It’s happening again.

In early September, a cluster of unexplained child deaths in a small town in Madhya Pradesh sent local health workers scrambling.

At least 11 victims – aged one to six – had died within days of taking a common cough syrup. Officials tested everything from drinking water to mosquitoes before the truth emerged: their kidneys had failed.

Weeks later, a state laboratory in the southern city of Chennai confirmed the worst. The syrup in question contained 48.6% diethylene glycol, a toxic industrial solvent that should never be found in medicine. Kidney failure is common after consuming this poisonous alcohol.

The horror wasn’t confined to Madhya Pradesh. In neighbouring Rajasthan state, the deaths of two young children, allegedly after consuming a locally-made Dextromethorphan syrup – a cough suppressant unsafe for very young children – sparked outrage and a government investigation.

For India, this brought a grim sense of déjà vu.

Over the years, diethylene glycol in Indian-made cough syrups has claimed dozens of young lives. In 2023, Indian syrups tainted with diethylene glycol were linked to the deaths of 70 children in The Gambia and 18 in Uzbekistan.

Between December 2019 and January 2020, at least 12 children under five died in Jammu in Indian-administered Kashmir allegedly from cough syrup, with activists suggesting the number of casualties might have been higher. In the past, there’s also been abuse of cough syrups containing codeine, a mild opioid that can produce euphoria in high doses and lead to dependence, and is not advised for young children.

Each time regulators promise reform, contaminated syrups reappear – reflecting a fragmented drug market and, critics allege, a weak regulatory system struggling to oversee hundreds of low-cost, often unapproved syrups produced by smaller manufacturers and sold over the counter.

Days after the latest child deaths, India’s health ministry urged “rational” use of such medicines – effectively warning doctors to exercise more caution when prescribing them to young children – seized samples of the syrup, suspended and banned sales, and ordered an investigation.

But the problem, critics say, runs deeper than over-prescription. Each new tragedy exposes the rot in India’s drug oversight system – a maze of weak enforcement and regulation. The Indian cough syrup market is set to soar from $262.5m in 2024 to $743m by 2035, growing at a compound annual rate of 9.9%, according to Market Research Future.

But none of this would happen if India, and Indians, could wean themselves off their obsession with cough syrups. For decades, doctors have prescribed them, and patients have taken them, even though most do little good and can potentially do serious harm.

Marketed as quick relief for sore throats and stubborn coughs, these sweet syrups mix sugar, colour and flavouring with a cocktail of antihistamines, decongestants, expectorants.

In theory, each ingredient plays a role: one dries secretions, another loosens phlegm, a third dulls the cough reflex. In practice, evidence of them doing much good is small – most coughs get better on their own in a few days.

A cough can result from either infection or an allergic reaction. Cough syrups broadly fall into two types – sedatives that help the child rest, and bronchodilators that ease breathing – and doctors usually prescribe one or the other, not a mix.

Most persistent coughs in children in increasingly polluted Indian cities are not caused by infection but by allergies and irritation of the lower airways, according to Dr Rajaram D Khare, a Mumbai-based pediatrician. Allergies occur when the immune system overreacts to triggers such as dust and pollution.

These children often have a cold or runny nose and a cough that worsens at night or early morning, recurring every few weeks. In big cities, he says, such recurrent, wet coughs are commonly triggered by dust and smog, sometimes accompanied by mild bronchospasm.

Dr Khare said such coughs respond best to bronchodilators – medicines that open up the airways – preferably through inhalers or nebulisers, though many doctors still rely on syrups that offer only limited relief.

Most childhood coughs are viral, self-limiting, and resolve on their own within a week. Physicians say no syrup shortens their course; at best, they offer fleeting comfort. At worst, they carry risks of addiction, toxicity and overdose.

“I don’t usually prescribe cough syrups for ordinary coughs and colds – except occasionally for comfort. If a child is coughing badly and can’t sleep, I may give a dose of a mild syrup just to ease the discomfort. The main goal is relief, not treatment, especially when the cough is dry and part of a viral infection,” says Dr Khare.

So why are cough syrups so widely prescribed in India?

One reason is the weakness of India’s primary healthcare system, particularly in smaller towns and rural areas. As rising air pollution fuels persistent coughs, they are increasingly misused for routine respiratory infections.

The problem runs deeper in the countryside. In rural India, up to 75% of primary care visits are handled by informal providers – often self-taught “RMPs” or rural medical practitioners without formal medical training.

In places where the local public health clinic is far away, under-staffed, or shut, they are the de facto doctors – and syrups are their most trusted tools. When posted in Gorakhapur, a town in Uttar Pradesh, Dr Kafeel Khan, a pediatrician, remembers “syrups being handed out everywhere – even by those with no degree”.

In many of these towns, patients rely on anyone who seems medically knowledgeable – from informal practitioners to shopkeepers – to manage even routine coughs.

“Many poor patients turn to local chemists for advice, assuming the person behind the counter is a pharmacist; in 10 out of 10 times in rural India, that is a wrong assumption,” says Dinesh Thakur, a former Indian drug executive-turned-public health expert.

“While anecdotally, it appears that this problem is largely confined to small towns and rural India, there is some data that it is not. We see similar behaviour among people in big cities too. The only difference is the quality of drug supply in small towns and rural India is an order of magnitude worse compared to larger cities.”

Another factor driving the trend is the combined pressure from anxious parents and gaps in medical knowledge.

“Parents aren’t always well-informed, and they can become impatient. If a child’s cough or cold doesn’t improve in a couple of days, they often consult another doctor who will give a cough syrup,” says Dr Khan.

Low knowledge among doctors adds to the problem. Dr Khan says he has “seen even MD pediatricians prescribe ambroxol cough syrup for children”.

“It’s meant to break up sputum, but kids under two can’t spit it out, so the mucus can be aspirated into the lungs, causing pneumonia – yet it is still prescribed.”

India needs a clear policy on cough syrups and nationwide awareness among doctors and parents to curb reckless use. The stakes are real: the Madhya Pradesh doctor who prescribed the syrup linked to recent child deaths defended his practice, saying, “I’ve been prescribing this cough syrup for 15 years.”