Dr. Rhyddhi Chakraborty
Programme Leader (Health and Social Care), London Churchill College, UK
Email: rchak2012@gmail.com

Introduction and Background

Bhopal, the capital city of the Indian state of Madhya Pradesh, is the administrative headquarter of Bhopal district and Bhopal division. Around 500m above sea level, geographically Bhopal lies at the centre of India and is surrounded by hills, forests, and fields. The Bhopal Municipality covers about 285 sq km with two large dams formed in the structure of the lakes. In 1984, in the north of the dams housed the Old Town mainly with poor people and, on the South, was the villa quarters and modern building complexes.
In 1970, in the North adjacent to the slums and railway station, a pesticide plant has been set up by the Union Carbide India Limited (UCIL). From late 1977, the plant started manufacturing Sevin (Carbaryl) by importing primary raw materials, viz. alpha-naphtol and methyl isocyanate (MIC) in stainless steel drums from the Union Carbide's MIC plant in USA. However, from early 1980, the Bhopal plant itself started manufacturing MIC using the know-how and basic designs supplied by Union Carbide Corporation, USA (UCC). The plant at Bhopal also produced carbon monoxide (CO) and phosgene (COCI2) as intermediate required for the production of MIC.The manufacturing process for Sevin involves the reaction of a slight excess of alpha-naphtol with MIC in the presence of a catalyst in carbon tetrachloride solvent. 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. The Bhopal UCIL facility housed three underground 68,000 litres liquid MIC storage tanks: E610, E611, and E619 and was claimed to ensure all the safety from leakage.

Occupational Hazards of UCIL

Soon after the plant was set up, the plant has been in news.
1976: Local trade unions complained of pollution within the plant.
1980: A worker was reported to have accidentally splashed with phosgene while carrying out a regular maintenance job of the plant's pipes.
1982 (January): A phosgene leak exposed 24 workers, all of whom were admitted to a hospital. Investigation revealed that none of the workers had been ordered to wear protective masks.
1982 (February): An MIC leak affected 18 workers.
1982 (August): A chemical engineer came into contact with liquid MIC, resulting in burns over 30 percent of his body.
1982 (October): In attempting to stop the leak, the MIC supervisor suffered severe chemical burns and two other workers were severely exposed to the gases.
1983-1984: There were leaks of MIC, chlorine, monomethylamine, phosgene, and carbon tetrachloride, sometimes in combination.

Oversighted Causes

In early December 1984, most of the Bhopal plant's MIC related safety systems were not functioning 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. For the major maintenance work, the MIC production and Sevin were stalled in Bhopal plant since Oct. 22,1984 and the major regular maintenance was ordered to be done during the weekdays’ day shifts. The Sevin plant, after having been shut down for some time, had been started up again during November but was still running at far below normal capacity. To make the pesticide, carbon tetrachloride is mixed with methyl isocyanate and alpha-naphthol, a coffee-coloured powder that smells like mothballs. The methyl isocyanate, or MIC, was stored in the three partly buried tanks, each with a 15,000-gallon capacity.

During the late evening hours of 2 December 1984, whilst trying to unclog, water was believed to have entered a side pipe and into Tank E610 containing 42 tons of MIC that had been there since late October. Introduction of water into the tank began a runaway exothermic reaction, which was accelerated by contaminants, high ambient temperatures and other factors, such as the presence of iron from corroding non-stainless steel pipelines.

The Fateful December Night, 1984

December 2, 2:45 pm: It was a typical Sunday afternoon and the open-air market in the city was bustling with vendors, sellers. Across the street from the factory, children were playing outside their slum huts. In the factory, about 100 workers reported for duty on the eight-hour shift. The workers expected the day to be slow to go. The problem arose when the workers had not been able to use the methyl isocyanate in the tank, No. 610, to make the pesticide, for, more than a week they could not get the chemical out of the tank. Every time they tried to push it out and into the Sevin plant by pumping in nitrogen, the nitrogen leaked out somewhere, the location which was untraced of. The workers informed the supervisor who started his duty in the second shift.

December 2, 9:15 pm: The supervisor telephoned one of the MIC operators, asked him to come to the MIC area of the plant and clean a pipe. The pipe, about 25 feet long and 8 feet off the ground, led from a device that filtered crude methyl isocyanate before it went into the storage tanks. Inside the pipe there was a valve claimed to have been closed.

December 2, 9:30 pm: The MIC operator noticed that the closed valve had not been sealed with a slip blind, a metal disc that is inserted into pipes to make sure that water does not leak through the valve. The MIC operator and the supervisor left the area, while the pipe was being cleaned. Unattended, water flowed into the pipe, out pipe drains and onto the floor, where it entered a floor drain. The water continued to flow for about three hours. According to the MIC operator, it was the only pipe in the MIC unit being washed during the second shift of the day.

December 2, 10:30 pm: The workers on duty prepared for the change in shifts in about 15 minutes. Before leaving, they logged the pressure indicated on the gauge in the control room for MIC tank No. 610 which was normal at the time. Operators, however, did not record the temperature of the tank, for, there was no column to record it in the log books.

December 2,11 pm: Two staff noticed that the pressure gauge for Tank 610 read 10 pounds per square inch - five times what it had been half an hour earlier. However, considering one of the readings as faulty, they undermined any probability of the accident in the plant.

December 2,11:30 pm: Workers in the MIC area realized that there was a MIC leak somewhere as their eyes began to tear. The workers began to look for the source of the leak. One of the workers spotted a small but a continuous drip of liquid about 50 feet off the ground and observed some yellowish-white gas accompanying the drip. He went by himself to inform the MIC operator, while the other workers kept looking at it.

December 2, 11:45 pm: MIC operator, on being informed, affirmed that he would deal with the leak after the next tea break, scheduled at 12:15 am. and the workers continued to inspect the area.

December 3, 12:15 am: All the workers had tea together in the control room about 100 feet away from the storage tanks. The workers kept on discussing about the leak, among other things, over tea.

December 3, 12:40 am: A worker, while investigating the leak, stood on a concrete slab above three large, partly buried storage tanks holding the chemical MIC. The slab suddenly began to vibrate beneath him and he witnessed at least 6 inches thick crack on the slab and heard a loud hissing sound. As he prepared to escape from the leaking gas, he saw gas shoot out of a tall stack connected to the tank, forming a white cloud that drifted over the plant and toward nearby neighbourhoods where thousands of residents were sleeping. In short span of time, the leak went out of control.

December 3, 12:45 am: The workers were aware of the enormity of the accident. They began to panic both because of the choking fumes, they said, and because of their realization that things were out of control; the concrete over the tanks crack as MIC turned from liquid to gas and shot out the stack, forming a white cloud. Part of it hung over the factory, the rest began to drift toward the sleeping neighbourhoods nearby.

The supervisor ordered all water sources in the area to be shut off and ordered water sprayed on the leak to break down the MIC. The effect of the MIC became more pronounced by the minute - workers eyes began to hurt and tear more excessively; some began to cough, they said. Someone sounded an alarm by breaking its glass. The operator made an announcement on the factory loudspeaker that there was a large MIC leak and that people should leave. Workers ran around in panic, shouting ''massive MIC leak. Within a minute or so, the fire brigade arrived on trucks and turned on several hydrants to put a water curtain around the escaping gas but the curtain reached only about 100 feet high while the gas was escaping from the top of a stack 120 feet high and was shooting another 10 feet into the air.

December 3, 12:50 am: The public siren briefly sounded and was quickly turned off, as per company procedure meant to avoid alarming the public around the factory over tiny leaks. Workers, meanwhile, evacuated the UCIL plant. The control room operator then turned on the vent gas scrubber, a device designed to neutralize escaping toxic gas. The scrubber had been under maintenance; the flow meter indicated there was no caustic soda flowing into the device. He was not clear to him whether there was actually no caustic soda in the system or whether the meter was broken. Broken gauges were not unusual at the factory. In fact, the gas was not being neutralized but was shooting out the vent scrubber stack and settling over the plant. Inside the factory, the white cloud of methyl isocyanate engulfed the production plant and started wafting toward the control room. Nearly all members of the plant staff began to leave. Those fleeing looked at the wind direction indicator, a large sock on a pole, and ran into the win. Four buses were parked by the road on which workers ran to escape. There was a provision for drivers to man the vehicles and drive them to the nearby neighbourhood, loading some residents aboard and having the rest follow, workers said. But the buses stood idle, for everybody was busy running away.

December 3, 1 am: The supervisor called the assistant factory manager. He said to turn on the flare tower, which is designed to burn off escaping gas. The supervisor gave the instruction to workers and the control room operator reminded the supervisor that turning on the flare with all that gas in the air would cause a huge explosion. The workers considered other alternatives, such as dumping the escaping gas into a spare storage tank. One of the three tanks, No. 619, was supposed to be empty, but it was not; it also contained MIC, as did No. 611. The workers started grabbing their oxygen masks and tanks.

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. About 25,000 people were crammed into Hamidia Hospital. The floor was splattered with blood and vomit.

The railway station lay close to the factory and smack in the path of the gas cloud. The deputy chief power controller, risked his life by staying on, while his wife and 14-year-old son died in the neighbouring railway colony. The control room which monitors movements of all trains on this vital trunk route, was, however, in a mess: vomit and human excreta scattered all around, files and registers in disorder, chairs knocked down. After midnight, the 116 Up Gorakhpur-Bombay Express rolled in but its passengers miraculously escaped death, presumably because they kept their windows closed because of the cold night, but also because station superintendent risked his life to wave the train on to safety. The super, who was found dead later, also alerted all the nearby stations to stop trains from coming into Bhopal.

December 3, 1: 15- 1:30 am: At Bhopal’s 1,200-bed Hamidia Hospital, the first patient with eye trouble reported. Within five minutes, there were a thousand patients. Calls to the UCIL plant by police were twice assured that "everything is OK", and on the last attempt made, "we don't know what has happened, sir". In the plant, meanwhile, MIC began to engulf the control room and the adjoining offices.

December 3, 2 am: The pressure and temperature gauges were still off the top of their scales. Public siren was again switched on. Minutes later, 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."

December 3, 2:30 am: The gas that had begun shooting out of the stack nearly two hours earlier had stopped coming out. Meanwhile, 4,000 people suffering from not just eye ailments but also from respiratory problems were in the Hamida hospital. The hospital staff’s first response was of shock and bewilderment. Nobody knew what to do and Union Carbide was not volunteering any useful information. Several staff members at Hamidia, about three km from the factory, were soon overwhelmed by the gas themselves. They had to be replaced by a fresh medical team. When journalists visited the hospital, they saw only one doctor, and he had no medicine to treat patients with.

December 3, 2.45 am: The army had sent a fleet of vehicles and started a systematic search of houses for people trapped within. The effort was made for continuous evacuation channel to the Military Hospital as well as the Hamidia Hospital all through the night.

December 3, 3:00 am: The factory manager, arrived at the plant and sent a man to tell the police about the accident because the phones were out of order. The police were not told earlier because the company management had an informal policy of not involving the local authorities in gas leaks. Meanwhile, people were dying by the hundreds outside the factory. Some died in their sleep. Others ran into the cloud, breathing in more and more gas and dropping dead in their tracks.

December 3, 7:30 am: The major station of Bhopal remained to be cut off from the rest of the world. Hundreds of sick and writhing people were found all around, on platforms, on staircases, in the office rooms and even on the railway tracks. On the roads and footpaths around the station were the bodies of poor beggars and urchins. Those who could not flee made their way to the hospitals.

December 3, 9 am: At the Hindu cremation grounds, about 15 pyres were lit at a time. The crematoriums soon ran out of firewood and trucks had to be marshalled to bring in more. To save time, money, energy and manpower, five to ten persons were cremated on each pyre. As per Hindu rites, the children and infants were buried. At the Muslim burial ground, too, there was not enough space to bury the bodies coming in. Rescue workers dug graves each holding 11 bodies. When there was no more space left, old tombs were opened and 100-year old bones displaced to make room. The head priest of the Muslim clergy in Bhopal had to issue a fatwa to allow the digging up of old graves.

Immediate Consequences

• 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. They were then told that it was "MIC", which hospital staff had never heard of, had no antidote for, and received no immediate information about. Apart from MIC, based on laboratory simulation conditions, the gas cloud most likely also contained chloroform, dichloromethane, hydrogen chloride, methyl amine, 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. The chemical reactions may have produced a liquid or solid aerosol.

• Most city residents who were exposed to the MIC gas were first made aware of the leak by exposure to the gas itself. The 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.

• 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.

• By the time the sun rose, hundreds, some even say thousands, lay dead, many on the roads and many at home under their tattered quilts: corpses with distended bellies were beginning to rot, attracting vultures and dogs.

• 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; 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.

Subsequent legal action

• 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. Within weeks, the State Government established a number of hospitals, clinics and mobile units in the gas-affected area to treat the victims.

• 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, leading to the beginning of legal proceedings.

• Initial lawsuits were generated in the United States federal court system in April 1985. 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. 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.[32]

Post-settlement activity

UCC chairman and CEO Warren Anderson was arrested and released on bail by the Madhya Pradesh Police in Bhopal on 7 December 1984. Anderson was taken to UCC's house after which he was released six hours later on $2,100 bail and flown out on a government plane. Anderson, eight other executives and two company affiliates with homicide charges to appear in Indian court. In response, Union Carbide said the company is not under Indian jurisdiction. In 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. From 2014, Dow is a named respondent in a number of ongoing cases arising from Union Carbide’s business in Bhopal.

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".

In June 2010, seven former employees of UCIL, all Indian nationals and many in their 70s, were convicted of causing death by negligence. They were each sentenced to two years imprisonment and fined Rs.100,000 (US$2,124). All were released on bail shortly after the verdict.

US Federal class action litigation, Sahu v. Union Carbide and Warren Anderson, had been filed in 1999 under the U.S. Alien Torts Claims Act (ATCA), which provides for civil remedies for "crimes against humanity."[34] 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 subsequent appeal denied.[35] Anderson died in 2014.

Long-term health effects

• 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. The government of Madhya Pradesh confirmed a total of 3,787 deaths related to the gas release.

• 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.

Studied and reported long term health effects are:

  • Eyes: Chronic conjunctivitis, scars on cornea, corneal opacities, early cataracts
  • Respiratory tracts: Obstructive and/or restrictive disease, pulmonary fibrosis, aggravation of TB and chronic bronchitis, irritation to the lungs, causing coughing and/or shortness of breathing. Higher exposure caused build up of fluids (pulmonary enema), caused asthma.
  • Neurological 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.
  • Cancer Hazard: Caused mutation( genetic changes).
  • Milk Contamination: Traces of toxins were found in the breast milk of mothers and were in turn transmitted to the recipient babies.

Affect on Soil and Water: Lead, Nickel, Copper, Chromium, hexachlorocyclophexane and chlorobenzenes were found in soil samples. Mercury was found to be between 20,000 to 6,000,000 times the standard level in soil.

Health care

  • The 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.
  • Sambhavna Trust is a charitable trust, registered in 1995, that gives modern as well as ayurvedic treatments to gas victims, free of charge.

Environmental rehabilitation

  • 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.
  • 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.

Occupational and habitation rehabilitation

  • 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.

Economic rehabilitation

  • Relief measures commenced in 1985 when food was distributed for a short period along with ration cards.
  • 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.
  • On 24 June 2010, the Union Cabinet of the Government of India approved a ₹12,650 million (US$190 million) aid package which would be funded by Indian taxpayers through the government.

Other impacts

In 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.

Ethical Negligence

The "corporate negligence" argument: This point of view argues that management (and to some extent, local government) underinvested in safety, which allowed for a dangerous working environment to develop.

Safety audits: 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.

Causes of the disaster: the "disgruntled employee sabotage" case: Now 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.


References
1. The Bhopal Disaster. Health, India’s Environment-1984-85; 206-232. Available at https://web.archive.org/web/20160528042900/http://www.cseindia.org/userfiles/THE%20BHOPAL%20DISASTER.pdf (28 May 2018).
2. Diamond, Staurt. 1985. SPECIAL TO THE NEW YORK TIMES THE DISASTER IN BHOPAL: WORKERS RECALL HORROR. Available at https://www.nytimes.com/1985/01/30/world/the-disaster-in-bhopal-workers-recall-horror.html (Accessed on 19 August 2018)
3. Dr. S. Varadarajan et al. 1985. REPORT ON SCIENTIFIC STUDIES ON THE FACTORS RELATED TO BHOPAL TOXIC GAS LEAKAGE Available at https://bhopalgasdisaster.files.wordpress.com/2014/12/csir-report-on-scientific-studies-december-1985.pdf (Accessed 28 May 2018).

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Your comments are invited on some or all of the following. As part of your analysis include information as appropriate on the stakeholders and how they are impacted both positively and negatively.

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Comments

  • Shady Bernaba
    In the case of Bhopal Gas Tragedy there was multiple clauses and neglectful actions that caused this disaster that affected more than half a million people. A total of 3,787 deaths were related to this incident. In the beginning of starting the plant, the people who oversighted the construction clearly didn’t inspect the valves and pipes correctly, they were the first clause in this incident. Before the construction of the plant itself, there should have been an environmental study done properly to assess any sort of pollution that this plant might cause. Another responsible party to this tragedy could be the improperly trained employees that didn’t reach the leak from a good angle. The workers, after discovering the leak, decided to take a tea break for approximately 30 minutes rather than attending to the situation. Instead they could’ve called for assistance or at least let other people know around the plant or in the plant that there is danger nearby. If the workers had the right knowledge and skills to operate these machineries, certain outcomes could’ve been minimized or prevented at all. The best way to prevent mistakes to prepare for them and be correctly educated and skilled for your job. While its hard to make decisions that are 100 percent safe and keeps everyone happy, constant education and review of the code of ethics can help us decipher the right thing to do. In this terrible tragedy, things that could’ve been done right are using quality tested valves , good skilled and experienced workers ,and an environment study before plants like these are built.
    • You are completely right about how this incident could have been easily avoided if proper education and action were taken in time. Furthermore, analysis of the environmental and social impact of having this plant so close to a populated area should have been taken into further consideration before the plant was constructed. These tragedies however do allow us to learn from our mistakes and implement new technologies and prevention systems to avoid future tragedies such as the Bhopal Gas Tragedy. Specialization and more intense education in these work environments is extremely important. These tragedies are avoidable but are still seen today, for example, the fertilizer explosion occurring in Beirut in 2020. The before and after pictures show the immense power fertilizer and these compounds weild. Improper storage, handling, and negligence still plague our society, which continues to create ethical dilemmas with immense consequences after the fact.
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