treatment to approaching
30,000 people and provided support to about the same number
through its health initiatives in 10 communities close to
the Union Carbide factory.
At Sambhavna, survivors are offered free medical care through
allopathy, ayurveda [an indigenous system of medicine based
on herbs] and Yoga. The 21 staff members of the Sambhavna
clinic [among whom 9 are survivors themselves] include five
physicians, two yoga and two Panchakarma therapists and five
community health workers who carry out health surveys, health
education and community organisation for better health. Inside
the Sambhavna clinic
The Sambhavna clinic stands in two acres of medicinal herb
garden in the heart of the gas-affected area of Bhopal, half
a kilometre from the disused Union Carbide factory and directly
south of JP Nagar, the worst-hit neighbourhood. The modern
clinic was purpose-designed and built after we outgrew our
original building. The new clinic opened in 2006 is ecologically
constructed throughout and designed to provide a pleasant
and uplifting environment for people coming to us for care.
In contrast to government hospitals there are no paan (betel
leaf) stains on the walls. Such a tranquil exterior doesn't
really prepare you for the diversity and dedication of the
work inside - though it does reveal something of Sambhavna's
integrative approach to the health care of Bhopal gas survivors.
For instance, the shrubs, trees and climbing plants surrounding
Sambhavna, while contributing to a soothing environment for
gas-affected visitors, are also intensely functional. Many
have a specific use in Ayurvedic medicine, the traditional
Indian system employed at Sambhavna. Among the flower beds
you will find the heart shaped leaves of Tinospora cordifolia,
a plant used in Ayurvedic medicine to dispel different kinds
of fever. We grow 90 kinds of herbs in the garden. Distinctive
for their foliage are small trees of Ricinus communis, good
for relieving pain in the chest, abdomen, limbs and joints
- all key symptoms of gas exposure.
Visitors to the garden can find ample shade beneath a trees
and can also relax in the rustic hut we have made, which has
a clay hearth for making tea. With herbs everywhere, people
coming for panchakarma treatment, yoga or women's complaints
find themselves surrounded by a variety of medicinal plants.
Especially so when some of the plants are flowering, the garden
produces a sweet vegetative aroma under the heat of the sun.
This is mixed with the smells from the medicines being prepared
by our own staff in a well-equipped manufactury within the
clinic. More than 30 medicines are prepared at the clinic
from our own herbs. These medicines, based on standard Ayurvedic
texts, are three to five times cheaper than market preparations
and of much better quality.
Possibilities for care
In the airy Yoga room in the morning visitors are taught to
use a number of different Yoga exercises [('Asanas'
(body postures), 'Shodhana kriyas' (cleansing actions) and
Pranayama (breathing discipline)] by Sushmita and Amita, both
fully qualified instructors. The therapeutic effects of practicing
Hatha Yoga - the over two thousand year old science of uniting
and coordinating the physical and mental aspects of one’s
being through consciously attempted discipline of the body
- have been successfully applied at the Sambhavna. Chronic
respiratory disorders are the most prevalent complaints among
gas survivors: two years of research at Sambhavna using spirometry
testing has demonstrated that regular Yoga produces significant
and sustained improvement in lung function, decreases airway
restriction and greatly lowers dependence on drug-based therapies.
According
to Sushmita, early Yoga classes were poorly attended - "for
one year it was difficult to get people to understand. Many
people thought relief only came in the form of a pill. We
faced cultural barriers too: lots of our patients are Muslim,
they thought Yoga was only for Hindus. Yoga's remarkable efficacy
as a drug free therapy is possibly the principle reason for
its growing popularity among a people understandably sickened
by the idea of taking medicines all their life. In the study
mentioned above, more than half of the people taking Yoga
therapy for persistent breathlessness were able to remain
completely off drugs they have had to take everyday for the
last 10-12 years. Naturally, Yoga costs nothing and once learned
can be practiced outside of the clinic. Additionally, Yoga
calls for the individual to be an active participant in his
or her own healing.
In the afternoon, after sessions have finished, the four community
health workers (the only four in all of gas-affected Bhopal)
gather in the Yoga room to discuss their work. Their role
is to visit people in their homes everyday: following up on
1,000 people who have received care at the clinic every month;
collecting information on health and healthcare in the community;
and through health education, involving people in taking control
of their community's health. For example, women and men who,
with support from the health workers, have recovered from
TB (which is three times higher among gas-exposed Bhopalis)
in turn provide information and inspiration to other sufferers.
As in the case of Yoga, certain obstacles had to be overcome
before results could be achieved. Aziza explains: "early
on, I talked to one woman and said she should take her sputum
for a test. She went and hid under her bed. TB brought shame
with it and people did not want to get tested in case they
got 'found out'. Now people come up to us and ask for tests.
TB was a taboo, now it’s more open." According to
Ramesh, lack of education is the main problem: "the most
important thing is to educate people. To know that the disease
is actually curable and that treatment for TB is available
free of cost is a revelation for most untreated patients".
Even when somebody starts a six-month course of treatment
there is no guarantee they’ll finish it, meaning that
community monitoring and follow up visits are vital. "We
have to do our best in communication so that people are regular
with the treatment for the full course."
The health workers also collect information on current deaths
in the community; the clinic has pioneered the use of Verbal
Autopsy, a scientific and internationally validated technique
for ascertaining probable cause of death. The work of the
official government agency for documenting exposure-related
deaths was prematurely abandoned eight years ago. Sambhavna’s
ongoing data indicate that in this sixteenth year of the disaster
people continue to die of diseases related to their exposure
to Union Carbide's gases. Verbal Autopsy data shows many exposure-related
deaths are caused by cancer, among which 49% are cancers of
the respiratory system.
Just along the terrace is the fragrant Panchakarma room where
a fivefold detoxification treatment is provided, including
massage, enema and medicinal sauna. Panchakarma has been found
to be particularly beneficial in the treatment of chronic
back and joint pains. Also Shirodhara - pouring a steady stream
of medicine on different parts of the head, is most effective
for insomnia and anxiety. A few yards from the roof garden
is the Documentation Centre: here visitors can read about
all aspects of the December '84 Union Carbide disaster from
books, magazines, newspapers and a considerable number of
documents. Visitors benefiting from this resource include
researchers, journalists and activists.
Downstairs is a fourth waiting area. Just along from the hatch
of the Ayurvedic and Allopathic medical dispensary is the
pathology laboratory where clinical samples of blood, sputum,
urine, and PAP smears are analysed by Amita (who is also a
biochemist) and Mahendra, a qualified medical laboratory technician.
On the other side is the computer room where clinical data,
Verbal Autopsy data and registration details are inputted
by Pranay and Sushmita; and the office, where a small collection
of international volunteers is likely to be seen. This waiting
area, the hub of so many of the clinic’s activities,
symbolises the prevailing ethos of Sambhavna: that the person
coming for treatment is placed squarely at the centre of concern.
Off along a small corridor are the Registration area, the
Allopathic surgery of Dr Mohammed Ali Quaiser and the clinical
examination room.
Herbal medicine
Also next to the main waiting area is the surgery of Sambhavna's
Ayurvedic specialist, Dr Deshpande, who first applied Ayurvedic
medicine to the problems of gas exposure in 1985. He has been
at Sambhavna since it began nearly four years ago, facing
familiar difficulties early on: "the first problem was
that we had to create an awareness of herbal medicines. In
the beginning people did not think so highly of Ayurvedic
medicines. Then the patients who tried Ayurveda quickly found
they were getting much and sustained relief."
The
clinic’s use of Ayurveda - as a counterpart to Allopathic
treatment - along with Panchakarma and Yoga, presents a direct
challenge to the methods of treatment that have prevailed
in Bhopal since the gas leak. These methods have largely been
directed towards providing symptomatic relief without having
any effect on the chronic disease process. Steroids antibiotics
and psychotropic drugs continue to be the mainstay of treatment
through modern (Allopathic) medicine in the hospitals and
clinics run by the state government, the Bhopal Memorial Hospital
Trust and private doctors. It is quite common to find people
in Bhopal who say they have taken more than five or ten kilograms
of Allopathic pills and have had only temporary relief, if
at all. There is substantial evidence that indiscriminate
prescription of symptomatic drugs is compounding injuries
caused by the disaster on a large scale. On the other hand
the continuing disaster is a windfall for drug manufacturers.
A study carried out by Sambhavna in '96 showed that a dozen
transnational pharmaceutical companies in control of the drug
market in Bhopal were the chief beneficiaries of the situation
following the disaster.
Ayurveda, an over 3000 years old system of indigenous medicine
works on the principle of helping, with mostly herbal medicines,
the body/mind heal itself. Disease, according to this system,
occurs as a result of dis-equilibrium of the vata (air), pitta
(fire) and kapha (water) humours and healing is effected through
restoring this equilibrium. Ayurvedic toxicology (Agada tantra)
mentions the vitiation of "doshas" (humours) and
loss of vitality (Ojas) as a result of poisons entering the
body and the treatment recommended includes detoxification
through Panchakarma along with medicines for restoring vitality,
immunity and the natural equilibrium of the body. With the
realization of Ayurveda's potential for healing Bhopal victims,
the clinic has generated much interest among Ayurveda practitioners
and researchers in the country towards use of this ancient
system in the healing of modern industrial diseases. Unlike
allopathic drugs many of the Ayurvedic medicines can be prepared
locally and inexpensively.
Appropriate treatment
Most visitors walk to the clinic from the severely-affected
communities. Newcomers are welcomed, registered (which allows
for accurate recording of medical data and follow ups on those
who drop out in the middle of treatment) at a rate of 5-10
per day, given a Health Book, and after consultation are offered
a choice of systems of care. Those choosing Allopathy are
offered care by a general practitioner, a gynaecologist and
a psychiatrist. Dr Ali Quaiser, the GP, explains that visitors
are not made to feel like patients at Sambhavna, "We
try to have a friendly atmosphere. People are frank, apart
from relating their health problems they also report their
frustrations, their home lives. As well as looking after the
physical health of those who come here, we are also taking
care of their spirit."
Great
care is taken to ensure that any drugs that are prescribed
do not add to the damage already caused. As a matter of principle
the clinic buys its medicines from the only non-profit collective
in India producing quality medicines. A thorough medical examination
is one of the salient features of Allopathic care at the clinic.
Because it is usual for people coming to Sambhavna to be accustomed
to neglect, mistreatment and queues in dismal government and
other hospitals first-time visitors have broken down in tears,
explaining that in 15 years no doctor had ever listened to
their chests or felt their pulse during examination.
Since little is known about the efficacy of different drugs
in treating exposure-related injuries, special efforts are
made to monitor effects of both Allopathic and Ayurvedic therapies.
Doctors and other therapists have evolved a system of grading
severity of different symptoms so that relief obtained in
each symptom can be documented with some degree of precision.
Clinical data of each person is entered into a database with
analysis of data being presented on a monthly basis for assessment
of efficacy of different therapies.
Women's health
Given the official neglect towards monitoring and care of
gynaecological complications caused by the disaster, special
attention is paid by Sambhavna in this area. While officials
continue to deny any exposure-related gynaecological health
consequence, data collected at Sambhavna shows that of 190
females, aged between 13 and 19, who came to the clinic between
1st June 1999 and 31st March 2000, 113 reported menstrual
problems, including painful and irregular menses, heavy bleeding
and excessive vaginal secretions.
The secretions, locally as ‘safed pani’ (literally
white water), are not often openly discussed because of social
taboos. Community health worker Aziza explains, "Women
do talk about it more now but are often confined to their
houses and can’t talk to their husbands about their problems
or get education." Worryingly, Sambhavna’s pathologist
has found a high proportion of abnormal PAP smears among women
survivors, increasing fears for a connection between cervical
cancer and gas exposure. Already in India, cervical cancer
is the highest occurring cancer for women, but there is no
provision for routine cervical screening in Bhopal. Women
who are referred to local hospitals after producing abnormal
smears have been reluctant to attend, given that the most
common medical procedure for cervical abnormalities is an
immediate hysterectomy. This is referred to as a "blind
hysterectomy" because no one including the doctor knows
how far or how little the malignancy is.
In response to this situation Sambhavna has initiated a cervical
screening project. The project involves educational work in
gas-affected communities to help surmount taboos concerning
gynaecological health; a thorough programme of PAP smears
coupled with cytological work (smear analysis); and where
necessary the employment of up-to-date colposcope diagnosis
and excision by LLETZ large loop excision of transformation
zone of suspect cervical tissue. At each stage of the project
the role of the community health worker is crucial to guiding
the women past social obstacles. And Sambhavna’s screening
project shows that there is a place for the latest technology
as well as 3,000 year old therapy when seeking the most rational
treatment for gas survivors.
How the clinic runs
Mid-morning is the busiest time at the clinic. Women wearing
colourful saris and shalwar-kameez, or the more sombre burkhas,
numerous children and men of differing ages and backgrounds
mingle together, quickly filling up the four main waiting
areas. The gas hasn't been able to mold the disposition of
the people affected. Without exception visitors wait calmly
and respectfully, talking quietly with each other or swapping
jokes and stories with the clinic staff. Sometimes small gifts
are brought in as expressions of gratitude. By their conduct,
visitors reveal a sense of the clinic existing for them. And
the vast majority of newcomers to Sambhavna arrive on the
recommendation of those already attending.
Collective
decision-making and individual responsibility taking distinguishes
the particular the style of working at the clinic. The highest
staff salary is not more than three times the lowest, and
opportunities for improving skills are offered to all in equal
measures. The staff bring a broad range of age, experience
and educational qualifications to the collective efforts.
Seven of the staff are women. Six of the 17 staff are victims
themselves: Aziza and Diwakar the community health workers,
Amita the pathologist and Yoga instructor, Alka the Panchakarma
therapist and Shinde and Manu, both registration workers.
There is no formal hierarchy of jobs at Sambhavna; every member
of staff is free to give suggestions on every aspect of the
clinic’s work; meaning, for example, that the health
workers contribute as much to the evolution of appropriate
medical care as do the doctors. Poornima, who runs the Documentation
Centre, finds a lot of advantages in this approach: "knowing
that we can apply our ideas gives us more confidence, develops
our thinking and makes us more willing to take on responsibility.
Because we have to make work plans for staff meetings, because
managerial skills are developed on a rotation basis, with
everyone being a co-ordinator for two months, it means everybody
has to take responsibility for themselves and everybody else."
Consensus is arrived at in weekly meetings, where the typical
quiet and calm of the clinic can occasionally be shaken. The
meetings determine the day-to-day and long-term activities
of the clinic.
The staff perspective
On the matter of working at the clinic, the staff of Sambhavna
express very similar feelings. "Working in a social organisation
you have a completely different relationship with those who
come for care. And in a non-hierarchical workplace you also
have a different relationship with your co-workers,"
says Biju. Ritesh, another of the community health workers,
adds that "it’s like being in a family – there’s
no difference, we feel like one big family. When I worked
in the National Insurance Agency people always left the minute
their work hours finished: here we stay until we are satisfied
that our work is finished for the day." Pranay, who does
Verbal Autopsy and data management at the clinic, echoes Ritesh:
"if my career had followed my studies I’d be a civil
engineer. Here I feel we all benefit from the collective spirit,
the sharing of ideas. If I worked somewhere else I think I’d
be trying to escape…"
Kamal,
the medical dispenser, is evidently proud of the clinic's
ethos: "the clinic staff treat people like fellow human
beings. We do a real social service here. Other clinics are
vocational; everything is oriented around salaries. I get
a lot of satisfaction from being able to help people in their
problems." Mr Chaudhary, who manages and administrates
the finances of the clinic, used to be an officer of the Finance
Department for the State government: "I’m retired
and so have no need to work. You could say I’m making
up for my previous work, because in that there was no attempt
to serve the people." And for Dr Deshpande, "it
is a very good time, a very precious time in my life. It is
a privilege to work here."
In many ways the four health workers at Sambhavna get the
deepest, most extensive contact with those the clinic has
been set up to help. Says Diwakar, "when we first started
it was like a dream come true because we set up the clinic
exactly how we wanted it. Even though money is very scarce
we offer four kinds of treatment, six days a week. No government
hospital provides so many things: in other hospitals there
is only Allopathy." Ramesh’s daytime health work
is combined with being Sambhavna’s sleep-in security
guard: "I’m never scared of hard work here because
I know that it’s for other people’s benefit. Once
I got to know my exact role in Sambhavna I was totally committed
– I’m very happy with my work."
Last words go to Aziza. "This work is different for me.
My family is gas affected. I didn’t start working here
for a salary, but for the opportunity to do humanitarian work
with the poor who needed helping. After 4-5 months, after
fully realising the kind of work I am doing, I was so happy
for my profession. Once we were doing a survey and we met
a woman, 55 years old, who had an infection of the cervix
– she had been bleeding for three months. We brought
her to the clinic. If we hadn’t done this she would have
died. Every time we see her now she smiles and gives us good
wishes.
We have many big dreams but our hands are tied because we
have to work within limitations. Because all the money is
donated we have to be very careful how we spend it. We want
to go to the root cause and real pains, so we can help people
to the core. If we got proper funds we would be able to do
so much more, to reach out to them and touch them – there
are lots of dreams."
Sambhavna’s
beliefs
* The disaster in Bhopal is not an isolated event. Workers
and communities are routinely poisoned all over the world.
* Reduction and eventual elimination of hazardous chemicals
from the planet and our daily lives is the only solution to
the growing number of slow and silent Bhopals in our midst.
* Until this happens, the safety of our health and lives depends
on watchful monitoring, strict enforcement of regulations
and exemplary punishment to offending agencies. In this respect,
ensuring justice in Bhopal can be seen as a public health
initiative with potential for significant and widespread change.
* Limits of modern medicine in taking care of modern industrial
diseases are becoming increasingly apparent. Evolution of
an appropriate system of health care, monitoring and research
for survivors of Bhopal is of consequence to all of us worldwide.
* It is possible to combine traditional and western systems
of health care when evolving appropriate care intended to
provide sustained relief to chronically ill survivors of Bhopal.
* It is possible for an individual to be an active participant
in the process of healing and the community to be involved
in all aspects of public health.
* It is possible to evolve systems of health surveillance
and environmental monitoring through active participation
of the community of survivors. Our work in documenting long
term consequences of exposure is part of the survivor’s
ongoing struggle of memoryagainst forgetting.
* It is possible to depend upon the compassion of ordinary
individuals and generate enough funds to run our clinic without
corporate charities, large grants from foundations or government
assistance.
* It is possible to generate opportunities for hope through
creative and collective intervention in a situation of despair.
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