REPORT OF

THE LATHTHA (HOOCH) COMMISSION OF INQUIRY

AHMEDABAD-2009

By

Mr. Justice K.M.Mehta

Former Judge of High Court of Gujarat

 

Chairman

Mr. G. C. Raiger IPS (DGP Retd)

 

Member

Dr. M. S. Dahiya Director, IFS, GFSU &

Dy. Director, DFS, Gandhinagar

 

Member

Dr. Kirit Mithawala Officer on Special Duty for

Cancer Screening Programme, MP Shah Cancer Hospital,

Ahmedabad

 

Member

ii  

REPORT OF THE HOOCH TRAGEDY COMMISSION OF INQUIRY

I N D E X

CHAPTER

NOS.

REFERENCE

NOS.

PARTICULARS OF REFERENCE PAGE NOS.

(1) -- Synopsis of the Tragedy 1 - 5

(2) -- Copy of the Notification 6 - 14

(3) Ref.(1) Glossary of the Causes and

circumstances of the

incidence in which number of

deaths have occurred from 5th

July to 30th August, 2009, due

to the consumption of illicit

liquor

15 - 49

(4) Ref.(2) Report of the Intra-

Departmental Action taken by

Police

50 – 74

(5) Ref.(3) Details of Action taken by the

hospitals in providing medical

assistance to victims

75 - 140

(6) Ref.(4) PART-I: Action Plan for

effective police action

PART-II: Medical

Recommendations

141 – 175

176 - 203

(7) -- Response to Questionnaire

issued by the Commission to

204 - 229

iii  

the Officers, NGOs., Social

Organizations and prominent

persons.

Consideration of previous

reports

(8) -- Consideration of Constitutional

Aspects

230 – 272

(9) -- Reply on behalf of the

Government

273 - 281

(10) -- Conclusions 282 - 298

(11) -- Recommendations 299 - 381

iv  

INDEX OF ANNEXURES

SR.NO. ANNEXURE PARTICULARS PAGE

NOS.

(1) “A” Copy of the Bill for amending the

Bombay Prohibition Act

382

(2) “B” Copy of the Act - Bill assented by

the Governor of Gujarat with the

Notification i.e. Amending Act

390

(3) “C” Views of Mr. H.C. Dholakia, former

Dean of Law Faculty, Vadodara

395

(4) “D” Note of Shri S.S. Khandwawala,

IPS, Ex-DGP of Gujarat State 398

(5) “E”

(COLLY)

Note regarding the implementation

and recommendation of the report

submitted by the State

Government of Gujarat and the

report submitted by the

Government dated 23rd September,

2011 and 15th November, 2011

402

(6) “F” (COLLY) Copies of four Circulars dated

28.12.1988, 12.09.2003,

15.09.2005 and 09.02.2010 issued

by Home Department. (Re.

Prohibition Policy)

440

(7) “G” Minutes of the meeting of the visit

to Navsari (Oct. 2011)

464

v  

(8) “H” Excerpts of the visit at Bardoli and

discussion with Mr. Prashant Joshi,

Head of MBT VT University (Oct.

2011)

467

(9) “I” Paper submitted by Ahmedabad

Women Action Group (AWAG) and

report on People Hearing and

Case Studies

470

Terminology……………………………………………………. 507 - 516

vi  

REPORT OF HOOCH TRAGEDY COMMISSION

CONTENTS  

DETAILED INDEX

Chapters Particulars Page

1. Synopsis of the tragedy…………………………...…...…1-5

2. Copy of the Notification……………………….….....…..6-14

3. Reference No. 1……………………………….…...…15-49

Glossary of Causes and circumstances of

the incidence in which number of deaths

have occurred from 5th July to 3rd August,

2009, due to the consumption of illicit

liquor.

vii  

A. Causes and circumstances of this gruesome tragedy.

B. Sources of the material and its acquisition.

C. Jurisdiction of police stations and hospitals where victims were admitted and charts showing admission pattern in various hospitals and the death of patients with reasons for it.

D. Seriously affected areas of the tragedy.

E. Alcohols and Liquors.

F. Ethanol Metabolism.

G. Methanol Metabolism.

H. Signs and symptoms, diagnosis and treatment management.

I. Effects of illicit liquors and reasons for people to for it.

4. Reference No. 2. …………………….………………..50-74

Report of Intra departmental Action taken

by the police.

A. E

xtract of the report from the Police

Commissioner, Ahmedabad City.

B. Details of Notified bootleggers of

the City and the details of police

viii  

station with records of more than 15

bootleggers.

C. Details of cases registered at

Kagdapith and Odhav Police

stations in connection with the

tragedy.

D. Details of actions taken against the

bootleggers during 2008 - 2009

before the tragedy by Ahmedabad

Police.

E. Details of Intensive action taken

by the Police from 07.07.09 to

20.07.09.

F. Details of action taken against the

errant police officers/ personnel for

their negligence and dereliction of

duty.

5. Reference No. 3. ……………………….……………..75-140

Details of action taken by the hospitals in

providing medical assistance to victims

A. Inferences on commission’s visit to

various hospitals.

B. Cross examinations of doctors and

their views and suggestions.

6. Reference No. 4. ……………………………….…...141-203

ix  

Details of adequacy of measures for the

effective implementation of prohibition laws

by the police and recommendations

A. Action Plan for effective

police action.

B. Action plan for effective medical

intervention including role and

function of medical infrastructures

in the hospitals of public and private

domain.

7. Public opinion and response to questionnaires..…204-229

8. Constitution aspect in terms of Prohibition

Policy. Article 47 and relevant

Supreme Court Judgments………………….……..230-272

9. Reply on behalf of the Government……..…......... 273-281

10. Conclusions of the commission and

observations made by the Supreme Court

in respect of spurious liquor and liquor in

General………………………………………….……282-298

11. Recommendations of the commission………......…299-381

x  

“If I was appointed as a director even for one hour for all India,

the first thing I would do is to close down all the iquor shops

without compensation.”

–MAHATMA GANDHI.

1  

 

Chapter-1

SYNOPSIS OF THE TRAGEDY

1.1 Before the misty monsoon evening clouds set on the city of

Ahmedabad, afternoon clouds of 7th July 2009 descended

with the most fateful day in the history of Gujarat particularly

in the city of Ahmedabad, as the worst ever hooch tragedy

occurred on that day. As many as 148 people lost their lives

and few hundreds have lost their vision or suffered with

morbidity. It all happened on 7th July 2009 as the people

belonged to few areas of Ahmedabad particularly

downtrodden people and labour class consumed liquor that

was manufactured illegally which was later found to be the

illicit liquor highly toxic for the human beings. It all came to

light after a large number of people who were affected

started getting admitted in various hospitals in the city out of

panic. In this chapter, the circumstances and the cause of

death would be dealt in detail in a chronological order.

1.2 The affected people had consumed country liquor as routine

from a vendor at Kantrodia vas, an alcohol prone pocket

located in Geetamandir area. They did not know that the

alcohol that they had consumed is adulterated with

2  

methanol. Methanol is a clear aromatic liquid which is toxic in

nature. Even a smaller quantity, if ingested has the capability

of producing detrimental effect on body physiology. People

who had consumed such adulterated liquor started

developing toxic symptoms during that night. The affected

people and their relatives had presumed that it as an

overdose of the liquor or some concomitant illness. They had

also presumed that the symptoms would subside on its own

by next morning and had resorted to household remedies but

with a passage of time, the toxic metabolites of adulterated

alcohol tightened the grip in the form of severe vomiting, pain

in abdomen, breathlessness and even unconsciousness.

These alarming physical symptoms due to the ill effects of

spurious liquor compelled the victims to seek medical

treatment in various public and private hospitals. The

patients had presented themselves as a case of vomiting,

pain in abdomen and had suppressed to mention the history

of ingestion of the illicit liquor. The attending physicians

initially could not understand that they were tackling with the

biggest tragedy in the next few hours. This has happened

mainly because of the non-availability of reliable information

either from the patients or from their relatives. They did not

3  

divulge any correct reason behind the symptoms. At the

same time, the treating doctors also could not get any clues

from any sources. As the number of victims increased very

rapidly and also in a massive number, there was a panic

among them. The police, social workers and doctors

exchanged the information about the affected people from

various localities. This rang a panic alarm to the hospitals

and the law enforcement agencies. The number of affected

people was not much on Monday morning i.e. on 6/7/2009

but later on with the passage of time more and more number

of victims who were abstaining from taking any treatment

either presented themselves or brought by their relatives as

there was a fear in them about the impending death, if they

did not take any treatment.

1.3 Nearly, 394 people were admitted in various hospitals of

Ahmedabad from 7th to 9th of July 2009. Altogether,148

persons have lost their lives and approximately 249

persons were adversely affected. Some could survive

because of the timely intervention by the officials of the

Forensic science laboratory and Doctors. The Professional

skill of both doctors as well as Forensic sciences department

4  

had really played a pivotal role to save many lives. All

possible and required treatment and antidotes were given to

patients who were admitted with the history/signs of

consumption of alcohol, later found to be illicit liquor /hooch.

1.4 Victims were mostly from labour class and majority of them

were living below poverty line and were daily wagers. In

hospitals, women were crying that was so deafening. Some

persons were running for medical help while others were

praying for the welfare of their kith and kin, while some

others were preparing for the victims’ last rites. Thus,

throughout these places, heart touching scenes was

witnessed by the Police, Media persons, Doctors’ team,

Nurses team and others in the city. Unfortunately, it has

happened in the State where a strict prohibition policy is in

force. Thus, the whole City was under the devil grip of this

panic and the state had suffered a piteous pitfall.

1.5 Not only this Commission but probably every citizen of

Ahmedabad would have read these reports in the

newspapers and on seeing them, it was highly depressing to

5  

all of us. It would not be possible for any government and

the related machinery and of course the responsible citizens

of the state to keep quiet.

1.6 How can the Public at large and the State Government in

particular be a mute spectator of this tragedy? In this

backdrop, the Government of Gujarat woke up very prudently

and on 8th July, 2009, issued a Notification for setting up a

(legal cum technical) Commission to inquire into this tragic

incident. However, at this juncture it is desirable to produce a

copy of the notification verbatim here.

“We need Power, only when we want to do something harmful.

Otherwise, Love & Compassion are enough to get everything

done.”

6  

Chapter-2

2.1 Copy of the Notification

No. GK/11/2009/CO1/102009/A.

“WHEREAS many people have died and many had to undergo medical treatment in different hospital in Ahmedabad due to consumption of illegally manufactured fluid suspected to be illicit liquor between 5th July, 2009 to 8th July, 2009:

AND WHEREAS in view of the death of many people and illness of many others on a large scale along with the agitated response of society within local limits of Ahmedabad, the matter has assumed significance as a matter of public interest touching broader spectrum of social life across the State of Gujarat:

AND WHEREAS the Government of Gujarat is of the opinion that it is important to thoroughly inquire into the cause and circumstances of the incident and to establish a mechanism to ensure that such incidents do not recur:

AND WHEREAS the Government of Gujarat is also of the opinion that the matter has assumed public importance:

7  

AND WHEREAS the Government of Gujarat is further of the opinion that an enquiry should be held into this matter of definite public importance: NOW THEREFORE, in exercise of the powers conferred by section 3 of the Commissions of inquiry Act, 1952(60 of 1952 ), the Government of Gujarat hereby appoints a Commission of inquiry consisting of Hon. Justice K.M.Mehta, former judge of the High Court Of Gujarat as the Chairman of the Commission and Shri G.C. Raiger, IPS, Retired Director General of Police, Gujarat State, Dr. M.S.Dahiya, Deputy Director, Directorate of Forensic Science and Dr. Kirit Mithawala, Officer on Special Duty for Cancer Screening Program, M.P. Shah Cancer Hospital, Ahmedabad as Members to inquire into and report on and in respect of the aforesaid matter.

The Commission shall inquire and report into:

(i) the cause and circumstances of the incident in which number of deaths have occurred and many more people had to seek medical assistance in different hospitals in Ahmedabad between 5th July, 2009 to 30th August, 2009 due to the consumption of illegally manufactured fluid suspected to be illicit liquor:

(ii) Adequacy of action taken by the police to implement

prohibition laws and omission, commission and negligence. If any:

8  

(iii) the action taken by the hospitals in providing medical assistance to the people taken to such hospitals including hospitalization, adequacy of treatment response, infrastructure and treatment facility and availability of antidotes and shortcomings, if any :

(iv) the adequacy of measures for effective implementation

of prohibition laws by the police and to recommend.

(a) Action Plan for effective police action:

(b) Action plan for effective medical intervention including role and function of medical infrastructures in public as well as private domain.

The Commission shall complete its inquiry and submit its report to the State Government on or before 30th November, 2009.

WHEREAS the Government of Gujarat is also of the opinion that having regard to the nature of the inquiry to be made by the Commission and other circumstances of the case, the provision of sub-section (2) to (5) of section 5 of the Commissions of inquiry Act, 1952 (60 of 1952) should be made applicable to the commission hereby appointed, in exercise of the powers conferred by sub-section (1) of the said section 5, the Government of Gujarat hereby directs that all the provisions of the

9  

said sub-section (2) to (5) shall apply to the said Commission.“

Sd. (K.M.LALA)

Deputy Secretary to Government

2.1.A Originally, the Notification was issued on 8th July, 2009. The

period was mentioned as 5th July 2009 to 8th July, 2009, but

subsequently the Government has extended the date from

5th July, 2009 to 30th August, 2009 considering the severity of

the tragedy.

2.2 Initially, this Commission was required to submit its report in

terms with the notification No. GK/11/2009/CO1/102009/A

dated 8th July 2009 on or before 30th November 2009 to the

Government of Gujarat, but since the timing was too short to

submit its full report to the Government covering all aspects,

the Commission has sought for further time to submit its

report on or before 31st January, 2012. This Commission

has prepared its report before the latest extended date as

under.

10  

2.3 However, this Commission takes a special note in respect of

this notification issued by the Government of Gujarat that

Unlike the other one man or two men commission, the

constitution of this commission shows the vision, foresight

and determination of the State Government, as the State

Government appointed the Chairman and Members from

different fields as to reach to the bottom or heart of the

tragedy. The Chairman is from the higher Judiciary side (a

retired Judge of High Court of Gujarat) which is usually seen

in formation of such type of commission but the significant

feature of this Commission is that the remaining three

members of the commission are from the Police, Forensic

science and medical field respectively. All these three

members are well known experts in their respective fields. It

seems that the same has been done with a view to

strengthen the Commission and its findings. Thus, it

appears that the Government is committed to curb this

repeated tragedy at least once after every ten years. Also at

the same time it seems that the State Government is

desirous to drive out this social evil. The consumption of

Methyl Alcohol is like an infection which has gone deep into

the lives of some people particularly the labour class and

11  

those living below the poverty line. Therefore, unless this

infection is first eradicated, we would not be able to give

healthy future generation. It is a legal cum technical

Commission.

2.4 Not only the State Government constituted high power

Commission, but has also suggested very wide ranging

reference to the Commission viz., adequacy of action taken

by the police to implement prohibition laws and omission,

commission and negligence, if any and to suggest police

reforms; similarly the Government also made wide ranging

reference regarding the action taken by the hospitals in

providing medical assistance to the people taken to such

hospitals including hospitalization, adequacy of treatment

response, infrastructure and treatment facility and availability

of antidotes and shortcomings, if any and action plan for

effective intervention including role and function of medical

infrastructures in public as well as in the private domain. The

Government has also stated that the Commission should

also suggest establishing mechanism to ensure that such

incident does not recur. Thus the intention of the Legislature

12  

of the Government is very laudable and therefore, the

Commission has to work very hard, in this behalf.

2.5 However this Commission felt that unless we know the

antecedents of such cases, it would not be proper to deal

with reference given under the notification. Furthermore the

genuine endeavor on the part of this Commission is to see

that it is not the present but the future that worries us as one

cannot protect the future without the knowledge of the past.

Definitely, the time consumed by this Commission has

traveled beyond the initial time bound schedule not only

because of the lengthy work but the issue was highly

sensitive and delicate. The Commission is scared about the

future because the seeds of tomorrow lie in what we do

today and always the future is guided by the past

experiences. Therefore, in this back drop it is very essential

to know the antecedents of similar type of tragedy, so that

the Government would be able to provide better tomorrow to

its citizens. The Commission has studied the previous

reports of Honorable Mr. Chief Justice Miabhoy (Retd) and

Honorable Mr. Justice A. A. Dave (Retd) and others and has

13  

made reference to those reports and recommendations in

Chapter-7, in response to questionnaire in this behalf.

2.6 Now, after the preliminary discussion, this commission tables

the report in respect of the hooch tragedy in question

occurred in July 2009 in accordance with the reference

made by the notification as under.

2.7 Further the Government of Gujarat was pleased to appoint

senior Advocate Mr. R.C. Kodekar and Shri Nareshbhai

Kishorilal Dahiya. (Junior Advocate) to assist this

commission but later on by resolution No. KN/102009/UO-

371/H dated 4th May 2010, the appointment of senior

Advocate Mr. R.C. Kodekar and Shri Nareshbhai Kishorilal

Dahiya. (Junior Advocate) were replaced and appointment of

Senior Advocate,Shri Kiran Jani was made.

2.8 Similarly the appointment of advocate Shri Chetan Shah has

been made to plead the case before this commission on

14  

behalf of the State Government through the resolution no.

KAN/102009/UO-37/H dated 4th February, 2010.

“Effort is never wasted even when it leads to disappointing results, because it always makes us stronger, more capable & more experienced”

15  

Chapter- 3

REFERENCE NO. 1

CAUSES AND CIRCUMSTANCES OF THE TRAGEDY

3.1 “The cause and circumstances of the incident in which

number of deaths have occurred and so many people had to

seek medical assistance in different hospitals at Ahmedabad

between 5th July, 2009 to 30th August, 2009 due to the

consumption of illegally manufactured liquor which is

suspected to be illicit "

3.2 This Commission, while dealing with the cause and

circumstances of this gruesome tragedy, has dealt with

various aspects like:

(A) Cause of this tragedy;

(B) Sources of the material and its acquisition;

(C) Jurisdiction of police stations and hospitals where

victims were admitted and a chart showing admission

pattern in various hospitals that how many patients

died and reasons for it.

16  

The occurrence of tragedy is given below in

chronological order.

3(A) Causes and circumstances of this gruesome tragedy.

Now coming to this episode of hooch tragedy, the victims

normally having a habit of consuming country liquor

consumed the illicit liquor as usual from different dens in

Ahmedabad city on 5th evening (i.e. 5/7/2009). Many of them

suffered from methanol poisoning after consumption of liquor

adulterated with methyl alcohol which was supplied by one

supplier of Vanthvali village of Mahemdabad Taluka. The

affected victims started seeking treatment at various

hospitals. These include civil Hospital, Municipal Corporation

run hospitals, charitable hospitals and private hospitals of

Ahmedabad. The number of patients increased by the

evening of 6th July (i.e. 6/7/2009), when active interventions

were made by the state Government and Ahmedabad

municipal health authorities after the diagnosis of Methyl

alcohol poisoning. The State Government constituted the

Commission for further inquiry of hooch tragedy on 8/7/2009.

The members of the commission immediately took charge

17  

and started functioning by visiting affected victims who were

undergoing treatment in various hospitals. On 9th July 2009,

members of the Commission visited Sheth L.G Hospital, Smt

S.C.L Hospital and Sheth V.S. General Hospital.

3(A).1 Further, on 10/7/2009 as well as on 16/7/2009 the Chairman

with all members of the Commission visited above referred

hospitals once again, including Civil Hospital to apprise

themselves of the treatment modalities and to know the

hospital infrastructure, role and utility of skilled manpower

deployed by various hospitals. During all these occasions,

the Chairman and members of Commission apprised

themselves with every minute detail of treatment given and

also in respect of men and machineries deployed by

hospitals for the betterment of the victims of hooch tragedy.

The members interacted with hospital authorities and subject

specialists for the appropriate remedies for the complications

like blindness and need of haemodialysis due to toxic effects

of formaldehyde. Increased methanol content in blood with

alarming symptoms and signs demonstrated the need of

haemodialysis. They discussed to formulate a strategy to

refer the serious cases for haemodialysis which played an

18  

important role to decrease the mortality and morbidity due to

methanol poisoning. Thus, the cause of tragedy was

established to be of Methyl Alcohol Poisoning.

3(A).2 The tragedy claimed 148 human lives. The cause of death

was established to be the consumption of illegally

manufactured liquor commonly termed as ‘Laththa’, during

the first-hand or primary police and forensic investigations.

3(A).3 The patients seeking treatment had the symptoms of

poisoning. The patients, who were admitted in hospitals, had

the typical symptoms and signs of ‘Methyl Alcohol

Poisoning’. Methanol when consumed even in smaller

quantities is a dreaded poison for a human body and its

toxic metabolite, Formaldehyde, is responsible for death

of the patients. Formaldehyde when fixed in human cells

causes irreversible damage to the nervous tissue.

3(A).4 The common symptoms of consumption of illegally

manufactured illicit alcohol are burning in epigastria,

19  

profound vomiting, abdominal cramps, breathlessness,

unconsciousness, convulsions and diminished vision.

3(A).5 The patients exhibited clinical signs of shallow and speedy

respiration, profound hypotension and those of metabolic

acidosis including papilledema of Fundus of the eye. The

History, Symptoms and signs of the admitted patients were

typically of Methanol poisoning.

3(A).6 Additionally, the cases were taken in the category of Medico

Legal on hospital records. So, upon admission, the blood

samples of the patients were collected and were sent for

chemical analysis at Gandhinagar Forensic Science

Laboratory, which revealed the presence of Methanol in

those blood samples.

3(A).7 The postmortem examinations of the deceased persons

were carried out mainly at Civil Hospital and Sheth Vadilal

Sarabhai Hospital. The internal examinations of different

body organs were conclusive of Methanol Poisoning. The

20  

viscera were sent for chemical examination at Toxicology

department of Forensic Science Laboratory. The reports of

forensic laboratory confirmed that the deaths were due to

Methanol Poisoning.

3(A).8 The Forensic and medical experts were examined during the

sessions of hearing by the commission and the fact that

people died due to the consumption of illegally manufactured

alcohol, which was adulterated with Methyl Alcohol, was

established.

Thus, the cause of the tragedy was confirmed

through postmortem and forensic report.

3(B) Sources of the material and its acquisition

3(B).1 Efforts are made to know whether alcohol is easily available

in Gujarat, It is also to know whether the available alcohol is

locally made or being imported from neighbouring wet states.

The mode of access by consumer to procure liquor is

studied.

21  

3(B).2 The Commission has tried to understand the most common

source of supply and the raw materials used for the

manufacture of illicit liquor. A rampant use of methyl alcohol

and its availability to the bootleggers has been studied in

detail.

3(C) Details of the jurisdiction of police stations and

hospitals where victims were admitted and a chart

showing admission pattern in various hospitals ,the

number of deaths of the patients and the reasons for it

Table given below shows the above details

The police station wise break up of victims who suffered of

methyl alcohol poisoning is as under:

Sr.no. Name of police station

No. of Persons took treatment

No. of Persons died

1 Odhav 61 33

2 Bapunagar 43 27

3 ShaherKotda 15 21

4 Kagdapith 33 17

5 Amraiwadi 20 18

6 Gomatipur 19 8

7 Naroda 2 8

22  

8 Rakhial 8 6

9 Khadia 0 3

10 Meghaninagar 6 2

11 Ramol 10 1

12 Gaikwad Haveli 0 1

13 Sardarnagar 10 0

14 Madhupura 5 0

15 Isanpur 2 0

16 Karanj 1 0

17 Kalupur 1 2

18 Shahibag 2 0

19 GIDC Vatva 0 1

Total 238 148

The information as per police sources regarding the number of

victims who took treatment at various hospitals is as under:

Sr. No.

Name of Hospital No. of patients

No of Patients Expired

1 Smt. Shardaben Hospital, Saraspur

92 57

2 Civil Hospital, Asarva 55 19

3 “Sheth L.G. Hospital, Maninagar 49 17

4 Sheth V.S. Hospital, Ellisbridge 32 21

5 Bapunagar General Hospital, Hardasnagar

4 Nil

23  

6 Dhanvatri Hospital 2 3

7 Kakadia Hospital, Bapunagar 2 Nil

8 Rudraksha Hospital, Naroda 2 Nil

The details of hospitals where affected patients were treated with

dialysis as a part of treatment are as under:

No. Name of Hospital No. of patients

No of Patients Expired

1 Kidney Hospital, Asarva 95 3

2 V.S. Hospital 35 Nil

3 Shalby Hospital 4 Nil

4 Medisurge Hospital 4 1

The reasons for the death of the number of hooch victims are more

due to the following reasons:

[1] The victims resorted to treatment with considerable

time lapse. They had experimented with homemade

remedies in the initial stages. Patients and relatives

mostly sought for medical treatment when their

condition got worsened. In short, the treatment seeking

behavior of patient and relatives account for increase in

the mortality and morbidity rate.

24  

[2] The patients and relatives refrained from admitting the

history of liquor ingestion due to the fear of impending

police action.

[3] The treating physicians, either private or government,

did not recognize the hooch episode in initial phase

due to poor interdepartmental communication system.

[4] The antidote, ethyl alcohol plays a vital role in reducing

the morbidity and mortality during hooch tragedy. The

initial delay in providing ethyl alcohol led to more

casualties. The treatment with ethyl alcohol requires

certain administrative formalities. The hospitals in

private domain were not properly provided with the

antidote, ethyl alcohol.

[5] Timely haemodialysis is life saving, if done with the

onset of metabolic acidosis. The treatment protocols

were not known to all concerned doctors for subjecting

a victim for haemodialysis which has led to more

deaths.

3(D) Seriously affected areas of this tragedy

Areas those were worst affected were predominantly

belonging to the labour class people like Odhav, Bapunagar,

Rakhial, Kagdapith and other areas. These are the areas

25  

wherein mostly daily wagers and labour class people are

dwelling and are consuming such spurious alcohol as it is

cheap, easily available and affordable to their pocket either

for their entertainment or with a view to forget their domestic

worries. Lack of education unawareness about the evil

effects of lattha, and scarce mode of entertainments are the

main reasons. Today, it seems that no one is scared about

the present law and the quantum of punishment with its

consequences, as the present law so far as prohibition is

concerned, is very liberal, lenient and the quantum of

punishment is very minor. Further the ratio of conviction has

been reported to be very low i.e. approximately 8.3%. (To

stop this, the Prohibition Law must have denting effect).

3(E).1 Alcohols and Liquors

Before going for the detailed report, it is more pertinent to

know the facts about alcohol and its ill effects and also how

the commercial ethyl and methyl alcohols find way into

bootlegging and spurious illicit drinks.

26  

3(E).2 Alcohol, the most noxious and the so called beverage has a

long root of its use by the human society. The consumption

of such drinks in one or the other forms has been found in

the history since the time immemorial. With the emergence

of civilization, alcohols have found their presence felt in

many forms; even they are being used with a religious fervor

among the contemporary societies of various religions. They

are called with many nomenclatures according to the

situations and status of the society that uses the alcoholic

beverages such as hard drinks, liquors, arracks, chara and

so on to mention a few. With a gradual evolution,

consumption of alcohol has become a part of life for many

people, because of its physical, chemical and biological

properties and therefore they have been abused.

3(E).3 By its physical nature, they are watery [looks like water as

colourless in its pure form] and chemically they are volatile.

They have a characteristic fruity odour with a burning taste

and easily miscible with water and many other solvents.

Biologically and more precisely, medically they are the

depressants of central nervous system. They are

euphemistically called as inebriants i.e. they are highly

27  

intoxicating substances. They impart a feeling of excitement,

relaxation and apparent mental well-being to the consumers.

This is the property that makes people to go for its

consumption.

3(E).4 Out of various alcohols in common use, ethyl and methyl

alcohols are available in drinks, methyl alcohol is found only

in cheep adulterated liquors. Alcoholic beverages vary in

their ethanol content and the foodstuffs from which they are

prepared. They can be classified as fermented beverages,

which are prepared by the action of yeast on sugary food

stuffs; and distilled beverages, prepared by concentrating the

ethanol in fermented beverages by distillation. This is

obtained by the enzymatic fermentation of carbohydrates,

fruits etc, yeast enzyme zymase changes the simple sugars

into ethanol and carbon-dioxide. The final fermented mass

contains about 10% alcohol which is purified and

concentrated by the simple distillation. All beverage alcohols

and majority of industrial ethanol are made by this process.

Now a days ethanol for industrial use is also produced from

by- products of petroleum refining 95% mixture of alcohol

and water is azeotropic, i.e., it boils at a constant

28  

temperature without change in composition and alcohol of

greater purity cannot be obtained by fractional distillation.

The strength of distilled alcohol can be obtained

approximately 95% by volume. The absolute alcohol of

99.95% purity may be obtained by azeotropic distillation or

the use of dehydrants. Ethanol has widespread use as

essential industrial solvent of substances intended for human

contact or consumption including medicines. Since long time

it has been used as a fuel for heat and light and also as a

fuel for internal combustion engines.

3(E).5 The concentration of beverages is usually measured in terms

of the volume fraction of ethanol expressed either as

percentage or alcoholic proof units. The approximate

concentration of ethyl alcohol of many social beverages such

as wines, beers, whiskies, brandies etc. being as follows:

Beer : 4-6 %

Malt liquor : 5-8 %

Wines : 10-15 %

Champagne : 8-14 %

29  

Sherry and port wines : 15-20 %

Grain alcohol : 95-97.5 %

Hard alcohols like distilled spirit, vodka, rum, gin, brandy,

whiskey, and liquors etc : 40-95 %

3(E).6 Beer is prepared from cereal grains or other starchy

foodstuffs, meads from honey, and wines and ciders from

fruit juices. Distilled beverages are prepared by distilling

fermented beverages e.g. whiskey, distilled from fermented

cereal grains; brandies, distilled from fermented fruit juices,

and rum distilled from fermented molasses. Vodka and

similar neutral grain spirits can be distilled from any

fermented material e.g. grains or potatoes. Many other spirits

and liquors are made by adding flavors from fruits, herbs,

and spices into distilled spirits e.g. gin is prepared by adding

juniper berries into neutral grain alcohol. In some beverages

like apple jack ethanol is concentrated by freeze distillation,

by which water is frozen out of fermented apple cider,

leaving a ethanol rich liquid. Eisbier is also freeze distilled

from beer. Fortified wines are prepared by adding brandy or

some other distilled spirit to partially fermented wine. This

30  

kills the yeast and conserves some of the sugar in grape

juice; such beverages are not only ethanol rich, but are

sweeter than other wines.

3(E).7 Proof spirit: It is a term used to define alcohol (57.10 %)

which when poured on to gun powder allowed it to burn since

the remaining water (42.90%) did not prevent it. Hence, proof

spirit is a mixture having 57.10% by volume of absolute

alcohol. Spirits are described in terms of so many degrees

over or under proof (o.p. or u.p.) according to the quantity of

distilled water which must be added to, or deducted from 100

volumes of the sample in order to produce spirit of proof

strength. Hence, on the labels of alcoholic beverages, the

strength is given as number of degrees, proof spirit being

taken as 100o.

3(E).8 Absolute alcohol: Ethyl alcohol containing not more than

1% water i.e. 99% pure ethyl alcohol.

31  

3(E).9 Rectified spirit: It contains 90% by volume of ethyl alcohol

and 10 % water.

3(E).10 Denatured alcohol: Denatured alcohol means; alcohol

subjected to a process prescribed for the purpose of

rendering it entirely unfit for human consumption as

beverage, while allowing the use of the alcohol in various

industries. The most commonly used denaturants, either

alone or in combination are; benzene, methanol, ethyl ether,

acetone, acetaldehyde, toluene, cyclohexane, brucine

(bitterant), chloral hydrate, diethyl phthalate, camphor, amyl

alcohol, isopropanol, cadmium iodide, pyridine bases,

terpinol.

3(E).11 Mineral Denatured spirit: It is a mixture of 99% spirit and

two denaturants viz 0.5% v/v of light caoutchoucine and

0.5% v/v crude pyridine base of mineral origin.

3(E).12 Industrial denatured spirit: It is a mixture of 95% spirit and

5% v/v of methanol.

32  

3(E).13 Spirituous Medicinal and Toilet Preparations: Any

medicinal or toilet preparation containing alcohol or any

antiseptic preparation or solution containing alcohol or any

flavoring extract, essence or syrup containing alcohol, which

is determined to be fit for use as intoxicating liquor.

3(E).14 Spirituous medicinal preparation means any medical

preparation in liquid form, containing alcohol which is fit for

use as intoxicating liquor. It is a mixture or compound of any

wine with medicinal substances, whether fortified with spirit

or not, and includes medicated bitter.

3(E).15 Country made liquor:

The liquors prepared by bootleggers locally are known by

different names in different regions. These liquors are

especially distilled from the fermented mass of coco-palm,

rice and molasses or jaggery, and mahuva flowers etc. Its

strength is the same as that of whisky but being not matured;

contain high percentage of higher alcohols, acids and bases.

It is therefore more intoxicating than matured spirits.

Sometimes country made liquors are also fortified with

33  

industrial alcohols to increase the alcohol concentration or to

meet the demand. Hence, there is always an inherent risk of

methyl alcohol poisoning tragedies with the consumption of

such country made liquor.

3(E).16 Illicit liquors:

Sometimes bootleggers prepare liquor from varnish or

Mineral Denatured spirit or French polish. Water is added to

these, shellac, resins and / or caoutchoucine form a white or

yellow emulsion. This emulsion is precipitated by adding

alum and is then filtered out, suitably diluted, and sold at

cheaper rates. If the procured varnish or French polish or

mineral denatured spirit is prepared out of methyl alcohol, it

will cause methyl alcohol poisoning to the consumer.

3(E).17 Similarly, bootleggers tend to rely on rectified spirit to

prepare spurious Indian Made Foreign Liquor (illicitly

prepared from spirits by mixing various kinds of essence and

coloring matters) or to increase the quantity of country made

liquor. Since distillation takes considerable time, a sudden

increase in demand can be met by adding rectified spirit to

34  

the available stock. During rainy season, greater reliance of

rectified spirit is inevitable if supply is to be maintained when

distillation in the open no longer remains feasible. Similarly, a

shortage of Indian made foreign liquor from regular

breweries may prompt the bootlegger to prepare spurious

Indian made foreign liquor from rectified spirit. The low cost

of duplicate Indian made foreign liquor made from rectified

spirit may also prompt bootleggers. At any stage, any

accidental mixing of methyl alcohol or methylated spirit can

be the cause of “Hooch tragedy”.

3(F) Ethanol Metabolism

When taken in through the mouth, alcohol flows through the

esophagus and into the stomach and intestine, where it is

absorbed directly into the bloodstream. No digestion is

required; alcohol passes right through the walls of stomach

and intestine into the bloodstream. From there it circulates to

every part of the body that contains water, which is just about

everywhere. The more rapidly the alcohol is absorbed, the

higher the level in the bloodstream and the greater its

effects.

35  

3(F).1 In the human body, ethanol is first oxidized to acetaldehyde,

and then to acetic acid. The first step is catalysed by the

enzyme alcohol dehydrogenase, and the second by

acetaldehyde dehydrogenase. Some individuals have less

effective forms of one or both of these enzymes and can

experience more severe symptoms from ethanol

consumption than others. Conversely, those who have

acquired ethanol tolerance have a greater quantity of these

enzymes, and metabolize ethanol more rapidly. The

breakdown, or oxidation, of ethanol occurs in the liver.

Alcohol dehydrogenase strips electrons from ethanol to form

acetaldehyde. Another enzyme, aldehyde dehydrogenase,

converts the acetaldehyde, in the presence of oxygen, to

acetic acid, the main component in vinegar.

3(F).2 When ethanol is oxidized to acetic acid, two protons and two

electrons are also produced. The acetic acid can be used to

form fatty acids or can be further broken down into carbon

dioxide and water.

36  

3(F).3 The initial product of ethanol metabolism, acetaldehyde, is

more toxic than ethanol itself. The body can quickly detoxify

some acetaldehyde by reaction with glutathione and similar

thiol-containing biomolecules. When acetaldehyde is

produced beyond the capacity of the body's glutathione

supply to detoxify it, it accumulates in the bloodstream until

further oxidized to acetic acid. The headache, nausea, and

malaise associated with an alcohol hangover stem from a

combination of dehydration and acetaldehyde poisoning;

many health conditions associated with chronic ethanol

abuse, including liver cirrhosis, alcoholism, and some forms

of cancer, have been linked to acetaldehyde. Some

medications, including paracetamol (acetametaphin), as well

as exposure to organochlorides, can deplete the body's

glutathione supply, enhancing both the acute and long-term

risks of even moderate ethanol consumption. Ethanol can

intensify the sedation caused by other central nervous

system depressant drugs such as barbiturates,

benzodiazepines, opioids, and phenothiazines. Some

individuals have less-effective forms of one or both of the

metabolizing enzymes and can experience more-severe

symptoms from ethanol consumption than others.

37  

Conversely, those who have acquired alcohol tolerance have

a greater quantity of these enzymes, and metabolize ethanol

more rapidly.

3(G).1 Methanol Metabolism

In the human physiological system, methanol is metabolized

to highly toxic compounds that are responsible for the

acidosis and blindness characteristic of methanol poisoning.

The initial step in the metabolism of methanol involves the

enzyme alcohol dehydrogenase (ADH). First, methanol is

slowly oxidized by ADH to yield formaldehyde. Next,

formaldehyde is oxidized by formaldehyde dehydrogenase to

yield formic acid (or formate, depending on the pH). This

oxidation occurs rapidly so that little formaldehyde

accumulates in the serum. Finally, formic acid is metabolized

to carbon dioxide and water, which are excreted by the

kidneys and lungs.

3(G).2 The accumulation of formic acid is responsible for the

presence of metabolic acidosis. Formic acid also inhibits

cellular respiration leading to lactic acidosis. The ocular

38  

injury caused by methanol may be due to retinal injury, which

results from intra-retinal metabolism of methanol and the

accumulation of formic acid. Alternatively, it may be caused

by the inhibition of normal metabolism in optic nerve cells.

3(G).3 Methanol poisoning is extremely serious and can result in

death within a few hours if not immediately treated. As little

as a couple of tablespoons (about 14-28 ml) of methanol can

cause methanol poisoning in children. In adults, about 60 to

240 ml is lethal dose, however, the minimum fatal dose

reported is 30 ml likewise permanent blindness have been

reported with as little as 6-10 ml methanol. Death may occur

within 24 to 36 hours or may be delayed for 3-4 days.

3(H).1 Its symptoms, diagnosis and treatment management

Initial symptoms of methanol poisoning may appear as soon

as 12 hours post-ingestion, but usually develop 24 hours

after ingestion. These may resemble ethanol intoxication and

consist of drowsiness, confusion, and ataxia, as well as

weakness, headache, nausea, vomiting, and abdominal pain.

Collectively, these symptoms may mimic an alcohol

39  

hangover and are due to mild intoxication, caused by

methanol itself.

3(H).2 As methanol metabolism proceeds, a severe anion gap

metabolic acidosis will develop. Severe metabolic acidosis in

conjunction with visual effects is the hallmark of methanol

poisoning. Patients usually describe blurred or misty vision,

double vision, or changes in color perception. There may be

constricted visual field and, occasionally, total loss of vision.

Characteristic visual dysfunctions include pupillary dilation

and loss of pupillary reflex.

3(H).3 Further signs and symptoms may be shallow respiration,

cyanosis, tachypnea, coma, seizures, electrolyte

disturbances, and various hemodynamic changes including

profound hypotension and cardiac arrest. There may be mild

to profound loss of memory, confusion, and agitation, which

may progress to stupor and coma as the severity of the

acidosis increases. In severe cases, death is possible.

Surviving patients can be left with permanent blindness or

with other neurological deficits.

40  

3(H).4 Diagnosis

Methanol poisonings can be relatively difficult to diagnose

when a specific history of ingestion is not available.

Diagnosis requires both clinical and laboratory data;

however, there may be an initial lack of clinical data for

patients who are unable, or unwilling, to supply a history of

ingestion. In such situations, obtaining a patient's history

from family or friends can be valuable. In addition, it is often

difficult for a clinician to distinguish between poisoning by

methanol or by ethylene glycol.

3(H).5 The most direct means of diagnosing methanol poisoning is

through the measurement of serum methanol concentration.

The decision to perform a serum methanol determination

may be based on patient disclosure of methanol ingestion or

the presence of a methanol-containing product at the scene

of ingestion.

41  

3(H).6 Treatment/Management

As with ethylene glycol, the three primary goals of therapy

include treatment of metabolic acidosis, inhibition of the

methanol metabolism and enhanced elimination of the

unmetabolized compound and existing toxic metabolites.

Gastric decontamination is unlikely to be beneficial because

methanol is rapidly and completely absorbed from the gut. It

is doubtful activated charcoal has the ability to absorb

significant amounts of methanol; however, it may be useful if

a coingestant is suspected. Gastric lavage would need to be

performed soon after ingestion to be beneficial.

3(I).1 Effects of illicit liquors and the reason for people to go

for it

People consume alcohol to feel free from the stressful life

and to live in a world of fantasies for a short period. They are

mentally away from the harsh realities of life, which they find

more stressful. It alleviates pain [no pain perceptions]. The

drunkards will be simply in an uninhibited state leading to

more influential feelings of love, hatred, aggression, rage,

violent and criminal behaviours.

42  

3(I).2 The manufacture of such drinks needs more standard

specifications. Basically they are prepared by the

fermentation of sugars such as starch, grape, potato and

molasses. It has many forms depending on the concentration

of the alcohol levels called as beer, rum, wine etc., it is an

expensive one. Alcoholism has become a symbol of

grandeur in social gatherings. There is a distinct relationship

between alcoholism and socio-economic conditions of the

population. In the indigenous process of preparation involves

no specific standards including addition of crude substances

which are highly toxic. They may be done with an intention of

improving the intoxicating effects ignoring the biological and

chemical properties of such substances. This results in

toxicity and ultimately death of the individuals. Such a case

of misadventure has occurred in Ahmedabad on 7th July

2009.

3(I).3 On July 7, 2009, Ahmedabad city experienced a Hooch

tragedy, which was caused by the consumption of ethyl

alcohol with methanol. Many people were admitted in

different hospitals with poisonous effects. Blood and urine

samples of some people were forwarded to the Directorate of

43  

Forensic Sciences (D.F.S.), Gandhinagar, which were

analyzed immediately and the presence of methanol and

ethanol in blood was detected. With this, police started

raiding the liquor dens in the various parts of the city along

with an expert from FSL (Forensic Science Laboratory) and

ultimately found that the liquor was spurious. The distribution

of spurious liquor was made by a sub agent throughout the

city. At the end of the day, more and more people with

poisonous effects started getting admitted in various

hospitals. In total, there were 447 persons admitted in

different hospitals. In addition to blood and urine, stomach

wash samples were also collected by doctors on admission

of the patients and were analyzed. Blood samples were

collected periodically to monitor the methanol level in blood

for the purpose of giving anti-dote. A total of 764 samples of

447 people were sent to DFS (Director of Forensic Science)

between July 7, 2009 to July 17, 2009.

44  

3(I).4 Details of the number of samples forwarded to the DFS, Gandhinagar from various hospitals are listed below:

The viscera samples of 162 deceased individuals were

forwarded to the FSL, Ahmedabad. Out of which, methanol

was detected in visceral samples of 150 persons.

3(I).5 Consumption of illicit liquor causes mortality and morbidity. In

other words it results in permanent disability or temporary

impairment. Such deaths cannot be blamed because of

prohibition or non availability of potable liquors. There are

records of such deaths due to consumption of methanol that

have occurred in many states even though they are wet.

Such deaths have occurred even in abroad where liquor is

freely available. Recently 13 deaths have been reported in

Sr. No.

Name of the hospital

No. of samples submitted

No. of samples with the presence of Methanol

Presence of

Ethanol

Presence of

Ethanol + Methanol

1 Civil Hospital, Ahmedabad

134 59 20 28

2 L G Hospital 201 67 25 72

3 V. S. General Hospital

129 39 10 25

4 Shardaben General Hospital

288 106 25 85

5 HCG Medisurge Hospital

12 4 2 5

45  

U.P. state which is a wet state.Most recently in Dec. 2011

similar type occurred in Calcutta where 180 people died due

to the consumption of illicit liquor. It may be noted that

recently in Kolkata such tragedy has occurred and about 180

persons have died and lot many have lost their vision. These

deaths were attributed to the use of methyl alcohol with

ethanol. Hence, it can be concluded that illegal activities and

deaths resulting from such activities take place in both wet

and dry areas whenever illicit liquor made with methanol is

consumed. In the states where prohibition is in force, the

temptation to go for illicit liquor is due to the non-availability

or to meet the demand, while in wet areas, the motivation

factor may be the cost effectiveness or less expensive nature

of the illicit liquor. The cost effective factor even in dry areas

cannot be ruled out. In laththa case of Ahmedabad, the cost

calculations submitted by the investigating agency brought

out the fact that the illicit liquor preparation and sale of such

liquor earns a huge profit to the main bootleggers. In either

case, the illicit liquor has to be prepared surreptitiously and

the raw materials have to be obtained through illegal

sources. Hence, occurrence of such deaths by itself cannot

be correlated with the prohibition policy which is based on

46  

the socio-economic considerations. There is no foolproof

method of preventing such incidence. In future also,

there is a danger of such incidence will always be there so

long as the illicit manufacture of liquor prevails.

3(I).6(A) It has been brought to light that the illicitly distilled alcohol is

the principal drink in isolated areas of Gujarat which is done

in the interior villages, in river beds, jungles, hilly areas etc.,

to avoid easy and obvious detection. This is manufactured

from molasses or gur diverted by licenses. Some areas have

attained notoriety for such illicit distillation or trading. Most

commonly people from the lower strata of the society are

directly engaged in this business. Apart from the process of

distillation, illicit liquors are directly prepared from

commercial/ industrial ethyl alcohol. Pilferage of commercial

alcohol during its transportation has been a very convenient

and a major source and thereby yielding high profits. Some

people are totally engaged in this illegal business and carry

out this on the highways.

47  

3(I).6(B) Denatured spirit is also supplied by the licensed

manufacturing products like French polish, varnish etc. Many

a times, bootleggers procure large quantity of French polish

and varnish, which are prepared by adding shellac and/or

resin like chanduras. When, varnish or French polish is

diluted with water, shellac or other resins and denaturant like

coutchoucine form a white or yellow emulsion. This emulsion

is precipitated with alum and then filtered. The filtrate thus

obtained becomes shellac, resin and coutchoucine free and

sold as illicit liquor. Other sources of such alcohols are

tinctures, spirits and some toiletries like Eau-de-cologne

which contains high percentage of alcohol.

3(I).7 To meet the local demand, when there is a huge shortage of

illicitly distilled liquor or to make it cheaper, the bootleggers

procure industrial rectified spirit or denatured alcohol through

illegal sources. Sometimes, instead of ethanol, methanol

finds its way into illicit liquor and that also may be due to the

ignorance and negligence. It can be rightly pointed out that

the physical characteristics of both ethanol and methanol

being similar; it is not possible for a layman to distinguish

them. Even experts would find it too difficult to do the

48  

distinction. He will have resort to analysis to make the

distinction. Therefore methanol can be used for the

preparation of illicit liquor under the genuine belief that it is

ethyl alcohol and therefore harmless. This is vindicated in the

deaths of Arvind urfe Hadio Khimji Solanki and Pradip Arvind

Khimji Solanki, the father and son duo, accused for selling

the illicit liquor. Therefore, If at all the seller of illicit liquor

who is in this trade for profit knows that any raw material he

is using is likely to cause the death of consumers he would

certainly not use it. It is not the intension of him to kill any of

his customers on whose patronage and support he lives. He

would also not like to cause a major tragedy resulting from

the consumption of illicit liquor prepared or supplied by him.

Also the possibility of deliberate addition of methanol cannot

be ruled out just for enhancing the intoxication of the liquor.

Hence, it is viewed that the deaths due to the consumption of

illicit liquor are not the result of any deliberate action or

design. In fact, police officers, medical officers and many

others have characterized such deaths as accidental and are

in concurrence with our view. While saying so, it is

expression of a general view. It is not possible to say

whether deaths in Ahmedabad Laththa tragedy were caused

49  

by the deliberate use of methanol or a conspiracy or due to

ignorance or negligence.

“A single moment of misunderstanding is very poisonous. It makes us

to forget the hundreds of lovable moments spent together”

50  

Chapter-4

REFERENCE NO. 2

ACTION TAKEN REPORT BY POLICE

Here is the report of adequacy of action taken by the police to implement prohibition laws and omission, commission and negligence, if any:

4(A).1 As reported by the Police Commissioner, Ahmedabad City,

the first and initial information regarding the Hooch Tragedy

in Ahmedabad City was received by the Police Control

Room at 10.25 hrs on 7/7/2009 and it was promptly passed

on to the concerned officers of the city police. In all, 65

messages were received and sent by the Control Room on

that day. Similarly 116 messages were received / sent by

the Control Room on 8/7/09, 135 messages on 9/7/09 and

60 messages were sent / received on 10th July 09 by the

control room, with regard to the occurrence of the Hooch

Tragedy. These messages were in respect of the accused

involved, raids carried out, admission and treatment of the

victims in various hospitals and also about the police

bandobast to be maintained at various places. These

51  

messages were also about recording of dying declarations of

the victims by the Executive Magistrates etc. In all, 148

persons died in the hooch tragedy. Post mortem examination

was performed on the dead bodies of all the 148 victims.

About 230 persons survived after getting treatment in various

hospitals. Dying declarations of 134 victims were also

recorded. Similarly, 113 persons had undergone dialysis

treatment in various hospitals. Statements of the close

relatives of all the deceased and the victims who have

survived after the treatment in hospitals, have been recorded

by the police. For effective supervision of the investigation of

the cases registered in connection with the hooch tragedy, a

team of senior police officers has been formed by the

Director General of Police. It consists of I.G. Law and Order

and Crime in DGP Office; DCP (Crime), Ahmedabad City

and Assistant Commissioner of Police, “D” Division,

Ahmedabad City. The team was authorized to select the

officers of their choice for investigation.

4(A).2 A Special Cell under the leadership of DCP Control Room,

Shri D.H. Parmar, was created vide CP's order No.A-

1/755/3611/09 dated 10/7/2009 to look into all aspects of the

52  

matter, co-ordinate with all agencies, keep track of all the

developments, monitor investigations and act as the nodal

agency for the city for all matters relating to the hooch

tragedy.

4(A).3 Out of the 35 police stations, as many as 16 police stations

were affected in this regard. The worst affected police

stations are Odhav Police Station; Bapunagar Police Station,

Saher Kotada Police Station; Kagadapith Police Station;

Amraiwadi Police Station; Gomtipur Police Station; Naroda

Police Station; Rakhial Police Station, Khadia Police Station;

Meghaninagar Police Station and Ramol Police Station.

Most of the affected persons were taken to and treated at

Sharadaben Hospital, Saraspur; Vadilal Sarabhai Hospital,

Elis bridge; Civil Hospital Asarwa; LG Hospital Maninagar;

Bapunagar General Hospital; Hardasnagar Ahmedabad;

Dhanvantri Hopsital; Kakadia Hospital at India Colony

Bapunagar and Rudraksh Hospital, Naroda, Ahmedabad.

4(A).4 After going through the messages sent and received by the

police control room, Ahmedabad City, it is seen that as soon

53  

as the incidence of Hooch Tragedy was brought to the notice

of the police, it appears that the entire police administration

was on toes for the next few days to prevent all anti

prohibition activities in the city and also tried to arrest the

culprits. Also, efforts were made to take the victims to the

hospitals for the treatment and had a close watch on the

situation to prevent any problem of law and order situation or

any other kind of repercussions. The main accused of this

Tragedy is one Vinod Alias Dagli Chandubhai Chauhan of

Vantvadi Taluka Mahemdabad of Kheda District who had

earlier been detained under PASA for four times. He is a

listed bootlegger and has a massive criminal history with

regard to anti -prohibition activities.

4(A).5 The Police Commissioner had acted promptly and had sent a

strong signal to the errant police officers that if there was a

failure in the performance of their duty, stern action would be

taken against them. Further, a separate inquiry has been

ordered by the Police Commissioner for fixing the

responsibility of the concerned Police Officers for their failure

to prevent such an unfortunate incidence. Details of action

54  

taken against the errant police officers for their negligence

and dereliction of duty in given in para No. 4(F)1 (Page 67).

4(A.)6 After the occurrence of the hooch tragedy, intensive

prevention measures were taken by the police from 7/7/2009

to 20/7/2009 to stop the flow of illicit liquor completely in the

city, as under:

(i) Under Cr.P.C. Section 151 (Arrest to prevent the

commission of cognizable offence Action taken against

2494 persons out of whom – 303 were bootleggers.

(ii) Under Cr.P.C. Section 110 (Security for good behavior

from habitual offender) – Action taken against 21

persons out of whom 7 were bootleggers.

(iii) Under Section 93 of the Prohibition Act (Demand of

security for good behavior) – Action taken against 192

persons involved in prohibition activities.

(iv) Under Prevention of Anti Social Activities Act – Action

taken against 44 persons out of whom 10 were

bootleggers.

55  

4(B).1 Details of the notified bootleggers of the City and

details of the police stations having record of more than

15 bootleggers

There are 467 listed bootleggers in the City of Ahmedabad.

Prohibition activities of these notified bootleggers are

supposed to have been closely watched by the Police and

repeated raids were carried out on their dens or place of

activities to prevent them from carrying out the illegal

activities. Some of them have been detained under PASA.

Police Stations having 15 or more listed bootleggers are listed as

under:

Sr.No. Name of the Police Station No. of bootleggers

(1) Sardar Nagar Police Station 55

(2) Madhupura Police Station 39

(3) Sabarmati Police Station 38

(4) Kagadapith Police Station 38

(5) Saher kotda Police Station 23

(6) Gomtipur Police Station 22

56  

(7) Shahpur Police Station 19

(8) Shahibaugh Police Station 21

(9) Naroda Police Station 19

(10) Odhav Police Station 19

(11) Ramol Police Station 18

(12) Naranpura Police Station 17

4(C).1 Details of cases registered at Kagdapith and Odhav Police stations in connection with the tragedy.

4(C).2 In all 2 (two) criminal offences at Kagdapith and Odhav

Police Stations were registered in connection with the Hooch

tragedy as under:

4(C).3 After a detailed investigation, charge sheets have been filed

in the Court under the signature of Police Inspector M.B.

Chauhan of Crime Branch, Ahmedabad City Police. During

the course of investigation of both the cases, it has come to

the notice that accused Jayesh Thakkar along with Chirag

57  

Thakkar who dealt into illegal trading of chemicals had

provided methyl Alcohol to Vinod Dagri through Sunil More,

Rakesh Giri, Subhash Giri and Dlip Patel on 3/7/2009 and

6/7/2009 from their petrol pump and godown at village

Mogar, Anand District. The spurious liquor was

manufactured in open air breweries at village Vathwadi,

Taluka Memdabad, Kheda District by Vinod alias Dagri. The

above mentioned accused along with others had hatched a

conspiracy of selling spurious liquor with a thorough

awareness that such liquor is harmful and injurious for

human consumption and also may prove fatal. Spurious

liquor manufactured by Vinod Dagri at Vathwadi was

supplied to various bootleggers in Ahmedabad City by three

major bootleggers. (1) Ravindrasing Powar, who was in

partnership with Nazir procured spurious liquor through his

workers Amit and Bhagwan from Vathwadi and distributed it

to local bootleggers like Dhanu, Meena; (2) Yogendra @

Dadu s/o. Kishorbhai Kanaiyalal Chhara; He procured

spurious liquor from Vinod @ Dagri and with the help of

Baldev Rabari and Ranjitsinh Dabhi distributed it to Lataben,

Sumiben, Gangaben etc. (3) Harishankar @ Hariyo s/o.

Ramadev Kahar: He procured spurious liquor from Vathwadi

58  

through his workers Vipul, Uttam and Himmatsinh and

distributed it to local bootleggers like Kantaben, Jassiben,

Noorbibi etc., and which resulted in death of 148 persons

and affecting 238 other persons.

The details of the accused persons involved in these cases

are listed as under:

(i) Kagadapith Police Station: The offence was registered at

Kagadapith Police Station on 7/7/2009 vide I - CR No.

161/2009 under Sections 304, 328, 114 of IPC and Sections

65(A)(B)(C)(D)(E)(F), 66(1) (A,B) 68, 72, 75, 81 and 83 of

the Prohibition Act in which 26 accused have been named.

Two of the accused persons (1) Arvind @ Hadiyo Khimjibhai

Solanki and (2) Pradeep Arvind Khimjibhai Solanki have

already died due to the conssumption of illicit liquor whereas

other accused are (1) Yogendra @ Dadu Chhara S/o.

Kishorbhai Sisodiya; (2) Lataben wife of Manubhai Chunara;

(3) Sunita wife of Ashokbhai Govindbhai Chunara; (4)

Vimalben wife of Arjunbhai Bhikhabhai Chunara; (5)

Somiben wife of Manilal Jimaji; (6) Sajanben wife of

Babubhai Premjibhai Chunara; (7) Gangaben @ Ganga

Doshi wife of Bachubhai Gopalbhai Chunara; (8) Sunita @

Joni Maheshchandra Chunara; (9) Parshottam @ Pasho S/o.

59  

Arjanbhai Parmar; (10) Sunil s/o. Naranbhai Panchal; (11)

Subhashgiri Sitaramgiri Goswami; (12) Lilaben @ Tibi w/o.

Sureshbhai Jayantibhai Chunara; (13) Suryaben w/o. Kalidas

Fakirchand Chunara; (14) Ashaben w/o. Rajubhai Ramjibhai

Chunara; (15) Arvindbhai @ Ghanshyam @ Bahero s/o.

Ukabhai Talpada (Vaghri) (16) Dashrath Fula Talpada

(Vaghri); (17) Vinod @ Dagri s/o. Chandubhai Chauhan; (18)

Jayesh Hiralal Thakkar; (19) Sunil Dhandurao More; (20)

Ranjitsinh Ramsinh Dabhi (21) Baldev Kurshi Rabari; (22)

Rakeshgiri Satyabhusangiri Goswami; (23) Dilipbhai Kurji

Patel; (24) Chirag Pankajbhai Thakkar who were arrested

and remanded to police custody during the course of the

investigation. During the investigation, it was revealed that

the accused had consumed illicit liquor from the illegal liquor

den of one Yogendra @ Dadu Chhara.

A total of 647 witnesses have been cited in the charge sheet

including Police Officers, Officers of the Forensic Science

Laboratory and Doctors connected with the investigation of

this case. A Special Public Prosecutor has been appointed

for conducting this case in the Court of Law.

(ii) Odhav Police Station – I C.R. No. 252/2009 for the offence

under Sections 302, 307, 328, 272, 273, 201, 109, 114,

60  

120(B) of the Indian Penal Code and Sections 65 (A) (B) (C)

(D)(E), 66 (1)(B) 67(1)(A), 68, 72, 75, 81 and 83 of the

Bombay Prohibition Act was registered on 7/7/2009. A total

of 33 accused were arrested in connection with this offence

and after detailed investigation charge sheets have been

filed against all these accused. In all 1638 persons have

been cited as witnesses in the charge sheet of this case,

which also include police officers, forensic experts and

Doctors. A Special Prosecutor has also been appointed by

the Government to conduct these cases. This case was

investigated by the Crime Branch of Ahmedabad City Police

and charge sheet has been filed under the signature of the

Police Inspector, Crime Branch Shri M.B. Chaudhari.

(ii)(a) Other accused persons named in the offence are (1)

Harishankar @ Hariyo Ramdev Kahar; (2) Vipulbhai

Popatbhai Luhar; (3) Uttambhai Popatbhai Luhar; (4)

Himmatsinh @ Revo s/o. Kalusinh Parmar; (5) Kantaben

w/o. Chhaganji Udaji Vaghela; (6) Kantaben w/o. Chanduji

Dhanaji Rathod; (7) Shailesh @ Bunty Vaman Rao Rahate;

(8) Vinod @ Dagri s/o. Chanduji Chauhan; (9) Jayesh Hiralal

Thakkar and (10) Sunil Dhodurav More; (11) Tili w/o

Vihabhai Chunara; (12) Babiben w/o. Punambhai Shakrabhai

61  

Patni; (13) Jashiben w/o. Vijaybhai Ramanbhai Chunara;

(14) Noorbibi w/o. Hasambhai Kalubhai Maniar; (15)

Ravindrasinh @ Ravi S/o. Jayramsinh Pavar; (16) Dhyansing

@ Dhanu s/o. Rajendrasinh Parihar; (17) Subhashgiri

Sitaramgiri Goswami; (18) Rakeshgiri Satyabhushangiri

Goswami; (19) Mahendra Haribhai Makwana; (20)

Arvindbhai @ Ghanshyam @ Bahero s/o. Ukabhai Talpada

(Vaghri); (21) Dashrath Fla Talpada (Vaghri) @ Montu s/o.

Jayantibhai Parmar; (24) Nandaben w/o. Ghanshyambhai

Danabhai; (25) Bhagwandas Bhanwarlal Vaishnav; (26)

Dilipbhai Kurji Patel; (27) Rajeshbhai s/o. Rajubhai Fulwalo

s/o. Shankerbhai Thakore; (28) Amit @ Amratsinh s/o.

Ajmersinh Rajaramsing Shikarva; (29) Meenaben w/o.

Manjitsinh Jagdishsinh Rajput; (30) Nasir Mohammed s/o.

Noormohammed Shaikh; (31) Najir Hussein Kadarbhai

Shaikh; (32) Chirag Pankajbhai Thakkar; (33) Dinesh @ Dilo

s/o. Pratapsinh Solanki who were arrested during the course

of the investigation and were remanded to police custody.

Investigation of the case revealed that the main accused and

master mind of the offence was Vinod @ Dagri Chandubhai

Chauhan r/o Vanthwali, Taluka Mahemdabad, District

Kheda. The accused has a history of having been involved

62  

in a large number of prohibition offences and he had been

detained under PASA on as many as four occasions.

4(C).4 The details given in both the charge sheets show that the

investigations have included all aspects of investigation of a

criminal case and there appears to be sufficient evidence

against the accused about their involvement in the Hooch

Tragedy.

4(C).5 The main accused persons of Odhav Police Station are (1)

Vinod @ Dagri s/o. Chandubhai Chauhan; (2) Jayesh Hiralal

Thakkar; (3) Sunil Bholurao More were arrested and taken

on remand till 31/7/2009 and necessary actions were taken.

4(D).1 Details of actions taken against the bootleggers during the year 2008- 2009 before the tragedy by the Ahmedabad Police.

In defense of the Police, the Police Commissioner has stated

in his report that the City Police had been taking strict and

sustained action against the bootleggers operating

clandestinely by conducting raids periodically in the premises

and hideouts of the suspected bootleggers.

63  

During 2008, Police had made out a large number of cases in the

areas of the affected police stations i.e.

(i) Sardarnagar ... 724

(ii) Odhav ... 431

(iii) Ramol ... 351

(iv) Amaraiwadi... 560

(v) Kagdapith ... 559

Detention under PASA and externment cases:

YEAR PASA EXTERNMENT PROHI.93

2003 201 152 1019

2004 282 195 1777

2005 294 192 1252

2006 327 130 1252

2007 453 252 2721

2008 342 129 2145

2009 357 72 1982

64  

Preventive measures taken by the City Police from 1/1/2009 to 6/7/2009

Sr.

No.

SECTION ACTION

TAKEN

REMARKS

(1) Cr.P.C.107. 6851 Security For keeping peace.

(2) Cr.P.C.151. 5316 Arrest to prevent the

commission of cognizable

offence.

(3) Cr.P.C. 109 3422 Security for good behavior

from suspects)

(4) Cr.P.C.110. 1977 Security for good behavior

from habitual offenders.

(5) Prohi.93. 1673 Demand of security for good

behavior.

(6) B.P. Act. 122. 389 Action against suspect during

night.

(7) B.P. Act.124. 89 Found in possession of stolen

property.

(8) B.P. Act.142. 280 Action against externees for

violating conditions.

(9) B.P.Act. 56/57 94 Externment of a criminal from

an area by Magistrates.

(10) PASA 420 Prevention of anti-social

activities Act.

65  

4(E).1 Details of Intensive actions taken by the Police from 7.07.09 to 20.07.09.

Immediately after the incident of Hooch Tragedy, the Ahmedabad City Police took intensive preventive measures from 7/7/2009 to 20/7/2009, the results of which are as under:

Sr. No.

Particulars Bootleggers Others Total

1. Cr.P.C. 151 303 1191 1494

2. Cr.P.C.110 7 14 21

3. Prohi.93. 28 164 192

4. PASA 10 34 44

4 (E).2 In addition to the above mentioned preventive actions

between 7/7/2009 to 20/7/2009 a total number of 16,932

prohibition raids were carried out by Ahmedabad City Police.

Out of which, the raiding party could not locate any illicit

liquor in 16,699 cases. During this period 61 cases of

consumption of liquor and 185 cases of possession of liquor

were detected and a total number of 246 cases were

registered in which 262 accused persons were arrested. A

66  

total of 1525 litres of country liquor, 704 bottles of foreign

made country liquor, 16 bottles of bear and 50 liters of wash

were seized during this period.

4(E).3 Details of prohibition cases in the main area during the year

2009 till 30th June (before Hooch Tragedy took place on

7/7/2009) were made out as under:

Name of police station

No. of cases

NO. OF ACCUSED

COUNTRY LIQUOR (LITRES)

IMFL (Indian made

foreign liquor)

Sardarnagar 444 470 5980 37216

Odhav 184 238 3859 344 Amraiwadi 226 265 1833 388 Kagdapith 141 158 1731 108 Ramol 165 179 2007 140

The details of the number of prohibition cases registered and the

number of accused arrested during the past 7 years from 2003 to

2009 till 31/7/2009 are as under:

YEAR. CASES REGISTERED.

ACCUSED ARRESTED.

2003 6475 6948

2004 6772 7480

2005 6529 7346

67  

2006 6894 7636

2007 8108 8876

2008 8061 8703

till June 2009 5001

4(F).1 Details of action taken against the errant police officers/

personnel for their negligence and dereliction of duty

After the Hooch Tragedy, a number of police officers and

personnel were transferred out of Ahmedabad City to far off

districts, for their negligence / dereliction of duties in curbing

the bootlegging activities in their respective jurisdictions and

also for aiding or conniving with such illegal activities. These

include two police inspectors and 55 policemen. Apart from

this, two Assistant Commissioners of Police and four Police

Inspectors were placed under suspension for dereliction of

their duties. As an exercise to revamp the police set up as

many as 109 policemen were also transferred internally

within the city. During the course of the investigation of

Kagdapith PS I CR No. 161/09 registered under Sections

120-B, 304, 328, 114 etc., two policemen were also named

as accused and were arrested. They are (1) Ranjitsingh

Ramsinh Dabhi and (2) Baldevbhai Kurshibhai Rabari.

68  

4(F).2 Besides these actions, following initiatives were taken

against the guilty police officers and personnel:

4(F).3 Addl. Commissioner of Police, Special Branch, Ahmedabad

City has made a preliminary inquiry, which established the

fact that some police officers and personnel were hand-in-

glove or had connived with the activities of the bootleggers

in their nefarious trade. The Commission craves leave to

refer upon the details of his findings at appropriate tie. The

same is kept in separate file.

4(F).4 Two Assistant Commissioners of Police; in whose jurisdiction

the tragedy had its greater impact viz., Odhav and Kagdapith

Police Stations, were transferred out of Ahmedabad City

immediately and placed under suspension by the

Government.

4(F).5 Both the Sr. Police Inspectors and Second Police Inspectors

in-charge of Odhav and Kagdapith Police Stations were also

69  

transferred out of Ahmedabad City and placed under

suspension.

4(F).6 Six Assistant Police Sub Inspectors who were given ad-hoc

promotions as Sub-Inspectors of Police were reverted to

their original rank and were transferred to various districts

and were also kept under suspension. Further five Assistant

Sub Inspectors were transferred out of Ahmedabad City.

The Police Sub-Inspector of Prevention of Crime Branch was

also reverted to the rank of Assistant Sub Inspector and

transferred to a far off district.

4(F).7 39 police personnel, whose conduct was found to be

suspicious with regard to the control of prohibition activities

in their respective jurisdictions, were also transferred out of

Ahmedabad City to various far off districts.

4(F).8 As many as 109 police personnel working in Surveillance

Squads of various places for prolonged periods were

70  

reshuffled and transferred to various police stations within

the city.

4(F).9 The process of initiating departmental action against the

above police personnel is in progress.

4(F).10 In a significant move in 1997, the Government of Gujarat

after reviewing the implementation of the Prohibition Policy in

the State and after due consideration, decided to transfer the

task of enforcement of prohibition laws from the Police

Department to the Prohibition and Excise Department vide

Government Resolution No. NASHADH/1097/346/M dated

30/4/1997, and from 1/5/1997 all powers with regard to the

enforcement of Laws relating to prohibition, women and

youth welfare and cultural activities designed to spread the

message of prohibition was allotted to that department and

the Commissioner, Prohibition and Excise was made solely

responsible for the complete and holistic implementation of

the Prohibition policy of the State.

71  

4(F).11 After a year, it was felt by the State Government that the

Office of the Commissioner (Prohibition & Excise) was not

able to meet the challenge posed by illicit bootlegging and

hence, enforcement work was simultaneously re-entrusted to

the Police Department and enforcement of Prohibition laws

were implemented from then onwards by both the

Departments, vide Government in HD's letter No.

Nasha/1098/M.60/E-1 dated 22/5/1998. Later, after a further

review of this policy, vide Government Resolution

No.NASHADH/102006/1648/E-1, dated 25/7/2006, the

enforcement of prohibition laws were transferred back from

the Prohibition and Excise Department to the Police

Department.

72  

4(F).12 The total number of prohibition cases made out in Ahmedabad City for the last 10 years and the rate of pendency of cases in the Courts and the rate of conviction is as under:

YEAR WISE DETAILS OF PROHIBITION CASES –

AHMEDABAD CITY.

Year No.of Prohi. Cases

Cases pending in Court

Pendency %age

Conviction Conviction Rate

1999 6742 3935 58.37 % 348 5.16%

2000 5966 3606 60.44% 311 5.21%

2001 5294 3291 62.16% 309 5.84%

2002 4913 3014 61.35% 297 6.05%

2003 6409 4437 69.23% 340 5.31%

2004 6759 4499 66.56% 514 7.60%

2005 6532 3946 60.41% 561 8.59%

2006 6937 4673 67.36% 946 13.64%

2007 8126 5839 71.86% 995 12.24%

2008 8025 6170 76.88% 1094 13.63%

2009 Up to 30/9/09

5196 4145 79.77% 280 5.39%

TOTAL 70899 47555 67.07% 5995 8.46%

73  

Chart showing the details of convictions in the last 10 years:

Details of Convictions.

Year Total Convictions

Fine in Cash

Imprisonmentof 1 to 90

days

Imprisonment of 3 to 6 months.

Imprisonmentof 6 to

12 Months.

Imprisonmentof more

than 1 year

1999 348 181 154 6 1 6 2000 311 171 135 3 1 1 2001 309 177 128 3 0 1 2002 297 183 106 2 2 4 2003 340 226 106 3 2 3 2004 514 407 99 4 0 4 2005 561 432 120 8 0 1 2006 946 699 236 8 0 3 2007 995 764 229 2 0 0 2008 1094 800 291 2 0 0 2009 280 259 20 1 0 0 Total 5995 4299 1624 42 6 24 %age 17.17% 27.09% 0.70% 9.10% 0.40%

4(F).13 The figures mentioned above show that the disposal of

prohibition cases in the Court is very slow and conviction rate

is almost negligible. The quantum of punishment given in

the convicted cases is also negligible. Pendency of the

charge sheeted cases in the Court is above 67%. The

conviction rate is only 8.5%. The punishment exceeding 3

months prison term in convicted cases is only little more

than 1% and the hooch tragedy cases of 1977 and 1999 are

74  

still pending for disposal in the Courts and the accused who

are still surviving are yet to be punished.

DETAILS OF THE DETENTION OF BOOTLEGGERS UNDER PASA DURING LAST 5 YEARS ARE AS UNDER;

Year Total PASA

Released By

Advisory Board

Order Revoked

Released By High Court

Total released

One Year Completed

2005 437 57 21 349 427 10 13% 5% 80% 98% 2%

2006 419 111 4 288 403 12 26% 1% 69% 96% 3%

2007 649 205 8 405 618 7 32% 1% 62% 95% 1%

2008 514 206 6 287 499 1 40% 1% 56% 97% 0.2%

2009 Up to

30th Oct

620 190 2 288 480 0

%age 31% 0.3% 46% 77% 0%

4(F).14 As seen above, only 2% of the detainees in 2005; 3%

detainees in 2006; 1% detainees in 2007; 0.2% detainees in

2008 and 0% detainee in 2009 actually completed their full

detention term. The rest were either released by the

Advisory Board or by the Honorable High Court or by the

Government, before completion of their full term detention

which are shown in the above table.

75  

Chapter-5

REFERENCE NO. 3.

ACTION TAKEN REPORT BY HOSPITALS

The action taken by the hospitals in providing medical

assistance to the people taken to such hospitals including

hospitalization, adequacy of treatment response,

infrastructure and treatment facility and availability of

antidotes and shortcomings, if any :

What actions were taken by the hospitals? What treatments

were given to the patients of hooch tragedy? And how the

commission has found the infrastructure inadequate in

various hospitals has been reported as under:

5 (A).1 Inferences of commission’s visits cross examinations

particularly the Doctors and Administrative Officers of

various hospitals and study of records of various

hospitals:

The members of the commission visited various hospitals on

9th, 10th and 16th July 2009. The case records were studied

and doctors and administrators of hospitals were initially

76  

called and their Affidavits obtained and subsequently they

were examined on different occasions. The first hospital

visited was Smt. Shardaben Chimanbhai Municipal Hospital,

Saraspur.

5(A).2 Smt. Shardaben Chimanbhai Municipal Hospital:

This hospital experienced many difficulties on day 1 i.e.

7/9/2009. The absence of medical triage, short comings of

space and ethyl alcohol (antidote) availability caused

problems in the treatment. The treatment protocols and

hospital specific emergency preparedness plan were not

executed on day 1. Doctors and allied staff were carrying on

their best but deceased were sent to civil hospital for post-

mortem examinations. This is not acceptable for a very busy

hospital situated in the congested area of eastern

Ahmedabad. Patients were admitted in various wards. The

cleanliness and hygiene of the wards was not up to the mark

of satisfaction. All patients were prescribed with required

treatment and teams of the Doctors and paramedics were on

their allotted job.

77  

The emergency response mechanism and triage (A

mechanism to classify serious patients from non serious

patients) system were not activated at the time of first

response.

5(A).3 Existing infrastructure: The trauma unit to cater mass

casualties, Hemodialysis facility, Post mortem, CT

(Computerized Tomography) Scan and MRI (Magnetic

Resonance Imaging) facilities were found to be lacking. The

number of patients exceeded the number of available

ventilators. Many important gadgets were requiring repairs

(not in working condition). The antidote was not readily

available during initial phase of tragedy. Majority of victims

were brought to this hospital initially which created chaos in

early few hours but doctors and administrators managed the

situation later on.

Availability of Antidotes: Scarce in the initial phases

The second hospital visited was Sheth L.G. Hospital.

78  

5(A).4 Visit of Sheth Lallubhai Gordhandas hospital:

Majority of the patients were receiving treatment in ICU

(Intensive Care Unit). The medical triage was not performed.

So, non serious patients were also admitted in the ICU.

There was a overcrowding of the relatives and visitors in the

ICU resulting in chaos. The doctors and paramedical staff

were devoting their full time in the management of serious

patients but the relatives of non serious patients were

disturbing the doctors by asking questions. This would have

been resolved if only serious patients had been admitted in

ICU. This would have been resolved by implementing

medical triage by hospital authorities. The hospital specific

emergency preparedness plan was not up to the mark of

satisfaction. The antidote, ethyl alcohol was not readily

available at initial hours in the wards.

5(A).5 The post-mortem examinations were not performed at

L.G.Hospital, even though it was attached to a medical

college and also one of the largest hospitals of eastern part

of Ahmedabad.

79  

5(A).6 The placement of patients was not meaningful. The serious

patients were kept in general ward and stable patients were

found in the ICU. The measures of controlling rush of the

relatives were not properly planned. The wards, especially

ICU was overcrowded with relatives of the patients. So the

doctors found difficulties in treating the patients due to

overcrowding of the relatives. The emergency preparedness

plan and implementation of Triage system was not put into

action.

5(A).7 The existing infrastructure: The ideal trauma facility is lacking

which is required to cater mass casualty. Autopsy/

Postmortem examination, Dialysis, MRI (Magnetic

Resonance Imagination – an equipment which shows inner

organs of body) and CT (Computerized Axial Tomography –

an equipment which shows images of internal organs)

facilities required for hooch victims were not adequate.

Important equipments were lying in non working condition.

5(A).8 On revisit of Sheth L.G. Hospital, it was learnt that certain

serious patients who required haemodialysis were

80  

transferred to medisurge hospital. The Medisurge Hospital

was not having Ethyl Alcohol. So they requested L.G

Hospital authorities to supply it with the patients. One bottle

of ethyl alcohol (450 ml) was supplied by L.G. Hospital

bearing batch no. 06/0910 to Medisurge hospital. This

incidence when studied further, revealed many hardships

experienced by treating physicians. It is evidently learnt that

there was sluggish action on the part of the department of

prohibition and excise and health in this regard. This was

brought to the notice during the visit of all the hospitals to

solve the problem of non availability of antidote.

Availability of antidotes: Scarce in initial phase

The third hospital visited was Sheth V.S. Hospital.

5(A).9 Sheth V.S. General Hospital:

At V.S. General Hospital, the patients were first examined at

casualty department by casualty medical officer and were

then admitted in different wards designated to different

medical units. No special treatment ward was created for

victims of hooch tragedy. The patients were admitted in a

haphazard manner among the patients of other illness. This

81  

type of arrangement derailed the ease of treatment of

patients.

5(A).10 In this hospital, ICU was overcrowded and number of doctors

was less as compared to the patient load. Serious patients

were many and were requiring continuous Artificial Life

Support. The superintendent of the hospital was advised to

deploy more staff in ICU which was complied with. There

was adequate supply and stock of antidote and medicine in

the hospital. The needy patients were subjected to

haemodialysis and ophthalmic treatment. Hospital specific

emergency preparedness plan and evacuation plan was not

readily available with the hospital. The need of evacuation

plan was needed to be activated very soon for municipal

hospitals as the commission noted that it was required in

recent fire incident in hospital CATH lab (cardiothoracic

laboratory)

5(A).11 Here also the wards were overcrowded with relatives of the

patients. Doctors were right on their jobs but found difficulties

in treating the patients due to uncontrolled presence of the

82  

relatives. Emergency response system and implementation

of Triage plans were not up to the mark. The authorities at all

the three hospitals were requested to implement and activate

their emergency response system and isolate and place the

patients as per triage plan. Many serious patients were

placed in a general ward whereas other routine patients were

also admitted. The authorities of the hospital were requested

to classify the patients as per triage plan and separate wing

for hooch victims may be created in one ward so better care

may be dispensed with less hardship.

5(A).12 Available infrastructure: The hospital is having good

infrastructure to handle such emergencies due to newly

created Trauma unit. However, hospital should have its own

CT scan and MRI machines. Haemodialysis machines need

to be increased in number. Some equipment/appliances

were non working at the time of incidence.

Availability of antidotes: Adequate.

83  

5(A).13 Civil Hospital, Asarva

The patients were first examined at casualty department by

duty medical officers. The needy patients were admitted

under physicians of the hospitals in initial stage. Since 8th

July, 2009 morning, an isolated facility in form of a special

ward was created and all patients were admitted in one ward

under senior physician, Dr. B.S.Kazi. Doctors dedicated to

look after hooch victims solely eased the management part.

The stock of antidote and medicine was satisfactory. The

post-mortem examination facilities were satisfactory even

though the victims from other hospitals were brought here for

PM (Post Mortem) examination. The ‘medical triage’ was not

practiced at civil hospital as it should have been done during

mass casualties. The criteria of subjecting victim for

haemodialysis were symptoms and signs of metabolic

acidosis and blood gas analyzer’s reports were put into

action from 7th July 2009. The patients whose Bicarbonate

level less than 16 and pH less than 7.2 were subjected to

haemodialysis.

The treatment provided to hooch victims was appropriate.

84  

5(A).13(1) Available infrastructure: The hospital is having good

infrastructure to handle such mass casualties. The hospital is

under process of expansion. Its expansion and refurbishment

should be planned in such a way that hospitals can be easily

accredited by National Accreditation Board for Hospitals in

coming days. Certain gadgets required either repair or

condemnation at the time of incidence. We have been

intimated by hospital authorities that they have either

received or condemned non working equipments.

Availability of antidotes: Sufficient

5(A).13(2) Dhanvantari Hospital, Bapunagar

We asked for case records and carried out hearing of

doctors and trustee on different occasions, the following

findings were arrived at. Objections noted, conclusions

reached.

5(A).14 One patient, Mr. Satyanarayanasinh was admitted but was

not dispensed with antidote, Ethyl Alcohol on 8th July 2009.

The patient was transferred to Kakadiya hospital as patient

85  

needed the ventilator support. The hooch victims which are

having metabolic acidosis and shows sign of respiratory

depression require support of ventilator.

Available infrastructure: The hospital is not having ventilators

to support the respiration. This is very much required for

hospitals which admit patients in ICU/ICCU. The patients of

hooch tragedy needed the support investigations from an

ABG machine (Arterial Blood Gas Analyzer).

5(A).15 The hospital authorities should design an up gradation plan

to augment the treatment facilities in present ICU (Intensive

Care Unit) – Department of Hospital where serious patients

are kept – who require strict vigil treatment) and ICCU

(Intensive Coronary Care Unit) - Department where serious

heart patients are kept. It is equipped with instruments which

corrects the functioning of the heart).

5(A).16 Mr. Sheetalbhai Thakor was admitted on 10/7/2009. The

blood sample of the patient was not sent for chemical

analysis. This patient was not dispensed with antidote, Ethyl

alcohol.

86  

5(A).17 Patient named Rajeshbhai Vaghela was a victim of hooch

tragedy as his CT scan report of brain was conclusive of

necrosis of Basal Ganglia [part of brain]. Bilateral Putaminal

[part of brain] necrosis is one of the findings of Methanol

poisoning. The treatment given to Mr. Rajesh Vaghela was

incomplete, in view of the case records submitted on

24/8/2009. The patient died during treatment but his

postmortem examination was not asked for.

5(A).18 Mr. Champabhai Parmar was admitted as a case of hooch

poisoning but his blood was not sent to forensic science

laboratory for chemical analysis. He was also not treated

with antidote, Ethyl alcohol.

5(A).19 Blood of Mr. Prakashbhai Malaviya, a hooch poisoning case

was also not forwarded to forensic science laboratory for

chemical analysis. There was no mention of treatment with

antidote in case records provided on 24/8/2009. During

hearing, it was mentioned that patient was treated with

rectified spirit via Ryle’s tube. Patient was requiring urgent

87  

haemodialysis which was not carried out resulted in patient’s

death.

Availability of antidotes: not available

5(A).20 Kakadiya Hospital:

We have studied case records of Kakadiya hospital .It has

been observed that, the required medico legal formalities

were not observed at this hospital. Mr. Ramesh Rathod, a

hooch poisoning victim was admitted in the hospital but his

blood sample was not sent to forensic science laboratory for

chemical analysis.

Availability of antidotes: not available

The inferences drawn from visits and hearing of Doctors

of Hospitals respectively:

5(A).21 The hospital specific emergency preparedness plan was

neither readily prepared nor fully executed during initial hours

of tragedy. The action plan represents a comprehensive and

systemic approach to elevate baseline emergency response

system and enhance prompt treatment strategies

88  

implementation to save human lives as many as possible.

The action plan cover a range of areas including prompt and

modified treatment response in crisis hours, safety and

security of patients and hospital staff, training of how doctors

and staff react to perceived threats, drills and exercises,

public awareness and announcement, protective measures

after analysing and evaluating threat levels, introducing

security measures, sharing quick information and uniformly

implemented treatment protocols. This resulted in treatment

protocols and haemodialysis referrals were initiated after a

delay of two days.

5(A).22 The treatment protocols were not uniformly implemented in

all the treating hospitals. This was mainly noticed in the

treating hospitals of private domain.

5(A).23 The availability of antidote, Ethanol was a grave problem in

private hospitals. They were wandering in dark in the

absence of guidance from state health officials, particularly

the health Commissioner.

89  

5(B) Details of Cross examination and suggestions of some doctors.

The commission started hearing of concerned doctors on 30th March 2010.

5(B).1 Dr. Mukesh Lallubhai Patel appeared before commission and

mentioned that he was in charge of the superintendent of

Smt. Shardaben Hospital, Saraspur when tragedy stuck

Ahmedabad city. He deposed on oath the following

information.

5(B).2 Total 175 patients were admitted as indoor patients; 3

patients were bought dead so total 178 patients of hooch

tragedy were brought to Shardaben Hospital out of which 57

patients had expired. The dead bodies were sent to Civil

Hospital Ahmedabad for post-mortem examinations.

Forwarding cases for post mortem examination in Civil

Hospital is a laid down procedure followed since long. He

agreed that sending the deceased to Civil hospital is

cumbersome to relatives and unnecessary delays and

lengthens MLC (Medico Legal Cases) procedures. He felt

that hospital should have its own autopsy and mortuary

90  

facility and assured that the Shardaben Hospital authorities

will propose to start post mortem examination in the hospital

premises itself after new building starts functioning. He also

agreed upon the fact that at present, there is a lack of

Trauma care ward, post operative ward, Dialysis unit and CT

scan. He was hopeful that the things would be initiated once

seven storied new building becomes operational. The

hospital specific emergency preparedness plan is not ready

with the Shardaben Hospital and their role in state/city

disaster mitigation plan is not ready. They have not been

guided by state health authorities to do so. He expresses

opinion that the posts at Shardaben Hospital which are lying

vacant should be filled in, particularly those of Medical and

Para medical staff. He has also submitted that drugs like Inj.

Triamcinolone acetonide, Inj. Noradrenaline, Inj. Diazepam,

Inj. Epsolin, Absolute Alcohol, Tropicacyn eye drops,

Endotracheal tubes, Suction catheters, Foleys catheters,

Ryle’s tube, Airways and chest leads were not readily

available when tragedy struck. They managed it without

spending much time by procuring them from central

municipal medical store and superintendent, prohibition and

excise. Ethanol which is a very crucial antidote for methyl

91  

alcohol poisoning was required to be supplied by state health

commissioner. It was not in sufficient quantities at civil

hospital Ahmedabad. The report of chemical analysis of

blood for concentration of methyl alcohol was found to be

available within 6 to 8 hours on an average, but in initial

phase there was some delay as rapport was not established.

He said that coordination of all concerned departments

should immediately be made during such time of crisis with

the help of treating doctors. It seems that he had faced

problems in procuring ethyl alcohol. He has also

recommended that:

5(B).3 The list of antidotes of all chemical poisoning should be

prepared as ready reckoner and should be circulated to all

concerned doctors and should be kept readily available with

all Hospitals.

5(B).4 The availability of antidotes should be hassle free and all

concerned officials should know the source of its availability.

Health commissioner should play an active role to provide

92  

scarcely available antidotes to non Governmental hospitals

also.

5(B).5 The details of chemical formula, the dosage and side effects

of antidotes should be readily available in this booklet.

5(B).6 It is hereby recommended that training of all doctors should

be carried out at regular intervals for any kind of disasters

including chemical trauma, and accidents. This should also

be particularly replicated for manmade calamities like bomb

blasts or terrorist activities of any kind. The training program

should include all practical aspects for the efficient

management of routine/scarce calamities.

5(B).7 Mock drill at the regular intervals in association with the

revenue, police, forensic science , fire fighting and 108

ambulance services should be carried out. The gradation

and remarks on mock drills need to be recorded and

authoritities should see that previous mistakes are not

repeated. In case of such a mistake that should be rectified.

93  

The most efficient and responsible institutes should be

rewarded by the government or by the municipal authorities.

5(B).8 The calamities are of different nature where different

specialties require different roles to play. So a permanent

disaster management Committee comprising of different

specialists headed by the Superintendent of the Hospital

where invitee members from the Revenue, Police, Forensic,

Red Cross and Fire fighting should be included. All members

should collectively prepare and update emergency

preparedness plans at regular intervals in consultation with

subject specialists.

5(B).9 The life saving gadgets and instruments including ventilators,

dialysis equipment facility with life saving drugs should be

readily available in sufficient quantities round the clock with

the central stores. The stock and record of such life saving

drugs and equipment should be reviewed by disaster

management committee at regular intervals.

94  

5(B).10 A grid of all Municipal, Government, Trust run and Corporate

Hospitals should be formed and in case of dire emergencies.

The transfer of the patients need to be streamlined and

should be accepted by all competent Hospitals without

insistence of any financial/administrative formalities.

Treatment of the serious victims should be made compulsory

for all private hospitals on request of the Government/Semi

Government / Municipal Hospitals without insisting on fees

for such cases.

 

5(B).11 The deputation of the medicos and Para medics in an

emergency should be made easy during crisis management

and it should be on war footing basis. The Government

requires designing strategy for easy deputation of medics

and Paramedics and should provide necessary help by

supplying required drugs which are scarcely available.

5(B).12 An emergency hall should be identified in all the Hospitals. It

should be kept vacant along with all the required facilities.

This should be made compulsory even for the Corporate

Hospitals also.

95  

5(B).13 On 30th March, 2010 Dr. Laxman Taviad, RMO of Sheth

Lallubhai Gordhandas Hospital- Maninagar gave deposition

before commission. He informed that total 85 patients came

to L G Hospital and were treated as indoor case. 18 patients

were referred to other hospitals; 65 patients cured and sent

home; 3 patients were absconded and 17 patients expired in

the hospital. The police were informed about the absconding

patients as per prevailing rules. Regarding the death of 17

patients he said that post-mortems were not performed at L

G Hospital as they were having no facility for post mortem

examination. The L G Hospital is a leading hospital of thickly

populated south-east Ahmedabad and is being run by

Municipal Corporation. The L G Hospital and Shardaben

Hospital are the main stay for the treatment of eastern

Ahmedabad and not performing post mortem examinations

for the deceased brought to these hospitals. The commission

expressed concern about this lacuna to Dr. Taviad. In the

response, Dr. Taviad has agreed with the view of the

commission and has informed that he will send the proposal

to Municipal Corporation in this regard. He has also

mentioned that L G Hospital is also devoid of the facilities of

dialysis which is life-saving for the patients of methanol

96  

poisoning. He agreed to send proposal to create dialysis

facility, CT scan and MRI at L G Hospital in due course. Dr.

Taviad further stated that hospital is not having hospital

specific disaster mitigation plan and emergency

preparedness document ready with them and agreed to

prepare required plan documents for his hospital. The

absence of disaster readiness protocols with such large

hospitals is matter of great concern. It helps hospital staff to

know better about their role during such disasters.

Commission feels that all major municipal hospitals should

opt for required optimum standards laid down by National

Accreditation Board for hospitals (NABH) and Quality council

of India. This is an accepted policy for government hospitals

and health commissioner should have played a leading role

to guide these hospitals to go for NABH accreditation. Health

commissioner, being a head of all health and medical affairs

should not have refrained from providing guidance to these

hospitals as they are being administered by municipal

commissioner. During the visit of commission, the ICU was

full of serious and non serious patients which showed that

Triage plan was not known to hospital doctors. We feel that

health commissioner should have taken an initiative as EMS

97  

(Emergency Medical Service) act is already enacted by state

government in 2007. Commission felt inept attitude /action

inertia of the EMS authority and health commissioner in this

regard, since many natural and manmade catastrophes have

struck Gujarat after inception of EMS authority and during

the tenure of health commissioner since 2002.

5(B).14 Dr. Taviad said that his hospital is having vacancies of 35 in

technical staffs which need to be filled up. He also said that

sufficient quantity of ethyl alcohol which is an antidote for

methyl alcohol was not readily available with the hospital but

it was arranged in time. He has also agreed upon the

importance of round the clock availability of antidote and life

saving medicines. On asking his suggestions to cater to the

need in such emergency more efficiently in future, his

emphasis is on the readiness status of hospital staff by

implementing hospital specific emergency preparedness

plan. The documents should be prepared and regular mock

drills should be carried out at regular intervals. He has also

stressed the need for the formation of a disaster

management committee comprising of administrative and

subject specialists which will supervise and update action

98  

plan to face challenges during such crisis. He has mentioned

about the guidance provided by medical experts sent by

health minister and principal secretary of health was quite

helpful in tackling situation. The medical team helped in

deriving treatment protocols for smooth management of the

victims and timely transfer to a dialysis facility. He felt the

importance of a team comprising of subject and these

experts should be deployed to guide treatment providers. At

this juncture Commission was convinced of the decision of

health minister and secretary to send government medical

experts to L G Hospital which has yielded fruitful results in

patient’s outcome. If this phenomenon had been replicated in

other private hospitals by health commissioner, it would have

imparted better results in hooch tragedy management by

private hospitals like Rudraksh hospital and Dhanvantari

hospital. The patients at these private hospitals were treated

without laid down treatment protocols which were already

derived by civil hospital doctors. This treatment protocol, if it

had been percolated to private domain hospitals then

definitely it would have reduced the suffering of the hooch

tragedy victims treated in private domain. This is equally true

for the availability of antidote like ethyl alcohol which was in

99  

abundance with civil hospital while hospitals in private

domain deprived of it. Again health commissioner as a head

of the state should have taken leadership in providing

antidote and treatment protocols to the inexperienced

hospitals. The treating physicians were seen busy in

providing treatment to all the patients without discrimination.

The health administrators should play a role of facilitator so

the concentration of the treating physician is not diverted

from treatment in tackling small administrative issues.

Commission agrees with the issue of a visiting team

particularly in private domain so that identical and uniform

treatment is provided to victims and proactive role by head of

health department should be in places which seem to be

lacking in this episode. Commission also agrees with opinion

that all the treatment providers may not have sufficient

knowledge of issues relating to such scarcely striking

tragedy. So, timely intervention to resolve emerging issues is

mandatory by health commissioner. Dr. Taviad emphasises

on the need of awakening poor and down trodden victims

and their families against evils of consumption of liquor. This

can be done by intensive social education.

100  

5(B).15 Dr. Rakesh Prabhakar Khandekar, Head, Medical care, GVK

Emergency Management and Research Institute,

Ahmedabad remained present before the commission for

hearing on 30th March, 2010. He deposed before the

commission that it is not possible for him to say that how

many calls for 108 ambulances received by control room as

there were multiple calls for one patient and responders did

not receive clear cut complaints of consumption of illicit liquor

from callers but received complaints regarding vomiting,

unconsciousness, breathing problems and abdominal pains.

He revealed that 218 victims were attended out of which 3

were found dead on arrival at the site. There are certain

numbers of ambulances which are equipped with advance

life support equipments like ventilators. Certain patients were

transferred to other facilities in critical condition that needed

life support system in place. If the transferring doctors know

that such 108 ambulances are available with EMRI

(Emergency Medical Research Institute) then they can make

use of them. Dr. Rakesh Khandekar deposed that they will

circulate this information to treating physician so that they

can use the ALS (Active Life Support) ambulance if the

situation demands so. Dr. Khandekar has not registered any

101  

incidents where patient died during transport due to lack of

advanced life supporting system in ambulance. He also

deposed that they have not received any complaints for

Emergency Medical Technicians’ behaviour or 108

ambulance services. Their Emergency Medical Technicians

have also not experienced any problems in getting brought

patients admitted for treatment in the hospitals.

5(B).15(1) On asking recommendations from him, Dr. Khandekar

explained that during episode, for 24 hours they were not

able to decide which kind of emergency they are tackling

with. He has also suggested that a system should be evoked

in such a way where attending emergency medical

technician can easily identify the nature of emergency, he or

she is tackling. This is very relevant in methanol poisoning

cases because antidote ethyl alcohol plays a vital role, if

administered in early hours of methanol alcohol poisoning.

Ethyl alcohol is metabolised in acetaldehyde which blocks

the action of formaldehyde which is the metabolite of methyl

alcohol. Early ingestion of ethyl alcohol proves to be life

saving during such episode. In the past also during such

episodes, the facility to provide ethyl alcohol in quantity of 20

102  

ml was created for all victims of hooch tragedy in outpatient

department of the hospital. This strategy greatly reflects on

morbidity and mortality related to methanol poisoning. If it

was in the knowledge of Emergency Medical Technicians

that the patient to whom they are handling is a victim of

hooch tragedy then they would have dispensed with antidote,

ethyl alcohol during the transport itself. He said that as

seriousness of episode was not known to victims and their

relatives, the treatment seeking behaviour was so weak. So

he suggested that a system of announcing that hooch

episode has occurred so that the people who have

consumed alcohol would come forward and get admitted for

the treatment.

5(B).15(2) The 108 ambulance transported the patients to a nearby

facility. This policy proved to a constraint on day one as

maximum patients were shifted to Shardaben hospital which

created a chaos at Shardaben hospital. This experience

made him to recommend that during such tragedy EMT

should have the power to shift the patients to another

facilities depending upon the need of the patient and

infrastructure and facility available at the hospital. He has

103  

also recommended that a list of Ambulances with Artificial

Life Support should be made known to all district heads so

whenever needed, they can ask for ALS ambulances from

other areas. He has also recommended that state disaster

management authority should prepare a plan and a grid of

such ambulances should be formed to manage larger

disasters in future.

5(B).16 On 1st April 2010, Dr. Manjula Aanchaliya, Medical

Superintendent of civil hospital, Ahmedabad was examined.

She said that total 98 victims of hooch tragedy were

examined and treated at the civil hospital, Ahmedabad. Out

of which 51 were cured and discharged, 23 absconded and 4

patients were transferred to institute of kidney diseases for

dialysis. The police was informed for the patients who were

absconding from the treatment. The MLC (Medico Legal

Case) formalities like collecting blood samples and sending

them to FSL for chemical analysis for the presence of methyl

alcohol were performed for all patients. They made special

arrangements where two messengers were deployed to

carry samples to forensic laboratory and were bringing the

reports to hospital in return so there was no delay in getting

104  

reports of chemical analysis from the forensic laboratory,

Gandhinagar. Thus there is an importance could be attached

as the fact about the exact chemical intoxicant and its

concentration is of prime importance to decide the treatment

regimen of any chemical poisoning. The type and

concentration of intoxicant in blood and related antidote and

ancillary treatment greatly reflects the patient outcome. The

forensic laboratory at Gandhinagar is well equipped with

modern and high-tech, state of art equipments which speak

of kind and concentration of poisonous elements within

minutes. This is a boon for the definitive treatment of any

chemical poisoning. Apart from hooch tragedy, the cases of

organ phosphorous poisoning are very rampant in the district

hospitals of the state. The time lapse in getting report of

chemical analysis is quite big, so doctors remain in dilemma

many a times about the kind of poisoning case he is dealing

with. The Commission recommends that in the era of speedy

telecommunication, a system should be evolved in such a

way that treating physician should receive the report from

forensic lab without lapse of much time. This will go a long

way to save patients of various poisoning in the state

hospitals. The second issue emerges here about patients of

105  

hooch tragedy who were treated at private hospitals like

Rudraksh, Kakadia and Dhanvantri hospitals where blood

samples were not sent to forensic laboratory. The concerned

doctors from private hospitals said that they were not

cooperated by local police. The Commission is of the view

that in such a situation the superintendent of civil hospital

crafted a good system for getting reports for her hospital. If

same system had been replicated by health or police

commissioner, it would have yielded better results in

combating morbidity and mortality of hooch victims.

5(B).16(1) On inquiring about the criteria of subjecting victim for

haemodialysis, she said that patients who were exhibiting

symptoms and signs of metabolic acidosis and blood gas

analyser reports exhibit Bicarbonate level less than 16 and

pH less than 7.2 were subjected to haemodialysis. The first

patient for dialysis was referred on 7th July 2009. The

Commission feel that treatment protocols for various

epidemics and catastrophe are readily available in medical

science. If the analysis of blood with blood gas analyser had

been initiated in private domain by state authorities, it would

have made remarkable difference. She has also said that

106  

treatment protocols were derived at civil hospital on day 1 i.e.

7th July, 2009. All civil hospital doctors followed the decided

treatment protocols which is good to notice and to be

appreciated. The Commission is of opinion that municipal

and health commissioner jointly should have decided to

implement uniform strategy of treatment in municipal run

hospitals, particularly Shardaben and L.G Hospitals. The

health commissioner should have circulated this treatment

protocols to all treating private hospitals as they were

treating victims without decided norms. Same way the civil

hospital was having 44100 ml of antidote, Ethyl Alcohol. The

Commission feels that Superintendent, Prohibition – Excise

and Health Commissioner should have played a leading and

supportive role in instantly supplying antidote to Shardaben,

Kakadia, Dhanvantari and Rudraksh hospitals. There were

so many instruments at civil hospital not working at the time

of episode but later on, many of them were repaired. The

Commission is of opinion that a steward committee should

take a weekly round of hospital and evolve a mechanism that

any important instrument is not lying unrepaired in the

hospital. She is having hospital specific emergency

107  

preparedness plan ready and did not receive complaint from

any one regarding treatment of the hooch victims.

5(B).17 Dr. Aanchaliya is of the opinion that posts of 16 medical

officers which is lying vacant should be filled in. Immediately

the Commission agreed with that and felt that if these posts

were filled in, the commissioner might not have been

compelled to depute doctors from field. Dr. Aanchaliya has

recommended that the security system and sanitation

services of civil hospital need to be strengthened. It is

recommended that it should be looked into as early as

possible.

5(B).18 Dr. Mahesh Kapadiya, R.M.O (Resident Medical Officer) and

in charge police surgeon of civil hospital, Ahmedabad

remained present on 1st April, 2010, and deposed before

commission in this connection with affidavit filed on 2nd

September, 2009. He is having the responsibilities of

carrying out Medico legal processes in the hospital. Dr.

Mahesh Kapadia mentioned that 6 patients were brought

dead in the hospital. Total 126 post mortems were performed

108  

on the victims of methyl alcohol poisoning from 5th July to 3rd

August, 2009. The viscera of all the deceased were sent for

FSL examination, and the reports were received within 10 to

15 days. As far as time interval for reports of chemical

analysis in routine poisoning it is 24 hours. He also

emphasised that since FSL is updated and mechanism of

speedier communications are already set in; they should

receive analysis reports earlier which will help doctors to

save lives of the patients of poisoning. On inquiry, he gave

information that there were around 14 cases where there

was no presence of ethyl alcohol. The Commission is of the

opinion that details of these 14 cases should be studied and

facts should be brought out whether the antidote, Ethyl

alcohol was prescribed to them or not? While narrating

problems faced in management of hooch tragedy, Dr.

Kapadiya said that dead bodies for post-mortem

examinations were brought to civil hospital from VS, LG,

Shardaben, ESIS (Employees’ State Insurance Scheme),

Kakadiya, Sardar, Rudraksh and Dhanvantari hospitals.

Around 100 cases came from these hospitals. Dr. Kapadia

narrated about lessons learnt that identification of the methyl

alcohol poisoning was difficult in the initial phase as there

109  

was no leading clue either from patients, relatives or from

police. This led to time lapse in identifying the hooch tragedy.

He emphasised that if chemical analysis reports are

communicated speedily then it can make difference. As

recommendations to manage such episodes more efficiently,

5(B).18(1) Dr. Kapadiya suggests that:

(i) Training of all medical officers to identify the episode is a

case of methyl alcohol poisoning.

(ii) The strong and speedy link of communication should be

established between civil hospitals and forensic science

laboratory to convey the report of chemical analysis

which will help in early diagnosis and treatment of the

patients.

(iii) Post-mortem work should be decentralised and as per

the government norms all the hospitals should have

facilities for conducting the post-mortem, particularly in

municipal hospitals.

(iv) The MLC formalities like informing the police are a time

consuming process and diverts the attention of doctor

from the treatment. A mechanism should be set in

110  

during such catastrophe that a person having some

hospital experience from police should perform this

task.

(v) As per emergency preparedness plan the mock drills

are required to be carried out at regular intervals which

are not done routinely by all hospitals. This is being

done by the big Corporate like ONGC, where intra

sector coordination is already established and mock

drills are carried out as a regular process where all

departments like Medical, Police, Revenue, Fire and

108 will participate at regular intervals to keep the

system active and which can be implemented at the

time of crises and also catastrophic situation which took

place.

(vi) As a part of emergency preparedness the concerned

Departments like Forensic Science Laboratory, Police

and Hospitals should be connected by mobile phones in

a 'close user group' scheme, which will enable the

concerned officers to be in touch with each other for

speedy communication. The reports and information

should be transmitted by using internet for

communication of reports or alerts. The list of existing

111  

ambulances in the city with its registration number and

drivers' residential address as well as contact phone

numbers, should be made available to all the Hospital

and a nexus of this ambulance can be formed, so that

more numbers of ambulances can be deployed during

crisis hours.

5(B).19 On the same day, i.e. 1st April 2010, Dr. Dinesh Chandana,

Resident Medical Officer of Sheth Vadilal Sarabhai Hospital

which is being run by the Ahmedabad Municipal Corporation

remained present before the commission for a hearing. He

had filed the affidavit before the commission on 7th August

2009. He provided information that 69 patients were brought

to V.S. Hospital. Out of which 47 patients were discharged

from the hospital. 1 (one) patient absconded from hospital

during treatment. 20 (twenty) patients expired in hospital

during treatment and 1 (one) patient was brought dead in

casualty department of the hospital. Here also the hospital

authorities informed police for patient which was absconding

from the hospital. While narrating any constraints for

manpower or infrastructure, Dr. Chandana said that they

have not faced any hardship in treating patients during

112  

episode as newly designed trauma centre with modern

facilities to treat cases in emergency was made already

functional before tragedy struck Ahmedabad city. The

quantity of ethyl alcohol mentioned in affidavit was 10 + 50.

Dr. Chandana explained that 10 bottles of ethyl alcohol was

already in stock in hospital and they procured 50 bottles

more on the same day. On asking about the licensed

capacity to store ethyl alcohol permitted by department of

prohibition and excise, he showed his ignorance and said

that he will send the copy of the license to commission’s

office, which he did and it was studied that it was 200 litres

for absolute alcohol and 300 litres for rectified spirit per

month. This seems to be adequate for a busy hospital like

V.S. On interrogating about their hospital specific emergency

preparedness plan he said that it is ready and they will

adhere to it in future. He said that medical triage was

implemented during episode but during the visit of the

hospital, the I.C.U of the hospital was housed with many non

serious cases and the Commission observed chaos due to

presence of crowd of relatives in the hospital I.CU. Resident

doctors were busy in dispensing clinical care to the serious

patients but one patient on active life support system was

113  

already dead and life support was unnecessarily continued.

On drawing the attention of the treating resident, the active

life support was withdrawn. The Commission has studied the

emergency preparedness plan of the hospital and it was

lacking on many important fronts like:

5(B).19(1) Ambulance network with institutional and driver’s contact

details, registration number, pool of ambulances and

ambulances deployment plan during major emergency.

5(B).19(2) Hospital Evacuation Plan is not mentioned which will be

executed if situation demands. i.e. Bomb blast, collapse of

building or in case of fire.

The Hospitals Authorities are all well aware of the

incidence that took place in cardio thoracic laboratory of V.S

Hospital in the month of April, 2010. There was a fire and

evacuation of patients was required. Such incidences are

rare but readiness for disaster mitigation plan and its timely

implementation significantly diminishes the losses in terms of

life and money.

114  

5(B).19(3) Plan of mobilization and deployment of manpower in case of

extraordinary catastrophe

5(B).19(4) Details of mock drills carried out by Institute:

On discussion, Dr. Chandana agreed and assured

commission that they will take care of the lacunae and will

prepare a fool-proof plan. Dr. Chandana on examination

answers that nobody from the State Government visited the

hospital and provided guidance for treatment protocol and

implementation of emergency plan. Commission feels that

except civil hospital Ahmedabad, not a single hospital has

paid attention on this very vital issue which has its definitive

role in present era where emergent threat of terrorist activity

is impending in the country. It is not that hospitals do not

want to implement. On the contrary, every hospital wanted to

implement it but did not receive proper guidance from

concerned departments. The Commission felt that it is a duty

of Health commissioner under whom the EMS authority is

constituted and Director of Disaster Management Authority

should jointly provide leadership to take care of this

neglected task.

115  

5(B).19(5) Around 35 (thirty five) patients were subjected to

haemodialysis depending upon the test results which are

indicative of severe metabolic acidosis. On questioning,

whether blood samples of all hooch victims were sent to

Forensic Sciences Laboratory; Dr. Chandana replied that

initially one or two patients might have shirked due to extra

ordinary situation but then blood samples of all patients were

sent for chemical analysis. There was no complaint made by

any one regarding treatment during the hooch episode at

V.S. Hospital. Dr. Chandana recommends to the commission

after learning through this tragedy that Sheth Vadilal

Sarabhai Hospital should install more dialysis machines in

the nephrology department. The other major municipal

hospitals like Smt. Shardabaen Hospital and Sheth L.G.

Hospital should also own their independent dialysis units.

Commission agrees with this recommendation that all major

municipal hospitals should be equipped with dialysis units.

Dr. Chandana is also of opinion that V.S. Hospital should

have its own MRI machine in the campus for a better

treatment of the patients.

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5(B).20 The importance of police yaadi to a treating physician carries

vital importance. The value of police yaadi has been

discussed in detail previously. The police constables who

issued an yaadi reacted indifferently at Dhanvantari hospital.

Commission took notice of it and desired to examine him

under what circumstances he has not followed cases at this

hospital. So on 1st April, 2009, one police Head constable B.

No. 3154 of Bapunagar police station, Mr. Ramsinh

Cheharsinh remained present before the commission for

hearing. He was questioned and answered in Gujarati which

was translated and then recorded in English. During hooch

episode few patients were admitted in Dhanvantari hospital

of Bapunagar area. The case files of the patients admitted

and treated at Dhanvantari hospital were studied in detail by

commission. When patient is admitted in the hospital and

doctors feel that it needs to be notified to police as a medico

legal case, the duty doctor informs the concerned police

stations. The responsible police officer comes to the hospital,

meets him and discusses the case with the doctor and

gathers first hand information from the relatives and patient.

If patient is unconscious, then he exploits other sources of

information and proceeds with the processes of investigation

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as decided by rules. During his visit of hospital, he narrates

the brief details of facts he derived from primary information

and issue a ‘police yaadi’ to attending medical officer and

requests him to let him appraise of further findings pertaining

to health and also request him to issue a medical certificate

of the outcome. He frequently visits the hospital in a process

of investigation which is rarely been followed up by most of

the inquiry officers. The ’police Yaadi’ is an important tool for

the entire process of investigation. It is a vital clue for

preparing a charge sheet in due course and weighs as an

important document in the judicial proceedings. The

commission is of the opinion that ‘police yaadi’ is a guiding

force to decide the line of treatment by a medical officer.

Particularly in case of poisoning, if type of poison consumed

is made available to the treating doctor then he can direct

and modify treatment accordingly depending on symptoms

and signs with regard to the substance with information

provided to him in police yaadi. During course of study of

Dhanvantri hospital, one Mr. Prakashbhai Malaviya a case of

Methyl Alcohol poisoning was admitted under Dr. Arvind Giri.

The patient was admitted in the evening of 9th July, 2009 and

expired in the morning of 10th July, 2009. Patient was

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brought in serious condition. The police yaadi issued by Mr.

Ramsinh Cheharsinh is inconclusive of any fact which can be

helpful medically and/or legally. He wrote in police yaadi that

‘patient is brought to hospital as patient is having vomiting’.

This is a very common practice by police officers and doctors

during course of suicidal poisoning. If patient survives then

no case is registered on the ground of police yaadi which is

inconclusive. The favours done are appreciated in terms of

reward which is one of the ways of corruption. Here Prakash

Malavia died of Laththa poisoning and concerned police

personnel exhibited action inertia in investigation. So we had

brought this to the notice of the police inspector. He recorded

the statement of head constable on 11th November 2009 and

forwarded the statement to commission without any remarks

or opinion. During the course of hearing Mr. Ramsinh

confirmed that police yaadi and statement bears his

signature. While police yaadis are served in MLC case, a

question was asked whether complaint of ‘Vomiting’ bears

any MLC significance. He answered that he cannot say

exactly about it. He said that patient is having a history of a

breathing problem. On enquiring the doctor and discussing

about the patient, the answer was negative. He did not know

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the patient was a victim of hooch tragedy and he has not

followed up of reports of patient as investigation was done by

someone else. Here police yaadi is issued to doctor for the

sake of formality only. The responsibility to collect certificate

is not vested to the police who have initiated investigation.

The Commission has felt that the regularization and

innovative modification in the present system of investigation

and issuing police yaadi needs improvement and supervision

of the higher officer.

5(B).21 In the same way another police official also underestimates

the importance of police yaadi, so he was also summoned.

On 6th April 2010, Mr. J.S. Vaghela, police sub inspector of

Bapunagar police station was examined by commission. Mr.

Vaghela, A responsible police officer visited Dhanvantari

hospital during episode and carried out primary investigation.

During his visit, he issued a police yaadi to Dr. Arvind Giri in

case of Mr. Champakbhai Billubhai Parmar who consumed

illicit liquor. He deposed before the Commission that police

yaadi is issued when police suspects something wrong about

the patient. He mentioned that the symptom of ‘Vomiting’

ordinarily cannot be considered as a medico legal case. He

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further explained that during the episode all patients were

coming with the history of vomiting so he mentioned

‘vomiting’ only. The commission does not agree with his

explanation because ‘police yaadi’ is a valuable document in

medical treatment and charge sheet. It is a primary

document which may give important clue initially for entire

process of investigation and is given enough importance in

the court of law. For the attending doctor, Police yaadi gives

important and decisive clue for deciding line of treatment. If

the police yaadi had mentioned that patient has consumed

illicit liquor like ‘laththa’ then ignorant mind of treating

physician would have sufficiently alerted to think a case is

nothing but is a case of ‘Laththa Poisoning’. This has

happened at the Dhanvantari Hospital as treating doctors

were not aware of the situation that Laththa poisoning cases

have started getting admitted in their hospital. Mr. Vaghela

has not discussed the case with the attending doctor. The

doctors at the Dhanvantari hospital alleged that they were

not getting enough cooperation from police stations and

blood samples were not taken away by the police for

chemical analysis. In an endeavour to draw attention towards

this fact, Mr. Vaghela replied that he had asked for blood

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sample but he did not wait for it and left the place saying that

he had some work at the police station. The task was given

to Mr. Ramsinh who also did not collect the blood samples.

It is a very common experience of a doctor in a hospital

where a case of suicidal poisoning comes for the treatment.

Many a times, relatives do not come forward with history of

poisoning due to social stigma. The investigating police

constables also deliberately avoid mentioning of ingestion of

poison. In most of the cases, the patient is saved and on the

basis of inconclusive police yaadi, the case is filed. The

convinced relatives reciprocate this favour in cash or kind.

So at the Commission, we firmly believe that police yaadi

should be viewed seriously by investigating police officer and

should mention all the details which investigating officer has

come across. It should be treated as a priority both by the

doctor and police.

5(B).22 On 8th April 2010, the doctors of Dhanvantari hospital and

Kakadiya hospital were examined. At Dhanvantari hospital

seven Patients were admitted and treated who were victims

of hooch tragedy. The Dhanvantari and Kakadia hospitals

are private charitable hospitals. Earlier the Commission was

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informed of all treating hospitals to provide information on

various issues vide letter no. Hooch/COI/48/09 dated

31/07/2009. In response, Dhanvantari hospital also

submitted information and photostats copies of case records

of the patients. The information and case records were

inconclusive of certain facts. These raised queries regarding

the diagnosis and treatment given to the patients so a letter

to seek clarification no. 740/09 dated 4/11/2009 was sent to

Dhanvantari Hospital. In the reply, the treating doctors filed

an affidavit answering queries and these doctors appeared

before commission on 8th April 2010.

5(B).23 Dr. Hitesh Prajapati who is attached to Dhanvantari and

Kakadiya hospital filed an affidavit on 28th November and

30th November 2009 and remained present before the

commission on 8th April, 2010. In the initial report submitted

on 24/08/2009 by Dhanvantatri hospital, it was mentioned

that Mr. Pradeepsinh was admitted in the hospital as a

methanol poisoning case. The patient was transferred to

Kakadiya hospital for further treatment where his name was

mentioned as Satyanarayanasinh. This query was compiled

by Dhanvantari hospital by submitting an affidavit from Mr.

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Pradeepsinh that his father Satyanarayanasinh was admitted

after consumption of illicit liquor. Asking clarification on this

issue, Dr. Hitesh Prajapati submits that actually

Pradeepsinh’s father Mr. Satyanarayanasinh was a victim of

hooch tragedy and in a hurry Pradeepsinh gave his name as

a patient, which he rectified when patient was transferred to

Kakadiya hospital. It was a mistake of a case registering

clerk at the Dhanvantari hospital. Dr. Hitesh Prajapati

provided information that the blood of Mr. Satyanarayanasinh

was sent for chemical analysis. So during hearing, he was

requested to show the blood test reports of the patient, Mr.

Satyanarayanasinh. In reply to the same, Dr.Hitesh Prajapati

said that he had sent the blood for examination and he was

under the impression that the report has come to the

Kakadiya hospital. On searching from the records, he has

not seen the report of the chemical analysis of blood either

with Kakadiya hospital or Dhanvantari hospital. He said that

it seems that blood was not collected and sent for chemical

examination due to chaos during episode and this was his

first experience of treating such hooch victims. The

concerned hospitals were also experiencing attending hooch

victims for the first time ever since their inception. The case

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papers of Mr. Satyanarayanasinh at Kakadiya hospital

mentioned that on 16/7/2009 and 17/7/2009, ethanol 20 cc

with orange juice was prescribed by Dr. Prajapati. In an

endeavour to know the source from where the antidote was

procured by a private hospital, Dr. Hitesh Prajapati answered

that they used rectified spirit available in the hospital. The

same patient was treated by him at Dhanvantari hospital on

8/7/2009. The patient was not prescribed Ethanol when

treated on 8th July, 2009. On questioning, Dr. Hitesh

Prajapati said that the ethanol was not available at

Dhanvantari hospital when treatment was started. The

patient was first admitted at Dhanvantari hospital where the

facility of ventilator was not available so patient was

transferred to Kakadiya hospital. At Kakadiya hospital in an

effort to put him on ventilator, he inserted Ryle’s tube.

Aspiration smelt that of alcohol so he realized that the case

was of methanol poisoning and treated him on that line and

used the substitute which was readily available with the

hospital. Fortunately the patient has survived. Since Dr.

Hitesh Prajapati was a young, enthusiastic privately

practicing physician, commission requested him to provide

information about problems faced and lessons learnt during

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this episode. What Dr. Prajapati said was eye opening for all

of us and need drastic ramification and supervision by state

government health officials. Dr. Hitesh Prajapati said, he

had never attended this type of episode in the past so he

was not having practical experience of treating such cases.

Once he learnt that the cases are hooch victims, he gathered

the information from available sources and treated the

patients on the advice given by his seniors. He believes that

the training of the private doctors should also be carried out

by the Government Health Department so that if such

episode recurs then it can be tackled efficiently by physicians

in private domain. Dr. Hitesh Prajapati said that he was

treating the victims of hooch tragedy for the first time; he

would have been greatly helped, if treatment protocols and

the ways the methanol poisoning case manifests to a treating

physician had been circulated to private practitioners. He

treated the case with the help and clues from his seniors of

his own but he felt that this should have been done by the

experienced government health officials. He suggested that

ICU of all private hospitals should be equipped with the

facility of ventilator and should be connected with the

facilities where an ABG machine is available. The hospitals

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which are having tie up with laboratories having a facility of

ABG machine should only be allowed to treat such patients

officially and not by others.

5(B).24 He also stressed on the importance of social education of the

people which are engaged in consumption of country liquor

about the injurious and hazardous outcomes of the illicit

liquor and should be made knowledgeable that such habit

may even lead to death like this episode. He also suggested

that during such episodes, the treating doctors should be

informed regarding the kind of outbreak very promptly by

different sources like department of health or police. He also

suggested that hospitals which are ready to treat methanol

poisoning should be readily made available with the antidote

i.e. Ethyl Alcohol.

5(B).25 Dr. Mukeshbhai Patel, the visiting physician of Dhanvantari

Hospital remained present before commission on 8th April

2010, in response to affidavits submitted by him on

28/11/2009 and 30/11/2009. One Mr. Shitalbhai Thakore was

admitted under his care on 10/7/2009. The blood sample of

the patient was not sent for chemical analysis. In an

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endeavour to know the reason, Dr. Mukeshbhai Patel replied

that blood sample was collected by him but was not taken

away by the police for chemical analysis. He added that this

is a routine experience in Dhanvantari hospital, when a case

of organo-phosphorous poisoning is admitted in their

hospital. The indifferent attitude of police in obtaining

samples for chemical analysis needs to be rectified. On

questioning about administering the antidote, Ethyl Alcohol;

Dr. Patel replied in negative that patient didn’t exhibit the

symptoms of Methanol poisoning and police did not inform

him about the episode. However, he agreed that the

antidote, ethyl alcohol was not available with Dhanvantari

Hospital. The case records submitted on 24/8/09 were

differed with those submitted with affidavit, Dr. Patel clarified

that there may be fallacy on the part of the medical officer in

copying the records of the hospital. During discussion, Dr.

Mukeshbhai Patel has given few recommendations that there

should be a mechanism like alarming system by which the

doctors of the public as well as private domain should be

intimated that catastrophe has taken place and doctors with

their hospitals should remain in readiness to tackle the

situation. The nature and magnitude of the health related

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catastrophe should be intimated to all treatment providers.

The treatment protocols, possible transfer/reference

strategies should be intimated in shortest possible time. The

health department should owe responsibilities in making

antidote available to private hospitals and commissioner of

health should send government officials to guide private

doctors and should solve problems pertaining to Medico

Legal formalities. He adds that the episode of hooch tragedy

recurs at very long intervals, so there are possibilities that

doctors may not visualise that the patient to whom they are

attending is a hooch victim. Even if they know that the patient

is a hooch victim, the attending doctor may not have latest

updates in treatment of Methanol Poisoning. This situation

emphasises the need of training for all doctors. This should

be carried out at regular intervals. The Commission is of

opinion that Gujarat Forensic Sciences University has been

established recently and has got sufficient number of subject

experts with it. The forensic science university may be

requested to schedule different training courses for the

doctors as well as police personnel. He also recommends

that health department should set in a mechanism where in a

check list should be made available and should be monitored

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by competent health authority regarding availability of

manpower, infrastructure and antidote for different poisoning.

The hospitals lacking should not admit the patient but should

send them to a nearby facility. He expressed his concern that

nobody from the health department visited their hospital and

provided guidance. He felt that an effective chain of

communication and supervision should have set in. An

expert from State Government Hospital with treatment

protocols should have visited and guided them regarding

better management of this episode. On questioning from Mr.

Chetan Shah, the learned advocate from government, Dr.

Patel submits that their hospital is a charitable hospital run

by Swami Vivekanand Karnavati Charitable Trust. Dr. Patel

further denied about police cooperation regarding Medico

Legal formalities at Dhanvantari Hospital.

5(B).26 Dr. Arvind Giri of Dhanvantari hospital attended the hearing

on 8th April 2010, in connection to affidavits submitted by him

on 28/11/2009 and 30/11/2009. He was also asked about the

disparity in records submitted on 24/8/09 and with affidavits.

Dr. Giri explained that there was a rush at the time of

episode which resulted in disparity which they have

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corrected later on. The name of one patient named Mr.

Natwarlal Gohil was included previously but his name was

omitted later on. Explaining this, Dr. Giri said Mr. Natwarlal

Gohil was not a case of Methanol Poisoning. It was a

mistake in submitting the records. The case of one Mr.

Rajesh Vaghela was also submitted on 24/8/2009 as a victim

of hooch episode. His case is also denied by Dr. Arvind Giri

as a case of methanol poisoning. The CT scan report of

Brain of Mr. Rajesh Vaghela was mimicking those of

Methanol Poisoning. The treatment record also had certain

fallacies which were submitted on 24/8/2009 which was

corrected later on when commission raised certain queries

vide letter no.740/09 dated 4/11/09 about clarification of

certain facts. The post-mortem of the deceased was not

carried out. Commission is of opinion that Mr. Rajesh

Vaghela was a missed case of Methanol Poisoning. Partly on

agreeing upon this, Dr. Arvind Giri said that it may be a case

of methanol poisoning but relatives or police did not inform

about the episode and he treated the case as per the history

given by the relatives. On examining the records, the blood

sample of patient Mr. Champabhai Parmar was not sent to

Forensic Science Laboratory. On explanation, Dr. Arvind Giri

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submits that they have requested the police to take the blood

samples for chemical analysis but they did not do that. The

ethanol which is an antidote for methanol was not

administered at Dhanvantari Hospital; Dr. Giri agrees that it

was not available with the hospital. The police yaadis served

at hospital were vague. Dr. Arvind Giri agrees that police

yaadi plays an important role in investigation and gives a

clue to treatment provider about the disease or situation he is

tackling. He said that if police yaadi was conclusive of

‘ingestion of country liquor’ it would have given him the clue

that he is tackling the cases of Methyl Alcohol Poisoning.

This once again stresses on the point of writing police yaadi

just for sake of writing it. It should bear importance of having

content in it. The Commission advised the Commissioner of

Police to take the issue of training of police for tackling such

grievous situation more efficiently.

5(B).27 In one case Mr. Prakash Malaviya, the blood was not sent for

chemical analysis again and patient was given rectified spirit

via Ryle’s tube. On asking about not opting for urgent

haemodialysis, Dr. Arvind Giri explained that “very lately it

came to our knowledge that this is a case of Methanol

132  

Poisoning and by the time we learnt; the patient’s condition

got deteriorated very quickly, so it did not provide time to

send him for haemodialysis.” He agreed with the fact that if

he had received the report of presence of methyl alcohol in

the blood within few hours of admission and if the

concentration of the methyl alcohol alarming enough in the

blood he would have sent him for haemodialysis. This

situation, itself speaks high about importance of quick

diagnosis and prompt remedial actions. The cases in private

domain are left untouched by health commissioner, whom

we expect to play a leading and stimulating role in such

situation. The situation has exhibited obvious difference in

case of Mr. Babubhai Solanki who was timely transferred to

Sidhdhi Vinayak Hospital for hemodialysis. Dr. Arvind Giri

agreed upon the fact that he could not save Rajeshbhai and

Prakashbhai in the absence of proper history and clue from

others. During hearing, Dr. Arvind Giri recommended that

during the event of such rare type of episode, it should be

intimated to treating institute on war footing basis. Proper

training of doctors for tackling such emergencies should be

carried out regularly at the periodic intervals. The mechanism

of knowledge that methanol poisoning episode has taken

133  

place by different sources will help private doctors in treating

victims in future. He recommends that health department

should have taken initiative to guide them and provide those

help for making antidote available. If this is taken care of

then they will be able to cater such episode efficiently in

future.

5(B).28 On 8/4/2010, Dr. Hitesh Ramanuj remained present before

commission, in response to affidavit made by him in a

capacity of a superintendent and treating physician of

Dhanvantari Hospital. He submitted his affidavit on

30/11/2009. The Commission asked him about the

availability of antidote, Ethyl Alcohol at the Dhanvantari

Hospital, Dr. Hitesh Ramanuj replied that it was not available

with the hospital. Two different set of case records with

different information were provided by Dhanvantari Hospital.

Commission asked him to clarify the circumstances under

which they did it. Dr. Hitesh Ramanuj clarified that on receipt

of the letter from hooch tragedy commission of inquiry; Dr.

Paresh Patel gathered case records from the hospital and

presented the records to the commission without any

authenticity. He is not able to identify the signature with

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whom the information was submitted on 24/8/09. Dr.

Ramanuj mentioned that the concerned police authority did

not inform about hooch tragedy taking place in surrounding

area. During hearing, Dr. Ramanuj said that he was in

charge superintendent of the hospital but at the time of

episode he was not present in the hospital so personally he

cannot say that the police has not informed. While giving

suggestions and recommendations, Dr. Ramanuj feels that

there are many private, charitable and corporate hospitals in

the city. He feels that supervision of these hospitals in terms

of infrastructure, manpower, and availability of the medicines

as well as preparedness of institute to tackle such

catastrophe should be monitored and supervised by the state

health department. Nobody from health department did so

but somebody from health department should visit the

hospital and guide them and should solve their problems.

Some form of grants to charitable hospital should be made

available to charitable hospital so that the government may

make them more responsible during episode. At present they

are providing treatment at much subsidised rates. Talking

about emergency preparedness plan of his hospital, he said

that they are working with honorary personnel with less

135  

manpower so they have not prepared the plan document of

the disaster and emergency preparedness plan. Talking on

behalf of his trustee, he assured that he will initiate the move

in this direction. We at commission believe that since EMS

(Emergent Medical Service) act has enacted in 2007,

Government should pass directive where in all city hospitals

should have these plans ready with them as per decided

guide lines. The process to obtain licences for running a

hospital and providing uniform treatment at uniform charges

should also be thought to minimise recurrence of such

treatment fallacies during episode.

5(B).29 Mr. Paresh Jagjivandas, a trustee from Kakadiya Hospital

remained present on 8/4/2010 before the commission and

deposed that five patients of hooch tragedy were admitted to

Kakadiya Hospital. Out of which one patient has died. Mr.

Ramesh Rathod was admitted in the hospital on 11/7/2009

and was not given antidote, Ethyl Alcohol. On asking about

it, he showed his ignorance. On asking about the stock of

antidote, Ethyl Alcohol, he denied that his hospital was not

having the stock of Ethyl Alcohol. The commission asked him

to give suggestions, in response of which he recommended

136  

that prohibition policy should be strictly implemented. The

private hospitals which have no experience of treating such

rare incidences should transfer the patients to nearby well

equipped Hospital with such facility. The training of

administrators should also be taken up to clear up

administrative issues related to such emergency. Learned

advocate, Mr. Kodekar inquired about the sufficient

infrastructure existing at the hospital and licence of Ethyl

alcohol with the hospital. Mr Paresh Jagjivandas replied that

the hospital has enough infrastructure and they will process

further to obtain the licence of Ethyl Alcohol.

5(B).29(1) Looking at the experiences learnt during the visit of the

hospitals and the hearing process, we directed the health

commissioners to express their views in tackling hooch

disaster medically as in regards to availability of antidote and

uniformity in following treatment protocols.

5(B).30 In reference to our notice dated 25/3/2010, the present

commissioner filed an affidavit on 26/4/2010. Mrs. Vijay

Laxmi Joshi, the present commissioner took over charge

from 09/11/2009. She mentions that Dr. Amarjeetsingh had

137  

been on the post of commissioner during the time of

incidence. He was well versed with each and every

administrative and technical measures those have been

taken to overcome the situation. She said that appropriate

answers of certain points asked by commission can only be

replied by him so she has forwarded the copy of notice to Dr.

Amarjeetsingh. She further stated that hooch tragedy had

occurred in Ahmedabad on 7th July 2009 to 21st July 2009.

During this period 146 casualties and total 441 patients

(includes 146 casualties) were reported to civil hospital

Ahmedabad and Municipal corporation hospitals. She

narrated the details of action taken by her predecessor

Commissioner Dr. Amarjeetsingh and requested commission

to get further details from him.

5(B).30(1) Dr. Amarjeetsingh, Executive Director, Jansankhya Sthirta

Kosh and former commissioner of health and medical

services, Gujarat state was a responsible officer at the time

of catastrophe as he served on that post from 1/1/04 to

30/9/09. He submitted an affidavit dated 3rd May 2010 to

commission on 4/5/2010. He submits that the victims of

hooch tragedy started reporting at the Ahmedabad Municipal

138  

Corporation hospitals sporadically from 6th July 2009. Cases

reported in bigger numbers on 7th July, 2009 and by late

evening deaths were also reported. As the numbers were

increasing, an emergency meeting was called by commissioner of

health on 8th July, 2009 morning with medical officers of BJMC.

Anyhow, in spite of instructions, no minutes of meetings,

administrative orders or relevant records pertaining to this

episode were submitted to the commission’s office. The civil

hospital Ahmedabad was put in full state of readiness. This

was followed by a visit to the affected patients in the

municipal hospitals. The team met municipal mayor and

municipal commissioner and other municipal medical

professionals at Shardaben hospital. They identified the

patients who required immediate dialysis and ventilator

support. Control room was set up at civil hospital

Ahmedabad and commissioner’s office. Cashless IPD

(Indoor Patient Department) services were made functional

for victims treated at Shalby and Medisurge hospitals. He

states that total 2517 mock drills were carried out by Gujarat

State Disaster Management Authority. As per EMS act, such

drills also need to be carried out by government hospitals which

seem to be ignored by health department. The Commissioner of

Health control room collected the figures for review at highest

139  

level during the period 7th July to 21st July 2009 with a

total of 441 patients (including 146 casualties) reported in the

city of Ahmedabad. Expert eye care was provided to total

364 cases by M.J. Institute of Ophthalmology and Nagri

hospital. 14 doctors from peripheral (distant) health and

medical institutions were deputed at civil hospital

Ahmedabad for post-mortem and emergency duties. At

kidney hospital, 15 haemodialysis machines and 30 indoor

beds were identified for hooch victims. Dr. Amarjeetsingh

mentions that casualty at IKDRC (Institute of Kidney

Diseases and Research Centre) was prepared for immediate

management of affected patients from other hospitals at

IKDRC and antidote was procured from the department of

pathology, Lab. Medicine and Transfusion service. The

commissioner of health and medical mentions that as far as

hospitals in private domain concern Sterling, Shalby, Sal and

Apollo hospitals were kept in readiness. The Medisurge and

Shalby hospitals were contacted for haemodialysis

treatment. The commission visited various hospitals including

civil hospital where medical triage was not implemented and non

availability of antidote. Particularly to private hospitals like

Dhanvantari, Rudraksh and Kakadiya hospitals suffered with

140  

non availability of anti-dotes. The medical triage is

mandatory by State Disaster Management Plan, and must be

conducted by health department at its hospitals. These

activities are also mandatory as per requirements of the EMS

(Emergency Medical Services) Act.

5(B).31 Dr. Amarjeetsingh stated that a total of 2517 (two thousand

five hundred seventeen) mock drills were carried out by

Gujarat State Disaster Management Authority (GSDMA) but

does not mention any activities carried out by the health

department. It is very important for hospitals as high-

probability man-made or natural disasters are storming State

of Gujarat at regular intervals are earthquakes, cyclones,

floods, chemical poisoning, road-side or factory accidents,

and terrorist attacks. These all disasters require preparing

Action Plan which incorporates regular mock-drills, and

Hospital-specific Emergency Preparedness Plan for each

district and taluka level hospitals. This standard practice was

accepted as a regular phenomenon and as an important

policy of health department when EMS Act was enacted by

Gujarat State Assembly.

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Chapter-6

REFERENCE NO. 4

Details of the adequacy of measures for effective implementation of prohibition laws by the police and

recommendations

6(A) Action Plan for effective police action

(Police Reform Part – I)

PART I

STEPS REQUIRED TO BE TAKEN BY THE POLICE AND

GOVERNMENT SO AS TO AVOID SUCH TYPE OF

HOOCH TRAGEDIES IN FUTURE.

6(A).I Prohibition in Gujarat state is as old as the state itself i.e.

right from inception i.e. 1/5/1960. Every Government in the

Gujarat state has been very keen to effectively enforce the

policy of total prohibition. Even though large number of

offences committed against the Prohibition laws has been

detected, it is felt that there is a considerable scope for

improvement in the enforcement of prohibition. Many Laththa

tragedies have occurred during past about 33 years in

Gujarat state. In every such tragedy, methanol was found to

be the cause of death. Many inquiry commissions were set

142  

up by the successive State Governments to find out the

reasons and make recommendations so that prohibition

policy could be implemented effectively to prevent such

incidences. Recent Laththa tragedy in Ahmedabad city

highlights the need for a fresh look at the arrangements for

the effective enforcement of prohibition Laws and its policy.

With a view to probe into the circumstances leading to the

tragedy and to suggest ways and means for the prevention

of such tragedies in future, the State Government has

decided to constitute a high level commission. Many

changes have been made time and again in the prohibition

policy.

Steps for Amending Bombay Prohibition Act

6(A).2 The Government of Gujarat has introduced a Bill in the

Gujarat Legislative Assembly, known as Bombay Prohibition

(Gujarat Amendment) Bill 2009(Gujarat Bill 14 of 2009) with

a view to further amend the Bombay Prohibition Act, 1949.

The Bill was introduced on 15/07/2009 to amend Act viz.,

Bombay Prohibition (Gujarat Amendment) Act, 2009. Copy of

the Bill for amending Act is annexed herewith and marked as

ANNEXURE “A”. This Act may be called Bombay

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Prohibition (Gujarat Amendment) Act 2009. It shall come into

force on such date as the State Government may by a

Notification in Official Gazette appoint the date. Before we

refer to the provisions of the Act, we may also refer to the

very laudable object and reasons which have been

appended with the Bill which are as follows:

Objects and Reasons

6(A).2(1) The anti-social elements adulterate liquor by mixing the

methyl alcohol or other poisonous substances and make the

spurious liquor which is commonly known as Laththa. The

consumption thereof may cause harmful effect to human

body or cause death of a person.

6(A).2(2) Recently, due to such type of illegal activities, some people

have lost their lives. With a view to prohibiting the misuse of

such illicit and spurious liquor, it is considered necessary to

amend the existing provisions of the Bombay Prohibition Act,

1949, and make stringent provisions for offences relating to

manufacturing, selling, buying, keeping, transporting etc., of

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such spurious liquor and also the construction of distilleries

or breweries.

6(A).2(3) With a view to prevent such incidents of Laththa

consumption causing death of persons, it is considered

necessary to insert a new Section 65.A which inter alia

provides that any person who manufactures Laththa,

constructs any distillery or brewery, sells or buys, uses,

keeps, transports or possesses Laththa shall be punished for

a term which may extend up to ten years but not less than

seven years. There is another provision available by which,

if there is a report of death of a person by consumption of the

said Laththa, the person who has manufactured, kept, sold

etc., shall be punished with death or imprisonment for life

and also fine.( sum of rupees)

6(A).2(4) There is another stringent provision available with which the

vehicles that are used in transport of liquor (including

Laththa) shall not be released even on bond or surety. In

cases where the quantity of the seized liquor exceeds the

quantity as may be prescribed by rules, till the final order of

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the Court. Such vehicle would be liable to be confiscated as

per the existing provisions of Section 98.

6(A).2(5) In Sub-Section 2(23.A) Legislation has defined “Laththa” viz.,

“Laththa” means spurious liquor, which contains methanol or

any other poisonous substances, which may cause harmful

or injurious effects to the human body or death of a person.”

6(A).2(6) In Section 65.A it is introduced that “(1) Notwithstanding

anything contained in this Act, whoever, -

(a) manufactures laththa,

(b) constructs or works any distillery or brewery for it,

(c) sells or buys laththa, or

(d) uses, keeps, transports or has in his possession

laththa, -

shall, on conviction, be punished with imprisonment for a

term which may extend up to ten years, but shall not be less

than seven years and also with fine.

Sub-(2) of Section 65.A provides that when there has been

death or any person by the consumption of the said Laththa

mentioned in sub-section (1) above, the person who has

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manufactured, kept, sold or arranged to make it drink or

distributed laththa shall, on conviction, be punished with

death or imprisonment for life and shall also be liable to fine.

Sub-section (3) of Section 65.A provides that whoever

keeps, sells, buys or supplies any material for manufacture

of laththa and when there has been death of a person by the

consumption of the said laththa shall, on conviction, be

punished for a term up to imprisonment for life and shall also

with fine.”

6(A).2(7) The said Amending Act also provides under Section 94.A

that “Any Prohibition Officer or Police Officer duty bound

under Section 116.C, fails to send the sample of liquor to

Forensic Science Laboratory of the State for its detailed

report shall, on conviction, be punished with imprisonment

for a term which may extend up to one year and with fine

which may extend to three thousand rupees.”

6(A).2(8) Section 98 has also been amended. (Section 115 has also

been amended):

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6(A).2(9) Section 115 has also been amended; Section 116 has also

been amended; Section 116.C has been inserted which

provides that it shall be the duty of a Prohibition Officer or

Police Officer who have seized any liquor to forward

immediately without any loss of time, the sample of the same

to the Forensic Science Laboratory of the State for a detailed

analysis report.”

6(A).2(10) Now, the Governor of Gujarat has assented aforesaid Bill on

1st December, 2011. After assenting, the Government of

Gujarat has issued a Notification in exercise of power

conferred und`er Sub-section 2 of Section 1 of Gujarat

Amendment Act, 2009 (Guj. 29 of 2011) to appoint 13th

December, 2011 as the date on which said Amendment Act

shall come into force. Said Amendment Act has incorporated

almost same provisions which were contained in the Bill,

which the Commission has already referred earlier. The

aforesaid Amendment Act particularly Section 65.A of

Bombay Prohibition Act, 1949, was amended, wherein it has

been provided that any person by the consumption of the

said Laththa mentioned in sub-section (1) above, the person

who has manufactured, kept, sold or arranged to make it

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drink or distributed Laththa shall, on conviction, be punished

with death or imprisonment for life and shall also be liable to

fine. A copy of the said Notification for implementing the

Amendment Act giving assent of the Governor of Gujarat and

Gujarat Act 29 of 2011 is annexed as ANNEXURE “B”.

6(A).2(11) The Commission is of the firm view that while amending the

Act, the officer who administers the Bombay Prohibition Act

will have ample power and jurisdiction to curb the

manufacture, keeping, selling or arranging to make it drink or

distribute Laththa among the people. Thus, Prohibition Act

would now have more deterrent effect among the common

man who is dealing with spurious liquor known as Laththa.

6(A).3 The Commission has come out with the following

suggestions to control the illicit trade of liquor and import of

IMFL from other States.

6(A).4 The Government of Gujarat should strongly represent to the

Union Government to ensure that the distilleries situated in

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wet neighboring States and Union territories do not produce

excess liquor than the prescribed limit set under their

licenses. It has been observed that the excess quantity

produced by those States and Union territories is invariably

dumped into Gujarat State in violation of Prohibition Laws.

Similarly, it should also be impressed upon the Central

Government that strict regulation of production,

transportation and storage of methanol alcohol should be

strongly enforced. A strict vigil is also required at the check

post / entry points and other routes leading to Gujarat from

other States. It has been noticed that, almost as a rule, the

hooch tragedies not only in the State of Gujarat, but in the

entire country are caused mainly due to mixing up of

methanol with ethanol alcohol inadvertently or otherwise.

6(A).5 There is a greater need to muster public support and

cooperation through prolonged and active publicity

programmes. Earlier, most of the supply of IMFL to Gujarat

State was from adjoining states like Rajasthan, Maharashtra,

Daman and Madhya Pradesh. Now because of strict action

of Surat range police and change in the sale policy of

Rajasthan, most of the IMFL supplied is from Haryana and

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Punjab. This is more evident from the recent huge seizures

made by Ahmedabad Rural police.

6(A).6 Police should increase highway patrolling to check the

transportation of liquors and Gur / molasses used in the

manufacture of ethanol. The location of such patrolling

parties should be monitored by Global Positioning System

(GPS). The perpetual presence of police along the

highways/roads will certainly make a difference in the illegal

transportation of such consignments and will also be helpful

in preventing other crimes as well. The frequent police

patrolling may also be necessary in the areas that are found

to be vulnerable and notified and badly affected.

6(A).7 Both ethanol and methanol are very essential as industrial

solvents. Hence, a huge quantity of these solvents is

transported every day. A sizeable quantity of these solvents

is also kept in reserve by licensees in their stock. Mainly

ethyl alcohol is responsible for intoxication and methyl

alcohol for hooch tragedies. These are lucrative business for

bootleggers and paddlers. Because of the transportation of

huge quantity, it may not be possible for Excise and

Prohibition department to transport such consignments under

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their supervision. In such cases, important industrial solvents

should be transported in tankers which should have the

facilities to cover the outlets in a box. The outlet box and the

inlet of the tanker should be locked separately which cannot

be opened without breaking the lock. The nature and the

number inscribed on the seal should be written in the

delivery challan. Failing this, if there is any pilferage during

transportation of such solvents, the supplier should be held

equally responsible along with the person/persons

responsible for pilferage. A unit of vigilance should be set up

in prohibition and excise department to monitor the

irregularities. Even after this, If any irregularity occurs in the

form of pilferage of methyl and ethyl alcohols then the

vigilance department should also be held equally

responsible.

6(A).8 Gujarat Methyl Alcohol Rules, 1981, Rule 6(7) provides that

“licensee shall not write off losses on account of the transit or

storage exceeding 5% without the prior permission of the

licensing Authority”. This provision requires a re-look. People

indulging in illegal trade of these chemicals should certainly

be making the use of this provision. Because, this provision

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applies to all and there cannot be equal losses in all

circumstances and this 5% loss appears to be very high.

There are some factors such as the evaporation of volatile

compounds is not taken into consideration. The person

transporting these solvents for a shorter distance in cold

climate is allowed to write off 5% without intimation and this

is also applicable to the person transporting for longer

distance in hot climate. Similarly, same thing applies to a

person storing them for a short period or long period. There

appears a great discrepancy. The losses in all circumstances

should be justified. We suggest that the tanker of ethanol

and methanol should be emptied in the presence of

prohibition and Excise personnel who would record the

actual loss during transit.

6(A).9 Methanol which is responsible for hooch tragedies is a very

important and vital solvent in various industries. To avoid it’s

mixing with the liquor meant for consumption, a suitable dye

can be added into it. But such an added dye should not

interfere with the manufacturing and also should not increase

the cost of it much. Hence, Govt. should form a committee to

study this before implementation.

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6(A).10 The consumption of liquor should be discouraged by

extensive advertisements or social programmes with the help

of NGO’s. The adverse and evil effects of alcohol on the

health and society should be extensively advertised. Audio

visual aids can be provided to the social welfare department

or even to other NGOs to make the people aware of the

dangerous effects of illicit alcohol and can be depicted in

pictures i.e., pictorial representations of all the ill effects.

Even a step further, a sign board / sign can be provided

exclusively for this as it has been done for a cigarette which

indicates it as most dangerous.

6(A).11 After the occurrence of Laththa tragedy, police raided many

liquor dens and the spots where the remnant killer liquor was

suspected to be spilled. The police team involved a Forensic

Science Expert during raids of such places from where it was

supplied and remnant was spilled. This was identified by

examining the empty pouches and testing the soil of the

place. Hence, police team when goes for raiding a liquor

dens should always involve FSL experts, who can identify

the presence of methanol in the liquor on the spot itself. The

onset of the symptoms of methanol takes a longer time.

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Hence, if some information is available about the sale of

methylated liquor, the public and hospitals should

immediately be alerted so that timely treatment can be given

and thereby saving the lives. This will also be an effective

preventive measure.

6(A).12 The hospitals should always have sufficient amount of ethyl

alcohol in custody, which can immediately be used in cases

of Laththa poisoning. Hospitals should frequently organize

seminars and impart training to doctors specifically for the

management of such patients.

6(A).13 The state government can plan to establish analytical

Toxicology laboratories in the emergency wards in the civil

hospital, Ahmedabad and V. S. hospital. Or there is another

option of making MOU with the state FSL with regard to such

situations. This will make things simpler by way of detecting

the poison taken by the patient instantaneously from blood,

urine or vomitus etc. This will certainly facilitate to design the

right course of treatment. In some cases of methyl alcohol

poisoning, the monitoring of the level of methyl alcohol in

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blood is required to assess the level of methanol in blood so

that it is possible to decide the continuation or

discontinuation of the antidote therapy. During the recent

hooch tragedy, the DFS, Gandhinagar was kept open round

the clock to monitor the methanol levels of patients at various

intervals. During this period, total 764 samples of 447

patients were forwarded and result of each sample was

immediately conveyed by DFS.

6(A).14 Gujarat being the state with prohibition in force gets bashings

at the time of such incidence and also for the police force.

There is a general public perception that bootlegging

business flourishes with the consent and connivance of the

police. In a mature democracy like India, it is paradoxical

that prohibition is implemented only by police by using force.

The time is ripe that community service institutions and

social initiative should come to the fore in implementation of

prohibition policy. Swaminarayan parivar, Swadhyay parivar

and SEWA are some of the shining examples of social and

religious institutions that have successfully tackled the evil of

liquor. Police should be sensitized and motivated to perform

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their duties properly and effectively. Effective supervision

from higher ups is required at every stage.

6(A).15 The best way to protect society from alcoholism is to educate

people scientifically about the harmful and fateful effects of

alcohol consumption. This kind of education would be most

beneficial for the adolescents and school or college going

students. The voluntary social organization and mass-media

can also usefully impart this type of education.

6(A).16 The entire scope of legislation in India is directed against illicit

trafficking of alcoholic substances. Despite these efforts, the

sale and purchase of the alcohol is a major problem which

perturbs the law enforcement agencies who are more

concerned to maintain law and order and with prevention of

crime. Systematic rackets operate throughout the country to

supply liquor to alcoholics. Therefore, there is need to re-

define the problem of alcoholism in a socio-medical view

rather than considering it as a mere law enforcement

problem. Hence, sufficient numbers of de-addiction centers

are required to be setup.

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6(A).17 It has been noted that the majority of the victims of laththa

tragedy belonged to lower socio economic groups as it will

fetch them the livelihood in a short span of time and also

easily. So the responsibility of the State Government lies in

the improvement of their life style. They should also be

provided with some means of recreation/relaxation exercises

such as yoga and meditation therapy in health centers. This

will keep them mentally free from anxieties, depressions and

also keep them engaged in some creative activity. Thereby it

prevents them from indulging in such criminal activities.

There is also a necessity to improve their educational status

by introducing some free education schemes even for the

elderly. The nutritional status of such low economic group

needs attention. This can be achieved by providing them with

required nutritional diet in the selective and vulnerable areas.

6(A).18 It has also been noted that, the women belonging to such

areas are also involved in such bootlegging business. So the

State Government can introduce some welfare schemes in

the form of self employment options exclusively for these

women. This will improve their economic status and also

prevent them from indulging in such criminal activities.

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6(A).19 The State Government can have an option of encouraging

the establishment of “Alcoholic Anonymous”, an organization

that includes de-addicted individuals who lead a normal and

comfortable life. This is for the welfare of addicted individuals

to get them de-addicted. It can even be done by voluntary

organizations or NGOs. In this forum there will be periodical

lectures given by the de-addicted individuals to the currently

addicted alcoholics about their sufferings and pains

experienced by them during the period of alcoholism. This

will make the drunkards/ current alcoholics to understand the

harsh realities of life with alcoholism. This is a form of

psychotherapy which will definitely be effective in getting

them de-addicted.

6(A).20 Consumption of alcohol and intoxicating beverages results in

drunkenness. Thus, a word must be said about

‘drunkenness’ as a defense for criminal responsibility.

Section 84 of the Indian Penal Code provides immunity from

criminal responsibility on the ground of the unsoundness of

the mind. The modern processes of development have

opened the floodgates of offences. It hardly needs to be

stressed that alcoholism is the off-shoot of modern fast

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changing social pattern; hence this problem should be

tackled in its socio-legal perspective. It is high time that

Government should consider setting up special treatment

centers for rehabilitation of alcoholics.

6(A).21 Alcoholism falls in the category of public order crimes or

consensual crimes but they do carry with them secondary

victims such as family, dependents, friends and

acquaintances, etc. Alcohol is the drug of addiction and is

responsible for considerable morbidity and mortality. It is

involved in many crimes, directly or indirectly. Chronic

alcoholism is the most common cause of sexual jealousy

crimes and may prove to be a source of danger, to the

person involved and the society. Long term use of alcohol

may result in serious liver damage, cirrhosis, liver cancer,

coronary disorders etc,. Mass poisoning cases of methanol

toxicity occur frequently, due to its use in cheap illicit liquors,

which are manufactured by bootleggers; from toxic

substances like varnish, boot polish, denatured alcohol; at

times methanol itself is mixed with distilled alcohol. So the

State Government must make an effort to curb this menace

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of bootlegging, by imposing stringent laws and effective

enforcement of Bombay Prohibition Act.

6(A).22 The suggestion made by the Police Commissioner,

Ahmedabad city, is to make prohibition policy implementation

more effective and to strengthen the police department by

way of providing substantial number of good vehicles, filling

up of large scale vacancy in the ranks of constabulary and

officers for controlling prohibition activities, as most of the

existing staff remain preoccupied with other high priority

duties, such as handling law and order situation, VIP security

duties, investigation of serious crimes under IPC and

managing the ever increasing traffic in the cities.

6(A).23 On the basis of Justice Miabhoy Commission

recommendations the State Government had created

special prohibition task forces at the District and State level,

exclusively for controlling prohibition activities, which were

subsequently abolished. Similarly, the Government had

transferred the implementation of Prohibition Act to the

Prohibition and Excise Department and created a special

161  

force for this purpose. After some time of this transfer, it

was made a joint task of both the Prohibition and Excise

Department and the police, which was also subsequently

undone and the duty has again been transferred exclusively

to the Police Department.

6(A).24 It appears that the root of this failure, as mentioned in the

above paragraph was corruption at various levels in the

State Government Departments, which cannot be wished

away. The State Government has to give a serious thought

in this regard and consider setting up of special unit as a

part of Anti Corruption Bureau, at sufficiently higher level by

providing extra number of officers to keep close watch on

the activities of various Police & Prohibition Units with

regard to the handling of corruption in implementing

prohibition policy effectively.

6(A).25 Looking at the very large number of cases registered under

the Prohibition Act and the importance of prohibition policy,

special Courts have to be set up exclusively for conducting

trials of prohibition cases through summary trials, as decision

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of such cases after abnormal delays, has no meaning at all,

and it does not create any fear of punishment in the minds of

the criminals. Generally the bootleggers go scot free without

any harsh punishment. It is generally felt that in many cases,

as soon as the bootleggers are released by the Courts, they

straight away go to start anti prohibition activities again, either

in the same place or in some other places. The basic

evidence in prohibition cases is the Forensic Science

Laboratory report, mudda maal seized during the raids and

examination of panchas. The panchas normally do not turn up

for giving evidence. Hence, summary trial of such cases will

have a long term effect and fear in the minds of the criminals.

The quantum of punishment in second conviction and

subsequent convictions should be more deterrent.

6(A).26 The dry belt area between Gujarat and neighboring States

of Maharashtra, Madhya Pradesh and Rajasthan should be

increased to 25 Kms., as suggested by Justice Miabhoy in

his report. It is understood that this matter is under

discussion with these States in zonal meetings. Early

decision in this regard will help the enforcement agencies to

control the crime more effectively. The inflow of liquor from

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Selvasa and Daman has to be totally stopped by having

more number of check posts and effective surveillance and

of course by better coordination with Daman administration

by the neighbouring district /range officers.

6(A).27 The existing District Prohibition Committees presided over

by the Collectors in the Districts should be made more

effective in the matters of coordination and control of

prohibition activities. The Members of this Committee should

include District Superintendent of Police, Civil Surgeon,

District Health Officers, Forensic expert, Superintendent of

Prohibition and Excise and at least 10 leading social

workers and NGOs known for their anti-prohibition attitude

as Members. The information given by the social workers

has to be taken very seriously by the Committee to ensure

effective action in this regard. If the anti-prohibition activities

are not stopped by the local police officers in charge of their

respective jurisdictions in spite of being given the

information through the social workers repeatedly,

responsibility has to be fixed and serious action has to be

taken against them.

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6(A).28 There should be a constant monitoring of the quota of

alcohol issued to the industries, hospitals, educational

institutions etc. The concerned officers who have failed in

their responsibility should be penalized.

6(A).29 The issue and use of denatured spirit by authorized

industries has to be effectively supervised by the Excise and

Prohibition Department. All vehicles used for transporting

illicit liquor etc., must be confiscated by the competent

authorities. Offences under the Prohibition Act, Gambling

Act and prostitution crimes are generally inter connected by

one way or the other. These cases have to be properly

investigated to snap the nexus among them. In the police

stations, where a very large number of prohibition cases are

registered, the required staff and equipment must be

provided. At least the sanctioned posts of police units must

be filled, so that non-availability of staff does not become a

serious constraint in carrying out raids etc. Such police

stations should also be given good vehicles, with proper

communication systems so that they can nab the

bootleggers during transportation of liquors etc.

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6(A).30 Section 56 of the Bombay Police Act should be amended to

enable the concerned authorities to extern the persons who

are involved in more than 5 offences under Prohibition Act

and have been convicted previously in two such cases.

6(A).31 Section 57 of the Bombay Police Act should also be

amended to make it more effective. The existing provision

for taking into consideration, the offences, as mentioned in

Section 57 of Bombay Prohibition Act, should be

considered for a period of preceding three years. This

amendment should include that even the offence

committed prior to the period of three years can also be

taken into consideration for taking preventive action under

this Section. This will deter the criminal from indulging in

anti prohibition activities, at least to some extent.

6(A).32 Like Section 138-B of the Customs Act, police officers of

and above the rank of Deputy Superintendent of Police

should also be empowered to record statements and get

them signed by the bootleggers, which becomes an

admissible piece of evidence in the Court.

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6(A).33 Names of the informants in the prohibition cases must be

kept confidential. If at all, it is revealed that the same is

deliberately or negligently disclosed by any police officers,

a serious action has to be taken by the superior officers to

punish such officers.

6(A).34 The list of bootlegger maintained at police station level,

must be regularly updated and the senior police officers

must pay special attention towards the adequacy and

effectiveness of action taken against such bootleggers

during their inspections / visits of police stations etc.

Emphasis has to be laid down by the Investigating Officer

on the use of all available scientific aids for the

investigation of such cases.

6(A).35 A large number of cases are acquitted in the Courts due to

the lacunae in the procedures adopted in the handling,

packaging and forwarding of the samples. Hence, all the

concerned authorities are required to be given training in

the correctly laid down procedures. This type of training can

be provided by the forensic experts.

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6(A).36 The Municipal Corporations in the cities and Gram

Panchayats in rural areas should be made to realize the

importance of implementing prohibition and they should be

asked to shoulder the responsibility of eradicating the evil

of drinking in co-ordination with Police and Prohibition and

Excise Departments. Government should issue suitable

guidelines in this regard.

6(A).37 The Writer Committee’s recommendations include the case

of Suppressing of Immoral Traffic of Women and Girls Act,

in which the police can move the Sub Divisional Magistrate

to evict the occupier from the premises used for the

purpose. A similar provision should be made under the

Bombay Prohibition Act to evict the bootleggers who are

selling, distributing and dealing with any form of liquor in

private places or running common liquor houses in spite of

reported actions taken against them by Police who have at

least one conviction against their name earlier. This will

have a salutary effect on the bootleggers and their

activities.

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6(A).38 Dedicated social workers have a key role to play in the

eradication of the evil by way of educating the public by

constant propaganda in various ways and render active

assistance to rehabilitate and wean away from this evil.

The Director of Prohibition and Excise must effectively

coordinate the work of nearly 2500 voluntary social

organizations which exists in Gujarat at present. This can

prove to be an effective network for constant propaganda

through various methods.

6(A).39 There are certain definite areas in most of the cities and

towns, which are known for large scale bootlegging

activities and sometimes even police parties cannot enter

such areas for carrying out raids etc., as stiff resistance

from the local people of these areas and they sometimes

assault the police personnel of the raiding parties. Under

the provisions of Section 141 of the Bombay Prohibition

Act, round the clock police parties should be put up to

prevent prohibition activities in these areas and the costs of

these police men should be recovered collectively from the

residents of such affected areas. This provision has rarely

been used, but can prove to be very effective in controlling

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prohibition activities, if put to use, of course, only in

notorious and very badly affected areas.

6(A).40 The causes for ineffective implementation of Prohibition

Laws are very complex. There is the factor of very strong

motivation on the part of the buyer as well as seller. Buyer

does it out of the physical need and the seller for economic

gain. The weaknesses include corruption and inadequacies

of the enforcement machinery which cannot be ignored.

Similarly the flaws in legal process of bringing the criminal

to book are - (a) non-availability of reliable panchas; (b)

lack of good investigation due to sheer number of

prohibition cases which is almost in lakhs at the State level

and non-availability of sufficient and efficient staff (c) the

Courts in need of fool proof evidence for conviction.

Therefore, the only option to root out this evil is to make all

out efforts to strike at the main roots of this evil. But for

this, sufficient manpower, sufficient number of good

vehicles and means of communication and supervisory

officers of proven integrity are required to be deployed for

which the Government has to express its resolve by

providing extra resources to the implementing agencies.

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6(A).41 The existing system of maintaining lists of notified

bootleggers in a police station area should be modified as

under:

6(A).41(a) Names of the persons who are found to be involved at

least in three cases during last five years under Section 65

and Section 66 of the Bombay Prohibition Act i.e. cases of

possession and transportation of liquor and this will not

include cases of only drunkenness. One of these three

cases against the persons should have been registered

during the past two years.

6(A).41(b) In cases where a bootlegger may not have any prohibition

offence registered against him during last five years, but

such cases were registered against him prior to that period

of five years, but adversely noticed by police for his

continuing prohibition activities at a large scale in various

ways, which has to be approved by an Officer of the rank

of Deputy Superintendent of Police.

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6(A).42 Name of the top 25 bootleggers in an entire district should

be circulated to all police stations and branches of the

District and also to the neighboring districts for keeping a

close watch over their activities / for taking actions against

them wherever necessary.

6(A).43 These listed bootleggers should be checked at regular

intervals and all necessary action including PASA be

ensured against them.

6(A).44 Whenever action is taken against a bootlegger under

Section 93 of the Bombay Prohibition Act, provisions of

Section 101 should be kept in mind i.e. the amount of

money and other conditions etc. If the condition of bail is

violated, action should be ensured under Section 121 of

the Code of Criminal Procedure, 1973, i.e. cancellation of

bail etc.

6(A).45 During the hearing of bail in prohibition cases, the past

record of the bootlegger should also be presented to the

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Court and such bail should be opposed under Section 437

of the Code of Criminal Procedure. The present amount of

bail bond is from Rs.500/- to Rs.1000/- only for last so

many decades. It should be increased to at least an

amount of Rs.5000/- to 10,000/-. To make prohibition

policy really effective it is essential that the senior officers

in the District including the District Superintendent of

Police take personal interest and frequently lead such

raids in important cases. Whenever prohibition case is

registered, it should be mandatory for the Investigating

Officer to go to the root / source of liquor from where it was

procured in all cases. Raids should be carried out on such

sources promptly and the District limits should not come in

the way in such cases of tracing the sources of illicit liquor.

6(A).46 In the badly affected areas Range IGs should organize

inter-District raids, where the police party of one District

should be sent to another District.

6(A).47 Vehicles used for transportation of illicit liquor should be

seized under Section 98 of the Prohibition Act. In serious

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cases maximum proposals under Sections 56 and 57 of

the Bombay Police Act be prepared and followed up with

the concerned authorities for timely disposal. Abnormal

delays of six months or more in passing such orders

should be reported to the Government through D.G.P. for

taking appropriate action against such officers.

6(A).48 Wherever policemen / officers are found involved in

prohibition activities, inquiries against them should be

entrusted to senior officers of the areas other than the

police stations / sub division where these cases are made

out.

6(A).49 Lists of Panchas used in prohibition cases should be

obtained under Section 117 of the Prohibition Act from

village Panchayats, Nagarpanchayats and Municipal

Corporation authorities.

6(A).50 Instructions by the D.G.P. / Government with regard to

some of these points as mentioned above already exist,

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but what is really required is to set up a mechanism to

ensure proper and effective compliance of these

instructions to control the evil and manufacturing and sale

of liquor.

6(A).51 Enforcement of prohibition is the responsibility of the

police. If distilled alcohol is manufactured and sold, that

becomes the responsibility of police. But if methyl alcohol

or methylated denatured alcohol finds its way illegally into

the drinking market then it becomes the responsibility of

Excise and Prohibition Department. The responsibility

should be fixed accordingly.

6(A).52 Whenever there is a doubt about use of methyl alcohol in

illicit liquor, samples should immediately be sent to and

got examined by the Forensic Science Laboratory and

ensure prevention of distribution / protection of such

methyl alcohol on top priority basis to save the human life.

175  

6(A).53 All such villages / areas which became totally free from

prohibition activities should be rewarded by the

Government by way of good roads, regular electricity,

water supply and other facilities in such villages, as a

motivation.

“The Purity of the heart is true purity. Of all the pilgrimages, the journey inside the heart is the greatest”

– Ved Vyas 

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Chapter 6(B)

Reference No.4

MEDICAL RECOMMENDATIONS

(PART - II)

6(i) Here are the action plan for effective medical

intervention including role and function of medical

infrastructures in public as well as in private domain.

6(ii) Recommended Action plan for management of hooch

tragedy in future:

As already said at the cost of repetition, we say that our

observations are mainly aimed at with a view to keep in view

our constitutional provisions and our image as a welfare

state because article 47 provides that the state to regard, as

among its primary duties, the raising of the level of nutrition

and the standard of living of its people and the improvement

of public health. In particular, the state is to endeavour to

bring about prohibition of the consumption, except for

medicinal purposes, of intoxicating drinks and drugs which

are injurious to health.

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6(i)a The Commission while considering recommendations has

also considered Entry-6 List-II of the Constitution of India,

which provides “public health, sanitation, hospital and

dispensaries.” Even the said Entry also gives power and

jurisdiction to the State Government to maintain public

health, sanitation, hospitals and dispensaries, particularly

cleanly and hygienically with keeping better standard.

6(ii)b We have also observed that the treatment protocols were not

uniform in private hospitals. Each institute and attending

physician has behaved as a solo entity during the initial

phase of hooch episode. We here by feel that detailed

treatment modality and treatment algorithm should be

circulated to all treating facilities in future so uniform

treatment will be provided to all patients.

6(ii) This emphasises to mention on treatment plan and algorithm

of Methanol Poisoning treatment in this report which health

department may put into practice with relevant time to time

modifications as per circumstantial demands in future.

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6(B).1 Need to circulate uniform treatment /Management

Protocols to public and private Medical Practitioners.

6(B).1(a) This is a very vital issue in managing hooch tragedy. The

treatment protocols decided are to be followed by all

hospitals treating victims of methanol poisoning. All attending

hospitals should have written treatment protocols readily

available with them. The universal treatment protocols and

strict compliance by all is an important tool in saving lives.

The treatment protocols which are to be decided are the duty

of health commissioner as one of the components of

chemical disaster mitigation plan of the state. Only those

doctors belonging to Civil hospital, Asarva had started

following treatment protocols after the tragedy struck the city

after the lapse of two days. These treatment protocols need

to be circulated to all treating private hospitals of Ahmedabad

and Gujarat. The medico legal case formalities, sufficient

quantity of antidotes and proper dispersal of antidotes to all

the other hospitals irrespective of government or private run

hospitals in the appropriate time so that effective tackling of

the situation is possible.

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6(B).1(b) The three primary goals of therapy include the treatment of

metabolic acidosis, inhibiting the methanol metabolism and

enhancing the elimination of unmetabolised compounds and

toxic metabolites from the serum. Gastric lavage may be

beneficial if patient seeks the treatment immediately after the

ingestion. Usually methanol is rapidly and completely

absorbed from the gut within few hours.

6(B).1(c) Drugs for the treatment as antidote for methanol

poisoning:

(a) Ethanol (generic)

Parenteral: 5% or 10% ethanol and 5% dextrose drip for IV

Infusion.

There is an obvious difference between ethyl alcohol and

methyl alcohol poisoning specially in terms of amount of

quantity consumed. Ethyl Alcohol poisoning can result when

excessive amounts of alcohol are consumed. While Methyl

Alcohol exhibits symptoms and signs of toxicity even when

very small quantity of alcohol is consumed. Methanol

poisoning which is life threatening often causes a depression

or a discontinuance of nerve cell that control breathing and

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the gag reflex that prevent choking. The attending doctor

must become familiar with the warning symptoms and signs

of Methanol poisoning. The symptoms include vomiting,

mental confusion, delirium and seizures. The warning signs

include irregular breathing, low body temperature and pale or

cyanosed skin. The attending doctor must get the blood

sample checked to know the concentration of methyl alcohol.

(b) Supportive treatments include:

(1) careful monitoring, stay with the patient

(2) Gastric aspiration, if the patient presents within 4 (four)

hours of ingestion.

(3) Measures to keep Airways patent to prevent choking of

airways.

(4) Oxygen inhalation

(5) IV fluids to prevent dehydration.

(6) Look for evidence of concurrent trauma.

(7) To keep the patient in left lateral position and head is in

a lower position to avoid aspiration of vomitus.

(8) Thorough monitoring of vital parameters of the body

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(9) If blood pH is <7.2 or serum HCO3 <15mmol/L,

Intravenous Sodium bicarbonate should be given as

per following formula.

HCO3 = Body weight (Kg) x (0.4) x (Desired HCO3 –

measured HCO3 levels)

One half of the calculated deficit may be replaced in 4

hours. Usually 10 to 15 ampoules of 10ml, 7.5%

NaHCO3 are added to one litre of 5% Dextrose and

infused. Once the pH>7.2 or serum HCO3 level about

18 to 20meq/L is achieved, no further sodium

bicarbonate should be administered.

(10) Control of Seizures: IV Diazepam or phenytoin should

be administered. IV diazepam is given as 5 to 10mg

doses slowly at a rate of 1 to 2mg/minute and repeated

if and when seizures reappear. IV phenytoin is given

initially in a loading dose of 18 to 20mg/Kg in 0.9N

saline at a rate not exceeding 50mg/minute followed by

maintenance dose of 4.8mg/Kg daily.

(11) Parenteral nutrition with IV dextrose.

(12) Treatment of associated complications, if any.

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Specific treatments include:

6(B).1(d) Ethanol Therapy:

The rational of using ethanol is that it saturates Alcohol

Dehydrogenase and prevents the formation of toxic

metabolites.

Ethanol should be administered in following conditions:

[a] When methanol levels are not available but definite

history of methanol ingestion is present and osmolal

gap is>5mosm/l

[b] Presence of metabolic acidosis and osmolal gap of 5-

10mosm/l

[c] Blood methanol levels>20mg/dl

Desired serum level of ethanol is 100mg/dl

Dose of ethanol in methyl alcohol poisoning

Strength 5%IV 10%IV 50% Oral

Loading 15 ml/kg 7.5 ml/kg 1.5 ml/kg

Maintenance 2-3 ml/kg/hour 1-1.5 ml/kg/hour 0.2-3 ml/kg/hour

During

haemodialysis

3-5 ml/kg/hour 1.5-2.5 ml/kg/hour 0.3-0.5 ml/kg/hour

183  

6(B).1(e) Leucovorin and folic acid. Leucovorin is to be given in a

dose of 1mg/kg followed by folic acid 1mg/kg at every 4

hours. Folic acid may be given alone if patient is not

significantly ill. They enhance the conversion of formate to

CO2 and H2O. ( Carbon dioxide and Water)

6(B).1(f) Newer agents. 4-methyl pyrazole (Fomepizole), inhibits

alcohol dehydrogenase and prevents metabolism of

methanol to its harmful metabolites. It is given as 10mg/kg

IV infusion over 1 hour before dialysis and repeated once or

twice at 12 hourly intervals. During dialysis dose of

1.5mg/kg/hour is given. This molecule has been

recommended as a drug of choice in adjuvant to ethyl

alcohol by certain western countries. Referral Hospitals

should have sufficient quantities of these drugs are in their

store for future use.

6(B).1(g) Haemodialysis rapidly removes both methanol and

formaldehydes. Indications for haemodialysis are:

Suspected methanol poisoning with significant metabolic

acidosis

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Osmolal gap> 10mosm/L

Serum methanol concentration>40mg/dL

6(B).1(h) N.B At high serum levels (>20mg/dL), methanol can cause

diminished mental alertness, convulsions, renal failure and

coma. As metabolism of methanol proceeds further, a severe

anion gap metabolic acidosis will develop. The metabolic

acidosis is due to accumulation of formic acid, lactic acid and

ketones. Metabolic acidosis may not be evident but serum

osmolal gap might be elevated. An osmolal gap of as little as

10mosm/L is consistent with toxic concentrations of

methanol. Severe metabolic acidosis in conjunction with

dimness of vision is the hallmark of methanol poisoning

185  

Algorithm of Management of Methanol Poisoning

186  

6(B).1(i) Mechanism to gain control over private hospitals and

fool proof procedures to make antidote immediately

available:

Keeping in mind the Constitution of India as the highest

provision and poor person at the heart, we observed that the

treatment conferred to methyl alcohol poisoning cases were

not uniform in public and private domain. This was very

much true for the availability of antidote like ethyl alcohol

which is easy to procure for government hospital and difficult

for the private hospitals. Again to liberalise the policy to

distribute ethyl alcohol carry risk in future. The availability of

ethyl alcohol to small private hospitals was not given priority.

Every hospital played as a solo entity and treated victims in

their own way in the absence of decided treatment protocols.

We fear that the scarce availability of antidote and absence

of government decided treatment protocols in private domain

may have captured some lives.

187  

6(B).2 Need to decide uniform functionalities which are to be

followed by hospitals in private and public domain by

legislative control:

In India more than 3 lakh people face a medical emergency

each day, 2.4 million deaths account for on grounds of health

diseases, suicides, accidents, Agricultural, industrial and

accidental poisonings, thefts, murders and sexual assaults.

80% of deaths in hospital happen in the first few hours of

admission of emergency case. This speaks very high of

management of emergency case during ‘Golden Hours’. The

national Health Bill, 2009 is a stepping stone towards a

formation of legislation on public health and it is

contemplated that it shall cover all the important aspects

involved. Assam is likely to take the credit for being the first

state in India to make it mandatory for all hospitals including

private hospitals and nursing homes to provide at least first

aid treatment to emergency care. Gujarat when it has

completed its golden jubilee should take firm initiative in

enacting ‘National health bill-2009’ for the welfare of the poor

people who need emergency care. The Commission

recommends that the State may enact the same.

188  

6(B).3 The alternative solution to provide uniform and well designed

treatment protocols either in government or private health

institutes is to go ahead with “Public Health Bill” for the state

of Gujarat. The processes for both bills are already initiated

by the health department. We recommend that since

National health bill -2009 is likely to be implemented

throughout the country, it should be enacted in the State of

Gujarat without much delay.

6(B).4 The health bill makes it mandatory for all hospitals including

private hospitals and nursing homes to provide free

treatment, at least for the first 24 hours to emergency

patients. The proposed law guarantees people the right to

appropriate medicines and the right to effective measures of

prevention, treatment and control of epidemic and endemic

disease. It will facilitate health providers to exercise their role

more efficiently during the episode of hooch tragedy. It also

empowers the state health department to fix accountability

and responsibility in case of recurring outbreaks of viral,

communicable and waterborne diseases. Not only that, the

law makes it mandatory for all the development projects that

are coming up in the state to pass a Health Impact

189  

Assessment (HIA) test. The proposed law has recognised

the right to healthcare without a patient having to look for a

government hospital in case of an emergency just because

of financial constraints. Generally, the standard of care in

emergency cases in modern day Medicare envisages,

amongst other features, three primary obligations:

(a) Screening of patient;

(b) Stabilising the patient’s condition; and

(c) Discharging or transferring the patient to an appropriate

institute which can fulfil the goals of better or specialised

treatment.

More steps are required to be taken by the appropriate

health authority to ensure that at least emergency first aid is

given to patients during the hours of crisis which is broadly

described as ‘Golden Hours’.

6(B).5 To strengthen the role of EMRI-108 is also very vital in

such emergencies. There should be fully equipped 108

ambulances parked at strategic places that can be contacted

by helpless victims needing emergency help. The initial first

190  

aid many a times determines the fate of victim. The

Commission hereby would like to draw the attention to the

Doctors that Emergency Medical Technicians of 108

ambulances might have played a decisive role if health

commissioner had provided them with the antidote in 108

ambulances during actual hooch episode. The role of ethyl

alcohol is very important in the treatment of methanol

poisoning and determines the fate of victim favourably if

administered as early as possible after ingestion of methanol

is diagnosed. The present ‘ICU on wheel’ provided to all

District hospitals may be deployed during such emergencies.

The support staff of ambulances may be trained to to tackle

such emergency conditions..It would be still appreciable if

the services of the 108 ambulances are made available in

the taluk head quarters hospitals also. Because these areas

are more prone for the effects of such tragedies and the

accessibility of the facility to the victims are also very much

remote.

191  

6(B).6 Strengthening hospital infrastructure and documenting

hospital procedures under NABH:

Government civil hospitals have started being accredited by

National Accreditation Board for Hospitals and Health care

providers. This is a unique initiative by Government of Gujarat.

When Government hospitals which usually render free medical

care to patient when public hospital opts for NABH accreditation

then why not private hospitals? Private hospitals charge the

patients for each procedures but the uniformity and

consistency of treatment is still a dream for common man. The

Commission has noticed that private hospitals were

remained untouched by health department of Government

and they acted indecisively during this episode. This stresses

the need for all public and private domain hospitals should

go for hospital accreditation by NABH. Once accreditation is

made compulsory by private hospitals the burden of

government health department can be reduced during such

catastrophe.

6(B).7 National Accreditation Board for Hospitals (NABH) is a

constituent board of quality council of India. The hospitals in

192  

public and private domain should opt for accreditation

programme designed under NABH.

6(B).8 Accreditation to a hospital stimulates continuous, cognitive

and uniform stimulating environment. Accreditation benefits

institution itself and treatment seeking patients. The

continuous learning skills amongst staff are created and

professional development of medics and paramedics can be

brought in.

6(B).9 The patients are given the due service by the competent

medical staff with available infrastructure which is mandatory

treatment of particular ailment. Rights of patients are

respected and protected by capacity building of health care

providers.

6(B).10 Accreditation brings high quality of care with uniformity. This

brings patient’s safety irrespective of class whether the

patient is poor or rich. Accreditation also ensures whether

hospitals are public or private, play their effective roles in

193  

delivering health to the patients. The Commission suggests

that all hospitals which are having capacity of 100 or more

beds should comply with the accreditation by National

Accreditation Board for Hospitals. This will automatically

resolve the issues of keeping documents readily available

during catastrophe like Triage plan, (process to segregate

serious patients during mass casualty) hospital specific

emergency preparedness plan, Disaster mitigation plan or

hospital evacuation plan.

6(B).11 The number of beds may be kept ready in the wards

depending upon the type of emergency. The emergency

units may be properly housed with life saving gadgets.

6(B).12 Compulsory Implementation of Medical Triage system (A

process to segregate serious cases during mass

casualty) during man made or natural disaster:

The members of commission felt that emergency response

system was aroused but scientific approach to patients was

not universal. Disaster mitigation plan was ready but was

lacking in actual practice at various levels. The members felt

194  

that effective implementation of emergency response system

should be carried out for such disastrous situations. This will

also help institutions to tackle other situations where mass

casualties are expected like Road side accidents, Terrorist

attacks, Cyclone, Earthquake or chemical disasters in future.

6(B).12(1) The execution of Triage facilitates treatment plan by the

health providers and maximum benefit is dispensed to the

patients. Triage is mainly exercised in trauma care but

modified version of triage can help victims as we observed

that victims of hooch tragedy were treated with ‘first come

first served’ basis and doctors were compelled by relatives to

treat their patient first on priority basis. It is hereby

recommended to introduce triage system for all health

facilities as a routine and continuous process because it

provides maximum benefit to the greatest number of victims

of tragedy where facilities are limited. When the quantity and

severity of tragedy overwhelms the operational capacity of

health facilities, a different approach for medical treatment is

needed by sorting of the patients must be adopted. The

principle of ‘first come, first treat’ which is applied presently in

routine medical care is not much appreciable during mass

195  

disasters e.g. hooch tragedies, chemical disaster, terrorist

attack and road traffic/highway / railway accidents/ air

crashes etc.

6(B).12(2) Triage is a continuous ongoing categorisation process which

should be more efficient. It must also be as much

unemotional as possible. It stresses on prioritization for

immediate treatment and transfer of patients to adopted

health facilities for treatment of complications, i.e. to dialysis

centre, ICU (Intensive Care Unit) or ophthalmology institutes.

6(B).12.3 The Commission advocates its implementation routinely in

future as it is fast, simple, easy to remember and easy to

apply.

6(B).12(3)A It is four colour code system based on Respiration, Pulse

and B.P, Mental status [RPM] of the victims. A specially

trained team of medics and paramedics with counsellors

should be deployed for work who can deal with the situation

efficiently and sympathetically by attending the people.

196  

6(B).12(4) A triage officer is a trained medical officer who should lead

and observe the entire processes of triage and coordinate

with all treating medical teams and with the administration

head of the institute. He should be helped by team members

who are experts in First Aid treatment.

6(B).12(5) It is recommended that all patients must be identified with

tags stating their name, age, sex, residential address, triage

category, diagnosis and initial treatment.

6(B).12(6) The standardised tags must be chosen or designed in

advance as a part of state disaster mitigation plan and

should be supplied to all health facilities. The health

professionals should be provided with ‘Triage Bag’ which

contains 50 triage labels, 50 nylon ties, arm bands, 6

assorted airways, intubation set, ventilation beg and suction

device, B.P Instrument and stethoscope. Health

professionals should be thoroughly made familiar with their

proper use.

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6(B).13(1) Live rehearsals and Mock Drills are to be carried out at

regular intervals by all health facilities as a part of their

emergency response system manual. Detailed records of

drills with observational note by a team consisting of high

ranked officials of medical, police, forensic scientists and

revenue departments be made and the same should be

circulated to health commissioner for remedial actions for

observed lacunae in the drill. The health commissioner

should be entrusted with responsibility to prepare, implement

and analyse disaster mitigation plans and emergency

response system mechanism of all health infrastructures of

the state.

6(B).13(2) Need to form team of medical experts at the time of

hooch tragedy where ophthalmologists and

nephrologists are team members:

Formation of team comprising of super-specialists is very

crucial in the management of methanol poisoning. It has

been observed that toxic metabolites, if cleared out with the

help of haemodialysis greatly influence the morbidity and

mortality of the hooch victims. Doctors could save many lives

198  

as haemodialysis was introduced as part of treatment where

concentration of methanol was alarmingly high. The

knowledge of concentration of methanol in blood is a prime

factor to decide the course of medical management.

The inclusion of ophthalmologists and nephrologists should

be made compulsory as team members who will derive

treatment protocols and will supervise treatment during such

tragic episodes.

6(B).13(3) Live and immediate Coordination with other

departments:

It is also observed that ‘police yadi’ given by police

constables were not sufficiently conclusive for medical

attendants to conclude that the patient is a victim of the

hooch tragedy. The importance of ‘police yadi’ issued by

police constables carry a prime importance for medical

attendant to decide line of treatment. The police constables

are also required to be trained primarily that what are the ill

effects and symptoms of hooch. Once the doctor knows that

he is dealing with hooch tragedy victims, his primary duty is

to send blood samples for presence and concentration of

methyl alcohol in the body. It has been also observed that

199  

doctor of private hospital forgot to collect blood samples for

chemical analysis. This is required for medico legal and

treatment point of view. This emphasises the need of liaison

and coordination measures between private and government

hospitals. Competent officers from health and police

departments should be made responsible for this work. The

forensic science laboratory is equipped with the state of art

equipments to analyse blood for any kind of toxic substances

and they can derive minute details of toxic substances in the

blood. They can inform the hospitals in few hours if the

modern communication facilities are used in a coordinated

ways. At present this message has not been popular

amongst the medical officers and forensic experts of the

state. So a strong communication link between these two

departments will be more beneficial for victims of such

tragedies in many ways in future. This coordination will

facilitate the treatment of insecticide poisoning which is very

rampant in district hospitals. There should be a regular

interaction and symposia for key medical officers of all the

districts arranged at Forensic science university campus to

inculcate the medico legal knowledge and novel technologies

200  

that are available for the effective management of such

crisis.

6(B).14 To create Haemodialysis, CT Scan, MRI and post-

mortem facilities at Smt Shardaben Chimanbhai hospital

and Sheth Lallubhai Gordhandas Hospital:

It is high time to establish the CT scan, MRI facilities and

Haemodialysis facilities at these two hospitals. In addition to

these, there needs to be a facility for conducting post-

mortem examinations instead of depending on other

hospitals. The post mortem examinations should be

performed at the same institutes or nearby institutes without

causing undue delay.

6(B).14(1) Need of Regular Trainings, Interactive seminars and

Mock drills by hospitals:

Trainings and Mock drills are very essential in managing

emergency situation. It is a military quote that ‘More you

perspire in peace, shed less blood during war’. This equally

implies managing an emergency. If trainings and mock drills

are performed during quiescent phase it would be very much

helpful during the catastrophe. The state disaster mitigation

201  

plan for variety of disasters should be designed by the state

EMS authority and regular trainings and mock drills should

be planned under its supervision.

6(B).15 Determinant Role of EMS authority:

The episode of Methyl alcohol is sporadic and occurs

sometime after the interval of many years. The medical

graduate may not have the experience of treating hooch

victims during his entire undergraduate and postgraduate

curriculum. The emergency response system of the hospital

need to include continuous medical training and mock drills

at regular intervals as already mentioned previously. The

State Government has already enacted Emergency Medical

Act to synchronise and streamline medical response during

medical catastrophe. The state and district EMS authorities

should prepare guidelines for response of health, police and

revenue authorities during such hooch tragedies in future.

The protocols of action by each department and treatments

of victims need to be derived by EMS authorities. The action

plan regarding preparedness to cater to the need in such

emergencies in future should be kept ready by each medical

institute in future. EMS’s role during such disaster is very

202  

crucial. State and District EMS Authorities should come out

with treatment protocols for varieties of disasters, either

natural or man-made. At present, the role of EMS seems to

be negligible in preparing and percolating treatment

protocols for various disasters. Health department should

entrust the responsibility of evolving treatment protocols and

their timely implementation by all stake holders during the

hours of crisis to EMS.

6(B).16 District wise Formation of emergency response

committee.

There is a necessity of interdepartmental coordination during

such tragic episodes. A responsible committee should be

formed in each district comprising of District Magistrate,

Superintendent of police, Forensic scientist, Chief District

Medical officer cum civil surgeon, Chief District Health

officer, Information officer, representatives from fire,

ambulance and Red Cross society and prominent NGOs.

These committee members will coordinate for the effective

updates in disaster mitigation and will take control of the

situation when it demands. Thereby any situation would be

possible to tackle and the ill effects are nullified.

203  

6(B).17. The Commission has studied the Draft Bill sent by the Union

Government to the State Government, which has been

implemented by Assam Government. The Commission hope

and trusts that similar Bill and this Act by the State

Government will also be passed and that will go a long way

in hospital reforms in the State of Gujarat.

“Life is a “Book of Mysteries” You never know which page will bring a Good twist. So keep on reading.”

204  

Chapter- 7

RESPONSE TO QUESTIONNAIRE ISSUED BY THE

COMMISSION TO THE OFFICERS, NGOs. SOCIAL

ORGANIZATIONS AND PROMINENT PERSONS

7.1 A Comprehensive Questionnaire was issued by the

Commission to know the response of different segments of

Society with regard to the problem and solutions of the evil of

manufacturing, transportation and consumption of illicit

liquor.

A brief summary of the responses is given as under:

7.1(A) The drinking habits are very much rampant amongst

industrial workers, agricultural labourers, fishermen and

people from the poor strata of the Society.

7.1(A)(i) About 10% of the population is in the habit of drinking. About

5% of the female, especially from the lower class in tribal

society and fishing community and labour classes are

involved in the habit of drinking illicit liquor.

205  

7.1(A)(ii) Out of those people who regularly drink, about 40% are

drinking IMFL and about 60% people drink country made

liquor. The average consumption of liquor is about 100 ml.

per head and people are spending about 10 to 15% of their

income on this evil habit. Most people drink either at home or

at the adda. Heavy drunkards indulge in use of abusive

language, quarrels, family disputes and consequently in

committing offences. Main reasons for the consumption of

alcohol are physical tiredness, depression, celebrations, bad

company or due to habit formation. Mostly people consume

spurious liquor unknowingly, resulting in serious

consequence such as blindness, pain, hemorrhage and

death etc. About 5% medicinal and toilet preparation are

also misused as drinks.

7.1(B) Availability:

7.1(B)(i) Both locally prepared illicit liquor and the IMFL smuggled

from neighbouring States is not readily available, but can be

procured by making some efforts. Generally there is a

bootlegging network through which the liquor is supplied

206  

from rural areas to the city areas and from neighbouring

States to the cities, through various means of transport.

7.1(B)(ii) Main reason of availability of liquor are - demand - supply

dynamics, presence of smuggling and bootlegging

syndicates and poor enforcement by the concerned

agencies.

7.1(C) Sources of illicit liquor:

7.1C(i) Country made liquor, denatured spirit, conversion of alcohol

based produces like warmish, french polish etc., into potable

liquor and some medicinal preparations are main source of

illicit liquor. Rotten gur (jaggery) is the most commercially

used raw material for preparing illicit liquor. Similarly,

denatured spirit / methyl alcohol is procured by the

bootleggers, either during transportation or from the

concerned industries. It is realized by Investigating Agencies

that control on raw material like rotten gur etc., is not up to

the desired level, because of pressure from the vested

business interest.

207  

7.1(D) Enforcement:

7.1(D)(i) Though prohibition cases are registered in large numbers

throughout the State, still about 50% cases remain

undetected. Therefore, it can be inferred from the fact that

the prohibition implementation is successful only up to 50%

level. The main reasons of partial failure are enforcement

constraints, such as insufficient man power and lack of good

transportation system. Of course, corruption in the

enforcement agencies is also one of the important factors in

this regard.

7.1(D)(ii) No fear of Law in the minds of the criminals; as can be seen

from the fact that only a few cases result in punishment and

where-ever punishment is awarded it in mostly - symbolic.

Therefore, it is necessary, not only to make laws more

stringent, but also to strengthen the enforcement agency and

the judicial system, which is virtually collapsing under the

weight of sheer amount of work, in conducting large number

of cases. Strict and quick action has to be ensured against

the responsible officers and men in the enforcement

agencies, especially with regard to corruption and similarly

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an effective system of giving suitable rewards to the

informers will also be very helpful in this regard.

7.1(E) Minimum punishment:

7.1(E)(i) At present the prescribed maximum punishment for

prohibition offences needs to be increased, but in practice it

will have no meaning, unless the minimum punishment is

also prescribed in the Act. At present there are very few

cases, where the punishment in the convicted cases has

gone beyond the imprisonment of 1 or 2 months, which is

also awarded in very few cases. Generally the punishment

is till the rising of the Court, or doing some social services

like cleaning floor in the hospitals etc., as per the provisions

of the Amended Prohibition Act. One of the main reasons for

this state of affairs is the very large number of cases, which

are charge sheeted in the Courts and the Courts are not able

to cope - up with the volume of the work and therefore, they

find an easy way out of very light punishment or no

punishment at all as there is no minimum punishment is

prescribed. Similarly, the police force provided for the

purpose is grossly inadequate. A Committee needs to be set

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up by the State Government to fix a minimum yardstick of the

strength in the police as well as in the Courts. The police

patrolling in the affected areas go a long way in preventing

prohibition activities, for which sufficient resources need to

be provided to police force to make it smarter than the

bootleggers. Of course, some police officers who are found

hand in glove with the bootleggers need drastic surgery by

the Department and by State Government as the

punishment.

7.1(E)(ii) Some of the bootleggers are very influential and rich. They

also have support of the local mafia gangs and well

organized in their business. To tackle such a problem a

dedicated and motivated police force is required, for which

the State Government has to give a serious thought. It is

essential to strengthen the enforcement agencies, provide

them with adequate resources, motivate good officers and

ensure effective punishment to the guilty.

7.1(E)(iii) Enforcement of prohibition is the responsibility of the police.

If distilled alcohol is manufactured and sold, that becomes

the responsibility of police. But if methyl alcohol or

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methylated denatured alcohol finds its way illegally into the

drinking market then it becomes the responsibility of Excise

and Prohibition Department.

7.1(E)(iv) Lattha tragedies can be triggered by both poor enforcement

as well as by very strict enforcement, more often than not by

the later. When-ever there is a big shortage of illicit liquor to

the consumers, they try to lay their hands on what-ever type

of liquor is available. The bootleggers also take advantage

of this situation by supplying what-ever substance comes

their way. This needs a much focused attention to the

problem which should be concentrated for preventing

noxious substance such as methyl alcohol from reaching the

consumers and also FSL laboratory reaching to liquor

production / blending points with raiding police parties.

7.1(F) Public Cooperation:

7.1(F)(i) It is a well known fact that public support is not available by

way of information, identification of the accused before the

panch witnesses, giving the evidence in the Courts regarding

offenders etc., mainly because of social factors, criminal

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factors and lack of credibility in action taken by the police. In

case of threats from the accused to the people who help

police, the people are not at all satisfied with the police

response for their protection. Therefore, it is necessary to

provide protection to informers, giving them rewards, prompt

action on the information provided and encourages them to

come forward and help police to curb the evil of illicit

manufacture and sale of liquor.

7.1(F)(ii) To enhance public cooperation for effective implementation

of prohibition, it is essential to educate people about the ill

effects of illicit liquor and to improve general awareness

amongst people in this regard. Citizens who come forward

for active help must be protected and suitably rewarded by

the Department. It goes without saying that budgetary

provisions will have to be increased to really motivate people

to cooperate in this regard.

7.1(F)(iii) Taking help from electronic and print media, showing

documentaries in labour colonies and other affected areas,

organize lectures by experts in schools and colleges and

enlisting good NGOs for the purpose will be very useful and

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also taking help of spiritual leaders and organizations,

advocating "Vyasanmukti" will go a long way in persuading

the affected people to give up the evil habit of consuming

illicit liquor.

7.1(G) Residential treatment in rehabilitation centre may be

considered as part of the punishment to the offender for

alcohol addiction.

7.1(G)(i) Deaddiction treatment section may be introduced in jail as

part of the welfare services.

7.1(G)(ii) The schools and colleges may be encouraged to provide for

the services of counselors for prevention and awareness

programs of addiction. The school textbooks should

incorporate lessons about menace of alcohol and ill effects of

tobacco usage.

7.1(G)(iii) The training to the police officers may be organized to educate

them about the harms of addiction which may motivate them

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to be serious about their role and actions in prohibition

offences.

7.1(G)(iv) One treatment centre in every Government hospitals and

District Headquarters for children and women may be

considered by State Government as ratio of consumption is

growing in this group of society and also as such no separate

centre exists at present.

7.1(G) (v) A complaint box should be kept in each village. The

complaints made should be kept confidential and it should be

opened by a Sr. Police Officer in the presence of a team of

volunteers. Action with regard to such complaints should be

reviewed every month.

7.1(G)(vi) The psychological and social science of criminology suggests

that the minimum and maximum criteria of punishment do

not always play important role in case of repeat offenders.

One should think about literacy and their rehabilitation duly

supported by some meaningful alternative social and clinical

therapy / activities. It has also been observed that easy and

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quick money associated with trade of illicit liquor is one of the

causes of habitual offenders to stick to these activities in

spite of punishment. In such cases, law should be amended

to seize illegal property or destroy financial backing of

habitual offenders.

7.1(G)(vii) A dedicated blog should be created online and information

pertaining to disadvantages of liquor, interesting stories and

social drive against liquor should be freely discussed by

people on this blog. The information about nuisance of liquor

in specific areas obtained from blog should be given due

consideration. Same thing is applicable for the good

suggestions offered online by the blog visitor.

7.1(G)(viii) While discussing about health permits on the basis of

medical certificate, it was derived that in era of modern

medicine, the therapeutic role of foreign liquor is very limited.

It was also discussed that this system facilitates drinking by

the upper class of society as many health permits are

granted on basis of chronic addiction. Chronic addiction is

more prevalent in down trodden strata of the society,

particularly in slums. They cannot opt for the health permits

215  

as it is a costlier and complex issue for them. Sufficient

options for the treatment should be explored by area medical

board before recommending foreign liquor to a person who is

requesting for health permit. The Government should also

keep a check on licensing and recommending authorities. It

is brought to our notice that health department has issued

instructions and decided strategy to accept donations from

permit holders in ‘Rogi Kalyan Samitis’ of District and

medical college attached hospitals. This dilutes and kills the

motive behind issuance of health permits which is being

issued on medical grounds. There could be a possible

inspection to those institutions or centres where it has been

issued so that improper utility could be avoided The officers

who have played role in relaxing norms and instructing area

medical board to issue permits and accepting donations in

‘Rogi Kalyan Samitee’ should be prevented by adopting

appropriate administrative or punitive processes.

7.1(H) The Commission agrees with almost all the useful

suggestions as mentioned above by the people at large.

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7.1(I) Further the Commission has also issued a questionnaire to

various NGOs, institutions and individuals and out of them,

various people/organizations have recommended various

things, for which the Commission has made summary in this

behalf.

7.1(J) The Commission has sent the Questionnaire to Shri S.C.

Dholakia, an eminent Law Professor i.e. a Former Dean of

Law Faculty of Baroda as well as Former Member of Law

Commission of India/Gujarat State Law Commission. In

response to the said Questionnaire Mr. Dholakia was in

Ahmedabad and at that time the Members of the

Commission has a meeting with Mr. Dholakia and informed

him about the terms of Reference, working of the

Commission and also constitutional aspects of Article 47. He

stated that after going to Baroda, he will send a note in

connection with the working of the Commission, and

therefore, he has sent a note, which the Commission has

received on 7th August, 2010. The Learned Professor has

given his views on policy regarding prohibition in connection

with the Article 47 and stated that the duty of the State to

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raise level of nutrition and standard of living and to improve

public health. He has submitted that this problem should be

regarded not as a legal problem, but as sociological and

psychological problems. He has further emphasized about

some programme to tackle the evil of drinking should be

undertaken systematically and should involve rehabilitation

of the victims, socially and psychologically. He has further

stated that as this will essentially be a social welfare

measure/programme, it should be undertaken in

collaboration with the NGOs operating in the field in slum

areas and in areas inhabited by industrial workers. These

NGOs and also the women’s organizations operating in

these areas should be actively associated with the planning

and implementation of this programme of social upliftment.

The sustained campaign against the evil of drinking, carried

on in collaboration with the NGOs should be supplemented

by:

(i) De-addiction centres, suitably located, and operated by

motivated and trained staff for care and treatment of

the victims.

(ii) Programme of rehabilitation of the reformed addicts, so

that they may not relapse into bad habit;

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(iii) Arrangement for night-classes to provide literacy and

education to the adults;

(iv) To provide avenues for public entertainment and

organized corporate life to develop community spirit

and fellow-feelings among the group.

Thereafter he has stated that the State should make

adequate financial provision for this programme and it has

also stated that this programme may be handled not by the

Home/Police or Prohibition Department, but should be under

supervision and care of the social welfare department but

should be under supervision and care of the Social Welfare

Department and only a concerted, committed campaign

against the evil of drinking can help the situation and

promote the wider interest of society. Copy of the note

submitted by Shri H.C. Dholakia is enclosed herewith as

ANNEXURE “C”.

7.1(K) The Commission expresses a deep sense of gratitude

towards Mr. Dholakia who has spared his valuable time and

has given very valuable suggestions and Commission has

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also agreed with these suggestions. It may be treated as part

of the recommendations of this report.

7.2 The Commission has also sent a copy of Questionnaire to

Shri S.S. Khandwawala, IPS, (Retd), Ex-D.G.P. State of

Gujarat. The Commission has also discussed with him the

terms of Reference and working of the Commission. After

discussing the same Mr. Khandwawala has given a note with

regard to justification to improve implementation of

Prohibition Laws etc., in this connection.

7.2.1 He has suggested as follows:

It is further stated in para-4 regarding Law Enforcing Agency

duly supported by Prosecution Wing, Judiciary with the

determination to punish the guilty, including Mobile Courts in

Drunkenness cases with powers of heavy punishment.

7.2.2 In para-5 he has submitted that determined Government and

Voluntary Agencies with commitment and dedication.

220  

(a) To educate people addicted to alcohol through

Deaddiction campaign.

(b) To find alternate employment for the people involved in

business of illicit distillation.

(c) To explore the possibility of taking the help of various

Religious leaders like Pramukh Swamijee, Other

Swaminarayan, Hindu, Jain, Muslim, Christian and

Sikh Saints to organize a dedicated campaign against

this evil. In the past saints like Pandurang Shashtrijee

and saints of Swaminarayan cult had done great work

in this field. These efforts are required to be restarted.

7.2.3 In para-7 it further stated that consuming alcohol was always

considered to be very bad at least amongst the middle class

families in Gujarat. At any given time in the History of Human

race, middle class is always considered to be torch bearer of

Morality of the society. In recent past, majority of middle

class youth is also swayed away by the glamour of

alcoholism in the pursuit to look modern. Community leaders,

Elders in the family and female members are required to play

a very active role to bring them back to the track.

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7.2.4 In para 8 it is further stated that policy to permit also should

be more liberal and permits should be made easily available

to the deserving people irrespective of their social and

economical status. This will reduce the number of Law

Breakers and if the good quality of Alcohol is made available

to such people by Government, it will reduce corruption and

distillation of illicit alcohol.

7.2.5 At the last it is stated in para-9 that effective implementation

of the Act by Law Enforcing Authorities and any negligence

on their part is required to be viewed very seriously. But at

the same time there should be a dedicated staff in sufficient

number and very well equipped resources wise. It should

also be duly armed by Law. The entire system should be well

established, including the support from Prosecution Wing

and Judiciary.

7.2.6 Copy of the note submitted by Shri S.S. Khandwawala is

enclosed herewith as ANNEXURE “D”.

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7.2.7 The Commission expresses sincere thanks to Mr.

Khandwawala for his valuable note. The Commission hopes

and trusts that the State Government while implementing the

Prohibition Policy may consider these suggestions also. This

may also be treated as part of recommendation of the

Commission.

Previous Report of Hooch Tragedies:

7.2.7(1) This Commission has been constituted pursuant to the

Hooch Tragedy occurred in July, 2009 and the Government

has given very wide ranging Reference, for which the

Commission has to give report. In this connection when the

Commission initiated and started working, the Commission

also decided that this is not only the first tragedy, but there

were previous hooch tragedies that have occurred in the

State of Gujarat. To the knowledge of the Commission there

was first hooch tragedy occurred in February, 1977 and for

that the State Government has also constituted Commission

and Honourable Mr. Chief Justice M.N. Miabhoy (Retd) of

the Honourable High Court of Gujarat was appointed as

Chairman of the Commission. Honourable Mr. Justice

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Miabhoy also considered that tragedy and submitted his

report in May, 1978. The Commission has studied the said

report, particularly the recommendations made by the

Commission in this behalf. The report is dated 31st May,

1978.

7.2.7(2) Honourable Mr. Justice Miabhoy has also submitted second

report, which was given on October 25, 1978. This

Commission has also studied the said report. While giving

the report Honorable Mr. Justice Miabhoy has given useful

recommendations to see that in future such type of tragedy

may not recur. This Commission has considered the said

reports, in this behalf.

7.2.7(3) It may be noted that the State Government has also decided

the Inquiry into the existing Prohibition Policy of the State in

all its aspects and to recommend result oriented and more

particularly practical policy, which would beneficial to poor

and weaker Section of Society. For that the State

Government has issued Notification, somewhere on 20th

August, 1981, for constitution of a Commission. The said

Commission was also constituted under Section 2 to 5 of

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Section 5 of the Commission of Inquiry Act, 1952 and

Honorable Chief Justice Mr. M. N. Miabhoy (Retd) was

appointed as Chairman of the Commission and Honorable

Mr. Justice Miabhoy has also given report on 31st May, 1983.

The Commission has also studied the said report. It may be

noted that Honorable Mr. Justice Miabhoy while giving report

had made important recommendations to the State

Government.

7.2.7(4) Another incidence of hooch tragedy took place in March,

1989 and similarly the State Government had constituted the

Commission under the provisions of Commission of Inquiry

Act, consisting of Honorable Mr. Justice A.A. Dave (Retd) of

Honorable High Court of Gujarat. Honorable Mr. Justice A.A.

Dave had given his report on 30th April, 1990. This

Commission has also studied the said report, in this behalf.

7.2.7(5) Similarly, there was incident of death resulting from

consumption of Laththa in the State of Gujarat in Dabhoi of

District Baroda in November, 1978 and in pursuance to the

decision taken by the Government of Gujarat in this regard,

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whereby the Government of Gujarat vide Resolution dated

14/8/1978 constituted a Committee to inquiry of causes and

circumstances resulting in this tragedy and into other matters

mentioned in the said Resolution. Mr.P.N. Writer (IPS) was

appointed as Chairman of the Committee. The Committee

had given a detailed and exhaustive report also. This

Commission had also considered the said report in this

behalf, which is called as Writer’s Report.

7.2.7(6) Another incidence of hooch tragedy took place in March,

1990 at Sutrapada Taluka of Junagadh District. The

Government of Gujarat constituted a Committee headed by

Mr. P.K. Laheri I.A.S. H submitted the report. This

Commission has also studied the said report, in this behalf.

7.2.7(7) This Commission has also studied the report of High Level

Committee for stricter enforcement of Prohibition in Tamil

Nadu tabled April, 1977. Honorable Mr. Justice R.

Sadashivam, submitted the report in the month of April,

1977.

226  

7.2.7(8) The Commission has also considered the report of

Honorable Mr. Justice Tekchand of Honorable Punjab High

Court. This Commission has also studied the report of study

team on Prohibition Policy submitted by Honorable Mr.

Justice Tekchand along with other members, wherein the

said Commission has considered the working of Prohibition

Programme for the country as a whole. The said report was

connected with enforcement of prohibition and excise law,

measure intended. The said Commission has been working

on study of Prohibition programme for the country as a

whole. The Commission has also studied the problems

connected in enforcement in prohibition and excise law,

measure intended to reduce illicit drinking of liquor. The

report was tabled in the year 1964.

7.2.7(9) It appears that the State Government has also studied the

first report of Honorable Mr. Justice Miabhoy; second report

of Honorable Mr. Justice Miabhoy and also of Honorable Mr.

Justice A.A. Dave, in this behalf.

227  

7.2.7(10) As the Commission has to consider the action taken by the

Hospital in private medical societies to the people including

the hospitals. The action taken by the hospitals in providing

medical assistance to victims and also the adequacy of

measures for effective implementation of prohibition laws by

the police and recommendations; action plan for effective

police action; plan for effective medical intervention including

the role and function of medical infrastructures in the

hospitals of public and private domain.

7.2.7(11) This Commission had also studied the report of the

Commission of Inquiry wherein numbers of deaths taken

place in J.J. Hospital, Bombay, headed by Honorable Mr.

Justice Lentin, of Honorable High Court of Bombay

submitted in March, 1988.

7.2.7(12) As far as the reports given by Honorable Mr. Justice

Miabhoy, Honorbale Mr. Justice A.A. Dave and other reports.

While the Commission has gone through the

recommendations, the Commission addressed a letter to the

State Government of Gujarat vis-a-vis what happened to

228  

these recommendations. Out of these recommendations,

which are the recommendations implemented by the State

Government which are the recommendations which have not

been implemented and why. Because that will go a long way

in connection with shaping of future policy regarding

prohibition and even recommendations be made by the

Commission in this behalf. The State Government by a letter

addressed during 2011, by which on one hand they have

shown recommendations and a tabular statement in respect

of what actions are taken in this behalf. The Commission

has studied the same also while making recommendations,

has considered these recommendations and action taken by

the Government, in this behalf.

7.2.8 The Commission encloses herewith the note regarding the

implementation and recommendation of the report submitted

by the State Government of Gujarat dated 23rd September,

2011 and 15th November, 2011 along with the Tabular

Statement submitted by the Government are marked as

ANNEXURE “E”.

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7.2.9 The Commission has studied all these reports and is of the

view that these recommendations, particularly the

recommendation made by Honorable Mr. Chief Justice of

High Court of Gujarat M.N. Miabhoy (Retd) are very useful

and are more practical in nature. It is no doubt true that the

State Government has partly implemented the same. The

Commission hopes and trusts that the State Government

may also try to implement these suggestions also.

7.2.10 As regards to the Hospital reforms, the Commission has

studied the report submitted by Honorable Mr. Justice Linten

of High Court of Bombay. The report and recommendations

made by Lentin also are very useful and instructive. When

the State Government, particularly the Health Department

has a desire to improve the working of the Hospital, the

Commission requests the State Government to go through

the said recommendations and the Commission hopes and

trusts that the State Government may try to implement those

suggestions also. These suggestions may also be treated as

part of the recommendation of the Commission.

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Chapter – 8

Consideration of Constitutional Provisions

The Commission has considered this wide ranging

reference. The Commission is of the view that the policy of

the State Government for prohibition is the foundation of

Article 47 of the Constitution of India. So the Commission

has considered Article 47 as well as some of the important

judgment of the Apex Court in this behalf. However, before

the Commission discusses Article 47, there are certain other

important constitutional provisions, which have abearing with

Article 47, as well as considering wide range reference to the

Commission, that is how the Commission has considered

some of the important constitutional provisions also, in this

behalf.

PREAMBLE

8.1 The words in the Preamble, "We the people of India... in our

Constituent Assembly ... do hereby adopt, enact and give to

ourselves this Constitution", propounded the theory that the

'sovereignty' lies in the people, that the Constitution,

231  

emanates from them; that the ultimate source for the validity

of, and the sanction behind the Constitution is the will of the

people; that the Constitution has not been imposed on them

by any external authority, but is the handiwork of the Indians

themselves.

8.1(A) As to the grand objectives and socio-economic goals to

achieve which the Indian Polity has been established, these

are stated in Preamble. These are; to secure to all its citizens

social, economic and political justice; liberty of thought,

expression, belief, faith and worship; equality of status and

opportunity, and to promote among them fraternity so as to

secure the dignity of the individual and the unity and integrity

of Nation.

8.2 Thus, the source of the Constitution of India are the people

themselves from whom the Constitution derives its ultimate

sanction. This assertion affirms the republican and

democratic character of the Indian polity and the sovereignty

of the people. The People of India thus constitute the

sovereign political body who hold the ultimate power and

232  

who conduct the government of the country through their

elected representatives.

8.3 The Preamble does not grant any power but it gives a

direction and purpose to the Constitution. It outlines the

objectives of the whole Constitution. The Preamble contains

the fundamentals of the Constitution. It serves several

important purposes, as for example;

(i) It contains the enacting clause which brings the

Constitution into force.

(ii) It declares the great rights and freedoms which the

people of India intended to secure to all its citizens.

(iii) It declares the basic type of government and polity

which is sought to be established in the country.

(iv) It throws light on the source of the Constitution, viz.,

the People of India.

8.4 The goals and objectives of the Indian Polity as stated in the

Preamble are sought to be further clarified, strengthened and

concretized through the Directive Principles of State Policy.

Therefore, it is essential that the Preamble be read along

233  

with the Directive Principles of State Policy which lay down

certain goals for the government to achieve so as to

maximize social welfare of the people.

8.5 WELFARE STATE

8.5.1 The Indian Constitution has been conceived and drafted in

the mid-twentieth century when the concept of social

welfare state is the rule of the day. The Constitution is thus

pervaded with the modern outlook regarding the

objectives and functions of the state. It embodies a distinct

philosophy of the State Government, and explicitly declares

that India will be organized as a social welfare state, i.e., a

state which renders social services to the people and

promotes their general welfare. In the formulations and

declarations of the social objectives contained in the

Preamble. One can clearly discern the impact of the modern

political philosophy which regards the state as an organ to

secure the good and welfare of the people.

8.6 This concept of a welfare state is further strengthened by the

Directive Principles of State Policy which set out the

234  

economic, social and political goals of the Indian

Constitutional system. These directives confer certain non-

judiciable rights on the people, and place the government

under the obligation to achieve and maximize social welfare

and basic social values like education, employment, health

etc.

8.7 Article 21 confers right to life.

8.8 EXTENDED VIEW OF ARTICLE 21

A very fascinating development in the Indian Constitutional

jurisprudence is the extended dimension given to Article 21

by the Supreme Court in the post Maneka era.

8.9 Since Maneka Gandhi's case, Article 21 has proved to be

multi-dimensional. This aspect of Article 21 is brought out by

the following judicial pronouncements. This extension in the

dimensions of Article 21 has been made possible by giving

an extended meaning to the word 'life' and 'liberty' in Article

21. These two words in Article 21 are not to be read

235  

narrowly. These are organic terms which are to be

construed meaningful.

8.10 A grand step was taken by Honorable the Supreme Court in

expanding the scope of Article 21 when it held that 'life' in

Article 21 does not mean merely 'animal existence' but living

with 'human dignity'. The Court has thus given very

extensive parameters to Article 21.

8.11 "But the question which arises is whether the right to life is

limited only to protection of limb or faculty or does it go

further and embrace something more. We think that the right

to life includes right to live with human dignity and all that

goes along with it viz., the bare necessities of life such as

adequate nutrition, clothing and shelter over the head and

facilities for reading, writing and expressing oneself in

diverse forms, freely moving about and mixing and mingling

with fellow human beings. Of course, the magnitude and

content of the competent of this right would depend upon the

extent of the economic development of the country, but it

must, in any view of the matter, include the right to the basic

236  

necessities of life and also the right to carry on such

functions and activities as constitute the bare minimum

expression of human self." [Re. Francis Collie V/S

Administrator of Delhi AIR 1981 SC 746 (753)].

8.12 Thus the Supreme Court has introduced a qualitative

concept into Article 21. Whatever promotes quality of life

falls within the parameters of Article 21. The right to life

connotes not merely animal existence but includes finer

graces of human dignity, culture and civilization. The right to

life with human dignity encompasses within its purview some

of the finer facets of human civilization which make life worth

living. This gives a very expansive dimension to Article 21.

To reach such a result, the Supreme Court in a display of

judicial activism has integrated Article 21 with a number of

Directive Principles.

8.13 Article.21.A. Right to Education. (As amended by

86th Amendment to the Constitution of India, 2002).

237  

8.13.1 The right to education was initially not included as a

fundamental right in the Constitution and was included as a

fundamental Right for education. Initially directive principle

under Article 45 which required the State to endeavour to

provide, within a period of 10 years from the commencement

of the Constitution, for free and compulsory education for all

children until they complete the age of 14 years. The

directive in Article45 was not confined merely to primary

education; but it has been extended to providing free

education up to the age of 14 years, whatever the stage of

education it comes to.

8.14 Keeping the objective of Article 21-A in mind, its provisions

have been liberally construed allowing teachers and

educational institutions to obtain benefits there under. The

underlying logic is that the grant of benefits to those involved

in the process of education would also indirectly benefit

those for whom the Article was primarily intended. The same

logic persuaded the court to hold that the services of the

teachers may not be requisitioned on the days on which the

schools are open. However claims based on Article 21.A to

compel the State to give grant in aid, to control fees charged

238  

by private unaided schools or to challenge conditions for

grant of recognition have been negated by High Courts.

8.15 Article 21. It is to read with Article 19(1)(a) has been

construed as giving all children the right to have primary

education in a medium of instruction of their choice. Article

21.A has also been construed as the fundamental right of

each and every child to receive education free from fear of

security and safety so that children have a right to receive

education in a sound and safe building.

8.16 In 2001-2002, the Government launched Sarva Shiksha

Abhiyan to make elementary education free. However, no

Central Legislation was enacted to make the right a reality

despite the Court noting in P.A. Inamdar (AIR 2005 SC 3226)

that it was for the Central Government, or for the State

Governments, in the absence of a Central legislation, to

come out with a detailed well-thought-out legislation on the

subject and that such a legislation was long awaited. In

2008, Dalveer Bhandari, J. in Ashoka Kumar Thakur V.

Union of India, (2008 (6) SCC p-1) directed "the Union of

239  

India to set a time-limit within which this article is going to be

completely implemented. This time-limit must be set within

six months. In case the Union of India fails to fix the time-

limit, then perhaps this work will also have to be done by the

Court.

8.17 Ultimately the Right of Children to Free and Compulsory

Education Act, 2009, has been enacted by the Parliament.

The Act provides among other things for the right of every

child who has attained the age of 6 years to be admitted in a

neighborhood school and be provided free and compulsory

education in such school. Every state is responsible for

making such neighborhood school available. All schools,

whether state schools, aided or unaided private schools will

now have to provide free and compulsory education up to

specified percentages of the total number of children

admitted. Charging of capitation fees is prohibited. In

addition to this, a child or his/her family should not be

subjected to any screening procedure by a school

management before admissions. In keeping view of this

Article 51.A, the Act casts a duty on every parent or guardian

to admit or cause to be admitted his or her child or ward, as

240  

the case may be, for an elementary education in the

neighborhood school.

DIRECTIVE PRINCIPLES OF STATE POLICY AND BASIC

DUTIES

(CHAPTER-IV OF THE CONSTITUTION)

A NATURE OF THE DIRECTIVE PRINCIPLES

8.17.1 (a) STATE

The word ‘State’ used in these Directive Principles has the

same meaning as has been given to it by Article 12 for the

purpose of enforcement of Fundamental Rights unless the

context otherwise requires (Article36).

8.18 The makers of the Constitution had realized that in a poor

country like India, political democracy would be useless

without economic democracy. Accordingly, they

incorporated a few provisions in the Constitution with a view

to achieve and amelioration of the socio-economic condition

of the masses.

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8.18(A) The right to education was initially not included as the

fundamental right of constitution, but subsequently included

as fundamental right under Article 21 of the Constitution of

India.

8.19 The Directive Principles are designed to usher in a social

and economic democracy in the country. These principles

provide the state to take positive action in certain directions

in order to promote the welfare of the people and achieve

economic democracy. These principles give directions to the

legislatures and the executive in India as regards the manner

in which they should exercise their power.

8.20 In a number of pronouncements, Honorable the Supreme

Court has insisted that these Directive Principles seek to

introduce the concept of a welfare state in the country. “The

Constitution envisages the establishment of a welfare state

at the federal level as well as the State level. In a welfare

state the primary duty of the Government is to secure the

welfare of the people."

242  

8.21 The Directive Principles differ from Fundamental Rights

which enjoin the state to refrain from taking prejudicial action

against an individual and, thus, impose a negative duty on

the state. Fundamental Rights seek to introduce an

egalitarian society and to ensure liberty for all. The Directive

Principles seek to achieve a welfare state. The two together

constitute the conscience of the Constitution.

8.22 Originally, the Directive Principles were more akin to moral,

rather than to legal, precepts as they did not have much

value from a legal point of view. The main idea underlying

these principles was that they would serve an educational

purpose, and might serve as restraints on those who come in

power. These persons would have to pay some respect to

those principles while exercising power, and could be held

accountable for ignoring them before the electorate if not

before a Court of Law. In the Constituent Assembly, Dr.

Ambedkar had said that a party which failed to implement

these principles would stand to lose in the next elections.

Thus, the accountability to enforce these principles was left

to the political process. With the passage of time, however,

243  

greater emphasis has come to be laid on the fulfillment of the

goals set out in these principles.

8.23 Article 37 says that the Directive Principles "shall be not

enforceable by any Court, but the principles therein laid

down are nevertheless fundamental in the governance of the

country and it shall be the duty of the State to apply these

principles in making laws." The term 'state' in Article37 has

the same meaning as has been given to it in Article 12 and

which has been explained earlier.

8.24 SOCIAL ORDER BASED ON JUSTICE

Article 38(1) directs the State to strive “to promote the

welfare of the people by securing and protecting as

effectively as it may be a social order in which justice, social,

economic and political, shall inform all the institutions of the

national life.”

8.25 Article 38 needs to be read along with Article 14. This

directive reaffirms what has been declared in the Preamble

to the Constitution, viz., the function of the Republic is to

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secure, inter alia, social economic and political justice. To

secure justice to the people under the law, Courts with

broad powers and jurisdiction have been established in the

country.

8.26 Article 38 envisages not only legal justice but also the socio-

economic justice as well. The Supreme Court has

explained the idea of social justice as follows.

8.27 Means of Social Justice:

8.27.1 "The Constitution commands justice, liberty, equality and

fraternity as supreme values to usher in the egalitarian

social, economic and political democracy. Social Justice,

equality and dignity of person are cornerstones of social

democracy. The concept of 'social justice' is thus an integral

part of justice in the generic sense. Justice is the genus, of

which social justice is one of its species. Social Justice is a

dynamic device to mitigate the sufferings of the poor, weak,

dalits, tribals and deprived sections of the society...."

245  

8.27.2 Article 38(2) directs the state to strive "to minimize the

inequalities in income", and endeavor "to eliminate

inequalities in status, facilities and opportunities, not only

amongst individuals but also groups of people residing in

different areas or engaged in different vacations."

8.28 The Commission is of the view that the instrument of taxation

is not merely a means to raise revenue but it is also a means

to reduce inequalities. Therefore, proportionately greater

burden is put on the rich. The state has to use all its powers,

including the power of taxation, to achieve the goal

adumbrated in Article. 38.

8.29 Reading Articles. 21A, 38, 42, 43, 46 and 48A together, the

Supreme Court has concluded in Consumer Education &

Research Centre V. Union of India (AIR 1995 SC 923: (1995)

3 SCC 42; that "right to health, medical aid to protect the

health and vigour of a worker while the service or post

retirement is a Fundamental Right... to make the life of the

workman meaningful and purposeful with dignity of person."

246  

8.30 In the instant case, the Supreme Court has dilated upon the

theme of social justice envisioned in the Preamble to the

Constitution and Article 38. Social Justice is the arch of the

Constitution which ensures life to be meaningful and livable

with human dignity. Social Justice, equality and dignity of

the person are cornerstones of social democracy. Social

Justice is a dynamic device to mitigate the sufferings of the

poor, weak, dalits, tribals and the deprived sections of the

society and to elevate them to the level of equality to live a

life with dignity of person. The aim of social justice is to

attain substantial degree of social, economic and political

equality.

8.31 Health of the worker enables him to enjoy the fruit of his

labour, keeping him physically fit and mentally alert for

leading a successful life, economically, socially and

culturally. Medical facilities to protect the health of the

workers are, therefore, the fundamental and human rights of

the workmen.

247  

8.31.1 PRINCIPLES OF POLICY TO BE FOLLOWED BY THE

STATE.

8.32 Article 39 requires the state, in particular, to direct its policy

towards securing;

8.32.1 (a) that all citizens, irrespective of sex, caste and

religion equally have the right to an adequate means of

livelihood.

8.32.2 (b) that the ownership and control of the material

resources of the community are so distributed as best to

sub serve the common good;

8.32.3 (c) that the operation of the economic system does

not result in the concentration of wealth and means of

production to the common detriment;

8.32.4 (d) that there is equal work for both men and

women;

8.32.5 (e) that the health and strength of workers, men and

women, and tender age of children are not abused and

that citizens are not forced by economic necessity to enter

vocations unsuited to their age or strength:

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8.32.6 (f) that children are given opportunities and facilities

to develop in a healthy manner and in conditions of

freedom and dignity and that childhood and youth are

protected against exploitation and against moral and

material abandonment.

8.33 Article 39(a): MEANS OF LIVELIOOD.

8.33.1 Thus Article 39(a) is to be interpreted with Article 21A to

include therein the "right to livelihood." The state may not be

compelled, by affirmative action, "to provide adequate means

of livelihood or work to the citizens. ”But the state is under a

negative obligation, viz., not to deprive a person of this right

without justice and fair procedure.

8.34 The National Rural Employment Guarantee Act, 2005, was

passed with the object of giving employment to at least one

member of a family for hundred days in a year, on paying

wages as fixed under the Act. The Court refused to give

relief by way of regularization of employment of casual

worker in government service or in the service of its

instrumentalities saying that in the name of individualizing

249  

justice, it is not "possible to shut our eyes to the

constitutional scheme and the right of the numerous as

against the few who are before the Court". The directive

principles of State policy have to be reconciled with the rights

available to the citizen under Part III of the Constitution and

the obligation of the State to one and all and not to particular

group of citizens (Secy. State of Karnataka V. Umadevi (3),

(2006) 4 SCC 1, at page 41: AIR 2006 SC 1806).

8.35 Articles 39(b) and 39(c) relate to distribution of ownership

and control of material resources of the community. An act,

falling under the Clauses (b) and (c) of Article 39, must have

operation in the economic system and concentration of

wealth. Taking over of management by the government of a

sick textile mills has been characterized as being in

furtherance of Articles 39(b) and (c). (N.T. Corporation Ltd.,

V. Sitaram Mills, AIR 1986 SC 1234; 1986 Supp. SCC 117,

See also Tata Motors Ltd, V. Pharmaceutical Products of

India Ltd., (2008) 7 SCC 619.

250  

8.36 Article 47. Duty of the State is to raise the level of

nutrition and the standard of living and to improve

public health – The State shall regard the raising of the

level of nutrition and the standard of living of its people and

the improvement of public health as among its primary duties

and, in particular, the State shall endeavor to bring about

prohibition of the consumption except for medicinal purpose

of intoxicating drinks and of drugs which are injurious to

health.

8.37 On this behalf the Commission craves leave to refer to and

rely upon the judgment of the Honorable Apex Court in the

case of Razakbhai Issakbhai Mansuri V/S the State of

Gujarat – 1993(1) GLH p-1169. In that case the petitioner

and some of the appellants have challenged the

constitutional validity of amendment made in Bombay

Prohibition Act by the Gujarat Legislature prohibiting

possession of rotten gur in excess of prescribed limit as

considered by the Three Judge Bench Judgment consisting

of the Honorable Chief Justice of India, Honorable Mr.

Justice L.M. Sharma, and Honorable Mr. Justice S. Mohan

Venkatchalia JJ, considered provision of Entry 8 of List-2,

251  

(Intoxicating liquors, that is to say, the production,

manufacture, possession, transport, purchase and sale of

intoxicating liquors) wherein the Honorable Apex Court has

also considered the judgment in the case of State of Bombay

V/S… Balsara and others (AIR 1951 SC p-318). It is

observed in para-11 (p-1177) that:

8.38 Para-11, Page-(1177). Although the Directive Principles of

State Policy as contained in Part IV of the Constitution are

not enforceable by Courts, nonetheless it is the duty of the

State to give effect to those principles by enacting

appropriate laws. It has been described as matters of the

constitutional obligation of the State to do so in the public

interest. A large body of legislation under Article 19(1) (g)

when challenged has been upheld by Courts, as being in

furtherance of such policy, as valid on the ground of the

Directive Principles. So far as the intoxicating drinks are

concerned, their evil effects are well established especially

for the Indian Society. This was why the framers of the

Constitution considered it fit to include it, in expressed terms

in Article 47, while indicating the duty of the State to raise the

standard of living and to improve the public health. It is

252  

therefore, within the authority of the State to prohibit

consumption of intoxicating liquor and the State of Gujarat

was fully justified when it adopted the policy of prohibition. In

order that this policy may succeed, it is not sufficient to

merely ban manufacture and consumption of alcoholic

drinks. To render it really effective, further measures will

become essential in order to defeat the illegal activities of the

anti-social elements engaged in illicit manufacture and illegal

distribution of the liquor in the market. It, therefore becomes

obligatory for the State to take all such steps as found

necessary for implementing the prohibition policy, by not only

placing restrictions on the manufacture, sale and

consumption of liquors and also by adopting such other

regulatory measures, essential to achieve the objective.

8.39.1 Again, referring to liquor laws and liquor control, a learned

British author in the Encyclopedia Britannica, 14th Edition,

Volume 14, page 191) says as follows: (i.e. from Britannia P-

1178 of Reports).

253  

8.39.2 “The dominant motive everywhere, however, has been a

social one, to combat a menace to public order and the

increasing evils of alcoholism in the interests of health and

social welfare. The evils vary greatly from one country to

another according to differences in climate, diet, economic

conditions and even within the same country according to

differences in habits, social customs and standards of public

morality. A new factor of growing importance since the

middle of the 19th century has been the rapid urbanization,

industrialization and mechanization of our modern everyday

life in the leading nations of the world, and the consequent

wider recognition of the advantages of sobriety in

safeguarding public order and physical efficiency.

8.39.3 Para-13 (1178). The unlawful activities of bootleggers are

also well known. In this country as also in several other

countries of the world, where the policy of prohibition was

attempted, they have jeopardized its success. The problem

therefore, has been engaging the attention of the social

reforms and other experts on the subject. With that view in

mind several committees have been set up in this country

from time to time, which after making extensive and thorough

254  

study of the malady and its cure have reported that it is

necessary to adopt further remedial measures by way of

placing restrictions on the business of such articles which aid

the illegal manufacturers of liquors. Mr. Poti, the learned

Counsel appearing on behalf of the respondent-State has

placed before us certain portions of Prohibition Policy Inquiry

Commission Report, 1983, dealing with the potentiality of

“rotten gur” being used for this purpose. This aspect has

been dealt with in the affidavit of Shri D.K. Mehta, Deputy

Secretary, Labour, Social Welfare Tribal Development

Department, and State of Gujarat. It is stated that after

considering the matter thoroughly, the State Government

came to the conclusion that in Gujarat “rotten gur” was being

used for manufacture of illicit liquor. In paragraph-9 of the

affidavit reference has been made to the report of Teckchand

Committee wherein attention of Government was drawn to

the misuse of “rotten gur” for this purpose. This was widely

rampant especially in the district of Broach, Bulsar and Surat.

The exercise undertaken in this regard, before the impugned

provisions were enacted, is mentioned by the committees

constituted by persons having expert knowledge which were

placed before us on behalf of the State. We do not consider

255  

it necessary to discuss them in detail. The problem which

faced the State was that unscrupulous persons while

pretending to be engaged in business of “rotten gur” or for

that matter, ‘gur’ were aiding and abetting bootlegging on

large scale. For checking effectively this illegal activity it was

considered necessary to require a person in possession of

“rotten gur” in exercise of the prescribed quantity to obtain a

permit. This would help the administration in keeping a

vigilant eye on the violators of the law. We have examined

the materials placed before us by the parties. We are fully

satisfied that the impugned steps were taken after a detailed,

careful and deep deliberation of the problem and its solution

and that the impugned amendments fully satisfy the public

interest test.

8.39.4 Thus, Judgment in Supreme Court Razakbhai V/S State of

Gujarat Writ petition (Civil) No. 12532 of 1985 (decided by

Three Judge’s Bench of Apex Court. S. Mohan and

Vanketchalia decided on 4/12/1992. – SC has considered

Entry 8 as well as Article 47 (matter is connected to rotten

gur). (paras 11 and 13) and observed as above.

256  

8.39.5 Another judgment is AIR 2006 SC p-1987 in the case of Rav

Rao Gaikwad V/S Rajajinagar Youth Social Welfare

Association. Wherein the Honorable Apex Court has

observed in para-9 that – (para-9, p-1990) We have to keep

in mind that right to trade in liquor is only a privilege farmed

out by the State. Article 47 of the Constitution of India clearly

casts a duty on the State at least to reduce the consumption

of liquor in the State gradually leading to prohibition itself. It

appears to be right to point out that the time has come for the

States and the Union Government to seriously think of taking

steps to achieve the goal set by Article 47 of the Constitution

of India. It is a notorious fact, of which we can take judicial

notice, that more and more of the younger generation in this

country is getting addicted to liquor. It has not only become

a fashion to consume it but it has also become an obsession

with many. Surely, we do not need an indolent nation. Why

the State in the face of Article 47 of the Constitution of India

should encourage that too practically unrestrictedly, the trade

in liquor is something that it is difficult to appreciate. The

only excuse for the State for not following the mandate of

Article 47 of the Constitution is that huge revenue is

generated by this trade and such revenue is being used for

257  

meeting the financial needs of the State. What is more

relevant here is to notice that the monopoly in the trade is

with the State and it is only a privilege that a licensee has in

the matter of manufacturing and vending liquor.

8.39.6 The Commission has also come across the judgment of the

Honorable Apex Court in the case of Chandran Alias

Manichand Alias Maniyan and others V/S The State of

Kerala – 2011 (5) SCC 161.

8.39.7 In this case the Honorable Supreme Court was concerned

with the hooch tragedy in Kerala, wherein 31 persons had

lost lives, 6 persons had suffered total blindness in Kollam

District, whereas more than 500 persons suffered serious

injuries on account of drinking illicit liquor. The Honorable

Apex Court considered various provisions of Indian Penal

Code as well as the Kerala Abakari Act, 1077 and ultimately

the Honorable Supreme Court also considered mixing or

permitting to mix noxious substance with liquor. The

Honorable Supreme Court considered poisonous substance

methyl alcohol (also known chemically as methanol), added

258  

to ethyl alcohol (also known chemically as ethanol) the

Honorable Supreme Court also considered mixing not done

properly resulting in death, blindness and other ailments to

several persons. The Honorable Supreme Court also

considered criminal liability of Hooch King and others who

were involved in business of spurious liquor which had led to

tragedy in question. The Honorable Supreme Court

considered definition of Narcotics, Intoxicants and Liquor in

relation to Kerala Abkari Act. The Honorable Supreme

considered conspiracy in respect of spurious liquor business.

The Honorable Supreme Court has also considered criminal

liability of distribution of spurious liquor. The Honorable

Supreme Court has considered the provisions of Evidence

Act, Human Civil Rights, Universal Declaration of Human

Rights, 1948 and International Convention on Civil and

Political Rights, 1966 and has also considered Criminal Trial

and burden of proof in Criminal trial.

8.39.8 The Honorable Supreme Court has considered public

accountability and vigilance and liquor adulteration and also

production and sale of spurious liquor adulterated with

methyl alcohol. The Honorable Supreme Court with serious

259  

concern has expressed about such a sorry state of affairs

and has also directed to undertake review of its system and

to weed out and punish corrupt persons. The Honorable

Supreme Court has also considered Alcoholism and drug

addiction, deleterious effect of alcohol explained and has

also considered alcohol a general human weakness. The

Honorable Supreme Court has held bootleggers responsible

for the exploitation of this weakness with the result that poor

sections of society fall prey to spurious liquor.

8.39.9 The Honorable Supreme Court in para-5 on page 172

observed as under:

“Alcohol has already proved itself to be one of the major

enemies of human beings. However, its grip is not loosened

in spite of the realization of the evil effects of alcohol on

human life. On the other hand, the unholy grip is being

tightened day by day. Therefore, when the standard and

healthy alcohol in the form of liquor is not available or is too

costly for a common man, the poor section of the society

goes for illicit distilled liquor which is sold by the bootleggers.

The conscienceless bootleggers – thanks to their avarice for

260  

money – take full advantage of this human weakness and

without any compunction or qualms of conscience, distil illicit

liquor and then to increase the sale and to gain astronomical

profits make their product more potent at least in taste so as

to attract the poor customers. Such poor customers

invariably become the prey of such unholy avarice on the

part of the bootleggers and in the process even lose their

lives at times or suffer such injuries which are irreparable like

complete blindness, kidney failures and metabolic acidosis

etc., and that is precisely what has happened in this case.

8.39.10 Thereafter in para-131 on page-213 the Honorable Supreme

Court has observed as under:

8.39.11 Para-131 (page-213) before we part with the case, there

are some very disturbing facts which have been revealed

from the voluminous evidence by the prosecution in this

case. Here was a person who was unabashedly running his

empire of spurious liquor trade and for that purpose had

purchased politicians including public representatives, police

officers and other officers belonging to the Excise

261  

Department. The trade was going on unabated.

Unfortunately it is the elite of the society or the “haves” of the

society who never purchase this kind of spurious liquor for

obvious reasons. It is only the poor section of the society that

becomes the prey of such obnoxious trade and ultimately the

sufferers. As many as 31 persons have lost their lives, about

5 or more persons have lost their eye sight forever and

several others have suffered in their health on account of the

injuries caused to them. It is only by an accident that the

mixing was not done properly on the fateful day in the sense

that the liquor mixed did prove to be fatal or injurious. But

that does not mean that when it was mixed on other days for

months together that it was not injurious. The use of

methanol was a dangerous proposition. It only shows that

human avarice could create a hell in God’s own country,

Kerala.

8.39.12 The Honorable Supreme Court was not only perturbed by the

enormousness of the tragedy, but the enormousness of the

liquor trade run by A-7 and that was under the so-called

vigilant eyes of those who had duty to stop it. The avarice is

not only on the part of the accused persons, but also on the

262  

part of those who benefit from this horrible business. Though

10 years have passed, the reverberations of this grim

tragedy have not become silent.

8.40 VIEWS OF EMMINENT AUTHORS ON ARTICLE 47.

8.40.1 Mr. H.M. SEERVAI AN EMINENT JURIST ON HIS WORK ON CONSTITUTION OF INDIA;

(14TH Edition Vol. II) page-2012 Page.17:152).

Alcohol is a narcotic or a depressant. The prohibition of

intoxicating liquor had long been a part of the policy of the

Indian National Congress; and its inclusion in Article 47

received support from the Mohammedan community whose

social habits were reinforced by Koranic injunction against

intoxicating liquor. In considering the directive in Article47, it

may be observed that alcohol (the intoxicating ingredient of

liquor) is a “narcotic” * a word replace by the word

“depressant” to describe the same effect contrary to the

popular belief that it is a stimulant. ** It is no mere accident

that intoxicating liquor and dangerous drugs have been

clubbed together in entry 8, List II.

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*.. Narcotic: “A drug (as of the opium. Belladonna or

alcohol groups) that in moderate doses arrests

sensibility, relieves pain, and produces profound sleep

but that in poisonous doses produces stupor, coma, or

convulsion”: Webster’s New International Dictionary

(3rd ed).

**.. “Drug action: Alcohol exerts a depressant action on the

brain, it muffles the mind. It, therefore, belongs to the

group of depressant drugs, of which either and the

barbiturates are representative. Under the influence of

alcohol, the functions of the brain are depressed in a

characteristic pattern. The so-called higher or more

complex functions, rather than the semi-automatic

ones, are affected first (e.g. a stenographer under the

influence of alcohol may type at her usual speed, but

the errors become more numerous). The most

complex action of the brain – judgment, self-criticism,

the inhibitions learnt from earliest childhood – are thus

depressed first, and the loss of this control results in a

feeling of excitement in the early stages. For this

reason, alcohol is sometimes thought of, erroneously,

as a stimulant.” : Encyclopedia Britannica Vol. I (1970).

264  

8.40.1(A) After referring aforesaid paragraphs, the Learned Author has

considered various decisions on Article 47, particularly the

judgment of the Honorable Apex Court in the case of State of

Bombay V/S F.N. Balsara (AIR 1951 p-318) constitution

Bench judgment and others and ultimately on question, as to

whether can there be trade in liquor? According to Learned

another, the same is ambiguous and the Learned Author

explained the said ambiguity in his characteristic style in para

17.155 on page No. 2014.

8.40.1(AA) Submission on the real issues involved. The question,

“can there be trade in liquor?” is ambiguous. The

ambiguity explained. It will be seen that if there is no

fundamental right to carry on trade in liquor, no question of

reasonable restrictions on that right can arise. It is submitted

that the question “Can there be trade or business in

intoxicating liquor?” is ambiguous, and its answer depends

upon the situation in which it is asked. If the impugned law

permits the use of, and trade in, intoxicating liquor under

regulation, the question answers itself – “Of course there can

be trade in liquor, since it is allowed to be bought and sold”.

But if the impugned law prohibits the use of, or trade in,

265  

intoxicating liquor, the question acquires a different meaning.

It means: “Is intoxicating liquor an article of such a nature

that the law can with propriety [We have said “with propriety”

because harmless articles of ordinary food and drink cannot

be declared res extra commercium without violating Article

19(1)(f) and (g)] treat it as res extra commercium (outside

commerce)?” Opinions may differ on this question. But, in

India, there are two reasons for answering it in the

affirmative. First, the character of alcohol is a narcotic or a

depressant; secondly, the directive in Article-47. For, it would

be incongruous to speak of intoxicating liquor as an object of

commerce, entitled to the protection of fundamental rights as

to property and trade, when a directive principle, which is

also fundamental in the governance of the country, makes it

the duty of the State to secure the prohibition of the

consumption of intoxicating drinks. The directive in Article 47

is absolute – it is not dependent upon providing

circumstances which justify prohibition. It is submitted that

for the reasons given above there can be no fundamental

right of property or prohibit the exercise of that right, is the

same. This view encourages futile challenges to the

266  

reasonableness of restrictions imposed by liquor laws. (H.M.

Seervai, para 17:151 page No. 2014).

8.40.2 Durga Das Basu In Commentary on the Constitution of

India 8th Edition, 2008, Vol.3 has considered Article 47

in comparison to International Constitution (i.e. on page

4159 to 4166) - International Charters; (A) universal

Declaration of Human Rights, 1944. (B) International

Covenant of Economic, Social and Cultural Rights, 1966;

Additional Protocol to the American Constitution of Human

Rights in the Area of Economic, Social and Cultural Rights;

U.S.A. The 21st Amendment (1933); Eire – Article 45(4)(b),

U.S.S.R; The relevant provisions of Soviet Constitution of

1977; Citizens of the USSR have the right to health

protection. Article42. China, Article 45 of the 1982 –

Constitution of the Chinese Republic and Pakistan – Article

37(h).

8.40.3 On page 4164 the Learned Author (Mr. Basu) considered on

“Prohibition”, GRANVILLE AUSTIN In his book “THE INDIAN

267  

CONSTITUTION CORNERSTONE OF A NOTE” has stated

as thus:

“Hindus relying on Gandhi’s teaching and Muslims

deriving their authority from the Koran, could all inveigh

against the evils of drink. Moreover, drinking had never

been common among the Indian middle class. The

arguments for prohibition were not wholly

unreasonable. In many industrial areas (the steel mills

of Bihar and Bengal, for example) and especially in

Harijan areas, depressed underfed workers sought

solace in liquor to the great detriment of their health.

The advocates of prohibition and both social and

doctrinal strings to their bow, and they were supported

by the Congress’s decade-old official dedication to the

cause of prohibition. Opposition to this conservative

outlook came from more liberal elements in the

Assembly, who cited the United States’ disastrous

experience and particularly from members of provincial

government, who knew to what good use the huge

income from liquor excise could be put. The Assembly,

however, adopted a revised version of the amendment

moved by a Muslim and a Hindu. The prohibition of

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liquor and harmful drugs (e.g., opium) became a

fundamental principle of governance, and today the

sale of alcoholic drinks is in varying degrees restricted

in nearly every State in India.” Ninth Impression 2005,

page 82-83)

8.40.4 Thus Article 47 states to regard as among its primary duties,

the raising of the level of nutrition and the standard of living

of its people and the improvement of public health. In

particular, the state is to endeavour to bring about prohibition

of the consumption, except for medicinal purposes, of

intoxicating drinks and drugs which are injurious to health.

8.40.5 Ms. Sujata Manohar(former Judge of Supreme Court of

India) – Learned Author on her book on Constitution of

India. P – 430.

The history of prohibition laws is interesting. Particularly all

States have passed legislation prohibiting the consumption

of intoxicating drinks and drugs which are injurious to health.

However the evil of drink has not been eliminated. On the

contrary, it has been on the increase. This problem has

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become a major national problem. It is a matter of great

sorrow and regret to see Indians forgetting the teaching of

Mahatma Gandhi.

8.40.6 CONSTITUTIONAL ENTRIES:

8.40.7 As regards the Entry-6 list-II of Schedule.VII of the

Constitution of India, Public Health Sanitation, hospitals and

dispensaries. Thus medicinal and toilet preparation are

related to health. Therefore, the State Legislature by way of

enactment has a right to regularize the use of medicinal and

toilet preparations so that these do not affect the health of

citizens.

8.40.8 Entry 84 and Entry 6 and 8:

84.. Duties of excise on tobacco and other goods

manufactured or produced in India except –

(a) alcoholic liquors for human consumption.

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(b) opium, Indian hemp and other narcotic drugs and

narcotics;

8.40.9 Entry.8: List.II. Intoxicating liquor is that is to say, the

production, manufacture, possession, transport, purchase

and sale of intoxicating liquors.

The expression intoxicating liquors” confers power on the

State legislature to legislate on toilet and medicinal

preparations containing alcohol. Thus Entry-8, List-II does

not entitle the State Legislature to levy tax or duty on alcohol

which is not fit for human consumption. Tax on industrial

alcohol can only be levied by the Center. It was also pointed

out, relying on earlier cases that, Entry 8 was a general Entry

and formed part of Entries1-44 which mentions the subjects

on which the State could legislate. Entries 45-63 formed

another group dealing with taxes which my levied by the

State.

8.40.10 The State Government has to curb the consumption of liquor.

Prohibition is a programme intended for the benefit of the

people, to keep them away from self-destruction, to bring

271  

greater happiness to them and to improve the quality of their

life. For this purpose some revenue has to be sacrificed, it

will be a worthwhile sacrifice. It has to be appreciated that

for every rupee that the State realizes as excise revenue the

citizen spends a multiple on the consumption of liquor which

does not contribute in any way to his well being. On the

contrary, it leads him to addiction and causes distress to his

family. In any case the argument about the loss of revenue

fallacious. If the State does not get revenue directly in the

form of excise duty on liquor it is bound to get increased

revenues from other sources like Sales Tax, Entertainment

Tax, Property Tax etc., because the money saved on liquor

is bound to be spent elsewhere.

8.40.11 The Commission has extensively dealt with the constitutional

provisions and Article 47 in particular along with various

provision and relevant judgments of the Honorable Supreme

Court. The Commission is of the firm view that if the State

Government and the Union Government desire to give effect

to other provisions of the Constitution. Then the State

Government should first implement Article 47 in its spirit. The

Commission is of the firm view that once the people

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voluntarily giving up the consumption of liquor in any form,

then the people are bound to save sizeable amount in

addition to preventing domestic violence. Once such sizeable

amount is saved, the people shall be able to spend the same

amount for their food, shelter and education. That is how;

Article 47 has great impact on the welfare of the society.

 

 

 

“Your Vision will become clear only when you lock into your

heart….Who looks outside, dreams. Who looks inside, awakens…!!”

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Chapter – 9

 

REPLY ON BEHALF OF THE GOVERNMENT

 

The Government of Gujarat vide its communication dated 23rd

September, 2011, has submitted a comprehensive reply through

the Under Secretary, Home Department, Sachivalaya,

Gandhinagar Mr. Vijay Badheka. The said reply has been pressed

into service of this Commission through the learned advocate Mr.

Chetan Shah. The Reply is consisting of 17 pages signed and

affirmed by the said Mr. Vijay Badheka, Under Secretary, Home

Department, Sachivalaya, Gandhinagar, Government of Gujarat.

The reply of the Government has more emphasis on the

following aspects.

9.1 On perusal of the reply the State Government has made it

abundantly clear that the addiction of alcohol is a vice and

this vice has been developed particularly in the lower strata

of society. Further the Government has canvassed that the

main reason for addiction of liquor in the particular class of

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society is due to abject poverty and lack of education. That

appears to be the actual ground level situation. Also the

Government has very fairly narrated the background of the

country made substance and has also considered the

profiteering aspect due to less availability of natural

resources in preparation of liquor. However, at the same

time the usage of lethal chemicals, such as methyl alcohol

and methanol without being assessed its ill effects on the

health. Also the reply of the Government is in tune of that

with a view to forget domestic worries, because of abject

poverty and lack of education the vice turns into habit. On

other hand those who are engaged in this type of production,

never care for the ill effects, so far as the profit margin is

concerned.

9.2 So far as the para-2 is concerned, the State Government has

considered the aspect of methyl alcohol and its

transportation. In the said para it was submitted that the

officer of the Prohibition and Excise Department make

surprise check at the godown with a view to see that no

misuse is made of this chemical. Despite there being legal

restrictions and strict vigil on the movement of this poisonous

275  

chemical, it reaches the hands of unscrupulous elements

too, who use them for the manufacture of illicit liquor. The

Commission is of the view that it is no doubt true that this

fact happens. However, the Commission has made certain

recommendations in the report and also had an interaction

with the officers of the Prohibition and Excise Department.

The Commission is of the view that there is not enough

restriction or strict vigil on the movement of such poisonous

chemical in absence of proper Rules in this behalf. The

Commission has at this point in its recommendation stated

that even today no strict Rules are formed for the

transportation of methyl alcohol.

9.3 Under paragraph-3 of its reply, the Government has

considered Article-47 of the Constitution of India in length to

which the Commission appreciates. And this Commission

has also dealt with this point separately under its report.

9.4 So far as para-4 is concerned, the Commission appreciates

that so far as this tragedy is concerned, it has occurred

despite a strict prohibition policy being in force. The victims

276  

have flouted the Rules and have violated the Law of the

Land. The victims died, because of consumption of spurious

liquor and that too because of their addiction. However, for

this tragedy no compensation has been paid from the

Government Exchequer. Therefore, the stand taken by the

Government is appreciated, that it is better to prevent such

unfortunate incidents than doling out compensation to the

dependents of victims. No compensation has been paid, but

it seems that the Government is committed to uproot this evil

from the society as the reference under the Notification

shows the vision and foresight for it.

9.5 When this Commission came across para-5 of the reply, the

Commission is in total agreement with what the State

Government of Gujarat in its reply has submitted. However,

the Commission would like to add that what State is facing is

not a problem of dry and wet State, but the usage of lethal

chemicals which make liquor spurious. Unless the State has

control on methanol / methyl alcohol, such incidents are

bound to happen if there are no strict rules for its

transportation, usage and storage. At the same time, there

277  

is no fear of Law in the minds of persons engaged in these

nefarious activities.

9.6 Referring to para-6 of the Reply submitted by the

Government, the Commission entirely agrees with it and

wishes that the said point which the Commission has dealt in

detail under the Recommendation Part be carried out

punctually with immediate effect.

9.7 Over all the Commission appreciates the Reply of the

Government and the stand taken by it. However, the

Commission has dealt with important points in its

Recommendation Part.

9.8 In para-8, the Government has given details of various Rules

enacted by them. The Commission has gone through the

same and these Rules will have a bearing in connection with

carrying out prohibition policy.

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9.9 In para-9, The Government gives details about carrying out

effective measures i.e. due publicity to see that consumption

of liquor become less. The Government has also stated that

after the tragedy of 2009, five areas have been identified,

where strict vigil has to be carried out.

9.10 In para-10, the Government has given details regarding

equipment of District Hospitals.

9.11 Para-11, the Government also states that it is no doubt true

that certain police officers are having hand in glove with

bootleggers and connivance of bootleggers with the police

officers will have to be determined. The Commission also

appreciates that aspect in this behalf.

9.12 Para-12, the Government feels that the Society should also

take step in this behalf. The Commission has appreciated

that aspect, in this behalf.

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9.13 It is further to be noted that the Government of Gujarat has

filed an additional Reply dated 15/11/2011 signed and

submitted by Shri Chetan Shah, Learned Advocate,

appearing on behalf of the Government.

9.14 The Commission has perused it and the said reply dated

15/11/2011 has been taken on record.

9.15 In the said reply the Government has given earlier reports of

Justice M.N. Miabhoy and Justice A. A. Dave, the

Government has tried to carry out some of the

recommendation which was feasible and practical. In the

said reply the Government has also carried out educational

reform, social reform, The Govt. has also decided to

implement to integrated scheme of Samruddhi Yojana. The

Govt. has also carried out certain medical reforms, police

reforms, awareness programme for specific areas, publicity

to depict evil effect of alcohol, SC directions and also

regarding to police reforms, in connection with the case of

Prakash Singh. The Commission really appreciates the

steps taken by the State.

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9.16 The State Government has stated that they have taken some

measures which have been undertaken to see that such a

tragedy does not recur. The Commission has gone though

those aspects and the Commission appreciated the steps

taken by the Government in this behalf. Some of the steps

which have been envisaged here, the Commission has also

taken into consideration in connection with the conclusion

and recommendation, in this behalf.

9.17 When the Commission was perusing the replies submitted by

the Government in respect of the activities being carried out

by the Government to effectively implement the Prohibition

Policy, it was extensively discussed among the members of

the Commission that activities which are being carried out by

the Government ought to be given a professional touch to

the advertising aspect, both in newspapers and television, so

that the message which the Government desires to give

must have penetrating effect in the mind of the common

people, who are staying in the rural areas of the State. The

Commission has come across the advertisements given by

the respective Government department, so far as the

tobacco and family planning is concerned, which have

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proved to be very penetrating and effective with the common

man, similarly the advertisements with regard to the

prohibition policy should also be published and carried out in

this behalf.

9.18 It may be noted that in the earlier part, while annexing at

Annexure “E” note regarding implementation and

recommendation of the report submitted by the State

Government of Gujarat, the Commission has already

annexed the report of the State Government dated 23rd

September, 2011 and 15th November, 2011. The

Commission craves leave to refer and rely upon this Reply

also in this behalf. The Commission has extracted only

important part of the Reply of the State Government. But the

Commission agrees with the efforts taken by the State

Government in this behalf and the Commission also strongly

recommends the steps taken by the Government for

maintaining Prohibition in the State of Gujarat.

“Effort is never wasted even when it leads to disappointing

results, because it always makes us stronger, more capable &

more experienced”

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Chapter – 10

CONCLUSIONS

The Commission has come to the following conclusions

on account of this hooch tragedy:

10.1 As a result of bifurcation of the former State of Bombay into

two states, Gujarat and Maharashtra; the State of Gujarat

came in to existence on 1st May, 1960. The Commission is

quite aware and mindful of the fact that the State of Gujarat

from the day one of its formation has adopted the prohibition

policy. In real sense it has adopted Article 47 of the

Constitution of India. The directive principle of State Policy

which provides duty of the State is to raise the level of

nutrition and standard of living and to improve public health.

It has always remained a leading proponent of the

implementation of strict prohibition policy and has remained

a shining example across the country for the grand culture of

the land that suits the principles of Mahatma Gandhi. The

Commission is also well aware of the fact that since its

inception, the State of Gujarat has suffered a heavy loss of

the revenue because of this policy which otherwise could

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have been generated. Had the State not followed the strict

prohibition policy, then perhaps the state treasury could have

brimmed with unimaginable opulence. Really, an inspiring

example which is worth noting that various Governments in

the State of Gujarat have come to power and various State

Governments have come and gone in Gujarat, but the

consistent stand of all the State Governments remained the

same, which makes every citizen of the State proud. The

committed stand of our State political leaders of all hues is

really admirable that amid heavy loss of revenue they did not

change the dry State into wet. They did not budge even an

inch in the policy for lust of revenue. It shows an

extraordinary wisdom and courage and strength to curb this

social evil as it appears that all the State Governments

remained committed to uproot the evil of liquor.

Then why did this tragedy occur?

Who was responsible for this?

What was wrong with the strict implementation of prohibition

policy?

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Strict Action by Police Personnel

10.2 In that view of the matter the Commission summoned Mr.

Mayur Chawda (A.C.P.) of Crime Branch of Ahmedabad City

who remained present before this Commission on 22nd Feb,

2011 and on 9th March, 2011. Mr. Chawda was quite aware

of the facts of the tragedy and was also a supervising officer

of the investigation of two criminal cases registered for this

tragedy. He stated categorically that they have found

clinching evidences about their criminal involvement against

two errant police personnel i.e. a constable and a head

constable of Kagdapith Police Station. Both these police

personnel were arrested for their dubious role in this worst

tragedy as from the mobile call details of these two police

personnel a clear nexus of these two police personnel with

bootleggers was established on record without any doubt.

Apart from the above evidence of call details, the statements

of witnesses, panchnama and statements of accused

persons recorded, have established that these two police

personnel had gloved their dirty hands to facilitate

bootleggers to carry out their antisocial and nefarious

activities of liquor trade. (lattha) Further Mr. Chawda pointed

out from the investigation papers that except these two

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police personnel no criminal involvement of any police

personnel had come on record. On being further asked Mr.

Chawda stated that still these two police personnel are in

judicial custody despite their repeated attempts to get

themselves released on bail.

10.3 What we need is sincere and effective implementation of the

prohibition policy. Undoubtedly, one thing is very sure that

something is lacking at some level. Unless, strict action in

exemplary form is taken against errant police personnel no

fruitful result can be achieved. The present tragedy should

be seen as a wake-up call for an effective enforcement of

prohibition policy. The canker of the moral laxity in the public

sphere that is so prevalent everywhere cannot be allowed to

spread in the field of enforcing agencies of the law and

prohibition policy. The action taken by the state Government

as well as by the police commissioner of the Ahmedabad

City against so many police officers and men for their

negligence is really appreciable.

However, still the question remains that shall we be able to

uproot the menace of illicit liquor?

286  

10.4 The Commission has come to a firm conclusion that the

tragedy is the direct outcome of illegal usage of Methyl

Alcohol which made liquor spurious and proved fatal to 148

lives. When it has become abundantly clear that usage of

Methyl Alcohol is the root cause of this tragedy then a

question has lurked in the mind of the Commission that

whom should we hold responsible? And after due

deliberation and careful consideration among the Members

of the Commission it was decided to summon officers of the

Police department and Excise and Prohibition Department as

both these Departments are directly connected with the

process of enforcement of prohibition policy.

Liberal Rule of granting Bail

10.5 Again Mr. Mayur Chawda (A.C.P.) Crime Branch on 9th

March, 2011 remained present before the Commission and

expressed his anguish that because of lenient provision of

the bail in such type of cases, even if a person is arrested for

the violation of the Prohibition Laws, he would be released

on bail so easily that he in all probability would be induced

again to start his nefarious and lucrative activities of

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bootlegging. Mr. Chawda further canvassed before this

Commission that offenders have no fear of the law in their

minds because of liberal provisions of the bail. It appears to

this Commission that it is one of the amenable reasons on

the face of it. As the Bail is easily available law of Prohibition

has no impact on the person who violates the Law. Thus

sanction behind this Law is very weak. Thus obedience of

law is also weak. Thus there is no fear of Law.

10.6 On being asked whether there is any circular or instruction of

the State Government in respect of action to be taken

against any errant police personnel in case if he is found

negligent or if he is found of dereliction of his duty? Mr.

Chawda placed on record four different circulars dated

28.12.1988, 12.09.2003, 15.09.2005 and 09.02.2010 and on

perusal of all these circulars of Home Department the

Commission has come to a conclusion that these circulars

are issued with a view to see that there must be a strict

compliance of the prohibition policy. Further not only local

police officers but also supervisory police officers should be

held responsible in case if some other agency or agencies

carried out successful raid involving substantial Muddamal in

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the jurisdiction of that local police station. We annex these

four Circulars as ANNEXURE “F” (COLLECTIVELY).

10.7 It is not enough to be honest but one should also be careful,

vigilant and efficient. Senior officers of Police should not to

be found careless or negligent in carrying out their duties

within the area of their jurisdiction. That is the spirit behind

all these circulars.

10.8 Similarly, Mr. V.J. Dave, Deputy Director of Prohibition and

Excise Department of the State of Gujarat remained present

on 22nd day of Feb, 2011 before this Commission in

pursuance of oral (telephonic) summons issued to him. His

deposition is that the Government of Gujarat has not issued

any Rules so far as the transportation of methyl alcohol (i.e.

methanol) is concerned has staggered this Commission.

However, further he added that what has been issued is in

case of denatured spirit (i.e. ethanol and not methanol) the

Bombay Denatured Spirit Rules, 1959. He submitted a copy

of Rules and Regulations in respect of denatured spirit (i.e.

ethanol) the Bombay Denatured Spirit Rules, 1959. While

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looking at the Rules of methanol neither any specific

provisions nor any guidelines are framed for transporting

methanol, except under delivery challan, which merely states

the consignee and consigner’s name, destination and

quantity and not beyond these.

10.9 Literally, the submission of Mr. V.J. Dave, (Deputy Director of

Prohibition and Excise Department of the State of Gujarat)

has stupefied the Commission to the extent that the state

Government has not framed any strict enforceable rules for

the transportation of Methyl Alcohol. Under such ridiculous

situation, the said statement of Mr. V.J. Dave has not only

perplexed the Commission but the Commission was

astounded that why the Government of Gujarat has not

framed any strict rules regarding transportation of Methyl

Alcohol?

10.10 As it is, it is a poisonous substance, obviously its leakage or

pilferage can cause a horrible tragedy. The Commission in a

plaintive voice posed a question to itself that because of

usage of Methyl Alcohol the tragedy has happened and yet

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the Government has still not framed any such rules. The

Commission further in a very raspy voice adds that behind

every such hooch tragedy that has happened in the State of

Gujarat from 1977 to till date, the cause is found to be the

usage of Methyl Alcohol. Therefore, it was incumbent upon

the State Government to frame strict rules with regard to

transportation, possession and use of Methyl Alcohol.

Liquor Permit:

10.11 So far as the provision of liquor permit on health ground is

concerned, the Commission would like to clarify that the

liquor in therapeutic dose has got medicinal value.

Prohibition policy was introduced much before the State of

Gujarat had parted from old Maharashtra State. Even today,

liquor permit in Gujarat is governed by the Bombay Foreign

Liquor Rules 1953. Procedure to obtain liquor permit is quite

enumerated under rule 64 of the Bombay foreign liquor rules

1953.The drugs at that time were not enough and too

ineffective to take care of certain diseases and considering

medicinal value of liquor, it was prescribed for Anxiety,

Angina Pectoris and chronic addiction.

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10.11.1 The vasodilator and anxiolytic effect of alcohol has

medicinal value also. Alcohol has a tendency to cause

chronic addiction. The persons who are addicted to it or

having spasm of the coronary arteries due to stressful

situations are prescribed with moderate dose of alcohol to

reduce symptoms of the patient. Since in Gujarat, prohibition

is in force such individuals are given Liquor permit on health

grounds. One to five units are recommended by area

medical board on health grounds. This should be stringently

followed only on purely health grounds and individuals are

required to be screened as effective coronary vasodilator

and anxiolytic newer molecules have been developed

recently with the development of modern medicine.

10.11.2 Now science and medical technology is so advanced, that

the latest medicines are easily available in market to take

good care of one’s health in absence of consumption of

liquor. The Commission further adds that the concept of

granting liquor permit is too old and governed by the Bombay

Foreign Liquor Rules, 1953. So now after around 57 years

medical science and innovations have become substitute to

more than liquor permits. Practically the idea behind

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granting of liquor permit is required to be reconsidered

thoroughly.

10.11.3 Mr. V.J. Dave Deputy Director of Prohibition and Excise of

the Gujarat State has again appeared in view of the oral

summons before the Commission on 14th day of March, 2011

and was asked several questions in respect of this liquor

permit so as to reach the bottom of the said procedure and

system. The same proceedings are ordered to be taken on

record.

10.11.3(A) Generally, health permits are issued on the basis of medical

certificate. It needs to be reorganised in detail with riders.

The Commission has also thrown considerable light on the

issue of health permit in detail in the recommendation part.

10.12 Let us be very clear that the Commission does not wish to

level any irresponsible accusations against any department

of the State in the absence of any specific evidence but at

the same time the Commission cannot resist to express its

293  

displeasure against very poor implementation of the

prohibition policy. However, this commission has made

certain strong recommendations on account of this tragedy

as well as earlier tragedies and also certain

recommendations are made by way of precautionary

measures to avoid such tragedies in future.

10.13 Really a formidable task lies ahead of us (the State and its

people). Let us maintain unity to curb this social evil. The

Commission further firmly believes that it is a joint duty of

every one. Everywhere liquor is a perennial problem but has

proved fatal when Methyl Alcohol is used.

While launching the PEPSU Union at Patiala, Sardar Patel

had rightly observed.

“We must work with unity. If we falter or fail, we shall consign

ourselves to eternal shame and disgrace.”

10.14 We have to establish a solid foundation for mutual

cooperation rather than indulging in mudslinging on each

other after finding faults and failures. Today we are in a

state of moral decay and suffer from a flabby degeneration of

294  

our own conscience. Really the Commission veered

between shame and anger.

10.15 Before the Commission concludes its conclusion part, the

Commission cannot resist its woe and ire to add that shall we

succumb to this evil or shall we be able to eliminate the

menace of liquor? Also a lowly and manifest question has

arisen in the mind of this Commission that shall we do

something to stop this or time alone can efface those

unpleasant memories? It has been rightly observed by

eminent jurist Mr. Nani Palkhivala that people’s memory

retains nothing beyond fortnight.

10.16 The Commission could penetrate the depth of the notification

issued in respect of this Commission and took it with the

same spirit and seriousness. The Commission has very

minutely gone through all four circulars issued by the Home

Department given by Mr. Mayur Chavda (A.C.P.) and which

are placed on the record of the proceedings. The language

and tone of all circulars clearly lead us to visualize sincerity

of the State Government to cub this evil and in that backdrop

295  

we would like to give following recommendations as

enumerated below.

Visits to various places of Gujarat

10.16(1) Before the Commission concludes this part of the report it is

noteworthy that this Commission has paid various visits

across the State of Gujarat to come to above conclusion as

well as before making recommendation to the Government of

Gujarat. The followings are the details of visits undertaken by

the Commission.

10.16(2) The Commission has started working in July, 2009.

Regarding the visits to the Hospitals, the Commission has

already stated in the report. However, over and above – (i)

the Commission has visited Forensic Science Laboratory,

Gandhinagar; (ii) thereafter, the Commission has also

visited, Zydus Cadila factory at Vadodara, in connection with

the various ways of pilferage and transport of methyl alcohol.

10.16(3) The Commission first visited Valsad and Surat and second

time the Commission, in July/August 2011 visited Daman,

296  

Atul and Surat October, 2011, and got feedback from police,

various parties and NGOs for suggestion with regard to

control of prohibition activities.

10.16(4) The Commission has also visited Valsad and Surat, because

it is nearer to Daman and there also, very large quantity of

illicit liquor entering into the State of Gujarat, from there

(Daman). Thus, these neighboring States earn huge

amount of money, by sending illicit liquor to Gujarat.

10.16(5) The Commission has also visited Junagadh and Veraval, in

September, 2010 and thereafter again Junagadh and

Veraval in October, 2010. During those visits the

Commission has interacted with local police officers, local

leaders and Non Government Organizations in connection

with the problem, as to how the manufacture, distribution and

consumption of illicit liquor can be reduced. The

Commission visited Veraval, because it is in the seashore

and a large number of downtrodden people, particularly

fishermen also indulge in manufacture and consumption of

illicit liquor.

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10.16(6) The Commission has also visited Navsari and Bardoli in

October/November, 2011. In Navsari the meeting was held

with DSP, Local leaders, local village Sarpanchs and

discussed the matter in this behalf. The minutes of the

meeting of the visit of Navsari and Bardoli is enclosed as

ANNEXURE “G”.

10.16(7) The Commission has also visited Navsari and Bardoli. In

Bardoli one Mr. Prashant Joshi, Head of MBT VT University

was present. He is carrying on very laudable work in

connection with the education and training and giving lots of

work to women. He has stated that he is collecting women of

age of about 18 to 30 years and requesting them not to

indulge into the work of distributing, selling and dealing with

illicit liquor. He also helps the women who are in poverty and

illiteracy in this behalf. He has a beautiful building, wherein

he engages all the women folk and gives them alternative

work and also some remuneration is paid for working in the

class from 9.30 to 5.00 o’clock daily. Resultant effect is that

large numbers of women do not enter into this illicit work of

manufacturing, dealing and distributing the illicit liquor. Not

only that, he requested women that they should impress

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upon their husbands and their family members also not to

deal with the business of illicit liquor. Thus by this work one

family is saved. The Commission is of the view that in every

small village if one NGO like this starts carrying out such

type of work, the problem of manufacturing, dealing and

distributing of liquor, can be solved to a greater extent. Visit

at Bardoli and discussion with one Mr. Prashant Joshi, Head

of MBT VT University is found in ANNEXURE “H”.

“Never stop doing the BEST just because someone does not give

you credit.”

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Chapter – 11

RECOMMENDATIONS

11.1 In the aforesaid report, the Commission has considered the

synopsis of tragedy, copy of the Notification; also the

Reference No.1 i.e. cause and circumstances of the

incident in which number of deaths have occurred from 5th

July to 3rd August, 2009, (in view of Amending notification)

due to the consumption of Illicit liquor. The Commission

also has taken into consideration about the departmental

action taken report by the State Government as well as by

the police; also action taken by the hospitals in providing

medical assistance to victims. The Commission also

considered action plan for effective police action. The

Commission has also prepared a questionnaire and sent it to

several knowledgeable persons and field officers and the

Commission has received the replies. The Commission has

also considered constitutional aspect, particularly Article 47

of the Constitution of India considering various decisions of

the Honorable Supreme Court and conclusions in this behalf.

The Commission is of the view that it is no doubt true that for

effective prohibition policy and for establishing mechanism to

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ensure that such incident do not recur. In spite of existence

of prohibition Laws and enforcing agencies are also there,

but best way is to persuade the people not to consume licit

as well as illicit liquor. This has to be done by persuasion,

education and awareness; so that people are convinced

about the evil effects of drinking liquor and may try to give it

up. Once the people voluntarily give up, automatically the

consumption goes down the transportation and manufacture

of liquor will be reduced. Because by force there is always a

limit to control, whereas persuasion has no limit, it has long

lasting effect.

11.2 The Commission has already considered action plan for

effective police action along with the intra department action

taken report by the police and the Commission has also

considered action taken by the Hospitals in providing medical

assistance with medical recommendation. Those

recommendations will also be considered to be part of

recommendations of the Commission. Over and above the

Commission desires to make following recommendations in

connection with police action.

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11.3 From the above conclusions the commission hereby

recommends the following aspects to the State Government

of Gujarat in respect of the individual department of the

government and also would like to suggest future course of

action qua hospitals and police establishment are concerned.

The commission further recommends certain steps to be

taken by the government and strict implementation of the

prohibition policy. The recommendations are as under.

11.4 EDUCATION AND AWARENESS.

“Like poverty being a curse in the child hood, the

consumption of alcoholic liquid is equally a blight

on the whole family of drunkards.”

Poverty, lack of education and awareness are the main

reasons behind the evil of alcoholism. The Commission

firmly believes that there was no sufficient awareness; even

the rate of literacy might have increased marginally but not

satisfactorily. As according to the last survey conducted in

882 villages of Gujarat by "Save the Children" it is reported

that out of 1,63,357 children of fourteen years of age 21.8%

are not going to school. (as reported in Gujarat Samachar

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dated 11.12.2010 Sunday Page No. 3 upper right corner of

three columns) So it clearly appears that approximately 20%

of children are not getting any type of education is a hard fact

and a matter of sheer disgust. Also the Commission could

lay its hands to another report dated 9th of September, 2011,

as reported in Gujarat Samachar on the “World Literacy Day”

that out of 100 Ahmedabadies every 14 are illiterate and in

the report it has also been indicated that out of 400 schools,

there are no proper arrangements in half of the schools run

by Ahmedabad Municipal Corporation.

11.5 Though the Commission does not solely rely on news paper

reports, it is a matter which requires attention of everyone

who is interested in the upliftment of the Society.

11.6 As it has been rightly said that......

"If a girl gets educated and then becomes a mother, she

will be much less likely to let her son to push in to such liquor

business"

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11.7 Once a child remains uneducated and is used as child

labour, no power on earth can prevent him from indulging in

unfair practices of petty crime then go on to some bigger

crimes and then indulge in notorious and antisocial activities.

All these activities are a major threat to the society. In the

long run all the gates of such activities open at the door of

anti-social activities and will end mostly in a liquor or

prostitution or gambling business. Therefore how to stop this

degeneration is a real issue before the Government and the

society.

11.8 During the Commission’s visit to Surat, in October, 2010, one

of the NGOs has pointed out that in some of the remote

villages the school is going on and the school also shown on

the Register that there is strength of 50 students in the class.

However in reality there are only 15 to 20 students and in

view of this the rate of literacy the official report is reality the

actual realty is something else. The Commission is of the

view that the Education Department should direct the District

Education Officer (DEO) to look into this aspect physically

and should verify Registers personally along with the

physical presence of the students. That will solve the

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problem of literacy in the remote villages, in this behalf. This

will go a long way in the actual literacy drive. Over and

above, as indicated in para, there are heavy drop out i.e.

even though there are 50 students in the Class of standard

1, in the beginning by the time students goes to Class 10,

there will be hardly 10 – 15 students who go to Class 10 or

Class 12. In the meanwhile students discontinue their

education and carry on certain work including distribution of

illicit liquor. All this type of heavy drop out, if this can be

prevented it will go a long way to in eradication of the evil of

selling and distribution of illicit liquor by the students who

drop out from the schools.

11.9 Therefore, after due deliberations among the members of

this commission, the commission strongly recommends and

emphasis the need to identify the highly prone areas under

the grip of such antisocial activities. Primary knowledge of

this evil and its deteriorating effects on human body and

mind by adopting door to door propaganda in such highly

prone areas must be initiated on urgent basis. The

Commission further recommends that those who are

drunkards and addicts should be given primary and basic

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knowledge of alcohol’s side effects through audio visual

modes etc.... the Commission knows that for some

drunkards, it is hard to resist craving of consumption of such

alcoholic drinks. Therefore, especially for them some de-

addiction centers with the help of NGOs should be started in

the highly prone areas and in these centers periodically at

least thrice in a week educational awareness to prevent

deteriorating side effects of alcohol and some type of

coaching classes for the betterment of women and family

members of such areas should be conducted. Promotional

and motivational schemes of education especially for the

youth of such prone areas ought to be introduced. One more

important recommendation from this commission is that

teachers should be selected from the nearby areas of such

affected places, so that they shall have an easy access and

constant useful interaction with targeted people. This is

possible with the help of NGO's and some help from the

Government. Even the current de-addicts may be asked to

explain the hardships they had come across during their

period of addiction to the current addicts. This will have more

virulent impact on the addicts so that they may give up their

habits.

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11.10 The Commission recommends measures to elevate the

standards of literacy in slum areas and rehabilitation of

addicts/offenders duly supported by meaningful alternative

social and clinical therapy/ activities.

11.11 AWARENESS THROUGH VARIOUS MEANS OF ENTERTAINMENT.

The commission has an innate desire to recommend that

awareness through entertainment is also one of the best

ways to bring down addiction level. This can be done by

resorting to the old practice adopted by Prohibition and

excise department - that was "Mobile Cinema Theater" at

least once a week in the vulnerable areas. Once the prone

areas are identified the practice of "Mobile Cinema Theater"

would prove much helpful for de-addiction process. However

it should be further instructed that films which are intended to

be shown must be based on some moral theme, as it has

been rightly observed that

"Fiction is much more appealing than sordid facts."

11.12 Furthermore, the pamphlets showing pictures of victims

showing their physical position before and after addiction.

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Likewise so many other methods showing how liquor is

injurious to our health should be adopted.

11.12.A The Government has stated that there is already a provision

in the curriculum from nursery onwards covering primary and

secondary education, drinking liquor is depicted as an evil in

the society. In the educational reforms this sort of lessons is

given sufficient priority. So that from the tender age a specific

image builds in the minds of the students that drinking liquor

is an evil and hazardous to health of a person and it affects

adversely to the family. The Commission is of the view that in

spite of these provisions the Government must put more

emphasis in the educational institutions with regard to this

subject.

11.13 The mechanism to ensure that such incidents do not recur:

11.14 This is a very wide ranging reference in this behalf. In this

case, it is very difficult to suggest on hand that such difficult

situation will not occur in future as this is very uncertain

proposition which depends upon lot of future development on

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which no one has any control. However, the Commission in

its report has considered this aspect. Our emphasis has

been on the point that first and foremost the concerned

people have to voluntarily give up licit as well as illicit

consumption of liquor in this respect. First and foremost is

that we must educate our children right from Class-I to

Class-XII and there must be some lesson showing evil

effects of drinking. The State Government through Education

Department should set up such curriculum for students both

in primary and secondary school. There must be regular

lessons in the text-book about the same. When children are

young, such effect on their mind will be long lasting. The

State Government agencies should prepare audio cassette

and video cassette to show the evil effects of drinking the

liquor especially on the youth and the poor. The same should

also be widely advertised on the radio and Television.

Similarly, there should be campaigning through newspapers,

advertisements and articles.

11.15 The 1st and foremost effect has to be shown as the financial

tragedy for the family. Today, because we have lots of

illiterate and poor people in the society and if they spent their

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major source of money on liquor, they will hardly be left with

any money for food, clothing and shelter for their family. If

they are made to understand this properly, then they will not

spend that much money for liquor, which is item of luxury

and not necessity of life. This will help their children in

getting properly educated and spend a normal life in society.

11.16 The second bad effect is about health. It is well known that

consumption of liquor specially the illicit liquor badly affects

the liver and kidney of the drunkards. Therefore, if it is

properly depicted, then the people will feel motivated to give

up consumption of liquor. (The Commission is of the view

that as far as tobacco is concerned, the Union and State

Governments have made it mandatory show evil effect i.e.

fear of cancer and as a result now the people gradually

consume less tobacco.) Similar things can be thought about

to include in illicit liquor also.

11.17 To prevent such tragedies in future, Government agencies

will have to keep close vigil on manufacturing, transportation,

distribution and sale of illicit liquor. The police organization,

voluntary organization, NGOs, Sarpanch in the village must

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ensure that these young men and women do not indulge in

this trade. It may be necessary to offer alternative work,

employment and money, to keep them away from the liquor

trade, understand the evil effect of liquor, obviously she will

make all out effort to save her husband, children and other

members from this evil.

11.18(A) The State Government may also consider introducing some

schemes that liquor free village will get extra facilities such

as good roads, regular water and electric supply and

medicinal facilities etc. The scheme may be introduced to

give special status to such villages also. The special status

may be in the form of financial packages also.

11.18(AA) The Commission has a novel idea of giving a tag of special

status to such villages where is strict prohibition is followed.

The Commission is of the view that State Government is

spending huge amount on publicity, which is being disbursed

to various agencies. However the same is not notably

reflected in the media such as the print and electronic media,

particularly the newspapers, TV channels and through other

advertisements.

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11.18(B) The Commission is of the view that the State Government

should vigorously follow the integrated Scheme “Garib

Samrudhi Yojana”. The scheme is aimed at the overall

development of poor women and children by providing

opportunities for permanent employment by upgrading

generation skills, ensuing better health and proper nutrition,

providing shelters and adequate basic infrastructure facilities

with a strong focus on empowering women. This scheme

envisages a holistic approach for providing better standard of

living at par with urban population by coordinating and

integrating various programmes undertaken by different

Departments.

11.18(C) Publicity awareness: The Commission noticed that the State

Government has carried out publications to depict evil effect

of alcohol which is as under:

11.18(D) The Department of Prohibition and Excise is conducting

various publicity programs throughout the State to educate

the people and to make them aware about the

consequences of consumption of liquor. As the locally

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manufactured liquor is generally consumed by poor tribals

and people living near sea shore, the State Government has

been making more efforts to make people aware by

conducting programs in the rural areas of districts,

particularly the tribal and coastal districts. The publicity

should be done frequently so that there would not be a

sense of complacency among the people and the officers on

the task taken to curb this evil as the campaigning and

publicities would be more confined to the a particular period

of the year so called awareness weeks etc and later there

may be a tendency to forget about that. This is the reason

why the publicities are to be undertaken in regular intervals.

11.18(E) The details of beneficiary schemes delivered during the last

five years are given below:

SR.

NO.

YEAR GRANT (RS) PROGRAMMES ORGANIZED

NUMBER OF BENEFICIARIES

(1) 2006-07 48,00,000 5,000 6,06,183

(2) 2007-08 99,00,000 10,000 8,17,258

(3) 2008-09 70,00,000 10,894 11,97.568

(4) 2009-10 77,50,000 5,966 8,09,852

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(5) 2010-11 1,07,70,000 4,246 7,70,803

11.18(F) A perusal of details about the programmes organized in

various districts would make it amply clear that the

department is carrying on sufficient activities to educate and

make the people aware about Prohibition policy.

11.18(G) 80 “Nashabandhi Sanskar Kendras” have been sanctioned

by the department and grant provided to them in order to

carry out educational activities with respect to prohibition in

their respective areas.

11.18(H) The Department is publishing advertisement of about 30

seconds, propagating prohibition, on Ahmedabad

Doordarshan, E.T.V. Channel etc., during their popular

serials. Even advertisements regarding prohibition are given

on F.M. Radio, S.F.M. Radio, Radio – Mirchy and Big F.M.

Radio channel from Ahmedabad, Rajkot, Surat and

Baroda.

11.18(I) The people traveling by GSRTC buses being in millions,

advertisements aimed at generating Prohibition awareness

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are published on the buses, as these buses ply even in the

interior parts of the State.

11.18(J) Hoardings are displayed on National and State Highways to

educate all drivers, especially the truck and bus drivers, in

respect to prohibition.

11.18(K) Twenty lakh SMS’s regarding prohibition awareness have

been sent to the public on their Mobile Phones.

11.18(L) 25000 posters of “19x29” size and 18000 plastic charts of

various designs were prepared through the District Officers

and Gujarat Nashabandhi Mandal for display all over the

State in order to bring awareness among public regarding

Prohibition. Vinyle glowsign boards were kept on

Ahmedabad Railway Station on main platform and platform

No. 1 to 7 from dated 15/10/2010 to 19/1/2011 to draw

attention to large numbers of passengers visiting Railway

station at Ahmedabad.

11.18(M) The Department is celebrating Nashabandhi week, starting

from 2nd October, which is the birth date of Shri Mahatma

Gandhi, to 8th October, every year. During this week, the

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department is organizing various popular programmes

across the State with the help of Non Government

Organizations, Educational Institutes, and Religious

organizations etc., to create awareness in the Society.

11.18(N) The Commission is of the view that though the Government

is spending huge amount on publicity, but the same is not

effectively reflected in the media, particularly newspapers,

television and AIR etc. There is no penetrating effect on

their young mind in connection with evil effect of liquor.

11.19 POLICE DEPARTMENT.

“The struggle alone pleases us not Victory”

Only the stone deaf heart can miss such crisis. The epicenter

of such tragedies has always been on two sides, the first

side is the lust for consumption of alcoholic liquor on the part

of drunkards and it is the lure of lucre on the part of some

police personnel on the other side.

11.20 On perusal of charge sheets registered against the offenders

clearly show, an unholy nexus between police personnel and

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bootleggers. The Commission is compelled to record its

deep concern on such solid chain. The solid chain must be

snapped. It is quite obvious that the police personnel in all

probabilities would have facilitated bootleggers to carry out

their antisocial activities of bootlegging in return of hefty hafta

(handsome bribe). What intrigued more to this commission

are the sluggish actions on the part of the police personnel

than the intensive activity of bootleggers. It is very painful

and disgusting. It has been rightly observed by Mahatma

Gandhi that.

"It is never the activity of a rascal that destroys the

society but

it is always the inactivity on part of us that destroys a

system"

11.21 Little did the Mahatma ever dream of it?

Though, in 1960 when Gujarat became a state it banned the

sale of liquor in honour of the Mahatma but it could never

effectively stop the sale of it. Instead, it created a huge black

market. Really this fact has brought more shame on us.

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11.22 The Passivity on the part of police department is highly

intolerable. The Commission is of the view that unless there

is passive consent or connivance of Police Department, the

illegal nefarious activity of bootlegger cannot flourish. So the

chain between some of the errant police officers with

bootleggers should be snapped.

11.23 Between 1977 and 1989 there were seven big hooch

tragedies in which 500 people have died, out of which three

major tragedies of this state have been mentioned under the

heading of "Previous similar type of hooch tragedy.”

11.24 However, this is not the lone hooch tragedy that has

happened in the country in the recent past. Quite frequently

our country is witnessing hooch tragedies in different states

irrespective of their status whether it is a wet or a dry.

11.24(A) This type of tragedy has occurred in a dry State like Gujarat.

But it is not right as a whole. Previously we have come

across several hooch tragedies in wet States also i.e.

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Madras and Uttar Pradesh. However, recently in West

Bengal, in the month of November, such a tragedy has

occurred in which 180 persons died. The fact remains that

even in wet States, indigenously manufactured liquor and

Indian made foreign liquor is available. People who belong to

weaker and poor class or the so called down trodden people

resort to locally manufactured liquor.

11.24(AA) In view of the aforesaid situation, the Commission has

recommended that the State Government should frame

specific Rules, particularly for manufacture, transport, import

of methyl alcohol rules. The existing rules are not adequate.

The rules may be suitably amended or new set of rules may

be enacted to deal with such methyl alcohol.

11.25 As a part of the Society, the commission is really concerned

about this. How to strike a balance between these two; the

habit of the people and the lust of the enforcement

agencies? The adverse involvement of police has been

noticed with sickening frequency. The current malady is so

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deep rooted that its infection has been spreading unchecked.

It should be extradited before it becomes irreversible.

11.26 Certainly this can't be tolerated even for a while; unless stern

action is taken against the errant policemen and officers the

whole system will collapse. Strong signals and clarion call

must reach to the minds of police personnel that no one can

save them if their nexus with bootleggers are exposed or if

they are found negligent in their duties. At the same time

suitable rewards scheme must be introduced to motivate

sincere and honest police officers and informants as

motivation for curbing this social evil.

11.27 A special investigation team of the crime branch has found

the criminal involvement of two junior most rank of police

personnel i.e. a constable namely Baldevbhai Kurshibhai

Rabari B.No.3456 and a head constable namely Ranjitsinh

Ramsinh Dabhi B.No. 7415 attached to kagdapith police

station. No other evidence against any police personnel for

their criminal involvement has come on record throughout

the investigation is a factual scenario.

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11.28. Only the criminal involvement of a constable and a head

constable and no rank above it, is not amenable to a man of

an ordinary prudence. The gravity shows that those higher-

ups who were directly responsible for supervision of their

respective jurisdiction have also to own the responsibility. If

higher-ups, who are immediate supervising officer of Police

Sub Inspector and Inspectors of those areas then, how it is

possible that the said activity of bootlegging was going on

without their knowledge? No excuse is commonly acceptable

that the said fact was not under the notice or control of

higher ups. Higher ups even if honest are of no use if they

are not efficient and vigilant to carry out result oriented

supervision of their subordinates. They cannot take any

shelter behind their ignorance or unawareness in respect of

bootlegging activities of their areas. Why should the society

brook for their ineffectiveness of supervision? They have to

own up the responsibility for such major human tragedies.

11.29 Therefore in this view of the situation the commission hereby

recommends to fix the direct responsibility of all police

personnel up to the rank of Assistant Commissioner of Police

of those police stations which are badly affected and they all

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should be held responsible for their lethargy or negligence in

supervision. And accordingly action should be taken against

them, wherein evidence exists. The Commission also

proposes action against some dishonest De-staff of these

police stations. The listed bootleggers do have some

understanding with the jurisdictional police to carry out their

activities. The Commission further desires to clarify that

because of some deaths due to illicit consumption of liquor

take place in the area falling under the jurisdiction of

Assistant Commission of Police where reportedly no

bootlegging activities are going on, then under such

circumstances it would be highly undesirable to take action

against those Assistant Commissioner of Police only on the

basis of deaths in their jurisdictions.

11.30 Further the Commission strongly recommends stern action

and speedy trial in those cases which are registered against

police personnel and at the same time the Commission

further strongly recommends that departmental inquiry

against errant police personnel should be expedited and

should be concluded with clear intention as expeditiously as

possible and must reach to its logical end. Because

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invariably it has been seen that delay always alters the truth

to suit one's skin.

11.31 Still a screaming question for this commission is that............

Are we gingerly adopting the prohibition policy?

Or

Are we really sincere to follow the policy in the spirit in which

it has been introduced?

11.32 If we are really sincere for its effective implementation then

nothing can impair our zeal to follow the policy.

The Commission is not trying to peel away only the outer

layer of this evil through this report but the State Government

must look into it so deeply that no such tragedy happens in

future.

11.33 INVESTIGATION INTO THE NEXUS BETWEEN POLICE

AND BOOTLEGGARS.

“Character is easier to keep than to recover”

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Mobile numbers of the notified bootleggers must be tracked

regularly and should be examined thoroughly to find out

those police personnel who are maintaining rapport with

them. A plausible excuse perhaps could be made by them

that they were trying to develop rapport with the bootleggers

as informers and therefore they need to talk with them to get

updated information. Such claim may be proved wrong if a

thorough inquiry is made or the next superior officer should

be kept informed about such contacts with the bootleggers

for getting information.

11.34 Allegations of insincerity and involvement of the

enforcement organization. - There have also been

allegations of complicity of the police officials, particularly

those at the lower levels like the constables, head constables

and in some cases even the sub-Inspectors and Inspectors.

A large number of witnesses have pointed out that the police

of the area have full knowledge of the Prohibition offenders

like the distillers, transporters, traders, etc., and their

activities are carried on with connivance and under

protection of the police officials. Allegations have also been

made that the police officials receive regular haftas from

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those engaged in illicit activities. Mention was made on

certain police stations where the complicity by the police was

particularly large. What we would like to point out is that the

general public is definitely of the view that if Prohibition is not

being properly enforced it is largely because of the insincerity

and non-involvement of the enforcement organization itself.

Any effort for stricter or better enforcement must aim at

improvement in the performance of the Prohibition

enforcement organization.

11.35 Suggestions of witness for better enforcement. – The

criticism of the enforcement arrangements in the State has

produced a number of suggestions for better enforcement.

Some witnesses have suggested that a special police force

should be created for the enforcement of Prohibition. Others

have suggested that fresh recruits of the police force, after

training should be employed for prohibition duties and later

on transferred to other duties. It has been pointed out that

youth is the stage of idealism. It is likely that at younger age,

officials will be more inspired by social objectives and their

performance in implementing the social legislation or

Prohibition will be better. It has also been suggested that the

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administrative authorities at lower levels should also be

involved in the implementation of Prohibition. For example,

the municipalities, the panchayats and panchayat unions

should also play some role. Frequent transfers of police

officials, especially if they are found lacking in their duties;

improved mobility for the police; formation of village level

committees to secure cooperation from the public; rewards to

informants and public recognition of their service.

11.36 Enforcement is a difficult and complex problem –

Multipronged approach necessary – some suggestions. – the

Commission has given careful thought to the problem of

enforcement of Prohibition. The Commission feels that it is a

very difficult and complex problem. There can be no simple

solution. A multi-pronged approach is necessary. As has

been pointed out by the witnesses, prohibition is a social

legislation. Its success cannot be achieved only through

regulatory measures which alone the police organization can

be expected to adopt. If prohibition is to succeed, the State

Government must secure the cooperation of all those who

are interested in its success. Not only the help of the social

and voluntary organizations at various levels should be

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taken, but also the co-operation of the common man in the

cities, towns and villages should be secured. The

Commission also agrees with the suggestions made by

some of the witnesses that the local bodies like corporations,

municipalities and panchayats should also play a role to

educate public at large and so that quicker success can be

achieved by these measures than through dependence on

the police force alone. The object of the enforcement effort

should be to win over those who have the habit of drinking

alcohol rather than the punishment given to them. The

addicts are victims of bad habits. Some of them do not know

the harm they are causing to themselves and to their

families. Some are aware of the consequences of their

addiction and want to overcome it. The enforcement

agencies should assist the addicts to get over their addiction

rather than convert them into confirmed and incorrigible

drunkards. Greater attention should be paid to the coming

generation to see that it is kept away from the evil of

drinking. All this can be secured through methods of

persuasion. The results achieved this way, will be naturally

slow, but steadily. They should concentrate their attention on

the exploiters than on the exploited. In other words their

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prime object should be to detect offences relating to illicit

distillation, smuggling, transport, sale etc. The Commission is

not suggesting that they should completely ignore the

individual drinker who violates the law. But such a person

should be of interest to the police more from the point of view

of securing information about the sources of supply and

plugging them rather than for the purpose of prosecution.

11.37 Enforcement organization has recommended. – For the

proper and effective enforcement of Prohibition a suitable

and adequate organization must be set up. The Commission

considers that the present police set up dealing with the

Prohibition require both strengthening and refinement. The

prohibition intelligence unit should be created either at the

police headquarter or as a part of A.C.B (Anti Corruption

Bureau) under the control of a senior officer known for his

integrity. In the field, the police organization requires to be

greatly strengthened. At the district level, there should be a

Special Deputy Superintendent in charge of Prohibition

enforcement. There should be an Inspector of Police in every

sub-division. The Deputy Superintendent at the district level

and the Inspectors at the sub-division level should be

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assisted by Junior Officers such as Head Constables and

Constables. The strength of the staff can be determined with

reference to the area of the sub-division, population, extent

of violations of the Prohibition laws, etc. The police parties at

the district and sub-division level should be sufficiently

mobile. Adequate transport facilities should be provided to

them.

11.38 Local police should continue to be responsible for

effective enforcement: - While the special cells of police at

the district and sub-division levels, referred to above will

constitute the striking force, the day to day enforcement

should continue to be the responsibility of the district police.

The police officers in charge of police stations and their staff

should be made squarely responsible for the effective

prevention of violations of the prohibition law. As has been

pointed out by several witnesses and mentioned above, the

illicit distillation and trade in liquor cannot be carried out

without the knowledge if not connivance of the police. It is,

therefore, reasonable to presume that the police officials

would have the requisite information and knowledge about

bootleggers in their area and their activities. It should,

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accordingly be expected of them to bring down and in due

course to eliminate such illicit activities. Among the criteria

for promotion and postings to jobs of higher responsibility the

performance of officers in the enforcement of Prohibition

should be given a prominent place. The Commission would

suggest that a specific column be provided in the confidential

reports of officers about their effectiveness in the

enforcement of prohibition. At the same time, the

Commission would recommend that some incentives and

rewards should be given to the police officers who show

good performance in Prohibition work and exhibit exemplary

courage, and devotion to duty in meeting the challenges of

the bootleggers.

11.39 According to police record only two police personnel were

found criminally involved in the tragedy. The Commission is

of the view that in view of such large scale tragedy, in the

Police Department there were only two police officers

connived with the bootleggers in prima facie, is not

believable/ untenable. The Learned Police Commissioner

should make thorough inquiry, because the Commission

believes that there is a wide ranging perception that unless

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there is consent and connivance of Police Department, such

huge manufacture, production, distribution, transportation

and sale of illicit liquor is not possible. So there may be

more officers who are hand in glove with all the bootleggers.

Unless this chain is snapped, the Police Department cannot

properly control this type of gravity of manufacturing, selling

and distributing illicit liquor.

11.40 Similarly, the police force that has been provided for this

purpose is also grossly inadequate. A Committee needs to

be set up by the State Government to fix a minimum

yardstick of the strength in the police as well as in the courts.

The police patrolling in the affected areas have to go a long

way in preventing manufacture, and distribution of illicit use

liquor activities, for which resources need to be provided to

police force to make them smarter than the bootleggers. Of

course, some police officers may be working hand in glove

with the bootleggers need drastic surgery by way of prompt

and strict punishment by the authorities.

11.41 The police machinery for implementing prohibition laws

should be strengthened by way of providing good vehicle,

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proper means of communication and sufficient manpower. It

goes without saying that strict control on anti-prohibition

activities will have good impact on law and order situation in

security which will promote welfare of the people.

11.42. Though the State Government is losing Excise Revenue

worth crores of rupees in implementing the prohibition policy

as per the spirit of Article-47 of the Constitution. Gujarat is

pursuing the idea of “welfare state” as mandated by

Article.47 of the constitution with whole hearted efforts.

Government has amended the Prohibition Act which includes

the provision of even the capital punishment in certain case

of death due to laththa tragedies. It is learnt that the State

Government is trying to overcome certain loopholes in the

implementation of Prohibition Policy which in due course will

bear good fruits.

11.42(A) It is no doubt true that the new Law has been mandated and

has already come into force. There are some very laudable

provisions in the amended Act. But it is essential to ensure

very strict and effective implementation of the various

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provisions to give relief to the affected families, which are

mostly poor and down trodden.

PROHIBITION AND EXCISE

11.43 Check on illegal usage of Methyl Alcohol:

It is abundantly clear that methyl alcohol (methanol) is widely

used for industrial and other small scale industries, rather

than diverting it for illegal manufacture of liquor. No doubt it

is a poisonous substance and also invariably it has been

seen that shortage of 5% methanol during transportation has

been given to licensee to write off at his own. It has been

said that many industries which are closed and still using

their license, can misuse methanol. Actually Prohibition and

Excise Department must put a proper check on such

licensees to ensure, whether methanol so purchased under

the license has actually been used for the manufacturing

process of prescribed article or it has been diverted

somewhere else. The Commission is also suggesting that

the requirement of methanol must be decided in terms of

production and for this random and periodical check would

yield a positive result and shall have a substantial control on

illegal usage of methyl alcohol.

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11.44 Rules for Methyl Alcohol and other provisions must be

framed.

The following points emerged during course of an interaction

on 22nd day of Feb, 2011 with Mr. V.J. Dave, Deputy Director

of Prohibition and excise department of the state of Gujarat,

who then submitted a brief reply on the points discussed with

him to this commission.

11.45 Issuing of license:

Under Gujarat Methyl Alcohol Rules, 1981, there is a

provision of the application form which is to be made to the

Department to issue a license in form No. MA. I and MA. II,

over and above the Department has issued a check list in

case if it is a fresh license and as per check list an inquiry is

made in detail and verification is also made by the field

officer or Superintendent of the Prohibition and Excise. Then

and only then a fresh license is issued.

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11.46 Transport Rules for methyl alcohol:

Presently, the Methyl Alcohol is governed by the rules of

Gujarat Methyl Alcohol Rules, 1981 under these Rules, a

simple provision is made that only a delivery challan is

required at the time of transportation indicating the name of

the consignee, the name of the consignor, quantity and the

destination. Nothing more is required to be mentioned. So at

present there is no other provision under the rules for

transport pass, import pass or supervision for the Methyl

Alcohol except to obtain license for its storage, sales and

purchase. The Bombay denatured Spirit Rules 1959 (for

Ethyl Alcohol) there are clear provisions in respect of all

these. The department of prohibition and excise is issuing

licensees, passes, permits etc.. under 36 different rules

which are framed under the Bombay Prohibition Act, 1949.

Moreover, providing escort and supervision during the

course of transportation of prohibited articles like ethyl

alcohol, liquor, molasses etc. are not in existence in case of

Methyl Alcohol.

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11.47 The Commission has received some report from Office of the

Director of Prohibition and Excise, in this behalf. They have

given certain information in connection with Ethyl alcohol,

acquisition of denatured spirit, the role of Methyl alcohol.

They have given certain information in connection with Ethyl

alcohol, acquisition of denatured spirit; the role of Methyl

alcohol. Along with that, they have also given copy of

Bombay Prohibition (Manufacture of Spirit) (Gujarat) Rules,

1993, the Gujarat Denatured Spirit Rule, 1959, Gujarat

Transport Rule, 1966 and Gujarat Methyl Alcohol Rules,

1987. They have also given details of annual budget, the

amount spent by them, in this behalf. They have also given

details about role played by them, in this connection. It is

their say that they are informed of liquor theft, illegal theft of

Methyl Alcohol during the course of its transportation in such

a large quantity within the Gujarat State and during the

course of transportation out of Gujarat, because there are no

provisions of requisition, transport pass, import-export pass,

escort, revenue lock or supervision in Methyl Alcohol Rules,

like Ethyl Alcohol Rules. Moreover, the drivers and people

involved in the theft of Methyl Alcohol may not be aware that

Methyl Alcohol is poisonous substance, so, because of the

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name of Alcohol, it is possible to use Methyl Alcohol in

manufacturing spurious liquor unknowingly. It has been

stated in the report that Prohibition and Excise Department is

performing duty of issuing license, permit, pass etc., under

Bombay Prohibition Act and various rules made under Act as

well as to recover the Excise Duty as per the provisions of

Medicinal and Toilet Preparations Act and verify the licenses

issued under the various rules under the Bombay Prohibition

Act. While the work of preventing illegal manufacturing of

illicit liquor, sale of illicit liquor / Indian – made foreign liquor,

transportation, import, export etc., is not with this

Department.

11.48 In view of the same, the Commission recommends that there

should be specific Rules for requisition, transport pass,

import export pass of Methyl Alcohol.

11.49 Further it was submitted that the consumption of ethyl

alcohol per annum is 4 crore litres while as the consumption

of Methyl alcohol per annum is 50 crore liters. According to

the Prohibition and Excise Department the available staff

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with prohibition and excise is only 40% of the sanctioned

strength and if Methyl alcohol is to be followed in like manner

of Ethyl Alcohol then the department is required additional

staff of 3,500 constables, 300 head constables, 200 sub

inspectors and 50 inspectors in addition to the present

vacant posts. Only then, it is possible to control Methyl

Alcohol. Obviously it may not be possible for the

Government to sanction so many posts for the Excise and

Prohibition Department, due to various constraints.

Therefore, devices like effective electronic lock system,

bottle-neck lock system or some special lock system must be

adopted to control pilferage or theft in transit in collusion with

driver and / or cleaner. On an average 150 to 200 tankers

are engaged every day for transporting Methyl Alcohol.

Therefore, an anxious thought must be given by the State

Government on this problem at the earliest.

11.50 Penalty:

Under Section 104 of the Bombay Prohibition Act, 1949,

there is a provision of compounding the case by the

Department in lieu of cancellation or suspension of license /

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permit. The power of recovery at the time of compounding of

the offence the Director of Prohibition & Excise is

empowered to recover ` 20,000/- while at District Officer is

empowered to recover Rs. 1500/- as a fine. The present

structure of recovery is required to be increased and it is

recommended that a District Officer should be given power

to recover Rs.10000/- in lieu of cancellation or suspension of

the license, Where as the Director should be empowered to

recover up to an amount of Rs. 50000/- as fine per case.

11.51 Cancellation of license:

In case if there is a breach of any of the provisions relating to

transportation, storage, purchase and sales of methyl alcohol

is concerned in a rarest of rare cases such breach should be

compounded in lieu of cancellation.

11.51(A) Stickers (3M) for poison:

As per the standing departmental instruction, whenever

methyl alcohol is stored, the premises must be displayed

with a board “methyl alcohol/poison”. Similarly, the same

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should be applied in a case where methyl alcohol is

transported with stickers of 3M indication of poison.

HOSPITAL REFORMS

11.52 FAILURE IN PROVIDING ANTIDOTE.

During the visits to the hospitals by the commission and

examination of doctors, it was felt by the commission that

there was a lack of antidote during the emergency situation

and also it was not given timely. The government should take

a note of this matter and a departmental enquiry should be

conducted regarding this failure of supply of antidote and fix

the responsibility.

11.53 The Commission strongly recommends that the list of

antidotes of all chemical poisoning should be prepared as

ready reckoner and should be circulated to all concerned

doctors and should be kept readily available with all

Hospitals. The antidotes availability should be hassle free

and all concerned should know about the source of its

availability. Health commissioner should play an active role

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in providing scarcely available antidotes to non

Governmental hospitals also.

11.54 IMPLEMENTATION OF MEDICAL TRIAGE:

(A process to segregate serious cases during mass casualty)

This is a simple but effective method to identify serious

cases that need active and life saving interventions on

priority basis.

11.55 A triage officer who is trained medical officer should lead and

monitor the entire processes of triage and coordinate with all

treating medical teams and with administrator of the institute.

He should be assisted by team members who are experts in

First Aid treatment.

11.56 It is recommended that all patients must be identified with

colour-coded red, yellow, and green tags stating their name,

age, sex, residential address, diagnosis and initial treatment.

The colour of the tag signifies triage category and patient

priority.

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11.57 These standardised tags must be chosen or designed in

advance as a part of state disaster mitigation plan and

should be supplied to all health facilities. The health

professionals should be provided with ‘Triage Bag’ which

contains 50 triage labels, 50 nylon ties, arm bands, 6

assorted airways, intubation set, ventilation bag and suction

device, B.P Instrument, and stethoscope. Health

professionals should be thoroughly made familiar with their

proper use.

11.58 The additional burden of the doctors can be lessened by

enabling the nurses to do the medico legal work in the

respective cases. Government may think about the

introduction of a special category of Forensic Nurses in this

regard. For this purpose they can be trained about all the

responsibilities related to the medico legal cases from the

Forensic sciences university where there is an exclusive

course available for them to become more qualified to deal

with such cases. The duties and the responsibilities of the

medical officers will be to examine and treat the patients and

all other medico legal work will be done by the Forensic

Nurses. The work and the responsibility of a Forensic Nurse

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will include collection, preservation and forwarding of the

evidences in all such cases. Even if required by the court of

law, they can be examined regarding these cases.

11.59 HEALTH PERMITS

Health permits issued on the basis of medical certificate

need to be reorganised. In era of modern medicine, the

therapeutic role of foreign liquor is very limited. It was also

discussed that due to this system facilitates, in the upper

class of society many health permits are granted on basis of

chronic addiction. Chronic addiction is more prevalent in

down trodden strata of the society, particularly in slums.

They cannot opt for the health permits as it is a costlier and

complex issue for them. Supplementary options for the

treatment should be explored by area/state medical board

before recommending foreign liquor to a person who is

requesting for health permit. The government should keep

extra check on licensing and recommending authorities

which appears very lax at present. It is brought to our notice

that State health department has issued instructions in past

and decided strategy to accept donation from permit holders

in ‘Rogi Kalyan Samitis’ of District and medical college

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attached hospitals. This kills the motive behind issuance of

health permits which is being issued on medical grounds.

The officers who have played role in relaxing norms and

instructing area medical board to issue permits and

accepting donations in ‘Rogi Kalyan Samiti’ [RKS] should be

booked by adopting appropriate administrative processes.

11.60 HEALTH BILL AND NABH (NATIONAL ACCREDITION

BOARD FOR HOSPITAL) ACCREDITATIONS

11.60(A) The Commission has studied the Draft Bill regarding Health

Bill sent by the Union Government to the State Government,

which has been implemented by Assam Government the

Commission has hope that similar Bill by the State of Gujarat

will also be passed and what will go a long way in hospital

reforms.

The Commission recommends that health department of

Gujarat should lead the nation by enacting Public Health Bill.

In the entire country, Assam has initiated a lead by enacting

“Public Health Bill, 2010”.

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It is also recommended making mandatory for all

Governmental and Non-Governmental health care facilities

to opt for National Accreditation Board for Hospital (NABH)

accreditations. Though seemingly a difficult and time

consuming task initially, it will play a pivotal role in the

standardization of health care facilities and uniform treatment

of patients in routine and emergency care. This is also true

for other private and trust run hospitals. Government of

Gujarat has accepted to strengthen hospital care for

providing quality care to all by obtaining accreditation of

Government health care facilities by National Accreditation

Board. The Gandhinagar Civil Hospital is the first

Government run Hospital which is accredited under NABH.

The same should be followed by all other Hospitals.

11.61 LOCK OF BASIC FACILITIES:

The municipal Hospitals particularly Smt. Shardaben

Hospital, Saraspur and Sheth L.G. Hospital, Maninagar are

lacking of basic facilities like emergency and trauma care,

CT Scan, MRI, Hameodialysis, Post-mortem room and their

own emergency mitigation plan in case of mass casualties.

These lacunae require to be corrected by instructing

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municipal authorities to make necessary provisions in

budget.

11.62 EMERGENCY MEDICAL SERVICE:

“Injury to human lives, human pain and human suffering has

always made this state more uncomortable and uneasy.”

Very few know that Emergency Medical Service Act is in

force.

Earlier, it had been consistently seen that in case of an

accident / catastrophe generally private hospitals do not

admit the victim of medico legal emergency. Also in

other such serious cases the stands of private hospitals

remain nugatory. The obvious reason behind the same is the

police follow up. It is presumed by the private practitioners

that the MLC (Medico Lang case) work is prerogative of the

government doctor. This belief requires to be rubbed off.

Many a times no one cares about the life of a victim who

could possibly be saved if, emergency medical treatment had

been provided during ‘golden hours’ in the nearby hospital.

As a result of this practice, we have lost many lives in the

past as immediate measures during golden hours could not

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be provided before reaching to the Government hospital; the

destiny of the patients was invariably fixed.

11.63 When Emergency Medical Services (EMS) Act was enacted

by State Assembly of Gujarat, it was targeted at minimising

fatality rate during disaster. Earlier, it was discussed at

length that the natural and man-made disasters are striking

at regular intervals resulting in avoidable loss in terms of

human lives. The disaster related morbidity and mortality can

be reduced to a larger extent if uniform policy of

preparedness and prompt response system is aroused

during the crisis hours. Looking into its vital need in the

present scenario [Increase in road traffic accidents and

impending terrorist threats] the government of Gujarat

decided to evolve effective mechanism of quickly responding

to disaster. After elaborate and thought provoking

discussions, the need to enact EMS act was accepted by the

assembly to hasten the health department of Gujarat in

combating disasters effectively.

11.64. The Commission feels immensely proud for the introduction

of EMS Act. What is more required is the awareness on the

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part of public to a greater extent and proper implementation

of this Law.

11.65. Now by this time after entering MOU with approximately 600

private hospitals throughout the state, every such hospital is

well prepared to provide treatment to emergency victims by

EMRI (Emergency Medicine Research Institute). This was to

percolate more deeply by EMS (Emergency Medical Service)

authority in providing emergency first aid care to victims for

first 24 hours which is mainly known as ‘Golden Hours’ to

emergency victims without looking at the paying capacity of

the victims throughout the state. The EMS authority has not

activated this policy even though good amount of time has

elapsed since EMS law has been enacted. What more is

needed is the awareness amongst people about EMS act.

11.66. This commission observed that hospital-specific emergency

preparedness plan was not up to the mark and scientific. The

government can instruct the health authorities and thereby

the hospital managements to prepare more scientific

emergency plan and follow them strictly during the hours of

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crisis. This would definitely bring more success on the part of

the patient care during emergencies.

11.67 Role of EMS (Emergency Medical Services) authority

Generally the episode of hooch tragedy/Methyl alcohol

toxicity is sporadic and occurs once in many years. The

medical graduate may not have come across hooch victims

during his entire undergraduate or postgraduate curriculum.

The emergency response system of the hospital needs to

include continuous medical training and mock drills at regular

intervals as mentioned previously. The State Government

has already enacted Emergency Medical Act to synchronise

and streamline medical response during medical

catastrophe. The state and district EMS authorities should

prepare guidelines and action plans for the response of

health, police and revenue authorities during such tragedies

in future. The protocols of action by each department and

treatments of victims need to be derived by EMS authorities,

and be in compliance with the Emergency Medical Act of

Government of Gujarat.

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11.68 REGULAR TRAINING AND LIFE SAVING GADGETS AND

INSTRUMENTS

“Those who are well equipped and prepared for the worst

hardly doubt their success.”

The Commission recommends that regular training of all

doctors should be carried out at regular intervals for any kind

of disasters including chemical, natural, trauma, and

accidents. This should also be particularly replicated for

manmade calamities like bomb blast or terrorist activities of

any kind. The training curriculum should include all practical

aspects for the efficient management of routine/scarce

calamities. The life saving gadgets and instruments with life

saving drugs should readily available with central store

created in city in sufficient quantity round the clock. The

stock and record of such life saving drugs and equipment

should be reviewed by disaster management committee at

regular intervals.

11.68.A The regular interaction and symposia to percolate the medico

legal knowledge and availability of new technologies at

Forensic science university campus may be arranged for key

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medical officers of all the districts. Such trained medical

officer should be incorporated and given duties to liaison

between private and government hospitals.

11.69 TREATMENT PROTOCOLS

Commission has also observed that the treatment protocols

varied from institute to institute and from doctor to doctor.

Haemodialysis was resorted to very late resulting in

increased fatality at hospitals of eastern Ahmedabad. In

emergency medicine, the role of treatment protocols should

be emphasised enough. The treatment protocols as per

prevailing symptoms and signs, and blood concentration of

methanol need to be circulated to all medical attendants at

periodic interval. Evolution of disaster specific treatment

protocol is one of the important and vital activities of Disaster

Mitigation Plan by State Health Department which seems to

be missing during this episode.

11.70 The deputation of the medics and paramedics in an

emergency should be made easy during crisis management

and it should be on war footing basis. The State

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Government needs to design strategy for easy deputation of

medics and paramedics, and should provide necessary help

by providing required drugs which are scarcely available.

11.71 An emergency receiving area and ward should be identified

in all the Hospitals as per trauma care plan. It should be kept

vacant along with all the lifesaving facilities. It should be

made compulsory even for the Corporate/trust run Hospitals.

11.72 ACTION PLAN AND GRID AMONG HOSPITALS

The action plan regarding preparedness to cater with such

emergencies in future should be kept ready by each medical

institute in future. The role of ophthalmologists and

nephrologists are very crucial in the management of

methanol poisoning. It has been observed that toxic

metabolites, if cleared out early with the help of

haemodialysis greatly influence the morbidity and mortality of

the hooch victim. During this tragedy doctors were able to

save many lives as haemodialysis was introduced as part of

treatment where concentration of methanol was alarmingly

high.

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11.73 The calamities are of different nature where different

specialties require different role to play so a permanent

disaster management Committee comprising of the different

specialists headed by the Superintendent of the Hospital

where invitee members from the revenue, police, Red Cross,

and fire should be included. All members should collectively

prepare and update emergency preparedness plans at

regular intervals in consultation with subject specialists.

11.74 A grid and nexus of all Municipal, Government, Trust-run and

Corporate Hospitals should be formed and in case of dire

emergency, the transfer of the patients should be Hassel free

and need to be streamlined. Needy transfers should be

accepted by all competent Hospitals without insistence of

any financial/administrative formalities. Treatment of serious

victims should be made compulsory for all private hospitals

on request of the Government/Semi Government /Municipal

Hospitals without insisting on fees first for those cases.

11.75 Likewise, the details of ambulances available with NGOs,

Trust run and private hospitals should be readily available

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with contact details of drivers and should be included in a

pool which can be deployed at the time of mass causalities.

11.75(A) The Commission is well aware of the fact that the State

Government has taken following steps:

• Most of the District Hospitals are well equipped with

ventilators and oxygen concentrators from the month of

July-2010 for any critical conditions. Recently, all

district hospitals are provided with ‘ ICU on Wheels’.

• 10 District Hospitals are equipped with Disaster and

Rescue vehicles in the month of March-2011.

• Proposal to establish Haemodialysis Units in District

Hospitals.

• Proposal to establish Haemodialysis Units in District

Hospitals included in 2011-12 Budget.

The Commission also recommends that the State

Government should provide ventilators, oxygen

concentrator and Haemodialysis Units to other

Hospitals as per requirement. The Commission also

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recommends that the Government should provide

Disaster and Rescue Vehicles in all the Districts. The

Commission also recommends that for the treatment of

Hooch tragedy victims, hospitals have to provide

Absolute Alcohol, as the antidote and Procedure to get

License for the same is in process. However, the

Commission recommends that in this type of tragedy,

there should prompt action speed in obtaining alcohol,

because it is of vital importance from the survival of the

patient point of view.

GENERAL RECOMMENDATIONS

11.76 MIND SET OF PUBLIC AT LARGE

Notified bootleggers make huge money after adopting such

antisocial activity of lucrative liquor business keeping no

accounts for such activities as they are not accountable to

the income tax and other revenue departments. It is perhaps

one of the reason of giving hefty hafta to law enforcing and

prohibition personnel. They also spend some amount for the

public of the local area where they are carrying out such

activities. This creates a respectable image of them in the

minds of poor general public who benefit financially by their

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action. These people directly or indirectly become their

passive supporters. Thus the mind set of such people at

large require thorough IEC of local people. Their spending

should be discouraged.

This mind set of general public should be changed with …..

11.76(A) There should be an attempt to change the mindset of the

people. This can be done in the following way. The

bootleggers, though are spending huge amount for any

service, ultimately those are given at the cost of money

which they have earned through manufacture, production

and transportation as well as distribution of illicit liquor.

Therefore such an activity ought not to be lauded among the

public. Their spending should be discouraged.

11.77 LIQUOR PERMIT.

The procedure for permit is like ……….. A person (who

should not be a minor) can make an application in a

prescribed form on fees of Rs. 50/- (the cost of application

form fees.) He is also required to pay Rs.500/ as fees for

the medical examination as per the present structure and

after going through various medical tests if medical board

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thinks it fit , only then it will make a recommendation for

required units and duration of a permit. After a

recommendation from the medical board, a permit is issued

by the prohibition and excise department. The Medical board

clearly mentions in its recommendations that the number of

units required for a month and duration for the validity of a

permit ranging between one to five years upon paying a fees

of Rs.1,000 prescribed by the state Government. It has been

done purely on a recommendation of the area medical board.

11.78 The commission hereby recommends that the present fees

structure should be uniformly increased throughout the state

not exceeding Rs. 10,000 instead of the negligible fees of

Rs.1000 and renewal fees should be increased not

exceeding Rs.5,000 to 10,000/- instead of Rs.1000 at

present. Standards of Issuance of health permit are required

to be reviewed. No medical board shall recommend the

permit for a period exceeding one year and instead of

monthly unit it will recommend monthly unit not exceeding

two in any case.

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11.79 The Commission has given a serious thought about how the

consumption of liquor has been regularized by such permits?

If permits are granted on genuine health grounds, then

anyone can understand about the genuineness. However,

under the shelter or under the guise of medical grounds if the

permit is granted to non-deserving public then it is a

worrisome situation. The Commission has given due

consideration to this recommendation after due deliberations

For this, there should be a sort of caution created in the

minds of the licensee by way of making him accountable for

the purchase or the license having been obtained for the

alcohol got on the health grounds. They may be subjected to

a periodical inspection on the maintenance, possession and

distribution of such alcohol obtained through these permits.

Today, the medical science is so advanced that one cannot

take undue advantage of liquor permit. In recent times the

medical science has invented so many drugs which are quite

sufficient to take care of one’s health rather than depending

on liquor.

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11.80 RESIDENTIAL TREATMENT IN REHABILITATION

CENTRE

It is an unwritten rule of this universe that.."An Action

Speaks Louder than Words"

In this backdrop, this commission would like to recommend

that residential treatment in rehabilitation center may be

thought of seriously as a part of the punishment to the

offender for alcohol/drug addiction. Schools and Colleges

are always considered to be an alma mater, therefore the

schools and colleges may be encouraged to provide

counselors for prevention and awareness programs of

tobacco, drug and alcohol addiction. The school syllabus and

textbooks should incorporate lessons about menace of

alcohol and tobacco products. Even the rehabilitation centre

can be established in the corners of every street depending

on the vulnerability. Therefore, it is possible to have the

treatment and additionally the relaxation techniques and

other exercises can be taught for the complete withdrawal

from addiction / alcoholism. Even the presently de-addicted

people would be asked to explain the hardships they had

faced during the period of their addiction to those who are

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currently addicted to the habit of alcoholism. This would

make more impact on these addicts

11. 81 It has been widely seen that certain NGO and voluntary

organization along with religious institutions are found more

successful in carrying out their selfless services to leave the

evil habits of tobacco, liquor and gambling have proved more

successful than any other institution.

11.82 JOINT EFFORTS

“Your work is not measured by what you have got but

It is always measured by what you give to others”

At present, IEC [Information, Education and Communication]

activities against tobacco usage is carried out by health

department effectively. So, it is possible to apply the same

standard and plan here also. The funds are utilized for the

same purpose but without innovative and coordinated efforts.

A joint committee of members from prohibition and excise,

health, education, Information and broadcasting, social

welfare and police department should be formed to decide

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means to curtail the usage of tobacco and alcohol from the

society, more particularly targeting the vulnerable groups.

The other invitee members should be involved from experts

from the field of media, communication and experienced

NGO’s. It has been consistently observed that joint efforts

have brought record smashing performance in every field. It

is very hard to ignore beneficial effects of such Joint and

coordinated efforts.

11.83 SPECIAL CHECKING ON EVE OF FESTIVALS.

“We the Indians do not lack the strength but the will”

During the festival seasons more numbers of mobile police

squads must be deployed to nab the offenders. Police also

should regularly arrange for a drive with breath analysers

during such occasions. It is pertinent to note that the

common people and media people are familiar with the

locations of country liquor dens then definitely there is no

reason for the local police not to be aware of such activities.

Same fact is also applied for the routes by which the liquor is

transported from rural areas to cities, and from neighbouring

states to Gujarat State.

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11.84 THINGS TO BE DONE AT THE TIME OF RECOVERY

“There is never a wrong time to do right things”

To overcome the difficulties faced by the police while

preparing ‘panchnama’ at the scene of crime, it is suggested

that a team of respectable and educated citizens from

different areas be constituted who are willing and available to

reach the site of the crime when they are informed by the

police within reasonable time to support procedures like

‘panchnama’. This team of volunteers should be trained by

the police/various legal and forensic authorities on different

legal aspects. This team will work under the supervision and

guidance of Police Commissioners / Superintendent of

Police.

11.85 It is also suggested that as in case of anticorruption cases

police utilise Government employee as ‘pancha witnesses’

during raids/decoy. Same way, in prohibition cases it should

be made obligatory for the Government servants to become

panch witnesses as and when called by the Police.

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11.86 LUCRATIVE REWARDS SCHEME

Though money is not everything but it has played a vital role

in the life of an ordinary man. The Propensity of an individual

has always remained in favor of high yielding rewards.

11.87 Therefore, if lucrative rewards should be announced for

accurate information leading to recovery of big quantity of

liquor, the people would be attracted to provide information

to get rewards. Some people particularly those who are

jobless may engage themselves in developing information

rather than helping bootleggers.

11.88 A simple question may arise that why such scheme of

rewards should be announced and how it would be useful to

curb bootlegging activities is a question?

11.89 If people of the highly prone areas are consuming liquor to

forget their domestic worries, then the scheme would be

blessing for them, as thereafter for getting handsome

rewards, they would be busier in getting vital clues of

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bootleggers, their dens and errant police personnel having

close links with bootleggers.

11.89(A) This will help to trace of bootleggers who are carrying at their

activity in remote areas very surreptitiously or cleverly. This

will go a long way to curb manufacturing and distribution of

illicit liquor.

11.90 The Commission recommends this type of recommendation

on the ground that previously this type of rewards was also

going on in case of Customs and Excise Department, the

said Department has obtained some good results. If this

type of Scheme can be initiated and implemented, it will also

go a long way in this behalf. The Commission is of the view

that if a person is carrying on business of illicit liquor,

particularly manufacturing, selling and distributing, naturally

the neighborhood people will have first knowledge and if this

people divulge this information to nearest Police Station,

then the Government can have definite information, because

the Commission is of the view that by the very small force of

police staff, it will be very difficult for the police to know that

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at exactly what place the illicit liquor is manufactured, sold

and distributed. This will also go a long way, in this behalf.

11.91 Police protection should be provided to informants who come

out openly against the bootleggers.

11.92 STRICT PENAL ACTION

"Human behavior is such that it often tends to depart from

proper path where there is no control"

11.93 The common people have no fear of the law for many

reasons. Few among them are lesser punishment; no

minimum punishment is prescribed in the act, getting easy

bail even to the habitual offenders. Unless this sort of

mentality is eliminated, we shall not be able to implement the

laws.

Einstein has rightly observed that........

"Don't waste your time trying to be successful, spend your

time creating value"

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In other words it will be worth to note that we have multiplied

our possessions but have reduced its value.

11.94 There is also a vicious circle, as a large number of

prohibition cases are charge sheeted, Magistrate who is

always keen to dispose of the matter has an eye on disposal

rather than on justice. Even public prosecutor, who is

handling these cases on behalf of the State Government,

seemed to be equally interested in speedy disposal of the

cases. Therefore, certain steps have to be carried out for

improvement in this situation.

11.95 Minimum punishment should be prescribed for manufacturing, storing, distributing illicit liquor also.

At present the maximum punishment for prohibition offences

is prescribed which needs to be increased, but in practice it

will have no meaning, unless the minimum punishment is

also prescribed in the Act. At present there will be very few

cases, where the punishment in the convicted cases has

gone beyond the imprisonment of 1 or 2 months. Even this

also seems to be awarded in very few cases. Generally the

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punishment is till the rising of the Court, or doing some social

services like cleaning floors of hospitals etc., as per the

provisions of the recently amended Prohibition Act. One of

the main reasons for this state of affairs is the very large

number of cases, which are charge sheeted in the Courts.

The Courts are not able to cope up with the huge volume of

work. Therefore, easy way out is to give sentences with less

punishment and or no punishment at all or even awarding

minimal fine is also found.

11.96 Some of the bootleggers are very influential and rich. They

also have support of the local mafia gangs and well

organized in their business. To tackle such a problem, a

dedicated and motivated police force is required, for which

the Government has to give a serious thought. It is essential

to strengthen the enforcement agencies, provide adequate

resources, motivate good officers and ensure effective

punishment to the guilty.

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11.97 COMPLAINT BOXES IN THE HIGHLY PRONE AREAS

“One can mess up with the oral wordings but hard to mess

up with writing”.

We can twist the version but not the writing, based on this

rule or the maxim this commission further recommends that

the complaint box should be kept in each village and the

highly prone areas. The complaints made should be kept

confidential and the volunteer team and police authorities

should open those boxes publicly and necessary actions

should be taken by competent authorities and records of

which should be maintained confidentially by the police.

11.98 It is a feeling of common people that complaints / information

regarding trade of liquor are not attended quickly by the

concerned police stations. Some police officers show least

interest and respond negatively to the given information. This

kind of attitude may lead to a diminished flow of information

from the general public. The strict vigilance and prompt

police action is required to be taken when the complaint is

lodged against such activity or on the existence of ‘adda’

[Den]. In case of repeated failures, the police officers of the

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area should be held responsible/answerable. If a complaint is

made or an individual is booked for the crime for multiple

times, continuous and strict vigilance should be kept on such

persons by the police to avoid further repetition of crime. It

has also been observed that easy and quick money

associated with the trade of illicit liquor is one of the causes

for habitual offenders to stick to these activities in spite of

punishment. In such case, law should be amended to seize

illegal property or destroy unlawful financial backing of

habitual offenders. Such habitual offenders should also be

cornered by involving the authority of tax and revenue

intelligence.

11.99 It is more important that confidentiality of the informer should

remain intact. At the same time, the state must consider to

offer them incentives for giving information. People have also

suggested that authority should arrange for providing all

information online as well. A dedicated blog should be

created online and information pertaining to disadvantages of

liquor should be made available. People should feel free to

discuss the social drive against liquor in this blog. The

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information about the nuisance of liquor in specific areas

obtained from this blog should be given due consideration.

Same thing implies for the good suggestions offered online

by the blog visitors. They should be duly honoured for their

important suggestions/clues.

11.100 Role of non-official organizations discussed - In order to

secure public cooperation, which in Commission’s view is

extremely important for the successful implementation of the

Government’s Prohibition policy, suitable institutions have to

be created. It will be the best if completely non-official

organizations consisting of men and women who are

devoted to the cause of Prohibition can be created. The

State Government may give its patronage, help and

assistance in the form of grants and other facilities. But the

primary responsibility should be shouldered by the non-

officials. But the primary responsibility should be shouldered

by the non-officials. Such organizations will be best suited to

influence the public mind and win their support in favour of

Prohibition. There may be a State level organization with

branches at Districts, Taluka and Village levels. Apart from

the honorary workers, it should also have paid whole-time

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and part time workers chosen carefully from amongst those

who sincerely believe in Prohibition and are prepared to work

for its success. The Commission feels that there would be

no dearth of such people. Volunteers can be enrolled. The

workers should through personal contact influence and

persuade addicts to give up drinking. They can collect

pledges for not drinking, organize public opinion against

bootleggers and force them to give up the illicit business and

furnish information to police about recalcitrant offenders of

the law. They can even keep a watch on the activities of

corrupt official who connive with the bootleggers and help the

authorities to eliminate such undesirable elements from the

service. In other words, through the public and voluntary

agencies, the effort should be made to convert Prohibition

into a movement rather than keeping it an exclusive preserve

of law enforcement agencies. The Commission does

appreciate the establishment and successful running of such

an organization is an uphill task and is mainly dependent

upon finding persons with initiative, enterprise and devotion

to the case of Prohibition. The Commission do however

hopes and trust that it would be possible to attract such

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personalities. It is hoped that the freedom fighters.

Sarvodaya workers and social workers will be glad to help.

   

11.101 Liquor is a case of killer brew only lends credence to the

thinking among political parties and the State Government

that it might be better to introduce prohibition, as envisaged

under Article 47 of the Constitution of India, which has

already been recommended by the various Judgments of

Honorable Supreme Court. It is no doubt true that it is due to

connivance between bootleggers and a section of police.

Most, if not all, victims tent to be poor labourers and their

family end up paying terrible price. Alcoholism is a social

menace that needs to be tackled in sensitive, intelligent,

multi-pronged way.

11.102 So far as the present state is concerned, it is a common

knowledge that connivance between the brewers and

sections of the police make the hooch flow, particularly in

festival season. Most, if not all, victims are the poor

labourers. These families end up paying a terrible price for

this. Alcoholism is a social menace that needs to be tackled

in a sensitive, intelligent, multi-pronged strategy. Driving it

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underground, to dangerous devices, is clearly not the way.

On the contrary as suggested by the Commission, proper

way is by persuasion, education and awareness, which we

have stated earlier.

11.103. In earlier part of the Commission, suggestions have been

received from various people, particularly from Professor

Shri H.C. Dholakia and Ex-DGP of Gujarat state Shri S.S.

Khandwawala, which the Commission we have already

referred to. The recommendations made by these eminent

personalities may be treated as part of recommendation of

the Commission. The Commission does not want to repeat

these recommendations here to avoid much of a burdening

of the report un-necessarily.

11.104 In regards to the previous hooch tragedies are concerned,

we have already referred the Reports submitted by

Honorable Chief Justice of Gujarat state Justice Shri M.N.

Miabhoy (Retd); Honorable Justice of the High Court of

Gujarat, Justice Shri A.A. Dave (Retd); Honorable Mr.

Justice Tekchand of the Punjab High Court and of Honorable

Mr. Justice Lentin of the Bombay High Court. The

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Commission has also considered them and has already

opined that the recommendations made by that Commission

may be treated as a part of the recommendations of this

Commission. The Commission does not want to repeat the

same here to avoid the burdening of the report.

11.105 The Ahmedabad Women’s Action Group-AWAG through its

Secretary Ila Pathak has also contacted the Commission.

They have also given reply dated 20th September, 2010, in

this behalf. We had also discussed with Shri Prakash N.

Shah and other persons, who had accompanied Ilaben

Pathak. They had also made prayer in PIL filed in the

Honorable High Court of Gujarat in this behalf. They have

people’s hearing and case studies and survey carried out by

Ms. Damayanti Parekh, Ms. Minaxi P. Joshi, Mrs. Jayashri V.

Joshi and others. The report in respect of AWAG is enclosed

herewith as ANNEXURE “I”.

11.106 The Commission is of the view that the Government may

study the same and try to take necessary action in this behalf

also. The Commission makes it clear that AWAG has also

filed a writ petition in Honorable High Court of Gujarat and

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therefore, some of the contentions which they have raised

before the High Court and the matter is subjudice and

therefore, the Commission has not dealt with their

recommendations in detail. As and when the Honorable

Court passes the order in the said petition, the State

Government will consider the judgment, in this behalf.

11.107 In the case of Prakash Singh reported in AIR 2006(8) SCC-1

the Honorable Supreme Court has given a landmark

judgment in connection with the Police Reforms. That was an

interim judgment. Thereafter the Honorable Supreme Court

has issued notice to the Union of India and all States and

called for their views. In that judgment the State of Gujarat

has also filed various Affidavits before the Honorable

Supreme Court. It is no doubt that the Honorable Supreme

Court has considered following reports:

(i) National Human Rights Commission Report

(ii) Law Commission’s Report

(iii) Ribero Committee’s Report

(iv) Padmanabhaiah Committee’s Report

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(v) Malimath Committee’s Report

(vi) Soli Sorabjee Committee’s Report

Out of that, the Commission has also considered report of

Soli Sorabjee and other relevant reports. However, other

reports are not available with the Commission. The State

Government of Gujarat has filed various Affidavits and the

Honorable Supreme Court has passed various orders from

time to time. The Commission has studied certain orders and

certain Affidavits of the Government also. However, still the

matter is pending before the Honorable Supreme Court and

the Commission hope and trusts that as and when the

Honorable Supreme Court passes order regarding police

reforms in connection with the Prohibition Law, the State

Government will abide by the same as the same is binding to

them. As the matter is subjudice the Commission did not

observe anything for the same.

 

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ACKNOWLEDGMENTS

(1) Before I conclude the report, I must profusely thank my

esteemed colleagues viz., Dr. M.S. Dahiya, Director, Institute

of Forensic Science, Gujarat Forensic Sciences University

and Deputy Director, DFS, Gandhinagar who has helped a

lot in resolving certain issues regarding alcoholism and its

effects.

(2) I also profusely thank Shri G.C. Raiger IPS Retired Director

General of Police, Gujarat State, who has also immensely

helped the Commission in connection with the role of Police

with regard to the activities of the bootleggers and also about

the police reforms, in this behalf.

(3) I also profusely thank Dr. Kirit Mithawala, former Officer on

Special Duty for Cancer Screening Program, M.P. Shah

Cancer Hospital, Ahmedabad, who has helped the

Commission, during the examination of doctors of various

hospitals and their Affidavits and ultimately when the

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Commission examined certain Doctors. He also helped the

Commission in preparing the medical reforms.

(4) I also profusely thank the Learned Government Pleader

Chetan Shah and also Learned Senior Advocate Shri R.C.

Kodekar for helping and assisting the Commission. However

due to his personal engagement in the High Court he

expressed his inability to continue as he would not be able to

cope up with the work. Therefore, the Commission had to

request the State Government to relieve him and thereafter

the Government was kind enough to appoint Shri Kiran R.

Jani, Learned Sr. Advocate as a replacement.

(5) The Commission is beholden to Mr. Kiran R. Jani who has

procured lots of materials for preparing the report, in this

behalf. He has also given lots of innovative ideas in

preparing the report with some practical solutions for the vice

which the society is facing. During the course of examination

in chief as well as cross-examination of various witnesses,

he has asked some crucial questions to the witnesses on

behalf of the Commission which were vital to come to a

logical conclusion. He has decided not to charge his legal

fees from the State Government for appearing and to assist

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the Commission, he has never claimed for reimbursement for

any type of transportation, conveyance, stationery and

telephone. The Commission at this juncture adds with deep

sense of gratitude that for 20 long months Mr. Kiran R. Jani

has worked with missionary zeal for the Commission. Mr.

Jani was also readily available during his tenure of 20

months at the costs of his personal practice of the High Court

and other judicial institutions, where he usually appears.

(6) Last, but not the least, I thank the staff members of the

Commission, who have helped me a lot in this behalf.

Without their help this work of the Commission, would have

become very difficult and the report would not have been

completed, timely and smoothly.

(7) I also profusely thank the Secretary of the Commission

Mr. K. Parameshwaran, who has looked after the office and

also maintained discipline and decorum of the office and

proper working of the office, as I was not able to attend the

office every day due to my other engagement. I also thank

the Personal Secretary to the Commission Mr. Z.G. Kadri

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and the Shirestedar Mr. H.M. Nayak, who also helped me a

lot in preparing this report.

(8) I also thank each and every member of the staff who has

helped me, in this behalf.

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GANDHI’S TALISMAN

I will give you a talisman. Whenever you are in doubt or

when the self becomes too much with you, apply the

test;

Recall the fact of the poorest and weakest man whom

you have seen and ask yourself if the step you

contemplate is going to be of any use to him. Will he

gain anything by it? Will it restore him to control over

his own life and destiny? In other words, will it lead to

Swaraj for the hungry and spiritually starving millions?

Then you will find your doubts and yourself melting

away.

As displayed in Gandhi Smiriti,

Birla House, New Delhi.

(Quoted from : Working A Democratic Constitution – A

History of the Indian Experience by Granville Austin –

OXFORD INDIA PAPERBACKS.

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AHMEDABAD DATE:

(KAMAL M. MEHTA)

Former Judge of Gujarat High Court

Chairman, Hooch Tragedy Commission of Inquiry

(G.C. RAIGER) Member

(Dr. M. S. DAHIYA) Member

(Dr. KIRIT MITHAWALA) Member

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Annexure-A

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Annexure-B

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Annexure-C

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Annexure-D

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TERMINOLOGY

Adjuvant

Anything that aids in removing or preventing a disease,

especially A substance added to A prescription to aid the

effect of the main ingredient.

Algorithm A step-by-

step protocol, as for management of health careproblems.

ALS Advanced Life Support

Anion any negatively charged atom or group of atoms

Antidote An agent used to neutralize or counteract the effects of apo

son.

Authenticities. accurate in representation of the facts;

Barbiturates Organic compound having powerful soporific effect

Baseline An imaginary line or standard by which things are

measured or compared

Benzodiazepines A lipophilic amines used as tranquillizers or sedatives or

hypnotics or muscle relaxants

Bilateral Having identical parts on each side of an axis

Bicarbonate A salt of carbonic acid in which one hydrogen atom has

been replaced

Biomolecule

any molecule that is produced by a living organism,

including large polymeric molecules such

as proteins, polysaccharides, lipids, and nucleic acids as

well as small molecules such as

primary metabolites, secondary metabolites, and natural

products.

Blend To mix together different elements

Blight Disfigurement

Bloodstream The blood flowing through the circulatory system

Boon Benefit, advantage

509  

Bash To hit hard

Cardio thoracic Of or relating to the heart and the chest

Cashless OPD &

IPD.

Cashless Outpatient Department and Inward Patient

department

CAT Scan. an x-ray image obtained by examination with a CAT

scanner

Choking To stop the breath of by squeezing or obstructing the

windpipe; strangle; stifle.

Cider An alcoholic drink made from fermented apple juice

Cirrhosis

A chronic disease of the liver characterized by the

replacement of normal tissue with fibrous tissue and the

loss of functional liver cells.

Clinician A physician or other qualified person who is involved in the

treatment and observation of living patients

Coco-palm Tall palm tree bearing coconuts as fruits

Cognitive of, relating to, or being conscious intellectual activity

Constricted to make narrow or draw together

Convulsion Contortion of the body caused by violent, involuntary

muscular contractions of the extremities, trunk, and head.

Couchoucine A chemical added to the denatured alcohol to make it unfit

for human consumption

CT Computed tomography.

CT scan A medical imaging method employing tomography created

by computer processing

Cyanosis Blueness or lividness of the skin, as from imperfectly

oxygenated blood.

Dehydrants A dehydrating substance

Dehydrogenase An oxidoreductase enzyme that catalyzes the removal of

hydrogen.

510  

Delirium

A more or less temporary disorder of the mental faculties,

as in fevers, disturbances of consciousness, or

intoxication, characterized by restlessness, excitement,

delusions, hallucinations, etc.

To denature

To render (any of various alcohols) unfit for drinking by

adding an unwholesome substance that does not alter

usefulness for other purposes.

To detoxify To rid of poison or the effect of poison.

Dialysis The process by which uric acid and urea are removed from

circulating blood by means of a dialyzer.

Diazepam A synthetic tranquilizer used especially to relieve anxiety

and tension and as a muscle relaxant

Dimness Not seen clearly or in detail; indistinct: A dim object in the

distance.

Drunkard A person who is habitually or frequently drunk.

Drunken intoxicated with or as if with alcohol

EMS Emergency Medical Services

Endotracheel

Tubes

A tracheal tube is a catheter that is inserted into the

trachea in order for the primary purpose of establishing

and maintaining a patent airway and to ensure the

adequate exchange of oxygen and carbon dioxide.

Epigastria The upper middle region of the abdomen.

Esophagus A muscular passage connecting the mouth or pharynx with

the stomach

Euphemistically The use of inoffensive words or phrases

Excrete

To separate and eliminate from an organic body; separate

and expel from the blood or tissues, as waste or harmful

matter

Fantasy A mental image, especially when unreal or fantastic

511  

Fever

An abnormal condition of the body, characterized by undue

rise in temperature, quickening of the pulse, and

disturbance of various body functions.

Foleys Catheters A thin, sterile tube inserted into your bladder to drain urine.

FSL Forensic Science Laboratory

Gadgets

A small technological object such as a device or

an appliance that has particular function, but is often

thought of as a novelty.

Gag Reflex A normal reflex in humans that prevents the passage of

anything from the throat, except during normal swallowing.

Ganglia A part of brain

Gastric aspiration The flow of gastric content into the upper respiratory tract

due to an ant reflux reflex.

Gastric Lavage the process of cleaning out the contents of the stomach

Glutathione

an antioxidant, preventing damage to

important cellular components caused by reactive oxygen

species

GNLU Gujarat National Law University

Golden hours A time period lasting from a few minutes to several hours

following traumatic injury being sustained by a casualty

Grid Network, Frame

Gut The part of the alimentary canal between the stomach and

the anus

Haemodialysis The process by which uric acid and urea are removed from

circulating blood by means of a dialyzer.

Hemodynamic The branch of physiology that studies the circulation of the

blood and the forces involved

Hypotension Abnormally low blood pressure

ICU A hospital unit staffed and equipped to provide intensive

care

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ICU on wheel. An ambulance with trained staff and emergency medical

service

IEC Information, Education, Communication

IKDRC Institute of Kidney Diseases and Research Centre

IMFL Indian made Foreign Liquor

Incorrigible Impervious to correction by punishment

Inculcate Teach and impress by frequent repetitions or admonitions

Inebriate A chronic drinker

Inept revealing lack of perceptiveness or judgement or finesse

Inertia disposition to remain inactive or inert

Intestine The part of the alimentary canal between the stomach and

the anus

Ingestion the process of taking food into the body through mouth

Inhibitions The process whereby nerves can retard or prevent the

functioning of an organ or a part.

Inhibits cellular

respiration

Inhibitions of the series of metabolic processes by which

living cells produce energy through the oxidation of organic

substances.

Intubation The insertion of a cannula or tube into a hollow body organ

Ire anger, rage

Isopropanol Alcohol used as antifreeze or a solvent

Jaggery Unrefined brown sugar made from palm sap

Lacuna A blank gap or missing part

Lavage Washing out a hollow organ( especially the stomach) by

flushing with water

Laxity The quality of being lax and neglectful

Leucovorin

A reduced folic acid and is used in combination with other

chemotherapy drugs to either enhance effectiveness or as

a chemoprotectant.

Malaise Physical discomfort ( as mild sickness or depression)

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Medics A medical practitioner

Malady Impairment of normal physiological function affecting part

or all of an organism

Menace Something that is a source of danger

Metabolic Acidosis

Acidosis and bicarbonate concentration in the body fluids

resulting either from the accumulations of acids or the

abnormal loss of bases from the body

Metabolize Produce by metabolism

Metabolism The organic processes (in a cell or organism) those are

necessary for life.

Metabolite Substance involved in metabolism

Methylated Having received a methyl group

Mimic Imitate, Impersonate

Miscible Capable of being mixed

MLC Medico Legal Case

Molasses Thick dark syrup produced by boiling down juice from

sugar cane

Molecule The simplest structural unit of an element or compound

Morbidity The relative incidence of a particular disease

Mortality The ratio of deaths

Mortuary

Is used for the storage of human corpses awaiting

identification, or removal for autopsy or disposal by

burial, cremation or otherwise.

MRI Magnetic Resonance Imaging

NABH National Accreditation Board for Hospitals

Nausea The state that precedes vomiting

Nephrology The branch of medicine concerned with the kidney

(anatomy, physiology, and disorders)

Notoriety The state of being known for some unfavorable act or

quality

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Noxious Injurious to physical or mental health

Ocular Of or relating to or resembling the eye

Opiods

A psychoactive chemical that works by binding to opioid

receptors, which are found principally in

the central and peripheral nervous system and

the gastrointestinal tract.

Opthathalmology The branch of medicine concerned with the eyes

(anatomy, physiology, and disorders)

Optic Related to sight

Organ Phosphorus

Poisoning.

Organophosphate poisoning most commonly results from

exposure to insecticides, one of the most common causes

of poisoning worldwide, and are frequently intentionally

used in suicides in agrarian areas

Organochlorides An organic compound containing at least one covalently

bonded chlorine atom.

Organs edible viscera of butchered animals

Osmolal One osmolal solution contains 1 mole of solute in 1 L of

water.

Oxidized Add oxygen or combine with oxygen

Oxygen inhalation

Inhalation of oxygen aimed at restoring toward normal any

pathophysiologic alterations of gas exchange in the

cardiopulmonary system, as by the use of a respirator,

nasal catheter, tent, chamber, or mask.

Pale Very light coloured

Papillema of

fundus

Swelling of the optic disc(Where the optic nerves enter the

eye ball)

Paramedics A person trained to assist medical professionals and to

give emergency medical treatment

Peripheral On or near an edge or constituting an outer boundary

pH It shows the hydrogen-ion concentration in gram atoms per

515  

liter

Phenothiazines An organic compound that occurs in

various antipsychotic and antihistaminic drugs.

Phosphorus name of an element

Piteous Deserving or inciting pity

Pitfall An unforeseen or unexpected or surprising difficulty

Plaintive Expressing sorrow

Poor unsatisfactory

Prioritization To assign a priority

Proponent A person who pleads for a cause or propounds an idea

Putaminec Part of brain

Pyrazole

(Fomepizole)

Indicated for use as an antidote in confirmed or suspected

methanol or ethylene glycol poisoning.

Quiescent Causing no symptoms

Rampant Uncontrolled

Respiration A single complete act of breathing in and out

Raspy Unpleasantly harsh or grating in sound

Referrals A recommendations to consult the person or group to

whom one has been referred

Regimen A systematic plan for therapy

Replication The act of making copies

Ryle’s Tube

A thin flexible tube of rubber or plastic, which is inserted

into the stomach through the mouth or nose of a patient

and is used for withdrawing fluid from the stomach or for

giving a test meal.

Salutary Tending to promote physical well-being

Serum An amber, watery fluid, rich in proteins, that separates out

blood coagulates

Shellac A thin varnish made by dissolving lac in ethanol

Smashing very good

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Sporadically In a sporadic manner

Sporadic Recurring in scattered and irregular or unpredictable

instances

Stethoscope A medical instrument for listening to the sounds generated

inside the body

Steward One having charge of

Streamlined Designed or arranged to offer the least resistance to fluid

flow

Stupor The feeling of distress and disbelief that you have when

something bad happens accidently

Suction Catheters

A flexible, long tube attached on one end to the breathing

tube and the other end is connected to a collection

container (suction canister) and a device that generates

suction.

Suction device

Devices are sometimes necessary to create suction.

Suction is used to remove fluids from the airways, to

facilitate breathing and prevent growth of microorganisms.

Tachypnea Rapid breathing, a respiration rate greater than 20 breaths

per minute.

Thiol-containing an organo-sulfur compound that contains a carbon-bonded

sulfhydryl

Trauma Any physical damage to the body caused by violence or

accident or fracture etc.

Triage Sorting and allocating aid on the basis of need for or likely

benefit from medical treatment or food

Triamcinolone Long-acting synthetic corticosteroid given orally,

by injection, inhalation, or as a topical ointment or cream.

Un-metabolized

compounds The compounds which are not metabolized

517  

Ventilation bag

A bag valve mask, a hand-held device used to provide

positive pressure ventilation to a patient who is not

breathing or who is breathing inadequately.

Ventilator A device that facilitates breathing in cases of respiratory

failure

Viscera Internal organs collectively

Volatile Evaporating readily at normal temperatures and pressure

Vomitus The matter ejected in vomiting

Woe Misery resulting from affliction