History repeats in cough syrup horror: Killer drugs claimed 14 lives at Mumbai’s JJ Hospital in 1986

Hospital

A spate of child deaths in Madhya Pradesh linked to contaminated cough syrup has exposed a chilling failure to learn from a nearly identical medical tragedy that shocked the nation nearly four decades ago.

In Chhindwara district, at least 14 children have died after consuming ‘Coldrif’ cough syrup, which subsequent tests by Tamil Nadu drug control authorities found contained 48.6% diethylene glycol (DEG). The industrial solvent is a known cause of acute, often fatal, renal failure. The state government has since banned the syrup, announced compensation and launched a probe into the manufacturer, Sresan Pharmaceuticals.

The case is a grim replay of the 1986 JJ Hospital disaster in Mumbai, where 14 patients, including a 10-year-old child, died after being administered glycerol contaminated with DEG. According to a TOI report, the commission of inquiry led by Justice BS Lentin found the glycerol used then contained 90% DEG.

"The glycerol used at JJ Hospital came from an industrial supplier with no pharmaceutical clearance. It was a lethal oversight," said Dr Ishwar Gilada, who was the resident medical officer at the hospital during the 1986 tragedy. He recalled that Justice Lentin had described the incident as "a tragic monument to neglect,” as cited by TOI.

The parallels are stark. The 1987 inquiry uncovered that the adulterated glycerol had been purchased from a small-time repackaging unit, which had sourced it from an industrial supplier. The product was marketed as "IP" - Industrial Pure - not the Indian Pharmacopoeia standard mandated for human consumption.

Justice Lentin’s 289-page report, submitted in November 1987, exposed a nexus of "apathetic" hospital administrators and "corrupt" officials from the FDA and state health department. Their collective failure, the report found, was directly responsible for the deaths.

Despite the commission’s call for major reforms, including the appointment of an assertive drugs commissioner, experts argue its lessons were never fully implemented. A key administrative post recommended for JJ Hospital had reportedly remained vacant for six years until 2022.

"The syrup should be banned across the nation, not just in a few states," Dr Gilada asserted, as cited by TOI, emphasising that India has yet to fully absorb the lessons from the past. He stressed the critical need for thorough investigations following each child’s death, including autopsies with chemical analysis of organs to detect DEG. "We must study, analyse and implement the findings of that report," he urged. "Those were written in blood."

The current crisis has prompted the Central Drugs Standard Control Organisation (CDSCO) to initiate risk-based inspections of manufacturing units across six states, including Madhya Pradesh and Tamil Nadu. However, the nation's fragmented drug oversight system continues to show alarming inconsistencies, with some government lab reports clearing syrup batches while others detected DEG levels far above safety limits.

To prevent future lapses, Dr Gilada advocates for a robust, multi-laboratory testing protocol. "Samples from every suspect cough syrup batch must be tested across multiple labs - the CDSCO Lab, state forensic labs, the Indian Pharmacopoeia Laboratory and at least one independent private lab," he told TOI.

Among the enduring reforms called for is the complete separation of food and drug administration. Dr Gilada stated that food and medicine are not the same, echoing a long-standing recommendation.