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Oh, good God, how long do you have?Do you want just Supreme Court blockbusters that are well-known, or do you want subtle cases in arbitration and administrative law that are virtually unknown outside of specific legal areas but that have a massive influence on how state and federal government is run? Are circuit court opinions all right? State court? I mean, we could really be here a while depending on how broadly you want to go.Here’s just some highlights from law school. I could go on like this for days. Months. I am not being facetious here. I promise I’m not going to just dump my law school outlines. That could get really long. Just my Constitutional Law outline was 40 pages.Constitutional Law - PowersJudicial ReviewMarbury v. Madison, 5 U.S. 137 (1803). Establishes the concept of judicial review as part of the United States judicial powers.Martin v. Hunter’s Lessee, 14 U.S. 304 (1816). Extends judicial review to being able to overrule state decisions if they conflict with the Federal Constitution.Enumerated PowersNecessary and Proper ClauseMcCulloch v. Maryland, 17 U.S. 316 (1819). Defines the scope of the Necessary and Proper Clause of the Constitution to essentially turbocharge all enumerated Federal powers. “Let the end be legitimate, let it be within the scope of the Constitution, and all means which are appropriate, which are plainly adapted to that end, which are not prohibited, but consist with the letter and spirit of the Constitution, are constitutional.”The Commerce ClauseGibbons v. Ogden, 22 U.S. 1 (1824). The Federal government has the plenary power under the Commerce Clause to regulate “channels of commerce,” including waterways, roads, and railroads.Lochner v. New York, 198 U.S. 45 (1905), decides that the freedom to contract is a fundamental right that the Federal government may not infringe upon by petty regulations like prohibiting bakeries from forcing bakers to work more than 60 hours a week or 10 hours a day.Hammer v. Dagenhart, (I’m getting lazy and I’m going to stop putting in the Bluebook cites,) (1918) key case of the “Lochner Era,” where the Court viewed itself as a sort of super-legislature and overrode Congress frequently where they didn’t think Congress made good policy. The Court decided that manufacturing is not “commerce” and struck down child labor laws.Carter v. Carter Coal (1936), decides manufacturing and labor rights are local issues, strikes down labor laws as an invalid exercise of the tax and spend clause.West Coast Hotel v. Parrish (1937), generally accepted as the end of the Lochner Era. Upheld a minimum wage requirement in Washington.Wickard v. Filburn (1942), upholds New Deal price controls on wheat, establishes the concept that economic activity can be viewed in the aggregate to see if there is a “substantial impact” on interstate commerce, which gives Congress the power to regulate activity under the Commerce Clause. The Court will not strike down another Congressional act based on the Commerce Clause for more than fifty years.Heart of Atlanta v. United States (1964), held that the movement of people is always considered commerce; upholds nondiscrimination laws barring segregation.Katzenbach v. McClung (1964), holds that refusing to serve black people at a restaurant has a substantial effect on interstate commerce because it’s connected to interstate commerce through interstate interactions - suppliers bring in things from out of state. Viewed in the aggregate, this has a substantial effect on interstate commerce and so Congress can regulate it.Lopez v. United States (1994), strikes down federal gun-free school zones because Congress did not sufficiently research or articulate how guns in schools are related to commerce. First time the Court strikes down a law passed pursuant to the Commerce Clause since before Filburn.United States v. Morrison (2000), after Lopez, Congress does a LOT of fact-finding when making laws pursuant to the commerce clause. Makes a ton of factual findings when passing the Violence Against Women Act about how violence against women impacts commerce in the aggregate; women who aren’t safe don’t buy things, have jobs, and so forth. The Court looks at it and goes, “ehhhhhhhh… ok, new rule - if it’s not inherently economic activity, then you can’t aggregate it.” They decide that individual violence against women isn’t economic activity, so it can’t be aggregated, and therefore, can’t be regulated under the Commerce Clause.Gonzales v. Raich (2005), decides that things that could end up in the marketplace (any commodity and the manufacture or growing of such commodity) is economic activity, can be regulated, and upholds the use of the Controlled Substances Act to slap a California grandmother growing small amounts of marijuana in her basement for personal use with a Federal crime.Sibelius v. NFIB (2012) Part I: The Attack of the Roberts Court, holds that non-participation in the market is not commerce and can’t be regulated; people cannot be forced into the marketplace.The Tax and Spend ClauseSouth Dakota v. Dole (1987) held that it’s perfectly fine to spend federal funds to dictate policy to the States, so long as it’s an unambiguous national interest (here, preventing drunk driving accidents on the federal interstate highway system,) and it’s not coercive (can’t compel the state to adopt the policy). Withholding federal highway funds from any state that didn’t raise the drinking age to 21 was not coercive enough.Sibelius v. NFIB, Part II: The Revenge of the Tax and Spend Clause; Roberts decides that the mandatory ACA Medicare expansion was coercive because it would have taken away all Medicare funding from any non-complying state, but also holds that the individual mandate was OK under the tax and spend clause, because the penalty for not having health insurance was a tax, collected by the IRS, and spent on paying off the assholes who show up at the ER without insurance and no money that the rest of us pay for through our premiums.Treaty PowersMissouri v. Holland (1920). Height of the Lochner Era, mass extinction-level hunting of migratory birds going on. The Court keeps striking down all sorts of Federal regulations on migratory birds under the Commerce Clause; birds and hunting are not commerce according to the Court. But, Woodrow Wilson got Canada to sign on to a treaty regarding migratory birds in 1916. The Court finds that valid, and regulations passed pursuant to that treaty are valid under the Necessary and Proper Clause.Executive AuthorityYoungstown Sheet and Tube (1952); Truman’s attempt to seize steel mills and nationalize the steel industry failed because Congress told him no, you can’t do that. Special concurrence by Justice Jackson establishes various “zones” of presidential powers.Constitutional Law - LibertiesFundamental Rights - Substantive Due ProcessBarron v. Baltimore (1833), decides that the Federal Constitution and particularly the Bill of Rights doesn’t apply to the states unless it explicitly says so. States and municipalities can seize property without compensation to their hearts’ delights.Lochner v. New York (1905) - decides that there is a fundamental right to contract, and that the more important a right is that is infringed upon, the more the Court should insist upon a close fit between the means of governmental intrusion and the ends.Palko v. Connecticut (1937) establishes that to find a fundamental right, it must be “deeply rooted in the traditional conscience,” and “essential to our notions of ordered liberty.” Fundamental if no potential system of justice would be complete without it.United States v. Carolene Products (1938), “magic footnote four” establishes the idea that infringement upon certain rights should be granted a higher level of scrutiny, significantly clarifies the notion laid out in Lochner.Duncan v. Louisiana (1968) refines Palko, must be necessary specifically to American scheme of justice. Starts the road of “incorporation,” which applies the Constitution to the States through the 14th Amendment. Starts with “strong selective” incorporation, generally assuming that the Bill of Rights applies, but still only on a case-by-case basis.Meyer v. Nebraska (1923), fundamental right to parent your children as you see fit, no legitimate end in prohibiting teaching of German language.Buck v. Bell (1927), Oliver Wendell Holmes decides that forced sterilization of mentally ill patients is just fine because, and I quote, “three generations of imbeciles is enough.” This has never been overruled.Skinner v. Oklahoma ex rel Williamson (1942), strikes down forced sterilization of prison inmates and establishes the concept of bodily autonomy and integrity for the first time in U.S. jurisprudence. Recognizes that there may be fundamental rights to marriage and procreation.Rochin v. California (1952), strikes down conviction for drugs after police forcibly pumped the man’s stomach to retrieve them; upholds idea of bodily integrity.Griswold v. Connecticut (1965), finds a fundamental right to personal medical privacy under the “penumbra” of the Bill of Rights; strikes down Connecticut statute prohibiting contraception or aiding someone in obtaining it. Establishes the idea that government does not belong in the bedroom, sets the stage for a huge abortion fight that will last at least the next 55 years.Loving v. Virginia (1967); holds that marriage is a fundamental right and strikes down anti-miscegenation laws nationwide.Eisenstadt v. Baird (1972), finds that the right to choose whether to procreate or not is fundamental, covering married people using contraception only in this case. Applies strict scrutiny; while preventing adultery is a legitimate governmental interest, it is not served here. If the right to sexual privacy is to mean anything, the Court reasons, it must be an individual one.Roe v. Wade (1973). Probably the biggest landmark decision affecting U.S. politics as a matter of fundamental rights ever. The Court applied the lines of cases stretching back to the beginning of fundamental rights, bodily integrity, sexual and medical privacy, and found that the right to an abortion falls under these rights. The Court holds that a fetus is not a person by definition of the Constitution.Bowers v. Hardwick (1986) found that there was no specific right to engage in sodomy in the Constitution.Planned Parenthood v. Casey (1992) ditches the rigid trimester framework that Roe came up with in favor of the “undue burden standard” and drawing the line when government can fully regulate or ban abortion at viability (then generally accepted at 24 weeks.)Also established a framework for when to overrule precedence, requiring balancing four factors: 1) how unworkable the previous standard has become, 2) the amount of reliance on the previous decision there has been, 3) whether the previous decision has been undermined or evolved, and 4) factual developments since the previous decision. This has a great deal of impact on our politics by providing lawmakers the criteria needed to undermine prior decisions and develop a factual basis to overrule prior cases.Lawrence v. Texas (2003), while there is no specific right to homosexual sodomy in the Constitution, consensual sex in the privacy of one’s own home is a fundamental right and discrimination against homosexuals is not a legitimate state interest.Obergefell v. Hodges (2015); extended fundamental right to marry found in Loving to same-sex marriages.Whole Women’s Health v. Hellerstadt (2016); struck down admitting privileges and other various TRAP laws as violating the undue burden standard laid out in Casey; reaffirmed Casey and Roe’s essential holdings.Equal ProtectionFrontiero v. Richardson (1973). Laid out the criteria for finding suspect classifications under the Equal Protection Clause. Suspect classifications get strict scrutiny. These are politically protected classes of people.Korematsu v. United States (1944). One of the most infamous decisions of the 20th century; established national security as a compelling state interest, allows facially racial discrimination. (Overruled since.)Brown v. Board of Education (1954), struck down racially segregated schools as a matter of equal protection. Overruled Plessy v Ferguson (1896) that upheld Jim Crow laws as “separate but equal”.Fisher v. University of Texas (2013, 2016), upheld affirmative action programs on a narrow basis, so long as race is only one factor among others and there is no other race-neutral alternative to achieve diversity.Also, states themselves can prohibit affirmative action programs after Schuette v. Coalition to Defend Affirmative Action (2014). This is affecting US politics on a state level as legislatures are pushing to ban affirmative action programs.Voting RightsBaker v. Carr (1962). Allowed the Court to intervene in redistricting at all; it had generally been viewed as a political question outside of judicial review prior to this.This case literally broke two justices. Justice Frankfurter had a stroke because of it and was forced to retire, and led to a psychological breakdown of Justice Whittaker, who never recovered and retired from the Court without a decision on Carr.Reynolds v. Sims (1964), established the “one person, one vote” principle.Kramer v. Union Free School District (1969), the right to vote is a fundamental right and requires strict scrutiny review. This is still impacting politics today as various politicians try to find ways around it, notably felon disenfranchisement.Nixon and his cabinet were furious about this decision and it was a piece of the reason for the War on Drugs; if they couldn’t simply undo the voting rights act and couldn’t restore Jim Crow, they’d basically have to find a way to criminalize being black. The War on Drugs specifically targeted drugs favored by the black community with greater enforcement. This is still a problem today.Bush v. Gore (2000), held that the right to a uniform process outweighed the individual’s right to have their vote counted because the electoral college operated on a deadline. This decision gave the election to George W. Bush.Evenwel v. Abbot (2015), after a naked attempt by Texas to reduce the influence of districts with a high population of non-citizen immigrants, the Court decided that districts should be drawn based on total population, not just eligible voters. The Court noted that this was explicitly debated and considered in the drafting of the Constitution and the people who wrote it explicitly went with total population.This is currently impacting the 2020 Census as the Trump Administration has been actively trying to get a citizenship question on the census for the first time in 70+ years for the purpose of trying to get undocumented immigrants not to answer the census, thus undercounting the number of people in those areas and decreasing representation for those districts.Free SpeechNew York Times v. United States (1971), ruling that even where the government has a compelling interest to restrict speech as a prior restraint (prevent someone from speaking,) it can’t be a pretense and the Court will really look at whether that compelling interest is real or not.Buckley v. Valeo (1976), held that money is the same as speech and struck down spending limits by campaigns. Upheld individual contribution limits.Central Hudson Gas and Electric v. Public Service Commission (1980). Held that commercial speech (advertising) is able to be regulated by law with a lesser degree of scrutiny.Texas v. Johnson (1989), burning the U.S. flag is protected by the First Amendment, and conservatives have been fucking pissed about this ruling ever since, including proposing actual constitutional amendments to overrule the Court.Citizens United v. FEC (2009). Struck down corporate contribution limits to campaigns, allows disclaimer and disclosure requirements, but severely weakened the FEC’s ability to regulate electioneering. Allows corporations to donate unlimited amounts of money to campaigns.McCutcheon v. FEC (2014), struck down aggregate limits on contributions as impermissible abridgement of First Amendment rights. People can now donate up to the individual limits to every candidate they want, and if you’re the Koch Brothers, you can now use corporations to get around individual limits.This also severely restricted the definition of quid-pro-quo corruption to require basically an explicit bribe-for-performance.Free PressBranzburg v. Hayes (1972), can try to protect your sources all you want, but if a grand jury calls you up, reporters get no special exemption. If they ask you and you refuse, that’s contempt.Florida Star v. B.J.F. (1989); you can publish information gathered illegally by others so long as you didn’t gather it illegally yourself. And you can publish public records all you’d like.So, if someone wants to send a copy of the Mueller Report on over to the Times…Freedom of Religion and Establishment ClauseReynolds v. United States (1878), the government has no right to compel you to believe anything or punish your religious beliefs. Congress cannot do anything about your “mere opinion.”Santa Fe Independent School District v. Doe (2000), a prayer before sporting events, even if the students are the ones who brought it up and led it, is an impermissible government endorsement of religion.Again, conservatives have been losing their shit about this every since, and it’s become something of a hidden litmus test for Supreme Court nominees for conservatives ever since, even though the case was decided with a conservative-dominated Court.Burwell v. Hobby Lobby (2014), held that closely held corporations (such as a family-owned business,) have religious free exercise rights.This has been a political hot button lately with the ACA.ArbitrationYou have no idea how much these cases affect everything you do, including your politics.Southland Corp. v. Keating (1984). The Federal Arbitration Act pre-empts damned near everything. State laws trying to get around it are null and void.Mitsubishi Motors Corp. v. Soler Chrysler-Plymouth, Inc. (1987), even if you have a statutory claim that would let you bring a case in open court, if you signed an arbitration agreement, say, in the process of buying car, you get stuck in arbitration.Buckeye Check Cashing (2006). Even if the entire contract is illegal, the arbitrator gets to decide whether or not it’s valid.Hall Street v. Mattel (2008). The only grounds to get an arbitration award vacated is in the FAA, and it more or less requires “manifest disregard” of the law. The arbitrator can make “silly, even improvident” findings of fact or conclusions of law, but as long as the arbitrator doesn’t say, “Well, I know that law says that, but I’m ignoring it!” you are stuck with whatever the arbitrator decides.AT&T Mobility v. Concepcion (2014); even if a company is cheating millions of people out of small amounts of money such that they make billions of dollars and nobody would bother going to arbitration individually over $30 when if they lose, they could be forced to pay for the entire arbitration, class action waivers in “adhesion contracts,” (think, clicking “I agree” on your phone to literally anything,) class action waivers are enforceable.Administrative LawChevron v. Natural Resources Defense Council (1984). Courts should defer to an agency’s interpretation of a statute if it’s at all ambiguous and so long as it’s not arbitrary and capricious.The conservative-dominated Supreme Court developed this deference during the Reagan Administration. During the Obama Administration, when the President starting using agency action because Congress preferred to sit on its hands and do jack shit nothing just to spite him, suddenly the still-conservative-dominated Supreme Court had a change of heart, as will be discussed momentarily.Ironically, folks irritated with the sudden lack of deference to the executive should be hoping for the Court to continue that lack of deference right now.Citizens to Preserve Overton Park v. Volpe (1971). Agencies can change course or undertake rulemaking actions, so long as they aren’t arbitrary and capricious.The Trump administration can’t seem to either hire a lawyer that understands this or just plain won’t listen to them, which is why a metric shit ton of their attempts to create or undo various administrative agency rules keep getting rejected by the courts.Bowles v. Seminole Rock and Sand Co. (1945). Courts should defer to an agency’s interpretation of its own regulations if there’s a dispute over it.Auer v. Robbins (1987). Courts should really, really defer to an agency’s interpretation of its own rules if there’s a dispute over it.Kisor v. Wilkie (2019). Not yet decided, but conservatives who suddenly got really itchy all over about agency deference under Obama and liberals who suddenly got really itchy all over about agency deference under Trump are suddenly really hoping that the Supreme Court will ditch Seminole Rock and Auer and stop letting agencies have their way.Criminal Law and ProcedureMapp v. Ohio (1961) established the exclusionary rule; if police violate your constitutional rights, the evidence they gain from that can be excluded.This impacts our politics still today, because in the push to be “tough on crime” and for “law and order,” especially in a post-9/11 world, police are more and more frequently using tools that massively invade on personal privacy. Add to it that we now basically carry much of our essential information, our “papers” if you will, on a little slab in our pockets.Miranda v. Arizona (1966). This was an enormous shift in how police had to treat suspects, and it still affects our politics today.TortsYou think civil suits can’t affect public policy? Think again! Products liability has had a huge impact on our politics over the years.MacPherson v. Buick (1916). A wheel fell off a guy’s car, and for the first time, the court allowed the victim to sue the manufacturer and not just the retailer, for a manufacturing defect rather than just faulty installation.Leichtamer v. AMC (Ohio 1982). While the manufacturers aren’t on the hook to design totally crash-proof cars, unreasonably dangerous product designs or defective designs can still make them liable even where the victims were idiots.Knitz v. Minster Machine Co. (Ohio 1982). Safety features shouldn’t be optional add-ons. *Ahem, cough, Boeing, cough, cough.*New York Times v. Sullivan (1964). This case raises the bar for recovery for public figures; they have to show that a false statement was published with “actual malice.” This is the reason that Trump doesn’t actually sue anyone for defamation.Liebeck v. McDonald's Restaurants (1994). This is the infamous “hot coffee” case. Stella Liebeck was a) not driving, b) in a car that had pulled into a parking stall, c) did not suffer little tiny burns from some spilled coffee, but third degree burns over pretty much her entire downstairs region, d) after McDonald’s had been repeatedly cited for storing their coffee as much as 30 degrees above the maximum safe limit and settled literally hundreds of cases where people had suffered serious burns from this practice, and e) Liebeck was only trying to get McDonald’s to cover her medical bills after they offered her $800 to just go away.It was the jury that imposed a 2.5 million fine on the company as punitive damages for actions that “shocked the conscience.” That number is equivalent to two days’ worth of coffee sales to the corporation.Business lobbies have been trying to make this into a frivolous case ever since by reducing it to “woman burned with hot coffee, duh.” This case has been the front case for 25 years by these pro-business lobbies to enact tort reform to try to block suits like this, even though it was completely legitimate.It is still repeatedly brought up by politicians trying to make cases sound frivolous by comparing a case to Liebeck’s.I could go on like this forever. We haven’t even touched on contract law, civil procedure, or secured transactions. These are just highlights. There are literally thousands of cases, big and small, that continue to have large impacts on our national and local level politics.You read all the way this far, and deserve a reward. Here’s a kitten.Thanks for the A2A.Mostly Standard Addendum and Disclaimer: read this before you comment.I welcome rational, reasoned debate on the merits with reliable, credible sources.But coming on here and calling me names, pissing and moaning about how biased I am, et cetera and so forth, will result in a swift one-way frogmarch out the airlock. Doing the same to others will result in the same treatment.Essentially, act like an adult and don’t be a dick about it.Getting cute with me about my commenting rules and how my answer doesn’t follow my rules and blah, blah, whine, blah is getting old. I’m ornery enough today to not put up with it. Stay on topic or you’ll get to watch the debate from the outside.If you want to argue and you’re not sure how to not be a dick about it, just post a picture of a cute baby animal instead, all right? Your displeasure and disagreement will be duly noted. Pinkie swear.I’m done with warnings. If you have to consider whether or not you’re over the line, the answer is most likely yes. I’ll just delete your comment and probably block you, and frankly, I won’t lose a minute of sleep over it.Debate responsibly.

“Being an amputee myself with functional lower limb prosthetics, I can say that the device enable me to function normally. My prosthetics brought back my confidence and self esteem to participate in mainstream activities of the society, thus changing my outlook in life to positive to more positive. Definitely, my prosthetics had an impact on my present status or the quality of life I am enjoying now because I basically perform all the task that is assigned to me which at the end the day results to quality output and good pay.” Johnny “Coming from a country where there is not much awareness and resources for dealing with post-spinal cord injured victims, my return home was indeed an enormous challenge. Living in a house that was inaccessible, members of my family have had to persevere with daily lifting me up and down the house. Physiotherapy had become a crucial necessity and as a result of the continuous costs incurred, my mother took up the task to administer physiotherapy as well as stand in as my caretaker. During my rehabilitation process, getting admitted for treatment during times of illness or to use physiotherapy facilities was close to impossible as a result of the overwhelming numbers on the waiting list. My rehabilitation period despite challenging was a humbling moment of my life and a continuous process that I face until today. I have learned disability is not inability and a strong mentality and great attitude have been very important!” Casey “Families find themselves in difficulty after a member of the family has a stroke. I consider myself a stroke survivor but my family are stroke victims. I have been fortunate and have been able to return to work, but I have had to battle all the way. We do not get the help we need, services are so variable and there is not enough speech and language therapy and physiotherapy. After my stroke I had to learn to do everything again, including swallowing and to learn to talk. The first thing that came back to me with my speech was swearing, my first sentence had four expletives in it, but I am told that was normal.” Linda “If you don’t have a proper wheelchair, that is when you really feel that you are disabled. But if you have a proper wheelchair, which meets your needs and suits you, you can forget about your disability.” Faustina 4 Rehabilitation 95 Rehabilitation has long lacked a unifying conceptual framework (1). Historically, the term has described a range of responses to disability, from interventions to improve body function to more comprehensive measures designed to promote inclusion (see Box 4.1). The International Classification of Functioning, Disability and Health (ICF) provides a framework that can be used for all aspects of rehabilitation (11–14). For some people with disabilities, rehabilitation is essential to being able to participate in education, the labour market, and civic life. Rehabilitation is always voluntary, and some individuals may require support with decision-making about rehabilitation choices. In all cases rehabilitation should help to empower a person with a disability and his or her family. Article 26, Habilitation and Rehabilitation, of the United Nations Convention on the Rights of Persons with Disabilities (CRPD) calls for: “… appropriate measures, including through peer support, to enable persons with disabilities to attain and maintain their maximum independence, full physical, mental, social and vocational ability, and full inclusion and participation in all aspects of life”. The Article further calls on countries to organize, strengthen, and extend comprehensive rehabilitation services and programmes, which should begin as early as possible, based on multidisciplinary assessment of individual needs and strengths, and including the provision of assistive devices and technologies. This chapter examines some typical rehabilitation measures, the need and unmet need for rehabilitation, barriers to accessing rehabilitation, and ways in which these barriers can be addressed. Understanding rehabilitation Rehabilitation measures and outcomes Rehabilitation measures target body functions and structures, activities and participation, environmental factors, and personal factors. They contribute 96 World report on disability Box 4.1. What is rehabilitation? This Report defines rehabilitation as “a set of measures that assist individuals who experience, or are likely to experience, disability to achieve and maintain optimal functioning in interaction with their environments”. A distinction is sometimes made between habilitation, which aims to help those who acquire disabilities congenitally or early in life to develop maximal functioning; and rehabilitation, where those who have experienced a loss in function are assisted to regain maximal functioning (2). In this chapter the term “rehabilitation” covers both types of intervention. Although the concept of rehabilitation is broad, not everything to do with disability can be included in the term. Rehabilitation targets improvements in individual functioning – say, by improving a person’s ability to eat and drink independently. Rehabilitation also includes making changes to the individual’s environment – for example, by installing a toilet handrail. But barrier removal initiatives at societal level, such as fitting a ramp to a public building, are not considered rehabilitation in this Report. Rehabilitation reduces the impact of a broad range of health conditions. Typically rehabilitation occurs for a specific period of time, but can involve single or multiple interventions delivered by an individual or a team of rehabilitation workers, and can be needed from the acute or initial phase immediately following recognition of a health condition through to post-acute and maintenance phases. Rehabilitation involves identification of a person’s problems and needs, relating the problems to relevant factors of the person and the environment, defining rehabilitation goals, planning and implementing the measures, and assessing the effects (see figure below). Educating people with disabilities is essential for developing knowledge and skills for self-help, care, management, and decision-making. People with disabilities and their families experience better health and functioning when they are partners in rehabilitation (3–9). The rehabilitation process Identify problems and needs Assess eects Relate problems to modiable and limiting factors Dene target problems and target mediators, select appropriate measures Plan, implement, and coordinate interventions Source: A modified version of the Rehabilitation Cycle from (10). Rehabilitation – provided along a continuum of care ranging from hospital care to rehabilitation in the community (12) – can improve health outcomes, reduce costs by shortening hospital stays (15–17), reduce disability, and improve quality of life (18–21). Rehabilitation need not be expensive. Rehabilitation is cross-sectoral and may be carried out by health professionals in conjunction with specialists in education, employment, social welfare, and other fields. In resource-poor contexts it may involve non-specialist workers – for example, community-based rehabilitation workers in addition to family, friends, and community groups. Rehabilitation that begins early produces better functional outcomes for almost all health conditions associated with disability (18–30). The effectiveness of early intervention is particularly marked for children with, or at risk of, developmental delays (27, 28, 31, 32), and has been proven to increase educational and developmental gains (4, 27). 97 Chapter 4 Rehabilitation to a person achieving and maintaining optimal functioning in interaction with their environment, using the following broad outcomes: ■ prevention of the loss of function ■ slowing the rate of loss of function ■ improvement or restoration of function ■ compensation for lost function ■ maintenance of current function. Rehabilitation outcomes are the benefits and changes in the functioning of an individual over time that are attributable to a single measure or set of measures (33). Traditionally, rehabilitation outcome measures have focused on the individual’s impairment level. More recently, outcomes measurement has been extended to include individual activity and participation outcomes (34, 35). Measurements of activity and participation outcomes assess the individual’s performance across a range of areas – including communication, mobility, self-care, education, work and employment, and quality of life. Activity and participation outcomes may also be measured for programmes. Examples include the number of people who remain in or return to their home or community, independent living rates, return-to-work rates, and hours spent in leisure and recreational pursuits. Rehabilitation outcomes may also be measured through changes in resource use – for example, reducing the hours needed each week for support and assistance services (36). The following examples illustrate different rehabilitation measures: ■ A middle-aged woman with advanced diabetes. Rehabilitation might include assistance to regain strength following her hospitalization for diabetic coma, the provision of a prosthesis and gait training after a limb amputation, and the provision of screen-reader software to enable her to continue her job as an accountant after sustaining loss of vision. ■ A young man with schizophrenia. The man may have trouble with routine daily tasks, such as working, living independently, and maintaining relationships. Rehabilitation might mean drug treatment, education of patients and families, and psychological support via outpatient care, communitybased rehabilitation, or participation in a support group. ■ A child who is deafblind. Parents, teachers, physical and occupational therapists, and other orientation and mobility specialists need to work together to plan accessible and stimulating spaces to encourage development. Caregivers will need to work with the child to develop appropriate touch and sign communication methods. Individualized education with careful assessment will help learning and reduce the child’s isolation. Limitations and restrictions for a child with cerebral palsy, and possible rehabilitation measures, outcomes, and barriers are described in Table 4.1. Rehabilitation teams and specific disciplines may work across categories. Rehabilitation measures in this chapter are broadly divided into three categories: ■ rehabilitation medicine ■ therapy ■ assistive technologies. Rehabilitation medicine Rehabilitation medicine is concerned with improving functioning through the diagnosis and treatment of health conditions, reducing impairments, and preventing or treating complications (12, 37). Doctors with specific expertise in medical rehabilitation are referred to as physiatrists, rehabilitation doctors, or physical and rehabilitation specialists (37). Medical specialists such as psychiatrists, paediatricians, geriatricians, ophthalmologists, neurosurgeons, and orthopaedic surgeons can be involved in rehabilitation medicine, as can a broad range of therapists. In many parts of the world where specialists in rehabilitation medicine are not available, services may be provided by doctors and therapists (see Box 4.2). 98 World report on disability Table 4.1. Child with cerebral palsy and rehabilitation Difficulties faced by the child Rehabilitation measures Possible outcomes Potential barriers People involved in the measures Unable to care for self → Therapy – Training for the child on different ways to complete the task. – Assessment and provision of equipment, training parents to lift, carry, move, feed and otherwise care for the child with cerebral palsy. – Teaching parents and family members to use and maintain equipment. – Provision of information and support for parents and family. – Counselling the family. → Assistive technology – Provision of equipment for maintaining postures and self-care, playing and interaction, such as sitting or standing (when age-appropriate) – Parents better able to care for their child and be proactive. – Reduced likelihood of compromised development, deformities, and contractures. – Reduced likelihood of respiratory infections. – Access to support groups or peer support. – Coping with stress and other psychological demands. – Better posture, respiration, feeding, speech, and physical activity performance. – Timeliness of interventions. – Availability of family and support. – Financial capacity to pay for services and equipment. – Availability of well trained staff. – Attitudes and understanding of others involved in the rehabilitation measure. – Physical access to home environment, community, equipment, assistive devices and services. – The child, parents, siblings, and extended family. – Depending on the setting and resources available: physiotherapists, occupational therapists, speech and language therapists, orthotists and technicians, doctors, psychologists, social workers, community-based rehabilitation workers, schoolteachers, teaching assistants. Difficulty walking → Rehabilitation medicine – Botulinum toxin injections. – Surgical treatment of contractures and deformities (therapy interventions usually complement these medical interventions). → Therapy – Therapy, exercises and targeted play activities to train effective movements. → Assistive technology – Orthotics, wheelchair or other equipment. – Decreased muscle tone, better biomechanics of walking. – Decrease in self-reported limitations. – Increased participation in education and social life. – Access to post-acute rehabilitation. – Doctor, parents, therapist, orthotist. Communication difficulties → Therapy – Audiology. – Activities for language development. – Conversation skills. – Training conversation partners. → Assistive technology – Training to use and maintain aids and equipment, which may include hearing aids and augmentative and alternative communication devices. – Better communication skills. – Participation in social, educational and occupational life opportunities. – Improved relationships with family, friends, and the wider community. – Reduced risk of distress, educational failure, and antisocial behaviour. – Availability of speech language therapists. – Social and economic status of the family. – Costs of purchasing and maintaining devices. – Parents, speech and language pathologist/therapist, communication disorders assistant, community-based rehabilitation worker, teachers, and assistants. Note: The table shows some potential rehabilitation measures for a child with cerebral palsy, possible outcomes, potential barriers, and the various people involved in care. 99 Chapter 4 Rehabilitation Box 4.2. Clubfoot treatment in Uganda Clubfoot, a congenital deformity involving one or both feet, is commonly neglected in low and middle-income countries. If left untreated, clubfoot can result in physical deformity, pain in the feet, and impaired mobility, all of which can limit community participation, including access to education. In Uganda the incidence of clubfoot is 1.2 per 1000 live births. The condition is usually not diagnosed, or if diagnosed it is neglected because conventional invasive surgery treatment is not possible with the resources available (38). The Ponseti clubfoot treatment involving manipulation, casting, Achilles tenotomy, and fitting of foot braces has proven to result in a high rate of painless, functional feet (Ponseti, 1996). The benefits of this approach for developing countries are low cost, high effectiveness, and the possibility to train service providers other than medical doctors to perform the treatment. The results of a clubfoot project in Malawi, where the treatment was conducted by trained orthopaedic clinical officers, showed that initial good correction was achieved in 98% of cases (39). The Ugandan Sustainable Clubfoot Care Project – a collaborative partnership between the Ugandan Ministry of Health, CBM International, and Ugandan and Canadian universities – is funded by the Canadian International Development Agency. Its purpose is to make sustainable, universal, effective, and safe treatment of clubfoot in Uganda using the Ponseti method. It built on the existing health care and education sectors and has incorporated research to inform the project’s activities and evaluate outcomes. The project has resulted in many positive achievements in two years including: ■ The Ugandan Ministry of Health has approved the Ponseti method as the preferred treatment for clubfoot in all its hospitals. ■ 36% of the country’s public hospitals have built the capacity to do the Ponseti procedure and are using the method. ■ 798 health-care professionals received training to identify and treat clubfoot. ■ Teaching modules on clubfoot and the Ponseti method are being used in two medical and three paramedical schools. ■ 1152 students in various health disciplines received training in the Ponseti method. ■ 872 children with clubfoot received treatment, an estimated 31% of infants born with clubfoot during the sample period – very high, given that only 41% of all births occur in a health care centre. ■ Public awareness campaigns were implemented – including radio messages and distribution of posters and pamphlets to village health teams – to inform the general public that clubfoot is correctable. The project shows that clubfoot detection and treatment can quickly be incorporated into settings with few resources. The approach requires: ■ Screening infants at birth for foot deformity to detect the impairment. ■ Building the capacity of health-care professionals across the continuum of care, from community midwives screening for deformity, to NGO technicians making braces, and orthopaedic officers performing tenotomies. ■ Decentralizing clubfoot care services, including screening in the community, for example through communitybased rehabilitation workers, and treatment in local clinics, to address treatment adherence barriers. ■ Incorporating Ponseti method training into the education curricula of medical, nursing, paramedical, and infant health-care students. ■ Establishing mechanisms to address treatment adherence barriers including travel distance and costs. 100 World report on disability Rehabilitation medicine has shown positive outcomes, for example, in improving joint and limb function, pain management, wound healing, and psychosocial well-being (40–47). Therapy Therapy is concerned with restoring and compensating for the loss of functioning, and preventing or slowing deterioration in functioning in every area of a person’s life. Therapists and rehabilitation workers include occupational therapists, orthotists, physiotherapists, prosthetists, psychologists, rehabilitation and technical assistants, social workers, and speech and language therapists. Therapy measures include: ■ training, exercises, and compensatory strategies ■ education ■ support and counselling ■ modifications to the environment ■ provision of resources and assistive technology. Convincing evidence shows that some therapy measures improve rehabilitation outcomes (see Box 4.3). For example, exercise therapy in a broad range of health conditions – including cystic fibrosis, frailness in elderly people, Parkinson disease, stroke, osteoarthritis in the knee and hip, heart disease, and low back pain – has contributed to increased strength, endurance, and flexibility of joints. It can improve balance, posture, and range of motion or functional mobility, and reduce the risk of falls (49–51). Therapy interventions have also been found to be suitable for the long-term care of older persons to reduce disability (18). Some studies show that training in activities of daily living have positive outcomes for people with stroke (52). Box 4.3. Money well spent: The effectiveness and value of housing adaptations Public spending on housing adaptations for people with difficulties in functioning in the United Kingdom of Great Britain and Northern Ireland amounted to more than £220 million in 1995, and both the number of demands and unit costs are growing. A 2000 research study examined the effectiveness of adaptations in England and Wales, using interviews with recipients of major adaptations, postal questionnaires returned by recipients of minor adaptations, administrative records, and the views of visiting professionals. The main measure of “effectiveness” was the degree to which the problems experienced by the respondent before adaptation were overcome by the adaptation, without causing new problems. The study found that: ■ Minor adaptations (rails, ramps, over-bath showers, and door entry systems, for example) – most costing less than £500 – produced a range of lasting, positive consequences for virtually all recipients: 62% of respondents suggested they felt safer from the risk of accident, and 77% perceived a positive effect on their health. ■ Major adaptations (bathroom conversions, extensions, lifts, for example) in most cases had transformed people’s lives. Before adaptations, people used words like “prisoner”, “degraded”, and “afraid’ to describe their situations; following adaptations, they spoke of themselves as “independent”, “useful”, and “confident”. ■ Where major adaptations failed, it was typically because of weaknesses in the original specification. Adaptations for children sometimes failed to allow for the child’s growth, for example. In other cases, policies intended to save money resulted in major waste. Examples included extensions that were too small or too cold to use, and cheap but ineffective substitutes for proper bathing facilities. ■ The evidence from recipients suggests that successful adaptations keep people out of hospitals, reduce strain on carers, and promote social inclusion. ■ Benefits were most pronounced where careful consultation with users took place, where the needs of the whole family had been considered, and where the integrity of the home had been respected. Adaptations appear to be a highly effective use of public resources, justifying investment in health and rehabilitation resources. Further research is needed in diverse contexts and settings. Source (48). 101 Chapter 4 Rehabilitation Distance training was used in Bangladesh for mothers of children with cerebral palsy in an 18-month therapy programme: it promoted the development of physical and cognitive skills and improved motor skills in the children (53). Counselling, information, and training on adaptive methods, aids, and equipment have been effective for individuals with spinal cord injury and younger people with disabilities (54–56). Many rehabilitation measures help people with disabilities to return or continue to work, including adjusting the content or schedule of work, and making changes to equipment and the work environment (57, 58). Assistive technologies An assistive technology device can be defined as “any item, piece of equipment, or product, whether it is acquired commercially, modified, or customized, that is used to increase, maintain, or improve the functional capabilities of individuals with disabilities” (59). Common examples of assistive devices are: ■ crutches, prostheses, orthoses, wheelchairs, and tricycles for people with mobility impairments; ■ hearing aids and cochlear implants for those with hearing impairments; ■ white canes, magnifiers, ocular devices, talking books, and software for screen magnification and reading for people with visual impairments; ■ communication boards and speech synthesizers for people with speech impairments; ■ devices such as day calendars with symbol pictures for people with cognitive impairment. Assistive technologies, when appropriate to the user and the user’s environment, have been shown to be powerful tools to increase independence and improve participation. A study of people with limited mobility in Uganda found that assistive technologies for mobility created greater possibilities for community participation, especially in education and employment (60). For people in the United Kingdom with disabilities resulting from brain injuries, technologies such as personal digital assistants, and simpler technologies such as wall charts, were closely associated with independence (61). In a study of Nigerians with hearing impairments, provision of a hearing aid was associated with improved function, participation and user satisfaction (62). Assistive devices have also been reported to reduce disability and may substitute or supplement support services – possibly reducing care costs (63). In the United States of America, data over 15 years from the National Long-Term Care Survey found that increasing use of technology was associated with decreasing reported disability among people aged 65 years and older (64). Another study from the United States showed that users of assistive technologies such as mobility aids and equipment for personal care reported less need for support services (65). In some countries, assistive devices are an integral part of health care and are provided through the national health care system. Elsewhere, assistive technology is provided by governments through rehabilitation services, vocational rehabilitation, or special education agencies (66), insurance companies, and charitable and nongovernmental organizations. Rehabilitation settings The availability of rehabilitation services in different settings varies within and across nations and regions (67–70). Medical rehabilitation and therapy are typically provided in acute care hospitals for conditions with acute onset. Follow-up medical rehabilitation, therapy, and assistive devices could be provided in a wide range of settings, including specialized rehabilitation wards or hospitals; rehabilitation centres; institutions such as residential mental and nursing homes, respite care centres, hospices, prisons, residential educational institutions, and military residential settings; or single or multiprofessional practices (office or clinic). Longer-term rehabilitation may be provided 102 World report on disability within community settings and facilities such as primary health care centres, schools, workplaces, or home-care therapy services (67–70). Needs and unmet needs Global data on the need for rehabilitation services, the type and quality of measures provided, and estimates of unmet need do not exist. Data on rehabilitation services are often incomplete and fragmented. When data are available, comparability is hampered by differences in definitions, classifications of measures and personnel, populations under study, measurement methods, indicators, and data sources – for example, individuals with disabilities, service providers, or programme managers may experience needs and demands differently (71, 72). Unmet rehabilitation needs can delay discharge, limit activities, restrict participation, cause deterioration in health, increase dependency on others for assistance, and decrease quality of life (37, 73–77). These negative outcomes can have broad social and financial implications for individuals, families, and communities (78–80). Despite acknowledged limitations such as the quality of data and cultural variations in perception of disabilities, the need for rehabilitation services can be estimated in several ways. These include data on the prevalence of disability; disability-specific surveys; and population and administrative data. Prevalence data on health conditions associated with disability can provide information to assess rehabilitation needs (81). As Chapter 2 indicated, disability rates correlate with the increase in noncommunicable conditions and global ageing. The need for rehabilitation services is projected to increase (82, 83) due to these demographic and epidemiological factors. Strong evidence suggests that impairments related to ageing and many health conditions can be reduced and functioning improved with rehabilitation (84–86). Higher rates of disability indicate a greater potential need for rehabilitation. Epidemiological evidence together with an examination of the number, type, and severity of impairments, and the activity limitations and participation restrictions that may benefit from various rehabilitation measures, can help measure the need for services and may be useful for setting appropriate priorities for rehabilitation (87). ■ The number of people needing hearing aids worldwide is based on 2005 World Health Organization estimates that about 278 million people have moderate to profound hearing impairments (88). In developed countries, industry experts estimate that about 20% of people with hearing impairments need hearing aids (89), suggesting 56 million potential hearing-aid users worldwide. Hearing aid producers and distributors estimate that hearing aid production currently meets less than 10% of global need (88), and less than 3% of the hearing aid needs in developing countries are met annually (90). ■ The International Society for Prosthetics and Orthotics and the World Health Organization have estimated that people needing prostheses or orthotics and related services represent 0.5% of the population in developing countries; and 30 million people in Africa, Asia, and Latin America (91) require an estimated 180 000 rehabilitation professionals. In 2005 there were 24 prosthetic and orthotic schools in developing countries, graduating 400 trainees annually. Worldwide existing training facilities for prosthetic and orthotic professionals and other providers of essential rehabilitation services are deeply inadequate in relation to the need (92). ■ A national survey of musculoskeletal impairment in Rwanda concluded that 2.6% of children are impaired and that about 80 000 need physical therapy, 50 000 need orthopaedic surgery, and 10 000 need assistive devices (93). Most of the available data on national supply and unmet need are derived from 103 Chapter 4 Rehabilitation disability-specific surveys on specific populations such as: ■ National studies on living conditions of people with disabilities conducted in Malawi, Mozambique, Namibia, Zambia, and Zimbabwe (94–98) revealed large gaps in the provision of medical rehabilitation and assistive devices (see Table 2.5 in Chapter 2). Gender inequalities in access to assistive devices were evident in Malawi (men 25.3% and women 14.1%) and Zambia (men 15.7% and women 11.9%) (99). ■ A survey of physical rehabilitation medicine in Croatia, the Czech Republic, Hungary, Slovakia, and Slovenia found a general lack of access to rehabilitation in primary, secondary, tertiary, and community health care settings, as well as regional and socioeconomic inequalities in access (100). ■ In a study of people identified as disabled from three districts in Beijing, China, 75% of those interviewed expressed a need for a range of rehabilitation services, of which only 27% had received such services (101). A national Chinese study of the need for rehabilitation in 2007 found that unmet need was particularly high for assistive devices and therapy (102). ■ United States surveys report considerable unmet needs – often caused by funding problems – for assistive technologies (103). Unmet need for rehabilitation services can also be estimated from administrative and population survey data. The supply of rehabilitation services can be estimated from administrative data on the provision of services, and measures such as waiting times for rehabilitation services can proxy the extent to which demand for services is being met. A recent global survey (2006–2008) of vision services in 195 countries found that waiting times in urban areas averaged less than one month, while waiting times in rural areas ranged from six months to a year (104). Proxy measures may not always be reliable. In the case of waiting times, for instance, lack of awareness of services and beliefs about disability influence treatment-seeking, while restrictions on who is legitimately waiting for services can complicate data interpretation (105–107). Indicators on the number of people demanding but not receiving services, or receiving inadequate or inappropriate services, can provide useful planning information (108). Data on rehabilitation often are not disaggregated from other health care services, however, and rehabilitation measures are not included in existing classification systems, which could provide a framework for describing and measuring rehabilitation. Administrative data on supply are often fragmented because rehabilitation can take place in a variety of settings and be performed by different personnel. Comparing multiple data sources can provide more robust interpretations, if a common framework like the ICF is used. As an example, the Arthritis Community Research and Evaluation Unit in Toronto merged administrative data sources to profile rehabilitation demand and supply across all regions of the province of Ontario (109). The researchers triangulated population data with the number of health-care workers per region to estimate the number of workers per person: they found that the higher concentration of workers in the southern region did not coincide with the highest areas of demand, causing unmet demand for rehabilitation. Addressing barriers to rehabilitation The barriers to rehabilitation service provision can be overcome through a series of actions, including: ■ reforming policies, laws, and delivery systems, including development or revision of national rehabilitation plans; ■ developing funding mechanisms to address barriers related to financing of rehabilitation; 104 World report on disability ■ increasing human resources for rehabilitation, including training and retention of rehabilitation personnel; ■ expanding and decentralizing service delivery; ■ increasing the use and affordability of technology and assistive devices; ■ expanding research programmes, including improving information and access to good practice guidelines. Reforming policies, laws, and delivery systems A 2005 global survey (110) of the implementation of the nonbinding, United Nations Standard Rules on the Equalization of Opportunities for Persons with Disabilities found that: ■ in 48 of 114 (42%) countries that responded to the survey, rehabilitation policies were not adopted; ■ in 57 (50%) countries legislation on rehabilitation for people with disabilities was not passed; ■ in 46 (40%) countries rehabilitation programmes were not established. Many countries have good legislation and related policies on rehabilitation, but the implementation of these policies, and the development and delivery of regional and local rehabilitation services, have lagged. Systemic barriers include: ■ Lack of strategic planning. A study of rehabilitation medicine related to physical impairments – excluding assistive technology, sensory impairments, and specialized disciplines – in five central and eastern European countries suggested that the lack of strategic planning for services had resulted in an uneven distribution of service capacity and infrastructure (100). ■ Lack of resources and health infrastructure. Limited resources and health infrastructure in developing countries, and in rural and remote communities in developed countries, can reduce access to rehabilitation and quality of services (111). In a survey on the reasons for not using needed health facilities in two Indian states, 52.3% of respondents indicated that no healthcare facility in the area was available (112). Other countries lack rehabilitation services that have proven effective at reducing longterm costs, such as early intervention for children under the age of 5 (5, 113–115). A study of users of community-based rehabilitation (CBR) in Ghana, Guyana, and Nepal showed limited impact on physical well-being because CBR workers had difficulties providing physical rehabilitation, assistive devices, and referral services (116). In Haiti, before the 2010 earthquake, an estimated three quarters of amputees received prosthetic management due to the lack of availability of services (117). ■ Lack of agency responsible to administer, coordinate, and monitor services. In some countries all rehabilitation is integrated in health care and financed under the national health system (118, 119). In other countries responsibilities are divided between different ministries, and rehabilitation services are often poorly integrated into the overall system and not well coordinated (120). A report of 29 African countries found that many lack coordination and collaboration among the different sectors and ministries involved in disability and rehabilitation, and 4 of the 29 countries did not have a lead ministry (119). ■ Inadequate health information systems and communication strategies can contribute to low rates of participation in rehabilitation. Aboriginal Australians have high rates of cardiovascular disease but low rates of participation in cardiac rehabilitation, for example. Barriers to rehabilitation include poor communication across the health care sector and between providers (notably between primary and secondary care), inconsistent and insufficient data collection processes, multiple clinical information systems, 105 Chapter 4 Rehabilitation and incompatible technologies (121). Poor communication results in ineffective coordination of responsibilities among providers (75). ■ Complex referral systems can limit access. Where access to rehabilitation services is controlled by doctors (77), medical rules or attitudes of primary physicians can obstruct individuals with disabilities from obtaining services (122). People are sometimes not referred, or inappropriately referred, or unnecessary medical consultations may increase their costs (123–126). This is particularly relevant to people with complex needs requiring multiple rehabilitation measures. ■ Absence of engagement with people with disabilities. The study of 114 countries mentioned above did not consult with disabled people’s organizations in 51 countries, and did not consult with families of persons with disabilities about design, implementation, and evaluation of rehabilitation programmes in 57 of the study countries (110). Countries that lack policies and legislation on rehabilitation should consider introducing them, especially countries that are signatories to the CRPD, as they are required to align national law with Articles 25 and 26 of the Convention. Rehabilitation can be incorporated into general legislation on health, and into relevant employment, education, and social services legislation, as well as into specific legislation for persons with disabilities. Policy responses should emphasize early intervention and use of rehabilitation to enable people with a broad range of health conditions to improve or maintain their level of functioning, with a specific focus on ensuring participation and inclusion, such as continuing to work (127). Services should be provided as close as possible to communities where people live, including in rural areas (128). Development, implementation, and monitoring of policy and laws should include users (see Box 4.4) (132). Rehabilitation professionals must be aware of the policies and programmes given the role of rehabilitation in keeping people with disabilities participating in society (133, 134). National rehabilitation plans and improved collaboration Creating or amending national plans on rehabilitation, and establishing infrastructure and capacity to implement the plan are critical to improving access to rehabilitation. Plans should be based on analysis of the current situation, consider the main aspects of rehabilitation provision – leadership, financing, information, service delivery, products and technologies, and the rehabilitation workforce (135) – and define priorities based on local need. Even if it is not immediately possible to provide rehabilitation services for all who need them, a plan involving smaller, annual investments may progressively strengthen and expand the rehabilitation system. Successful implementation of the plan depends on establishing or strengthening mechanisms for intersectoral collaboration. An interministerial committee or agency for rehabilitation can coordinate across organizations. For example, a Disability Action Council with representatives from the government, NGOs, and training programmes was established in Cambodia in 1997, to support coordination and cooperation across rehabilitation providers, decrease duplication and improve distribution of services and referral systems, and promote joint ventures in training (136). The Council has been very successful in developing physical rehabilitation and supporting professional training (physical therapy, prosthetics, orthotics, wheelchairs, and CBR) (137). Further benefits include (136): ■ joint negotiation for equipment and supplies; ■ sharing knowledge and expertise; ■ continuing education through sharing specialist educators, establishing clinical education sites, reviewing and revising curricula, and disseminating information; 106 World report on disability ■ support for the transition from expatriate professional services to local management. Developing funding mechanisms for rehabilitation The cost of rehabilitation can be a barrier for people with disabilities in high-income as well as low-income countries. Even where funding from governments, insurers, or NGOs is available, it may not cover enough of the costs to make rehabilitation affordable (117). People with disabilities have lower incomes and are often unemployed, so are less likely to be covered by employer-sponsored health plans or private voluntary health insurance (see Chapter 8). If they have limited finances and inadequate public health coverage, access to rehabilitation may also be limited, compromising activity and participation in society (138). Lack of financial resources for assistive technologies is a significant barrier for many (101). People with disabilities and their families purchase more than half of all assistive devices directly (139). In a Box 4.4. Reform of mental health law in Italy – closing psychiatric institutions is not enough In 1978 Italy introduced Law No. 180 gradually phasing out psychiatric hospitals and introducing a communitybased system of psychiatric care. Social psychiatrist Franco Basaglia was a leading figure behind the new law that rejected the assumption that people with mental illness were a danger to society. Basaglia had become appalled by the inhuman conditions he witnessed as the director of a psychiatric hospital in northern Italy. He viewed social factors as the main determinants in mental illness, and became a champion of community mental health services and beds in general hospitals instead of psychiatric hospitals (129). Thirty years later, Italy is the only country where traditional mental hospitals are prohibited by law. The law comprised framework legislation, with individual regions tasked with implementing detailed norms, methods, and timetables for action. As a result of the law, no new patients were admitted to psychiatric hospitals, and a process of deinstitutionalization of psychiatric inpatients was actively promoted. The inpatient population dropped by 53% between 1978 and 1987, and the final dismantling of psychiatric hospitals was completed by 2000 (130). Treatment for acute problems is delivered in general hospital psychiatric units, each with a maximum of 15 beds. A network of community mental health and rehabilitation centres support mentally ill people, based on a holistic perspective. The organization of services uses a departmental model to coordinate a range of treatments, phases, and professionals. Campaigns against stigma, for social inclusion of people with mental health problems, and empowerment of patients and families have been promoted and supported centrally and regionally. As a consequence of these policies, Italy has fewer psychiatric beds than other countries – 1.72 per 10 000 people in 2001. While Italy has a comparable number of psychiatrists per head of population to the United Kingdom, it has one third the psychiatric nurses and psychologists, and one tenth of the social workers. Italy also has lower rates of compulsory admissions (2.5 per 10 000 people in 2001, compared with 5.5 per 10 000 in England) (131), and lower use of psychotropic drugs than other European countries. “Revolving door” readmissions are evident only in regions with poor resources. Yet Italian mental health care is far from perfect (130). In place of public sector mental hospitals, the government operates small, protected communities or apartments for long-term patients, and private facilities provide longterm care in some regions. But support for mental health varies significantly by region, and the burden of care still falls on families in some areas. Community mental health and rehabilitation services have in some areas failed to innovate, and optimal treatments are not always available. Italy is preparing a new national strategy to reinforce the community care system, face emerging priorities, and standardize regional mental health care performance. Italy’s experience shows that closing psychiatric institutions must be accompanied by alternative structures. Reform laws should provide minimum standards, not just guidelines. Political commitment is necessary, as well as investment in buildings, staff, and training. Research and evaluation is vital, together with central mechanisms for verification, control, and comparison of services. 107 Chapter 4 Rehabilitation national survey in India, two thirds of the assistive technology users reported having paid for their devices themselves (112). In Haiti, poor access to prosthetic services was attributed partially to users being unable to pay (117). Spending on rehabilitation services is difficult to determine because it generally is not disaggregated from other health care expenditure. Limited information is available on expenditure for the full range of rehabilitation measures (68, 74, 138). Governments in 41 of 114 countries did not provide funding for assistive devices in 2005 (110). Even in the 79 countries where insurance schemes fully or partially covered assistive devices, 16 did not cover poor people with disabilities, and 28 did not cover all geographical locations (110). In some cases existing programmes did not cover maintenance and repairs for assistive devices, which can leave individuals with defective equipment and limit its use (76, 112, 140). One third of the 114 countries providing data to the 2005 global study did not allocate specific budgets for rehabilitation services (110). OECD countries appear to be investing more in rehabilitation than in the past, but the spending is still low (120). For example, unweighted averages for all OECD countries between 2006 and 2008 indicate that public spending on rehabilitation as part of labour market programmes was 0.02% of GDP with no increase over time (127). Health care funding often provides selective coverage for rehabilitation services – for example, by restricting the number or type of assistive devices, the number of therapy visits over a specific time, or the maximum cost (77) – in order to control cost. While cost controls are needed, they should be balanced with the need to provide services to those who can benefit. In the United States, government and private insurance plans limit coverage of assistive technologies and may not replace ageing devices until they are broken, sometimes requiring a substantial waiting period (77). A study of assistive device use by people with rheumatic disease in Germany and the Netherlands found significant differences between the two countries, thought to result from differences in country-related health care systems with respect to prescription and reimbursement rules (141). Policy actions require a budget matching the scope and priorities of the plan. The budget for rehabilitation services should be part of the regular budgets of relevant ministries – notably health – and should consider ongoing needs. Ideally, the budget line for rehabilitation services would be separated to identify and monitor spending. Many countries – particularly low-income and middle-income countries – struggle to finance rehabilitation, but rehabilitation is a good investment because it builds human capital (36, 142). Financing strategies can improve the provision, access, and coverage of rehabilitation services, particularly in low-income and middle-income countries. Any new strategy should be carefully evaluated for its applicability and cost–effectiveness before being implemented. Financing strategies may include the following: ■ Reallocate or redistribute resources. Public rehabilitation services should be reviewed and evaluated, with resources reallocated effectively. Possible modifications include: – changing from hospital or clinic-based rehabilitation to community-based interventions (74, 83); – reorganizing and integrating services to make them more efficient (26, 74, 143); – relocating equipment to where it is most needed (144). ■ Cooperate internationally. Developed countries, through their development aid, could provide long-term technical and financial assistance to developing countries to strengthen rehabilitation services, including rehabilitation personnel development. Aid agencies from Australia, Germany, Italy, Japan, New Zealand, Norway, Sweden, the United Kingdom, and the United States have supported such activities (145–147). 108 World report on disability ■ Include rehabilitation services in foreign aid for humanitarian crises. Conflict and natural disaster cause injuries and disabilities and make people with existing disabilities even more vulnerable – for example, after an earthquake there are increased difficulties in moving around due to the rubble from collapsed buildings and the loss of mobility devices. Foreign aid should also include trauma care and rehabilitation services (135, 142, 148). ■ Combine public and private financing. Clear demarcation of responsibilities and good coordination among sectors is needed for this strategy to be effective. Some services could be publicly funded but privately provided – as in Australia, Cambodia, Canada, and India. ■ Target poor people with disabilities. The essential elements of rehabilitation need to be identified, publicly funded, and made available for free to people with low incomes, as in South Africa (149) and India (8). ■ Evaluate coverage of health insurance, including criteria for equitable access. A study in the United States on access to physical therapy found that health care funding sources provided different coverage for physical therapy services depending on whether people had cerebral palsy, multiple sclerosis, or spinal cord injury (74). Increasing human resources for rehabilitation Global information about the rehabilitation workforce is inadequate. In many countries national planning and review of human resources for health do not refer to rehabilitation (135). Many lack the technical capacity to accurately monitor their rehabilitation workforce, so data are often unreliable and out-of-date. Furthermore, the terms to describe the workers vary, proven analytical tools are absent, and skills and experience for assessing crucial policy issues are lacking (150, 151). Many countries, developing and developed, report inadequate, unstable, or nonexistent supplies, (83, 152, 153) and unequal geographic distribution of, rehabilitation professionals (82, 140). Developed countries such as Australia, Canada, and the United States report shortages of rehabilitation personnel in rural and remote areas (154–156). The low quality and productivity of the rehabilitation workforce in low-income countries are disconcerting. The training for rehabilitation and other health personnel in developing countries, can be more complex than in developed countries. Training needs to consider the absence of other practitioners for consultation and advice and the lack of medical services, surgical treatment, and follow-up care through primary health care facilities. Rehabilitation personnel working in low-resource settings require extensive knowledge on pathology, and good diagnostic, problem-solving, clinical decision-making, and communication skills (136). Physiotherapy services are the ones most often available, often in small hospitals (144). A recent comprehensive survey of rehabilitation in Ghana identified no rehabilitation doctor or occupational therapist in the country, and only a few prosthetists, orthotists, and physical therapists, resulting in very limited access to therapy and assistive technologies (68). Services such as speech pathology are nearly absent in many countries (144). In India people with speech impairments were much less likely to receive assistive devices than people with visual impairments (112). An extensive survey of rehabilitation doctors in sub-Saharan Africa identified only six, all in South Africa, for more than 780 million people, while Europe has more than 10 000 and the United States more than 7000 (142). Discrepancies are also large for other rehabilitation professions: 0.04–0.6 psychologists per 100 000 population in low-income and lower middle-income countries, compared with 1.8 in upper middle-income countries and 14 in high-income countries; and 0.04 social workers per 100 000 population in low-income countries compared with 15.7 in high-income countries (157). Data from official 109 Chapter 4 Rehabilitation statistical sources showing the large disparities in supply of physiotherapists are shown in Fig. 4.1, and data from a survey by the World Federation of Occupational Therapists showing the disparities in occupational therapists are shown in Fig. 4.2. The lack of women in rehabilitation professions, and the cultural attitudes towards gender, affect rehabilitation services in some contexts. The low number of women technicians in India, for example, may partly explain why women with disabilities were less likely than men to receive assistive devices (112). Female patients in Afghanistan can be treated only by female therapists, and men only by men. Restrictions on travel for women

Union CarbideBhopal gas tragedy.The Bhopal disaster, also referred to as the Bhopal gas tragedy, was a gas leak incident on the night of 2–3 December 1984 at the Union Carbide India Limited (UCIL) pesticide plant in Bhopal, Madhya Pradesh, India. It is considered to be the world's worst industrial disaster.[1][2]Over 500,000 people were exposed to methyl isocyanate (MIC) gas. The highly toxic substance made its way into and around the small towns located near the plant.[3]Bhopal disasterMemorial by Dutch artist Ruth Kupferschmidt for those killed and disabled by the 1984 toxic gas releaseDate2 December 1984 – 3 December 1984LocationBhopal, Madhya Pradesh, IndiaCoordinates23°16′51″N 77°24′38″EAlso known asBhopal gas tragedyCauseMethyl isocyanate leak from Union Carbide India Limited plantDeathsAt least 3,787; over 16,000 claimedNon-fatal injuriesAt least 558,125Estimates vary on the death toll. The official immediate death toll was 2,259. The government of Madhya Pradesh confirmed a total of 3,787 deaths related to the gas release.[4]A government affidavit in 2006 stated that the leak caused 558,125 injuries, including 38,478 temporary partial injuries and approximately 3,900 severely and permanently disabling injuries.[5]Others estimate that 8,000 died within two weeks, and another 8,000 or more have since died from gas-related diseases.[6]The cause of the disaster remains under debate. The Indian government and local activists argue that slack management and deferred maintenance created a situation where routine pipe maintenance caused a backflow of water into a MIC tank, triggering the disaster. Union Carbide Corporation (UCC) argues water entered the tank through an act of sabotage.The owner of the factory, UCIL, was majority owned by UCC, with Indian Government-controlled banks and the Indian public holding a 49.1 percent stake. In 1989, UCC paid $470 million (equivalent to $845 million in 2018) to settle litigation stemming from the disaster. In 1994, UCC sold its stake in UCIL to Eveready Industries India Limited (EIIL), which subsequently merged with McLeod Russel (India) Ltd. Eveready ended clean-up on the site in 1998, when it terminated its 99-year lease and turned over control of the site to the state government of Madhya Pradesh. Dow Chemical Company purchased UCC in 2001, seventeen years after the disaster.Civil and criminal cases filed in the United States against UCC and Warren Anderson, UCC CEO at the time of the disaster, were dismissed and redirected to Indian courts on multiple occasions between 1986 and 2012, as the US courts focused on UCIL being a standalone entity of India. Civil and criminal cases were also filed in the District Court of Bhopal, India, involving UCC, UCIL and UCC CEO Anderson.[7][8]In June 2010, seven Indian nationals who were UCIL employees in 1984, including the former UCIL chairman, were convicted in Bhopal of causing death by negligence and sentenced to two years imprisonment and a fine of about $2,000 each, the maximum punishment allowed by Indian law. All were released on bail shortly after the verdict. An eighth former employee was also convicted, but died before the judgement was passed.BackgroundThe UCIL factory was built in 1969 to produce the pesticide Sevin (UCC's brand name for carbaryl) using methyl isocyanate (MIC) as an intermediate.[6]An MIC production plant was added to the UCIL site in 1979.[9][10][11]The chemical process employed in the Bhopal plant had methylamine reacting with phosgene to form MIC, which was then reacted with 1-naphthol to form the final product, carbaryl. Another manufacturer, Bayer, also used this MIC-intermediate process at the chemical plant once owned by UCC at Institute, West Virginia, in the United States.[12][13]After the Bhopal plant was built, other manufacturers (including Bayer) produced carbaryl without MIC, though at a greater manufacturing cost. This "route" differed from the MIC-free routes used elsewhere, in which the same raw materials were combined in a different manufacturing order, with phosgene first reacting with naphthol to form a chloroformate ester, which was then reacted with methylamine. In the early 1980s, the demand for pesticides had fallen, but production continued, leading to build-up of stores of unused MIC where that method was used.[6][12]Earlier leaksIn 1976, two local trade unions complained of pollution within the plant.[6][14]In 1981, a worker was accidentally splashed with phosgene as he was carrying out a maintenance job of the plant's pipes. In a panic, he removed his gas mask and inhaled a large amount of toxic phosgene gas, leading to his death just 72 hours later.[6][14]Following these events, journalist Rajkumar Keswani began investigating and published his findings in Bhopal's local paper Rapat, in which he urged "Wake up people of Bhopal, you are on the edge of a volcano".[15][16]In January 1982, a phosgene leak exposed 24 workers, all of whom were admitted to a hospital. None of the workers had been ordered to wear protective masks. One month later, in February 1982, an MIC leak affected 18 workers. In August 1982, a chemical engineer came into contact with liquid MIC, resulting in burns over 30 percent of his body. Later that same year, in October 1982, there was another MIC leak. In attempting to stop the leak, the MIC supervisor suffered severe chemical burns and two other workers were severely exposed to the gases. During 1983 and 1984, there were leaks of MIC, chlorine, monomethylamine, phosgene, and carbon tetrachloride, sometimes in combination.[6][14]Leakage and its effectsLiquid MIC storageThe Bhopal UCIL facility housed three underground 68,000-liter liquid MIC storage tanks: E610, E611, and E619. In the months leading up to the December leak, liquid MIC production was in progress and being used to fill these tanks. UCC safety regulations specified that no one tank should be filled more than 50% (here, 30 tons) with liquid MIC. Each tank was pressurized with inert nitrogen gas. This pressurization allowed liquid MIC to be pumped out of each tank as needed, and also kept impurities out of the tanks.[17]In late October 1984, tank E610 lost the ability to effectively contain most of its nitrogen gas pressure, which meant that the liquid MIC contained within could not be pumped out. At the time of this failure, tank E610 contained 42 tons of liquid MIC.[17][18]Shortly after this failure, MIC production was halted at the Bhopal facility, and parts of the plant were shut down for maintenance. Maintenance included the shutdown of the plant's flare tower so that a corroded pipe could be repaired.[17]With the flare tower still out of service, production of carbaryl was resumed in late November, using MIC stored in the two tanks still in service. An attempt to re-establish pressure in tank E610 on 1 December failed, so the 42 tons of liquid MIC contained within still could not be pumped out of it.[18]The releaseTank 610 in 2010. During decontamination of the plant, tank 610 was removed from its foundation and left aside.Methylamine (1) reacts with phosgene (2) producing methyl isocyanate (3) which reacts with 1-naphthol (4) to yield carbaryl (5)By early December 1984, most of the plant's MIC related safety systems were malfunctioning and many valves and lines were in poor condition. In addition, several vent gas scrubbers had been out of service as well as the steam boiler, intended to clean the pipes.[6]During the late evening hours of 2 December 1984, water was believed to have entered a side pipe and into Tank E610 whilst trying to unclog it, which contained 42 tons of MIC that had been there since late October.[6]The introduction of water into the tank subsequently resulted in a runaway exothermic reaction, which was accelerated by contaminants, high ambient temperatures and various other factors, such as the presence of iron from corroding non-stainless steel pipelines.[6]The pressure in tank E610, although initially normal at 10:30 p.m., had increased by a factor of five to 10 psi (34.5 to 69 kPa) by 11 p.m. Two different senior refinery employees assumed the reading was instrumentation malfunction.[19]By 11:30 p.m., workers in the MIC area were feeling the effects of minor exposure to MIC gas, and began to look for a leak. One was found by 11:45 p.m., and reported to the MIC supervisor on duty at the time. The decision was made to address the problem after a 12:15 a.m. tea break, and in the meantime, employees were instructed to continue looking for leaks. The incident was discussed by MIC area employees during the break.[19]In the five minutes after the tea break ended at 12:40 a.m., the reaction in tank E610 reached a critical state at an alarming speed. Temperatures in the tank were off the scale, maxed out beyond 25 °C (77 °F), and the pressure in the tank was indicated at 40 psi (275.8 kPa). One employee witnessed a concrete slab above tank E610 crack as the emergency relief valve burst open, and pressure in the tank continued to increase to 55 psi (379.2 kPa) even after atmospheric venting of toxic MIC gas had begun.[19]Direct atmospheric venting should have been prevented or at least partially mitigated by at least three safety devices which were malfunctioning, not in use, insufficiently sized or otherwise rendered inoperable:[20][21]A refrigeration system meant to cool tanks containing liquid MIC, shut down in January 1982, and whose freon had been removed in June 1984. Since the MIC storage system assumed refrigeration, its high temperature alarm, set to sound at 11 °C (52 °F) had long since been disconnected, and tank storage temperatures ranged between 15 °C (59 °F) and 40 °C (104 °F)[22]A flare tower, to burn the MIC gas as it escaped, which had had a connecting pipe removed for maintenance, and was improperly sized to neutralise a leak of the size produced by tank E610A vent gas scrubber, which had been deactivated at the time and was in 'standby' mode, and similarly had insufficient caustic soda and power to safely stop a leak of the magnitude producedAbout 30 tonnes of MIC escaped from the tank into the atmosphere in 45 to 60 minutes.[3]This would increase to 40 tonnes within two hours time.[23]The gases were blown in a southeasterly direction over Bhopal.[6][24]A UCIL employee triggered the plant's alarm system at 12:50 a.m. as the concentration of gas in and around the plant became difficult to tolerate.[19][23]Activation of the system triggered two siren alarms: one that sounded inside the UCIL plant, and a second directed outward to the public and the city of Bhopal. The two siren systems had been decoupled from one another in 1982, so that it was possible to leave the factory warning siren on while turning off the public one, and this is exactly what was done: the public siren briefly sounded at 12:50 a.m. and was quickly turned off, as per company procedure meant to avoid alarming the public around the factory over tiny leaks.[23][25][26]Workers, meanwhile, evacuated the UCIL plant, travelling upwind.Bhopal's superintendent of police was informed by telephone, by a town inspector, that residents of the neighbourhood of Chola (about 2 km from the plant) were fleeing a gas leak at approximately 1 a.m.[25]Calls to the UCIL plant by police between 1:25 and 2:10 a.m. gave assurances twice that "everything is OK", and on the last attempt made, "we don't know what has happened, sir".[25]With the lack of timely information exchange between UCIL and Bhopal authorities, the city's Hamidia Hospital was first told that the gas leak was suspected to be ammonia, then phosgene. Finally, they received an updated report that it was "MIC" (rather than "methyl isocyanate"), which hospital staff had never heard of, had no antidote for, and received no immediate information about.[27]The MIC gas leak emanating from tank E610 petered out at approximately 2:00 a.m. Fifteen minutes later, the plant's public siren was sounded for an extended period of time, after first having been quickly silenced an hour and a half earlier.[28]Some minutes after the public siren sounded, a UCIL employee walked to a police control room to both inform them of the leak (their first acknowledgement that one had occurred at all), and that "the leak had been plugged."[28]Most city residents who were exposed to the MIC gas were first made aware of the leak by exposure to the gas itself, or by opening their doors to investigate commotion, rather than having been instructed to shelter in place, or to evacuate before the arrival of the gas in the first place.[26]Acute effectsReversible reaction of glutathione (top) with methyl isocyanate (MIC, middle) allows the MIC to be transported into the bodyThe initial effects of exposure were coughing, severe eye irritation and a feeling of suffocation, burning in the respiratory tract, blepharospasm, breathlessness, stomach pains and vomiting. People awakened by these symptoms fled away from the plant. Those who ran inhaled more than those who had a vehicle to ride. Owing to their height, children and other people of shorter stature inhaled higher concentrations, as methyl isocyanate gas is approximately twice as dense as air and hence in an open environment has a tendency to fall toward the ground.[29]Thousands of people had died by the following morning. Primary causes of deaths were choking, reflexogenic circulatory collapse and pulmonary oedema. Findings during autopsies revealed changes not only in the lungs but also cerebral oedema, tubular necrosis of the kidneys, fatty degeneration of the liver and necrotising enteritis.[30]The stillbirth rate increased by up to 300% and neonatal mortality rate by around 200%.[6]Gas cloud compositionApart from MIC, based on laboratory simulation conditions, the gas cloud most likely also contained chloroform, dichloromethane, hydrogen chloride, methylamine, dimethylamine, trimethylamine and carbon dioxide, that was either present in the tank or was produced in the storage tank when MIC, chloroform and water reacted. The gas cloud, composed mainly of materials denser than air, stayed close to the ground and spread in the southeasterly direction affecting the nearby communities.[29]The chemical reactions may have produced a liquid or solid aerosol.[31]Laboratory investigations by CSIR and UCC scientists failed to demonstrate the presence of hydrogen cyanide.[29][32]Immediate aftermathIn the immediate aftermath, the plant was closed to outsiders (including UCC) by the Indian government, which subsequently failed to make data public, contributing to the confusion. The initial investigation was conducted entirely by the Council of Scientific and Industrial Research (CSIR) and the Central Bureau of Investigation. The UCC chairman and CEO Warren Anderson, together with a technical team, immediately traveled to India. Upon arrival Anderson was placed under house arrest and urged by the Indian government to leave the country within 24 hours. Union Carbide organized a team of international medical experts, as well as supplies and equipment, to work with the local Bhopal medical community, and the UCC technical team began assessing the cause of the gas leak.The health care system immediately became overloaded. In the severely affected areas, nearly 70 percent were under-qualified doctors. Medical staff were unprepared for the thousands of casualties. Doctors and hospitals were not aware of proper treatment methods for MIC gas inhalation.[6]:6There were mass funerals and cremations. Photographer Pablo Bartholemew, on commission with press agency Rapho, took an iconic color photograph of a burial on 4 December, Bhopal gas disaster girl. Another photographer present, Raghu Rai, took a black and white photo. The photographers did not ask for the identity of the father or child as she was buried, and no relative has since confirmed it. As such, the identity of the girl remains unknown. Both photos became symbolic of the suffering of victims of the Bhopal disaster, and Bartholomew's went on to win the 1984 World Press Photo of the Year.[33]Within a few days, trees in the vicinity became barren and bloated animal carcasses had to be disposed of. 170,000 people were treated at hospitals and temporary dispensaries, and 2,000 buffalo, goats, and other animals were collected and buried. Supplies, including food, became scarce owing to suppliers' safety fears. Fishing was prohibited causing further supply shortages.[6]Lacking any safe alternative, on 16 December, tanks 611 and 619 were emptied of the remaining MIC by reactivating the plant and continuing the manufacture of pesticide. Despite safety precautions such as having water carrying helicopters continually overflying the plant, this led to a second mass evacuation from Bhopal. The Government of India passed the "Bhopal Gas Leak Disaster Act" that gave the government rights to represent all victims, whether or not in India. Complaints of lack of information or misinformation were widespread. An Indian government spokesman said, "Carbide is more interested in getting information from us than in helping our relief work".[6]Formal statements were issued that air, water, vegetation and foodstuffs were safe, but warned not to consume fish. The number of children exposed to the gases was at least 200,000.[6]Within weeks, the State Government established a number of hospitals, clinics and mobile units in the gas-affected area to treat the victims.Subsequent legal actionVictims of Bhopal disaster march in September 2006 demanding the extradition of American Warren Anderson from the United States.Legal proceedings involving UCC, the United States and Indian governments, local Bhopal authorities, and the disaster victims started immediately after the catastrophe. The Indian Government passed the Bhopal Gas Leak Act in March 1985, allowing the Government of India to act as the legal representative for victims of the disaster,[34]leading to the beginning of legal proceedings. Initial lawsuits were generated in the United States federal court system. On 17 April 1985, Federal District court judge John F. Keenan (overseeing one lawsuit) suggested that "'fundamental human decency' required Union Carbide to provide between $5 million and $10 million to immediately help the injured" and suggested the money could be quickly distributed through the International Red Cross.[35]UCC, on the notion that doing so did not constitute an admission of liability and the figure could be credited toward any future settlement or judgement, offered a $5 million relief fund two days later.[35]The Indian government turned down the offer.[29]In March 1986 UCC proposed a settlement figure, endorsed by plaintiffs' U.S. attorneys, of $350 million that would, according to the company, "generate a fund for Bhopal victims of between $500–600 million over 20 years". In May, litigation was transferred from the United States to Indian courts by a U.S. District Court ruling. Following an appeal of this decision, the U.S. Court of Appeals affirmed the transfer, judging, in January 1987, that UCIL was a "separate entity, owned, managed and operated exclusively by Indian citizens in India".[34]The Government of India refused the offer from Union Carbide and claimed US$3.3 billion.[6]The Indian Supreme Court told both sides to come to an agreement and "start with a clean slate" in November 1988.[34]Eventually, in an out-of-court settlement reached in February 1989, Union Carbide agreed to pay US$470 million for damages caused in the Bhopal disaster.[6]The amount was immediately paid.Throughout 1990, the Indian Supreme Court heard appeals against the settlement. In October 1991, the Supreme Court upheld the original $470 million, dismissing any other outstanding petitions that challenged the original decision. The Court ordered the Indian government "to purchase, out of settlement fund, a group medical insurance policy to cover 100,000 persons who may later develop symptoms" and cover any shortfall in the settlement fund. It also requested UCC and its subsidiary UCIL "voluntarily" fund a hospital in Bhopal, at an estimated $17 million, to specifically treat victims of the Bhopal disaster. The company agreed to this.[34]Post-settlement activityIn 1991, the local Bhopal authorities charged Anderson, who had retired in 1986, with manslaughter, a crime that carries a maximum penalty of 10 years in prison. He was declared a fugitive from justice by the Chief Judicial Magistrate of Bhopal on 1 February 1992 for failing to appear at the court hearings in a culpable homicide case in which he was named the chief defendant. Orders were passed to the Government of India to press for an extradition from the United States. The U.S. Supreme Court refused to hear an appeal of the decision of the lower federal courts in October 1993, meaning that victims of the Bhopal disaster could not seek damages in a U.S. court.[34]In 2004, the Indian Supreme Court ordered the Indian government to release any remaining settlement funds to victims. And in September 2006, the Welfare Commission for Bhopal Gas Victims announced that all original compensation claims and revised petitions had been "cleared".[34]The Second Circuit Court of Appeals in New York City upheld the dismissal of remaining claims in the case of Bano v. Union Carbide Corporation in 2006. This move blocked plaintiffs' motions for class certification and claims for property damages and remediation. In the view of UCC, "the ruling reaffirms UCC's long-held positions and finally puts to rest—both procedurally and substantively—the issues raised in the class action complaint first filed against Union Carbide in 1999 by Haseena Bi and several organisations representing the residents of Bhopal".[34]In June 2010, seven former employees of UCIL, all Indian nationals and many in their 70s, were convicted of causing death by negligence: Keshub Mahindra, former non-executive chairman of Union Carbide India Limited; V. P. Gokhale, managing director; Kishore Kamdar, vice-president; J. Mukund, works manager; S. P. Chowdhury, production manager; K. V. Shetty, plant superintendent; and S. I. Qureshi, production assistant. They were each sentenced to two years’ imprisonment and fined ₹100,000 (equivalent to ₹170,000 or US$2,400 in 2018). All were released on bail shortly after the verdict.US federal class action litigation, Sahu v. Union Carbide and Warren Anderson, was filed in 1999 under the U.S. Alien Torts Claims Act (ATCA), which provides for civil remedies for "crimes against humanity."[36]It sought damages for personal injury, medical monitoring and injunctive relief in the form of clean-up of the drinking water supplies for residential areas near the Bhopal plant. The lawsuit was dismissed in 2012 and the subsequent appeal was denied.[37]Former UCC CEO Anderson, then 92 years old, died on 29 September 2014.[38]Long-term effectsIn 2018, The Atlantic called it the "world’s worst industrial disaster."[1]Long-term health effectsSome data about the health effects are still not available. The Indian Council of Medical Research (ICMR) was forbidden to publish health effect data until 1994.[6]A total of 36 wards were marked by the authorities as being "gas affected," affecting a population of 520,000. Of these, 200,000 were below 15 years of age, and 3,000 were pregnant women. The official immediate death toll was 2,259, and in 1991, 3,928 deaths had been officially certified. Ingrid Eckerman estimated 8,000 died within two weeks.[6][39]The government of Madhya Pradesh confirmed a total of 3,787 deaths related to the gas release.[4]Later, the affected area was expanded to include 700,000 citizens. A government affidavit in 2006 stated the leak caused 558,125 injuries including 38,478 temporary partial injuries and approximately 3,900 severely and permanently disabling injuries.[5]A cohort of 80,021 exposed people was registered, along with a control group, a cohort of 15,931 people from areas not exposed to MIC. Nearly every year since 1986, they have answered the same questionnaire. It shows overmortality and overmorbidity in the exposed group. Bias and confounding factors cannot be excluded from the study. Because of migration and other factors, 75% of the cohort is lost, as the ones who moved out are not followed.[6][40]A number of clinical studies are performed. The quality varies, but the different reports support each other.[6]Studied and reported long term health effects are:Eyes: Chronic conjunctivitis, scars on cornea, corneal opacities, early cataractsRespiratory tracts: Obstructive and/or restrictive disease, pulmonary fibrosis, aggravation of TB and chronic bronchitisNeurological system: Impairment of memory, finer motor skills, numbness etc.Psychological problems: Post traumatic stress disorder (PTSD)Children's health: Peri- and neonatal death rates increased. Failure to grow, intellectual impairment, etc.Missing or insufficient fields for research are female reproduction, chromosomal aberrations, cancer, immune deficiency, neurological sequelae, post traumatic stress disorder (PTSD) and children born after the disaster. Late cases that might never be highlighted are respiratory insufficiency, cardiac insufficiency (cor pulmonale), cancer and tuberculosis. Bhopal now has high rates of birth defects and records a miscarriage rate 7x higher than the national average.[16]A 2014 report in Mother Jones quotes a "spokesperson for the Bhopal Medical Appeal, which runs free health clinics for survivors" as saying "An estimated 120,000 to 150,000 survivors still struggle with serious medical conditions including nerve damage, growth problems, gynecological disorders, respiratory issues, birth defects, and elevated rates of cancer and tuberculosis."[41]Health careThe Government of India had focused primarily on increasing the hospital-based services for gas victims thus hospitals had been built after the disaster. When UCC wanted to sell its shares in UCIL, it was directed by the Supreme Court to finance a 500-bed hospital for the medical care of the survivors. Thus, Bhopal Memorial Hospital and Research Centre (BMHRC) was inaugurated in 1998 and was obliged to give free care for survivors for eight years. BMHRC was a 350-bedded super speciality hospital where heart surgery and hemodialysis were done. There was a dearth of gynaecology, obstetrics and paediatrics. Eight mini-units (outreach health centres) were started and free health care for gas victims were to be offered until 2006.[6]The management had also faced problems with strikes, and the quality of the health care being disputed.[42][43]Sambhavna Trust is a charitable trust, registered in 1995, that gives modern as well as ayurvedic treatments to gas victims, free of charge.[6][44]Environmental rehabilitationWhen the factory was closed in 1986, pipes, drums and tanks were sold. The MIC and the Sevin plants are still there, as are storages of different residues. Isolation material is falling down and spreading.[6]The area around the plant was used as a dumping area for hazardous chemicals. In 1982 tubewells in the vicinity of the UCIL factory had to be abandoned and tests in 1989 performed by UCC's laboratory revealed that soil and water samples collected from near the factory and inside the plant were toxic to fish.[45]Several other studies had also shown polluted soil and groundwater in the area. Reported polluting compounds include 1-naphthol, naphthalene, Sevin, tarry residue, mercury, toxic organochlorines, volatile organochlorine compounds, chromium, copper, nickel, lead, hexachloroethane, hexachlorobutadiene, and the pesticide HCH.[6]In order to provide safe drinking water to the population around the UCIL factory, Government of Madhya Pradesh presented a scheme for improvement of water supply.[46]In December 2008, the Madhya Pradesh High Court decided that the toxic waste should be incinerated at Ankleshwar in Gujarat, which was met by protests from activists all over India.[47]On 8 June 2012, the Centre for incineration of toxic Bhopal waste agreed to pay ₹250 million (US$3.6 million) to dispose of UCIL chemical plants waste in Germany.[48]On 9 August 2012, Supreme court directed the Union and Madhya Pradesh Governments to take immediate steps for disposal of toxic waste lying around and inside the factory within six months.[49]A U.S. court rejected the lawsuit blaming UCC for causing soil and water pollution around the site of the plant and ruled that responsibility for remedial measures or related claims rested with the State Government and not with UCC.[50]In 2005, the state government invited various Indian architects to enter their "concept for development of a memorial complex for Bhopal gas tragedy victims at the site of Union Carbide". In 2011, a conference was held on the site, with participants from European universities which was aimed for the same.[51][52]Occupational and habitation rehabilitation33 of the 50 planned work-sheds for gas victims started. All except one was closed down by 1992. 1986, the MP government invested in the Special Industrial Area Bhopal. 152 of the planned 200 work sheds were built and in 2000, 16 were partially functioning. It was estimated that 50,000 persons need alternative jobs, and that less than 100 gas victims had found regular employment under the government's scheme. The government also planned 2,486 flats in two- and four-story buildings in what is called the "widow's colony" outside Bhopal. The water did not reach the upper floors and it was not possible to keep cattle which were their primary occupation. Infrastructure like buses, schools, etc. were missing for at least a decade.[6]Economic rehabilitationImmediate relieves were decided two days after the tragedy. Relief measures commenced in 1985 when food was distributed for a short period along with ration cards.[6]Madhya Pradesh government's finance department allocated ₹874 million (US$13 million) for victim relief in July 1985.[53][54]Widow pension of ₹200 (US$2.90)/per month (later ₹750 (US$11)) were provided. The government also decided to pay ₹1,500 (US$22) to families with monthly income ₹500 (US$7.20) or less. As a result of the interim relief, more children were able to attend school, more money was spent on treatment and food, and housing also eventually improved. From 1990 interim relief of ₹200 (US$2.90) was paid to everyone in the family who was born before the disaster.[6]The final compensation, including interim relief for personal injury was for the majority ₹25,000 (US$360). For death claim, the average sum paid out was ₹62,000 (US$900). Each claimant were to be categorised by a doctor. In court, the claimants were expected to prove "beyond reasonable doubt" that death or injury in each case was attributable to exposure. In 1992, 44 percent of the claimants still had to be medically examined.[6]By the end of October 2003, according to the Bhopal Gas Tragedy Relief and Rehabilitation Department, compensation had been awarded to 554,895 people for injuries received and 15,310 survivors of those killed. The average amount to families of the dead was $2,200.[55]In 2007, 1,029,517 cases were registered and decided. Number of awarded cases were 574,304 and number of rejected cases 455,213. Total compensation awarded was ₹15,465 million (US$220 million).[46]On 24 June 2010, the Union Cabinet of the Government of India approved a ₹12,650 million (US$180 million) aid package which would be funded by Indian taxpayers through the government.[56]Other impactsIn 1985, Henry Waxman, a California Democrat, called for a U.S. government inquiry into the Bhopal disaster, which resulted in U.S. legislation regarding the accidental release of toxic chemicals in the United States.[57]CausesThere are two main lines of argument involving the disaster. The "Corporate Negligence" point of view argues that the disaster was caused by a potent combination of under-maintained and decaying facilities, a weak attitude towards safety, and an undertrained workforce, culminating in worker actions that inadvertently enabled water to penetrate the MIC tanks in the absence of properly working safeguards.[6][39]The "Worker Sabotage" point of view argues that it was not physically possible for the water to enter the tank without concerted human effort, and that extensive testimony and engineering analysis leads to a conclusion that water entered the tank when a rogue individual employee hooked a water hose directly to an empty valve on the side of the tank. This point of view further argues that the Indian government took extensive actions to hide this possibility in order to attach blame to UCC.[58]Theories differ as to how the water entered the tank. At the time, workers were cleaning out a clogged pipe with water about 400 feet from the tank. They claimed that they were not told to isolate the tank with a pipe slip-blind plate. The operators assumed that owing to bad maintenance and leaking valves, it was possible for the water to leak into the tank.[6][59]This water entry route could not be reproduced despite strenuous efforts by motivated parties.[60]UCC claims that a "disgruntled worker" deliberately connecting a hose to a pressure gauge connection was the real cause.[6][58]Early the next morning, a UCIL manager asked the instrument engineer to replace the gauge. UCIL's investigation team found no evidence of the necessary connection; the investigation was totally controlled by the government, denying UCC investigators access to the tank or interviews with the operators.[58][61]Corporate negligenceThis point of view argues that management (and to some extent, local government) underinvested in safety, which allowed for a dangerous working environment to develop. Factors cited include the filling of the MIC tanks beyond recommended levels, poor maintenance after the plant ceased MIC production at the end of 1984, allowing several safety systems to be inoperable due to poor maintenance, and switching off safety systems to save money— including the MIC tank refrigeration system which could have mitigated the disaster severity, and non-existent catastrophe management plans.[6][39]Other factors identified by government inquiries included undersized safety devices and the dependence on manual operations.[6]Specific plant management deficiencies that were identified include the lack of skilled operators, reduction of safety management, insufficient maintenance, and inadequate emergency action plans.[6][14]UnderinvestmentUnderinvestment is cited as contributing to an environment. In attempts to reduce expenses, $1.25 million of cuts were placed upon the plant which affected the factory's employees and their conditions.[16]Kurzman argues that "cuts ... meant less stringent quality control and thus looser safety rules. A pipe leaked? Don't replace it, employees said they were told ... MIC workers needed more training? They could do with less. Promotions were halted, seriously affecting employee morale and driving some of the most skilled ... elsewhere".[62]Workers were forced to use English manuals, even though only a few had a grasp of the language.[59][63]Subsequent research highlights a gradual deterioration of safety practices in regard to the MIC, which had become less relevant to plant operations. By 1984, only six of the original twelve operators were still working with MIC and the number of supervisory personnel had also been halved. No maintenance supervisor was placed on the night shift and instrument readings were taken every two hours, rather than the previous and required one-hour readings.[59][62]Workers made complaints about the cuts through their union but were ignored. One employee was fired after going on a 15-day hunger strike. 70% of the plant's employees were fined before the disaster for refusing to deviate from the proper safety regulations under pressure from the management.[59][62]In addition, some observers, such as those writing in the Trade Environmental Database (TED) Case Studies as part of the Mandala Project from American University, have pointed to "serious communication problems and management gaps between Union Carbide and its Indian operation", characterised by "the parent companies [sic] hands-off approach to its overseas operation" and "cross-cultural barriers".[64]Adequacy of equipment and regulationsThe factory was not well equipped to handle the gas created by the sudden addition of water to the MIC tank. The MIC tank alarms had not been working for four years and there was only one manual back-up system, compared to a four-stage system used in the United States.[6][39][59][65]The flare tower and several vent gas scrubbers had been out of service for five months before the disaster. Only one gas scrubber was operating: it could not treat such a large amount of MIC with sodium hydroxide (caustic soda), which would have brought the concentration down to a safe level.[65]The flare tower could only handle a quarter of the gas that leaked in 1984, and moreover it was out of order at the time of the incident.[6][39][59][66]To reduce energy costs, the refrigeration system was idle. The MIC was kept at 20 degrees Celsius, not the 4.5 degrees advised by the manual.[6][39][59][65]Even the steam boiler, intended to clean the pipes, was non-operational for unknown reasons.[6][39][59][65]Slip-blind plates that would have prevented water from pipes being cleaned from leaking into the MIC tanks, had the valves been faulty, were not installed and their installation had been omitted from the cleaning checklist.[6][39][59]As MIC is water-soluble, deluge guns were in place to contain escaping gases from the stack. The water pressure was too weak for the guns to spray high enough to reach the gas which would have reduced the concentration of escaping gas significantly.[6][39][59][65]In addition to it, carbon steel valves were used at the factory, even though they were known to corrode when exposed to acid.[12]According to the operators, the MIC tank pressure gauge had been malfunctioning for roughly a week. Other tanks were used, rather than repairing the gauge. The build-up in temperature and pressure is believed to have affected the magnitude of the gas release.[6][39][59][65]UCC admitted in their own investigation report that most of the safety systems were not functioning on the night of 3 December 1984.[67]The design of the MIC plant, following government guidelines, was "Indianized" by UCIL engineers to maximise the use of indigenous materials and products. Mumbai-based Humphreys and Glasgow Consultants Pvt. Ltd., were the main consultants, Larsen & Toubro fabricated the MIC storage tanks, and Taylor of India Ltd. provided the instrumentation.[29]In 1998, during civil action suits in India, it emerged that the plant was not prepared for problems. No action plans had been established to cope with incidents of this magnitude. This included not informing local authorities of the quantities or dangers of chemicals used and manufactured at Bhopal.[6][12][39][59]Safety auditsSafety audits were done every year in the US and European UCC plants, but only every two years in other parts of the world.[6][68]Before a "Business Confidential" safety audit by UCC in May 1982, the senior officials of the corporation were well aware of "a total of 61 hazards, 30 of them major and 11 minor in the dangerous phosgene/methyl isocyanate units" in Bhopal.[6][69]In the audit 1982, it was indicated that worker performance was below standards.[6][61]Ten major concerns were listed.[6]UCIL prepared an action plan, but UCC never sent a follow-up team to Bhopal. Many of the items in the 1982 report were temporarily fixed, but by 1984, conditions had again deteriorated.[61]In September 1984, an internal UCC report on the West Virginia plant in the USA revealed a number of defects and malfunctions. It warned that "a runaway reaction could occur in the MIC unit storage tanks, and that the planned response would not be timely or effective enough to prevent catastrophic failure of the tanks". This report was never forwarded to the Bhopal plant, although the main design was the same.[70]Impossibility of the "negligence"According to the "Corporate Negligence" argument, workers had been cleaning out pipes with water nearby. This water was diverted due to a combination of improper maintenance, leaking and clogging, and eventually ended up in the MIC storage tank. Indian scientists also suggested that additional water might have been introduced as a "back-flow" from a defectively designed vent-gas scrubber. None of these theoretical routes of entry were ever successfully demonstrated during tests by the Central Bureau of Investigation (CBI) and UCIL engineers.[59][61][68][71]A Union Carbide commissioned analysis conducted by Arthur D. Little claims that the Negligence argument was impossible for several tangible reasons:[58]The pipes being used by the nearby workers were only 1/2 inch in diameter and were physically incapable of producing enough hydraulic pressure to raise water the more than 10 feet that would have been necessary to enable the water to "backflow" into the MIC tank.A key intermediate valve would have had to be open for the Negligence argument to apply. This valve was "tagged" closed, meaning that it had been inspected and found to be closed. While it is possible for open valves to clog over time, the only way a closed valve allows penetration is if there is leakage, and 1985 tests carried out by the government of India found this valve to be non-leaking.In order for water to have reached the MIC tank from the pipe-cleaning area, it would have had to flow through a significant network of pipes ranging from 6 to 8 inches in diameter, before rising ten feet and flowing into the MIC tank. Had this occurred, most of the water that was in those pipes at the time the tank had its critical reaction would have remained in those pipes, as there was no drain for them. Investigation by the Indian government in 1985 revealed that the pipes were bone dry.Employee sabotageNow owned by Dow Chemical Company, Union Carbide maintains a website dedicated to the tragedy and claims that the incident was the result of sabotage, stating that sufficient safety systems were in place and operative to prevent the intrusion of water.[72]The Union Carbide-commissioned Arthur D. Little report concluded that it was likely that a single employee secretly and deliberately introduced a large amount of water into the MIC tank by removing a meter and connecting a water hose directly to the tank through the metering port.[58]UCC claims the plant staff falsified numerous records to distance themselves from the incident and absolve themselves of blame, and that the Indian government impeded its investigation and declined to prosecute the employee responsible, presumably because it would weaken its allegations of negligence by Union Carbide.[73]The evidence in favor of this point of view includes:A key witness (the "tea boy") testified that when he entered the control room at 12:15 am, prior to the disaster, the "atmosphere was tense and quiet".Another key witness (the "instrument supervisor") testified that when he arrived at the scene immediately following the incident, he noticed that the local pressure indicator on the critical Tank 610 was missing, and that he had found a hose lying next to the empty manhead created by the missing pressure indicator, and that the hose had had water running out of it.This testimony was corroborated by other witnesses.Graphological analysis revealed major attempts to alter logfiles and destroy log evidence.Other logfiles show that the control team had attempted to purge 1 ton of material out of Tank 610 immediately prior to the disaster. An attempt was then made to cover up this transfer via log alteration. Water is heavier than MIC, and the transfer line is attached to the bottom of the tank. The Arthur D. Little report concludes from this that the transfer was an effort to transfer water out of Tank 610 that had been discovered there.A third key witness (the "off-duty employee of another unit") stated that "he had been told by a close friend of one of the MIC operators that water had entered through a tube that had been connected to the tank." This had been discovered by the other MIC operators (so the story was recounted) who then tried to open and close valves to prevent the release.A fourth key witness (the "operator from a different unit") stated that after the release, two MIC operators had told him that water had entered the tank through a pressure gauge.The Little report argues that this evidence demonstrates that the following chronology took place:At 10:20pm, the tank was at normal pressure, indicating the absence of water.At 10:45pm, a shift change took place, after which the MIC storage area "would be completely deserted".During this period, a "disgruntled operator entered the storage area and hooked up one of the readily available rubber water hoses to Tank 610, with the intention of contaminating and spoiling the tank's contents."Water began to flow, beginning the chemical reaction that caused the disaster.After midnight, control room operators noticed the pressure rising and realized there was a problem with Tank 610. They discovered the water connection, and decided to transfer one ton of the contents out to try and remove the water.The MIC release then occurred.The cover-up activities discovered during the investigation then took place.After over 30 years, in November 2017, S. P. Choudhary, former MIC production manager, claimed in court that the disaster was not an accident but the result of a sabotage that claimed thousands of lives.Chaudry's counsel, Anirban Roy, argued that the theory of design defects was floated by the central government in its endeavour to protect the victims of the tragedy. Everyone else who was part of investigations into the case "just toed the line of the central government.... The government and the CBI suppressed the actual truth and saved the real perpetrators of the crime."[74][75]Roy argued to the district court that disgruntled plant operator M. L. Verma was behind the sabotage because he was unhappy with senior management. The counsel argued that there were discrepancies in the statements given by persons who were operating the plant at that time but the central agency chose not to investigate the case properly because it always wanted to prove that it was a mishap, and not sabotage. He alleged that Verma was unhappy with Chaudhary and Mukund.[76][2]Ongoing contaminationDeteriorating section of the MIC plant, decades after the gas leak.Chemicals abandoned at the plant continue to leak and pollute the groundwater.[55][85][86][87]Whether the chemicals pose a health hazard is disputed.[88]Contamination at the site and surrounding area was not caused by the gas leakage. The area around the plant was used as a dumping ground for hazardous chemicals and by 1982 water wells in the vicinity of the UCIL factory had to be abandoned.[6]UCC states that "after the incident, UCIL began clean-up work at the site under the direction of Indian central and state government authorities", which was continued after 1994 by the successor to UCIL. The successor, Eveready Industries India, Limited (EIIL), ended cleanup on the site in 1998, when it terminated its 99-year lease and turned over control of the site to the state government of Madhya Pradesh.[34][72]UCC's laboratory tests in 1989 revealed that soil and water samples collected from near the factory were toxic to fish. Twenty-one areas inside the plant were reported to be highly polluted. In 1991 the municipal authorities declared that water from over 100 wells was hazardous for health if used for drinking.[6]In 1994 it was reported that 21% of the factory premises were seriously contaminated with chemicals.[45][89][90]Beginning in 1999, studies made by Greenpeace and others from soil, groundwater, well water and vegetables from the residential areas around UCIL and from the UCIL factory area show contamination with a range of toxic heavy metals and chemical compounds. Substances found, according to the reports, are naphthol, naphthalene, Sevin, tarry residues, alpha naphthol, mercury, organochlorines, chromium, copper, nickel, lead, hexachlorethane, hexachlorobutadiene, pesticide HCH (BHC), volatile organic compounds and halo-organics.[89][90][91][92]Many of these contaminants were also found in breast milk of women living near the area.[93]Soil tests were conducted by Greenpeace in 1999. One sample (IT9012) from "sediment collected from drain under former Sevin plant" showed mercury levels to be at "20,000 and 6 million times" higher than expected levels. Organochlorine compounds at elevated levels were also present in groundwater collected from (sample IT9040) a 4.4 meter depth "bore-hole within the former UCIL site". This sample was obtained from a source posted with a warning sign which read "Water unfit for consumption".[94]Chemicals that have been linked to various forms of cancer were also discovered, as well as trichloroethylene, known to impair fetal development, at 50 times above safety limits specified by the U.S. Environmental Protection Agency (EPA).[93]In 2002, an inquiry by Fact-Finding Mission on Bhopal found a number of toxins, including mercury, lead, 1,3,5 trichlorobenzene, dichloromethane and chloroform, in nursing women's breast milk.A 2004 BBC Radio 5 broadcast reported the site is contaminated with toxic chemicals including benzene hexachloride and mercury, held in open containers or loose on the ground.[95]A drinking water sample from a well near the site had levels of contamination 500 times higher than the maximum limits recommended by the World Health Organization.[96]In 2009, the Centre for Science and Environment, a Delhi-based pollution monitoring lab, released test results showing pesticide groundwater contamination up to three kilometres from the factory.[97]Also in 2009, the BBC took a water sample from a frequently used hand pump, located just north of the plant. The sample, tested in UK, was found to contain 1,000 times the World Health Organization's recommended maximum amount of carbon tetrachloride, a carcinogenic toxin.[98]In 2010, a British photojournalist who ventured into the abandoned Union Carbide factory to investigate allegations of abandoned, leaking toxins, was hospitalized in Bhopal for a week after he was exposed to the chemicals. Doctors at the Sambhavna Clinic treated him with oxygen, painkillers and anti-inflammatories following a severe respiratory reaction to toxic dust inside the factory.[99][100]In October 2011, the Institute of Environmental Management and Assessment published an article and video by two British environmental scientists, showing the current state of the plant, landfill and solar evaporation ponds and calling for renewed international efforts to provide the necessary skills to clean up the site and contaminated groundwater.[101]Popular cultureActivismSince 1984, individual activists have played a role in the aftermath of the tragedy. The best-known is Satinath Sarangi (Sathyu), a metallurgic engineer who arrived at Bhopal the day after the leakage. He founded several activist groups, as well as Sambhavna Trust, the clinic for gas affected patients, where he is the manager.[6]Other activists include Rashida Bee and Champa Devi Shukla, who received the Goldman Prize in 2004, Abdul Jabbar and Rachna Dhingra.[105][106]Local activismProtest in Bhopal in 2010Soon after the accident, representatives from different activist groups arrived. The activists worked on organising the gas victims, which led to violent repression from the police and the government.[6]Numerous actions have been performed: demonstrations, sit-ins, hunger strikes, marches combined with pamphlets, books, and articles. Every anniversary, actions are performed. Often these include marches around Old Bhopal, ending with burning an effigy of Warren Anderson.International activismCooperation with international NGOs including Pesticide Action Network UK and Greenpeace started soon after the tragedy. One of the earliest reports is the Trade Union report from ILO 1985.[61]In 1992, a session of the Permanent Peoples' Tribunal on Industrial Hazards and Human Rights took place in Bhopal, and in 1996, the "Charter on Industrial Hazards and Human Rights" was adopted.In 1994, the International Medical Commission on Bhopal (IMCB) met in Bhopal. Their work contributed to long term health effects being officially recognised.Important international actions have been the tour to Europe and United States in 2003,[107]the marches to Delhi in 2006 and 2008, all including hunger strikes, and the Bhopal Europe Bus Tour in 2009.Activist organisationsBhopal People's Health and Documentation ClinicAt least 14 different NGOs were immediately engaged.[6]The first disaster reports were published by activist organisations, Eklavya and the Delhi Science Forum.Around ten local organisations, engaged on long term, have been identified. Two of the most active organisations are the women's organisations—Bhopal Gas Peedit Mahila-Stationery Karmachari Sangh and Bhopal Gas Peedit Mahila Udyog Sangthan.[6]More than 15 national organisations have been engaged along with a number of international organisations.[6]Some of the organisations are:International Campaign for Justice in Bhopal (ICJB), coordinates international activities.Bhopal Medical Appeal, collects funds for the Sambhavna Trust.Sambhavna Trust or Bhopal People's Health and Documentation Clinic. Provides medical care for gas affected patients and those living in water-contaminated area.Chingari Trust, provides medical care for children being born in Bhopal with malformations and brain damages.Students for Bhopal, based in USA.International Medical Commission on Bhopal, provided medical information 1994–2000.Settlement fund hoaxOn 3 December 2004, the twentieth anniversary of the disaster, a man falsely claiming to be a Dow representative named Jude Finisterra was interviewed on BBC World News. He claimed that the company had agreed to clean up the site and compensate those harmed in the incident, by liquidating Union Carbide for US$12 billion.[108][109]Dow quickly issued a statement saying that they had no employee by that name—that he was an impostor, not affiliated with Dow, and that his claims were a hoax. The BBC later broadcast a correction and an apology.[110]Jude Finisterra was actually Andy Bichlbaum, a member of the activist prankster group The Yes Men. In 2002, The Yes Men issued a fake press release explaining why Dow refused to take responsibility for the disaster and started up a website, at "Dow Ethics: My Blog about the Stock Market", designed to look like the real Dow website, but containing hoax information.[111]Monitoring of activistsThe release of an email cache related to intelligence research organisation Stratfor was leaked by WikiLeaks on 27 February 2012.[112]It revealed that Dow Chemical had engaged Stratfor to spy on the public and personal lives of activists involved in the Bhopal disaster, including the Yes Men. E-mails to Dow representatives from hired security analysts list the YouTube videos liked, Twitter and Facebook posts made and the public appearances of these activists.[113]Journalists, film-makers and authors who were investigating Bhopal and covering the issue of ongoing contamination, such as Jack Laurenson and Max Carlson, were also placed under surveillance.[114][115]Stratfor released a statement condemning the revelation by Wikileaks while neither confirming nor denying the accuracy of the reports, and would only state that it had acted within the bounds of the law. Dow Chemical also refrained to comment on the matter.[116]Ingrid Eckerman, a member of the International Medical Commission on Bhopal, has been denied a visa to visit India.[117](source[Wikipedia])All this happened and congress tried to cover up.Rajeev Gandhi was directly involved in this case.Corrupted Congress took money from Union Carbide.Thanks for reading