A lesson for Pakistan in Indian sweet syrup death

When 23 children died in India’s Madhya Pradesh after consuming tainted cough syrup in early September, the news soon registered across borders.

In Pakistan – where self-medication is rampant and bottles of syrup are household staples – the tragedy hits dangerously close to home.

Many in Pakistan are unaware that these over-the-counter sweet syrups can be fatal. In the recent Indian case, children – all under six – died of kidney failure after consuming syrup with diethylene glycol (DEG), a toxic solvent found at 500 times the legal limit.

Investigations revealed that the manufacturer, Sresan, had sourced industrial grade propylene glycol from local chemical and paint dealers instead of certified pharmaceutical suppliers. Without a skilled chemist to oversee production, the syrup was untested—and deadly.

This is not the first such incident. In 2022, Indian syrups caused the death of at least 70 children in Gambia and 18 in Uzbekistan. From December 2019 to January 2020, at least 12 children died in illegally occupied Jammu and Kashmir (IIOJK) after consuming similar contaminated syrup.

The prescriber in India was the first to be arrested, followed by the suspension of the drug inspector and deputy director. The maker, who had been on the run since September, has now been caught.

“It shows that even doctors can find themselves in legal and ethical trouble, even when they are unaware of a drug’s quality issues,” said Professor Mishal Khan of the London School of Hygiene & Tropical Medicine.

“The tragedy is a warning to Pakistan – weak regulation hurts everyone: doctors, drug companies and patients.”

A 2024 study by Khan found that about 40% of doctors in Karachi were receiving incentives in exchange for prescribing drugs from a bogus pharmaceutical company with no control over the company’s manufacturing standards or drug quality. Antibiotics and cough syrups were among the drugs they agreed to promote.

As Pakistan enters its flu season, Karachi’s hospitals are filling up. “Between 50 and 70% of children who visit our clinics have respiratory tract infections,” said Dr Wasim Jamalvi of Dr Ruth KM Pfau, Civil Hospital Karachi.

And with the flu comes a predictable companion: cough syrup.

“If a child is brought for consultation for fever, cough and cold, parents feel the prescription is incomplete without cough syrup,” said Dr DS Akram, a senior paediatrician, who stopped prescribing them two decades ago. “Cough syrups don’t work – they just make children sleepy or irritable,” she said.

Jamalvi agrees, “We don’t recommend syrups for children under five, but parents still give them – they’re readily available over the counter.”

Self-healing culture

In Pakistan, cough syrups – often called sherbet – are considered harmless remedies.

“I swear by this syrup that a doctor gave me years ago,” said Mohammad Yusuf, a 31-year-old householder. “A spoonful at night and I sleep better.”

Two weeks ago, when Rakhi Matan’s children, ages 10 and 13, came down with the flu, she packed a bottle of cough syrup left over from last year. “It saved me the doctor’s fee – he would have prescribed the same,” he said.

Such casual self-medication is common — and difficult to control.

Dr Qaiser Sajjad, former secretary general of the Pakistan Medical Association, said regulating cough syrup sales is almost impossible as thousands of quacks operate in the city. Medical shop worker Majid Yousafzai agreed, admitting that the syrups are sold freely without a prescription and “whole families share the same bottle”.

Health experts say Pakistan’s self-prescribing culture — bolstered by weak enforcement and cheap access to drugs — makes the system vulnerable to similar disasters.

Dr Obaidullah Malik, head of the Drug Regulatory Authority of Pakistan (DRAP), said IPS that Pakistan imported the majority of raw materials (for many medicines, including cough syrups) from India and China;

With more than 100,000 drug manufacturing companies, India, referred to as the ‘pharmacy of the world’, is known for affordable generic drugs. But recent deaths have cast a long shadow over its safety standards.

Stricter drug supervision

“It is of great concern,” Malik said, adding that domestic quality control scrutiny had been stepped up after receiving a global alert from the WHO on October 13 about three substandard cough syrups manufactured in India.

“Fortunately, the contaminated syrups were never exported to Pakistan,” Malik confirmed. “There is no evidence of illegal shipments, but we remain vigilant to ensure that a tragedy like the one in India does not happen here.”

“Drap has made it mandatory for all pharmaceuticals, including herbal and nutraceutical manufacturers as well as importers, to pre-test additives such as glycerin, propylene glycol and sorbitol — either in their own laboratories or through public sector facilities such as the Central Drugs Laboratory (CDL) in Karachi or the provincial Malik Drug Test.

The authority is double-checking vendors’ credentials and certifications and has instructed field teams to step up sampling and testing — both of incoming raw materials and finished syrups.

Recently, he trained representatives of pharmaceutical companies from Nepal, Gambia, Sierra Leone, Maldives and Sri Lanka in a rapid detection method called Thin Layer Chromatography (TLC), which helps detect contamination early — saving time, reducing costs and improving safety controls at the national level.

There are between 700 and 800 pharmaceutical companies across Pakistan, but only about 300 are members of the Pakistan Pharmaceutical Manufacturers Association — leaving much of the industry to operate with little oversight.

However, despite its fledgling status compared to India, Pakistan’s pharmaceutical sector is keen to expand into global markets. Khan warned that the recent scandal over unsafe drugs could jeopardize those ambitions before they even take off.

To avoid a similar crisis and protect its reputation abroad, Pakistan’s regulator has stepped up oversight at home.

“Since November 2023, Drap has recalled 63 finished products contaminated with diethylene glycol (DEG) and ethylene glycol (EG), identified 44 impurities and issued 13 alerts for contaminated raw materials,” said Drap’s CEO.

As Karachi’s clinics continue to fill up this flu season, bottles of syrup are flying off the shelves — often without a pharmacist in sight. “It’s just a syrup,” Yusuf said. He does not know, but for dozens of families across the border, this sweet bottle brought irreparable loss.

Zofeen Ebrahim is a freelance journalist. Posts on X @zofeen28

This article was originally published in the UN Office of the Inter Press Service news agency. Published on Geo.tv with permission.