NEW DELHI _ In the crowded waiting room of Dr. Sunil Sagar's clinic, in the working-class neighborhood of Bhagwanpur Khera, a toddler breathes from a nebulizer. Fever is widespread, and the air quality in Delhi has reached "severe-plus emergency." The patients sit, motionless, but there is somehow tremendous noise. The clinic is a squat cement building draped in wires, a red cross on the door. Sagar sits behind a desk in a small, open room, as a squad of assistants escort patients to him. He seems utterly unflappable.
A father with a troubled look sits down next to the doctor, holding a baby. Sagar listens to the baby's chest with a stethoscope, pulls out scrap paper and writes a prescription. The father hands over a few rupees, and Sagar places the bills into a money drawer under his desk. The entire exchange takes perhaps two minutes.
Medicine in India is transactional. A well-liked doctor hands over a prescription at the end of every visit. Why else have I paid cash to see the doctor, if not for relief? The precariousness of daily life leaves little room for downtime.
As the Indian government reluctantly loosens its prescription opioid laws after decades of lobbying by palliative care advocates desperate to ease their patients' acute pain, the nation's sprawling, cash-fed health care system is ripe for misuse. The sheer size of India's system _ tens of millions of doctors and pharmacies spread across the subcontinent _ makes oversight difficult but presents a tantalizing opportunity for India's burgeoning pain industry and multinational pharmaceutical companies seeking new markets.
A popular spot to purchase these bulk drugs is the Bhagirath Palace in the Chandni Chowk market, one of India's largest wholesale markets that dates to the 17th century. It is a dense maze where men _ and it almost entirely men _ press their bodies into a current of commercial ecstasy, frequently thrown off course by honking auto rickshaw drivers. One after the next, stalls of drug distributors advertise on brightly painted signs "all types of medicines," "life-saving anti-cancer drugs," "deal in Glaxo ... Johnson & Johnson." Inside the stalls, boxes of medicine are stacked from floor to ceiling.
One drug wholesaler in the market said the government has been cracking down lately on certain medicines. Recently, he had received a list of 328 drugs that he was not supposed to stock, including Sulpitac, an antipsychotic medication used to treat schizophrenia. The wholesaler said people had been taking it like "dal and rice" for headaches.
Like its rigid caste system, India's pain industry is stratified. The well-to-do visit well-appointed pain clinics, the working class turn to their neighborhood doctors, and the lower castes, especially those living in India's vast slums, scramble for relief at roadside pharmacies, called chemists.
In the Mankhurd slum in Mumbai, where the average life expectancy is 39, toddlers wander bare-bottomed, defecating in the street. Children scratch at infections on their legs. Without any municipal water, hawkers sell plastic sandwich bags filled with dirty water for 2 rupees. In this place, pain remedies are readily available.
At Shiv Medical & General Stores, an older boy tending the stall wrote out a receipt for Ultracet, branded tramadol tablets _ an opioid analgesic _ made by a Johnson & Johnson subsidiary. "Doctor's name?" he asked. Our guide, Mayur Helia, a community organizer, made one up. "Shagmu," Helia said, giggling, and the shopkeeper wrote it down.
Helia and his colleagues are activists agitating for drinking water and sanitation in the Mumbai-area slums. "Painkillers are part of the daily routine," said social worker Alfiya Mulla. "They have become more normalized."
"You go to the chemist," Helia added, "and you say, 'I have this pain,' and he will give you painkillers without any prescription."
Daily life here is a pageant of hustle. For women in the slums, Mulla said, that means lugging 35-liter buckets of water. "You have to take that from half a kilometer away, and that's why women have to take that" _ she motioned to the box of Ultracet _ "because they are hurting their backs."
She turned the box over in her hands. "Women are more affected and are more addicted to this tablet."
