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Blame game?

January 20, 2013

While authorities continue to blame the victims, Asif Chaudry explores the ins and outs of the cough syrup investigation

“Another drug addict has expired, sir,” a doctor at Mayo Hospital informed his senior on the morning of Nov 25 last year. It was the 17th Tyno-syrup related death in the Shahdara area within three-days. The treating doctors registered all the syrup-related victims as ‘drug addicts’.

“Who except my brother has died in the ward a few minutes ago?” thought Akmal Awan. He looked around; except for one, all beds had patients. “Dr Sahib, my brother was not a drug addict. He was quite healthy and never used any sedatives, yet you put him in a ward reserved for addicts,” the shocked Akmal told the doctor. “My questions infuriated the doctors,” Akmal said, adding that both the sides exchanged hot words which led to a scuffle. One of the doctors called the police and lodged a criminal case against his relatives. “Wali was first taken to a private health facility in Shahdara on the night of Nov 24,” Akmal said. “He was taken to Mayo Hospital when the private hospital refused to attend to him being a ‘Tyno’ user.”

Akmal alleged that the government authorities labelled the patients drug addicts to conceal their incompetence at devising a mechanism or keeping check on drug manufacturers and distributors. “My brother was not an addict at all. Wali didn’t smoke or use any other narcotic,” recalls Akmal. However, he admits that Wali drank Tyno, not for medicinal purpose but as a result of peer pressure, saying that the syrup was very popular among youngsters in the area.

Interaction with survivors and families of victims confirms that all the victims of ‘Tyno’ at Shahdara or Dextrometharphan in Gujranwala had consumed the syrup for recreational purposes. Most say that the victims were not drug addicts and they had consumed the syrup in the company of their ‘bad friends’ just for enjoyment; many for the first time. Police investigators, medical experts who treated the patients and the government officials involved in the inquiries have found it convenient to label all patients as drug addicts. They were of the view that the alleged addicts mixed some substance in the cough syrup to increase its sedation level which turned lethal for some.

Prof Dr Irshad Hussain, of Mayo Hospital, Lahore, who was also part of the inquiry committee on the Punjab Institute of Cardiology (PIC) drug scam in January 2012 which claimed over 150 lives, said that a majority of the victims were drug addicts.

He claimed this on the basis of the victims’ medical and family history. “I can’t blame the drug alone for the tragic incidents,” he said. “The patients might have mixed some other narcotic substance like sprit or diazepam with the syrup.”

The survivors strongly object to these allegations. Sajawal, who was taken to Mayo Hospital shortly after he consumed the syrup for the first time, says, “I am not a drug addict,” admitting, however, that he took the drug on the insistence of his friend who often consumed it. He states that his friend never mixed anything in the syrup and his health always remained normal. Sajawal believes that the fresh batch of the syrup distributed in November might have been adulterated.

Surprisingly, all the inquiries launched so far into the above-mentioned three tragedies are yet to be completed. This shows the pathetic response of the Punjab administration towards such a highly sensitive issue. The claims by the victims’ families, differences in lab reports issued so far and incomplete inquiries have further complicated the situation.

Authorities investigating the suspected cough syrups say that the people either over dosed, or there was a problem with the medicine itself. Punjab Health Director General, Nisar Cheema, said that two local pharmaceutical firms — Reko Pharma and Ethical Laboratories — had imported the raw material — Dextromethorphan — to manufacture the syrups. He alleged that the Dextromethorphan might have been adulterated and added that it had been initially established that excessive dose of Dextromethorphan was the cause of 19 deaths in Shahdara, Lahore, and over 30 others, largely in Gujranwala. “There is not a single lab in the country with standardised technology to analyse inactive ingredients in any in-question medicine to determine its adulteration,” Professor of Medicine and former Principal of Allama Iqbal College, Prof Dr Javed Akram, said. He is the key investigator in the committees formed at the departmental and provincial levels to probe these incidents.

DTL reports: Interestingly, the reports issued by the Central Drug Testing Lab (DTL), Karachi, and DTL, Lahore, do not match each other which confirms experts’ doubts on its authenticity. The DTL, Karachi has cleared the in-question cough syrup, while the report issued by DTL, Lahore, which analysed Dextromethorphan collected and dispatched by Drug Inspectors of Samanabad and Iqbal Town declared it ‘substandard’. Federal Minister for National Regulations and Services Dr Firdous Ashiq Awan says the Central Drug Laboratory had cleared the finished products and the raw material of the said cough syrups.

Forensic analysis: The forensic analysis of the stomach contents of the victims revealed the presence of many narcotics including alcohol, opium, marijuana, bhang and sleeping pills. According to a Punjab Health Department spokesman, the results clearly indicate that the users of Tyno syrup had also used these substances.

WHO investigations: The World Health Organisation’s initial report states that samples taken from the victims at Lahore revealed the presence of hazardous drugs including alcohol, opium, cannabis, haloperidol, alprazolam and lorazepam.

Discussions with recovered patients revealed that they had not introduced/used anything new for recreational activities. Further, the samples from victims at Lahore showed very high concentration: 4.1 to 7.8mg/ml of Dextromethorphan (lethal concentration is 3mg/ml). In case of Recko Pharma the ‘Dextromethorphan’ was taken from two sources — that from the first source fully complies with all the tests but that taken from the second source doesn’t comply with the standard optical rotation and melting point. WHO is collecting further information and providing technical assistance and guideline to the department of health.

PPMA stance: Pakistan Pharmaceutical Manufacturers Association vice chairman Nasir Qureshi expressed his doubt on the authenticity of the lab reports which were being used as evidence to declare the cough syrups defective. “At present over 65 local and multinational pharmaceutical companies are using Dextromethorphan (the active ingredient) in their cough syrups available all over Pakistan,” he said. If their claim was true then the deaths should have been much higher.

He said Reko Pharma had been manufacturing Tyno since 1978 without even a single complaint of this nature. In the recent case, he said, the individuals who consumed Tyno did so to get intoxicated. The misuse of any drug could cause serious consequences for which the manufacturers could not be held responsible, he said. “Dextromethorphan was a widely used active ingredient of cough syrups worldwide,” Mr Qureshi said adding that its safe dosage is 5 ml (10 mg) every five to six hours, and the maximum dosage should not exceed 20 ml in 24 hours. After failing to reach any conclusion on the basis of the local labs, the Punjab government has recently dispatched the samples abroad. The reports are awaited yet.

Findings: Experts believe that lack of coordination among the stakeholders and departments concerned is the major factor which led these investigations to a blind alley. They say that the government has not learnt a lesson from the first case (PIC scam). It was ‘blatantly mishandled’ by the Punjab administration. The experts blame the administration which did not take concrete steps to complete the probe into the PIC scam, to bring the actual culprits to the court of law.