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The pattern continues once more.

At the beginning of last month, a series of unexplained fatalities among children in a small town in Madhya Pradesh had local health workers working urgently.

No fewer than eleven victims - between 1-6 years - had died within days of consuming a widely-used cough syrup. Officials examined everything from drinking water to insects until the cause was discovered: their renal systems had failed.

After investigation, a government testing facility in Chennai confirmed the worst. The syrup in question was found to have nearly half diethylene glycol, a dangerous industrial solvent that must not be present in medicine. Renal shutdown is common after consuming this poisonous alcohol.

Broadening Crisis

The horror extended beyond to Madhya Pradesh. In adjacent Rajasthan, the fatalities of a pair of young children, reportedly after taking a locally-made Dextromethorphan syrup - a cough suppressant dangerous for very young children - caused public anger and a government investigation.

Across the nation, this brought a disturbing sense of repetition.

Over the years, the toxic chemical in Indian-made cough syrups has taken dozens of young lives. In 2023, locally manufactured medicines tainted with the solvent were connected to the deaths of seventy children in Africa and 18 in Uzbekistan.

From December 2019 and early 2020, at least twelve kids below five years died in Jammu allegedly from medication, with advocates indicating the number of victims might have been greater. In the past, there's also been misuse of cough syrups with codeine, a substance that can cause euphoria in high doses and cause addiction, and is not advised for young children.

Regulatory Shortcomings

Whenever regulators vow reform, contaminated medicines resurface - demonstrating a fragmented pharmaceutical industry and, critics allege, a weak regulatory system finding it difficult to oversee hundreds of cheap, often unauthorized syrups manufactured by smaller manufacturers and available over the counter.

Days after the most recent fatalities, India's medical authorities urged appropriate use of these medicines - effectively cautioning physicians to practice more care when recommending them to kids - seized batches of the medicine, suspended and prohibited distribution, and ordered an inquiry.

Market Expansion and Medical Reality

However the issue, experts argue, runs deeper than over-prescription. Each new tragedy exposes the rot in the country's pharmaceutical regulation framework - a maze of poor enforcement and regulation. The Indian cough syrup market is set to grow significantly from $262.5m in this year to $743m by 2035, expanding at a compound annual rate of 9.9%, as per industry analysis.

But these incidents would occur if the nation, and Indians, could wean themselves off their reliance with cough syrups. For decades, physicians have prescribed them, and patients have taken them, even though most do little good and can potentially do serious harm.

Advertised as fast solution for sore throats and persistent coughing, these flavored medicines mix sugar, colour and flavorings with a combination of antihistamines, nasal openers, mucus thinners.

Medical Perspective

In theory, every component has a function: some reduces mucus, another thins sputum, a third dulls the coughing impulse. Realistically, evidence of them doing much good is limited - the majority of coughs resolve on their own in a few days.

A cough can be caused by either infection or an immune response. Cough syrups broadly are categorized as two categories - sedatives that help the child sleep, and airway openers that ease respiration - and physicians typically recommend one or the other, not a combination.

The majority of ongoing coughs in children in heavily contaminated urban areas are unrelated to illness but by allergies and irritation of the lower airways, according to pediatric experts. Hypersensitivity reactions occur when the immune system overreacts to stimuli such as particles and contaminants.

These children frequently have a cold and a respiratory issue that intensifies at night or dawn, recurring every few weeks. In big cities, such repeating, productive coughs are commonly caused by dust and air pollution, sometimes accompanied by mild airway constriction.

Treatment Approaches

Medical professionals indicated such coughs respond best to bronchodilators - medicines that expand the breathing passages - preferably through puffers or mist devices, though numerous doctors still rely on syrups that provide only minimal benefit.

Most childhood coughs are virus-caused, temporary, and clear on their own within a few days. Medical experts state no syrup reduces their course; at best, they offer fleeting relief. At their most dangerous, they pose dangers of dependency, poisoning and excessive consumption.

"I don't usually prescribe cough syrups for ordinary symptoms and colds - except sometimes for symptom relief. If a child is severely symptomatic and has difficulty resting, I may give a small amount of a gentle syrup just to reduce the symptoms. The main goal is comfort, not treatment, especially when the symptom is non-productive and associated with a common illness," explains a pediatric specialist.

Root Causes

What explains is medication so widely prescribed in India?

One reason is the weakness of India's basic medical system, especially in rural communities and rural areas. As increasing air pollution fuels persistent respiratory issues, they are increasingly misused for routine respiratory infections.

The problem runs deeper in the countryside. In rural India, up to 75% of primary care consultations are managed by unqualified practitioners - often untrained rural medical practitioners without formal medical training.

In places where the government medical facility is far away, under-staffed, or shut, they are the actual doctors - and syrups are their primary treatments. When working in Gorakhapur, a