When Cough Syrup Kills: What Pharmacists Can Do to Prevent the Next Tragedy
Following the recent tragedy in India, the threat of substandard and falsified medicines is more pressing than ever
by Dr Scott Matafwali, Substandard and Falsified Medicines Technical Advisor
Last week, news broke that at least twenty children in India died after taking cough syrups that were contaminated with an industrial solvent.Â
India’s medicines regulator, the Central Drugs Standard Control Organization (CDSCO), has identified three commonly-administered cough syrups that contain diethylene glycol (DEG), a toxic substance that causes severe illness and rapid death when ingested, particularly in those under five years old. The World Health Organisation (WHO) has since issued a Medical Product Alert calling for enhanced surveillance and testing, and the CDSCO has reported that production of the contaminated brands has halted.Â
However, as pharmacists, this is a pattern we know all too well. Substandard and falsified medical products (SFMeds) often have fatal consequences, and form a significant global public health problem: the WHO estimates that 1 in 10 medicines in low- and middle-income countries (LMICs) are SFMeds.
Specifically, DEG poisoning is one of the most widespread and longstanding causes of preventable medicine-related deaths, from recent events in Cameroon where a popular cough syrup was found to contain 286 times the legally acceptable level of DEG, to its first recorded occurrence in the Sulfanilamide disaster of 1937, which precipitated the United States Federal Food, Drug and Cosmetic Act still in place today.
For pharmacists across the Commonwealth, these recurring deaths underscore a critical professional responsibility: ensuring that the medicines we dispense are not only available and affordable, but fundamentally safe.
The role of pharmacists in protecting patients
Pharmacists occupy a unique position in the medicine supply chain: we are a bridge between regulatory systems and patients. The DEG contamination in India was fundamentally caused by a failure in manufacturing and, in the opinion of some Indian medical groups, inadequate oversight from regulators; however, pharmacists can play a pivotal role in countering these deficiencies and improving patient outcomes.
The Commonwealth Pharmacists Association (CPA) SFMeds team, part of our Commonwealth Partnerships for Antimicrobial Stewardship (CwPAMS) programme, has identified five key areas in which pharmacists, as medicines experts, can and should be empowered to lead on.
1. Vigilance in procurement and supply
Pharmacists involved in procurement, whether in hospitals, private pharmacies, or ministries, should insist on sourcing medicines from WHO-prequalified manufacturers or suppliers verified through the WHO Listed Authorities.
Practical steps include:
- Checking manufacturer credentials against the WHO Prequalification Database before placing orders;
- Requesting certificates of analysis for high-risk liquid formulations, particularly for paediatric syrups;
- Prioritising suppliers from countries that have achieved maturity levels 3 or 4 on the WHO Global Benchmarking Tool;
- Avoiding grey-market suppliers offering suspiciously low prices.
2. Strengthening pharmacovigilance and reporting
Pharmacists, particularly those in community settings as a result of their frequent patient interactions and accessibility, are often the first to notice unusual patterns of adverse drug reactions and safety signals, including paediatric kidney failures or neurological symptoms following cough syrup use. Timely reporting through national pharmacovigilance systems can trigger life-saving investigations: even a single concerning case warrants documentation and escalation.
3. Community awareness and responsible dispensing
In many LMICs and small island developing states – which comprise a majority of Commonwealth countries – pharmacists are patients’ most accessible health professionals. As such, pharmacists are uniquely positioned to warn the communities they serve about the adverse effects of SFMeds, advise patients against purchasing medicines from unverified sources, and provide education about medicine storage, expiry dates and the dangers of sharing prescription medicines among patients.
Additionally, pharmacists’ conduct when dispensing medicines can have a vital mitigating impact on the prevalence of SFMeds, by checking batch numbers against WHO Medical Product Alerts, verifying manufacturers’ details, and ensuring proper labelling.Â
4. Advocating for stronger regulation
Pharmacy professional associations, including CPA member organisations, can advocate at policy forums for:
- Stronger national medicine regulation and enforcement
- Adoption of WHO benchmarking standards
- Regional cooperation through initiatives such as the Africa Medicines Agency
- Sustainable funding for medicine testing laboratories
- Clear accountability mechanisms for manufacturers and distributors
5. Personal responsibility
Pharmacists must ensure their own practices do not inadvertently contribute to medicine quality problems. To do so, we must adhere to the following list of ‘don’ts’ in our practice.
- Never compound paediatric syrups using non-pharmaceutical grade excipients: DEG contamination often enters through industrial-grade glycerine or propylene glycol;
- Avoid sourcing medicines from unverified online platforms or grey-market distributors;
- Never dispense products with damaged packaging, missing batch information, or suspicious pricing;
- Do not assume that brand recognition guarantees quality: SFMeds are becoming increasingly sophisticated and able to mimic legitimate ones.
The deaths in India, as well as those mentioned in Cameroon and the United States, were all preventable. While pharmacists should not bear the burden for them, we have the knowledge and credibility to prevent them from recurring.
Furthermore, these events demonstrate how these systemic failures extend far beyond any one region; however, countries with weaker regulatory systems are invariably more susceptible to the effects of SFMeds. Last week’s news of the DEG contamination in India – a country that accounts for 20% of Africa’s pharmaceutical imports – is a timely reminder of the need for harmonised standards and consistent testing to prevent manufacturing lapses that can have fatal consequences thousands of miles away in the communities we serve.
These recurring disasters demonstrate that medicine quality must be treated as a global health priority. By promoting vigilance, transparency, and education across the Commonwealth and beyond, our profession can turn tragedy into lasting reform – every pharmacist who understands SFMeds and acts against them strengthens the global chain of trust that patients depend on.Â
We must seize this opportunity to ensure that the latest DEG tragedy in India was not in vain, because when it comes to medicine quality, we all have a part to play in ensuring patient safety.
CPA, through the CwPAMS programme, has developed an online continuing professional development (CPD) course on Supply Chain and SFMeds to equip pharmacists with essential knowledge and tools in combating SFMeds.
The course covers:
- Recognising risk factors for SFMeds
- Understanding regulatory frameworks and quality assurance systems
- Strengthening surveillance and reporting mechanisms
- Designing practical interventions that protect patients
- Navigating WHO tools and regional regulatory initiatives
Click here to log in to the CPA Academy and enrol in CPA’s CPD course on SFMeds today!
About CwPAMS and the Fleming Fund
The Department of Health and Social Care’s Fleming Fund is a UK aid programme supporting up to 25 countries across Africa and Asia to tackle antimicrobial resistance (AMR), a leading public health threat across the world. The Fleming Fund invests in strengthening data surveillance systems through a portfolio of country grants, regional grants and fellowships managed by Mott MacDonald, and global projects managed by partners.