A man asked me twenty questions yesterday, listened to all twenty answers, and then declined the drug.
He is a hundred kilograms and five feet two inches tall. In the last two years we have opened his coronary arteries twice. His diabetes is not controlled. He has stopped walking because walking makes him breathless, and at night he stops breathing in his sleep, over and over, without knowing that it happens.
I had offered him semaglutide.
His questions were not foolish. Between them they covered most of a pharmacology syllabus, and he had plainly read before coming. I answered all of them. It took a long time and I did not mind.
Then he said he would reduce the weight naturally. He used to be a powerlifter. He had competed at state level.
The afternoon
In 2018 I was in cardiology training, and my job in the afternoons was to have the patient ready before Sir arrived.
He kept American hours in an Indian city. The clinic opened at two, we started assessing at two, he came in at four, and it ran until ten or eleven at night. Nobody thought this was strange. It was how the place worked.
The room I worked in had no windows. The air conditioner was not quite functioning and there was no fan. It had been humid and grey all day, and the computer was slow, as it always was.
The files came onto the table between us and there were a great many of them, different thicknesses, a garden variety of colours. Some prescriptions handwritten, some printed. Some pages had gone the yellow that paper goes when nobody has taken care of it, and some were new. He had been angioplastied several times, at several centres, by several interventional cardiologists in several cities, as though the family had set out to cover every premium hospital in the country one artery at a time. Now it was our turn.
I had been through all of it, the past history, the angio CD, the echo. I had one thing to do before four o'clock and I had done it. On his list was Pantocid DSR, once daily, and I had stepped it down to Pantocid, only when required.
This is not a dramatic act of medicine. In an Indian prescription the acid suppressant is dhania-mirchi, the coriander and green chillies the vegetable seller drops into your bag, free, unasked, with every purchase. It is simply there. In my whole training I do not think a single patient had asked me why it was there.
He asked.
He began in American English. Ten minutes in it had become British English, and ten minutes after that we were both speaking Hindi. I remember what I thought about that and I am not going to improve it now: whom are you trying to impress, this is a hospital, I am not your international client. He would go outside and fight the parking man over fifty rupees in the flattest Hindi available, and here he was, doing an accent for me.
“So you believe that you can safely transition me from this Pantocid DSR to Pantocid?”
I explained the difference. He asked what the difference was again, in a slightly different way. He asked why he could not simply continue taking it regularly, as he had been. He asked whether it would be safe. When I had answered that, he asked whether it would be safe.
And then: “Let Sir take a call on this.”
That one I felt in the chest. I was already a postgraduate in medicine. Every senior cardiologist in the country seemed to have written somewhere on those pages without being cross-examined, and here was a black-haired boy in blue scrubs adjusting an acid suppressant, and for that he wanted the consultant.
The staff nurse came to the door. “Sir, it's your turn now.” She came again fifteen minutes later and said the same thing. I looked at my watch three times in that hour, each time in a way I hoped he would not notice, and each time I had that scene from Interstellar in my head. One hour on that planet, seven years everywhere else.
The third time, two of them came. One said something to the other in Malayalam that I did not understand — ആയോ? — and I did not know whether they were speaking to each other or to me.
I gave her the stare, and turned back to the man, and tried again to end the conversation.
The palace
Sir's room is a different order of thing. वो कमरा अपने आप में महल जैसा है। A consultation in there looks like a king's court in session, the attendants and the patient himself, everybody seated, the whole mela of a family that has travelled for this.
I presented the case. Then Sir took the history again himself, which is standard practice, and every drug was finalised.
And then the man asked his questions again. All of them. What is the difference between the two. Why can he not have it regularly. Whether it would be safe. The same questions in the same order, now put to grey hair instead of black.
A trainee is placed in the outer rooms partly to prevent this. We take the history and absorb the questions so that the consultant's pace stays fast and more people can be seen before eleven. When the questions arrive at the palace anyway, everyone in the room understands whose job has not been done.
Sir gave me the stare. Brief, not angry, a slight tightening around the mouth, and then he moved on.
I had produced exactly that stare myself, forty minutes earlier, at a nurse.
Why I am telling you this now
Until Friday, fifty people were supposed to spend Saturday evening at India's first Peptide Party in Bengaluru.
Invite only, fifty seats, peptide tastings and music and food. The announcement ended with a line I had not been able to put down: “PS: The venue is NOT a hospital :)”
Then the Karnataka Food Safety and Drug Administration started asking questions.
The party was cancelled.
I should say how I came to know about any of this, because it does not reflect well on me. Not from medicine. From a fitness influencer's newsletter I subscribe to in the same spirit that people watch videos they find ridiculous — that small guilty appetite for the thing you disapprove of. He was explaining peptides to his readers. His argument was that doctors are the least reliable people to ask, precisely because a system trained us, and that he was reliable because he had escaped it.
I thought it was an American absurdity. Then I was in a Telegram group where an Indian trainer was explaining what these compounds do for hair and for ageing, to people who had already bought them.
A few months ago I could not have told you the first thing about this grey-market peptide world. I read new trials. I follow what is changing in practice. And still, this reached me through Telegram before it reached me through medicine.
The thing a stranger taught me
Somewhere in that argument, a man with no training in health science explained to me that insulin is a peptide.
He was right. Insulin is a peptide. So is semaglutide. So is BPC-157.
That fact should make the word less impressive, not more.
A peptide is a molecule built from amino acids joined in a chain. The word tells you something about its chemistry. It tells you almost nothing about its usefulness as a medicine. It does not tell you whether it works, whether it is safe, what dose to use, what happens after ten years, or whether anyone has ever given it to enough human beings to find out.
Insulin, semaglutide and BPC-157 belong to the same broad chemical family. They do not belong to the same universe of evidence.
That is the whole of the disagreement, and it took a layperson to make me state it properly.
How much is known, and how we know it
The loose version of my side of this argument is that there is no evidence. That is false, and the first person who checks will say so.
There is evidence. The problem is what kind.
When doctors talk about phases of drug development, we are not talking about a regulatory obstacle course. Different phases answer different questions.
Before a drug is given to people, laboratory and animal studies tell us whether the biological idea is plausible and whether there are obvious toxicities. Phase I is the first serious study in humans: what happens to the drug in the body, what dose can be given, what adverse effects begin to appear. Phase II starts asking whether it actually works in people with the condition it is meant to treat. Phase III tests that claim in much larger numbers, usually against placebo or existing treatment, and gives us a much better estimate of both benefit and harm. Approval is not the end; rare or delayed adverse effects may become apparent only after hundreds of thousands or millions of people have used a drug.
The distinction matters because evidence at one stage does not answer the questions belonging to the next. An animal experiment can be a very good reason to do a human trial. It is not evidence that a treatment works in humans.
And most drugs do not make it through this process. In one large analysis of clinical development from 2011 to 2020, fewer than eight per cent of drugs entering Phase I eventually reached approval. About half advanced from Phase I to Phase II. Fewer than three in ten made it from Phase II to Phase III.
That is the background against which I look at peptides.
For semaglutide, we are at the far end of that process. We have large randomised trials involving tens of thousands of people. We have cardiovascular outcome trials measuring heart attacks, strokes and deaths. We know a great deal about its adverse effects because those effects have been looked for, prospectively, in large numbers of people.
For BPC-157, we are almost at the other end.
A systematic review published last year searched five hundred and forty-four records going back to 1993 and included thirty-six studies. Thirty-five were preclinical. The entire human evidence in that review was one retrospective series of twelve patients with chronic knee pain. Seven reported prolonged relief. There was no control group. The reviewers found no clinical safety data.
After more than thirty years of published work, that was the human literature: twelve retrospectively observed patients.
That may be enough reason to study BPC-157 properly.
It is not enough reason to recommend it as a treatment.
If BPC-157 arrived in a blister pack with a pharmaceutical company's name on it instead of a vial marked research peptide, nobody arguing for scientific medicine would consider twelve uncontrolled patients an adequate evidence base.
There is no randomised human trial showing that BPC-157 produces the benefits for which it is currently being sold. There is no adequate human safety dataset. Those are not technicalities. They are the questions that would ordinarily have to be answered before we advised people to use a drug.
And between those two poles sits the compound that makes this genuinely difficult.
Retatrutide has now reported positive results from multiple Phase III efficacy trials involving several thousand participants, with weight loss of a kind we have not seen before. Its manufacturer has not yet received regulatory approval to sell it and plans to seek FDA approval early next year. A cardiovascular and kidney outcomes trial involving about ten thousand people is still running.
I want to be precise about what that means, because it is not a criticism of the drug. Retatrutide has crossed stages most candidate molecules never reach. The unfinished part is the one I would want finished — whether the weight it removes translates into fewer of the events I spend my working life trying to prevent. That is what the running trial is designed to answer. It has not answered it yet.
You can buy it today.
I want you to hold all of this next to the man from yesterday. He is a hundred kilograms with two stents and uncontrolled diabetes, sitting in front of one of the best-studied classes of drugs I can offer him, asking twenty careful questions and then declining. Somewhere else in this country tonight, a healthy man will inject BPC-157 on the strength of an evidence base that, in humans, fits into a room.
Both of them think they are being careful.
What “unknown” actually means
The American regulator has said the most honest sentence available in this argument. In explaining its concern about BPC-157, it wrote that there was insufficient information to know whether the drug would cause harm when administered to humans.
Not that it is dangerous.
That nobody knows.
I find that sentence steadying, because it is the one thing neither side of the internet argument likes to say. The sellers know it works. The debunkers know it is nonsense. The agency, which has read more of the material than either, says it cannot tell.
Whether the molecule is in the bottle
And all of that assumes a question already settled which is not settled at all.
When Belgian researchers analysed twenty-seven grey-market peptide samples, purity ranged from five per cent to ninety-nine point nine. Six vials contained more arsenic than the legal limit.
When researchers test-purchased semaglutide from grey-market sellers, three of six orders never arrived. In the samples that did, measured purity was between roughly eight and fourteen per cent despite claims of around ninety-nine per cent, while the amount of semaglutide in the vial was actually higher than the label claimed. No viable microorganisms grew in culture, but endotoxin was detected.
That combination is worth slowing down for, because it is the answer to the certificate.
Many sellers will show you a certificate of analysis. But identity, purity, quantity, sterility and endotoxin are different questions. A purity assay cannot tell you all of them. A vial can grow no bacteria on culture and still contain bacterial endotoxin left behind after the bacteria are gone.
So the question is not only whether BPC-157 helps a tendon heal. It is whether the powder in the vial is BPC-157, at the stated strength, without arsenic in it.
I could find no published analysis of grey-market BPC-157 specifically. That work has not been done either.
The sellers are careful in their way. The vials say research chemicals, not for human consumption, and the same websites sell you sterile water and syringes, and on some of them, the video showing you how to inject.
Here
In India, the public record is remarkably quiet.
I could find no CDSCO approval, safety alert, circular or public notice specifically addressing BPC-157 or the grey-market trade in these experimental peptides.
Not that our regulator lacks a framework for new and investigational drugs. The argument that these compounds somehow sit outside drug regulation merely because a seller calls them “research peptides” has the logic backwards. A label saying not for human consumption does not make the human use happening around it disappear.
You can buy BPC-157 on IndiaMART for eight thousand seven hundred rupees a box.
On the day I looked, a listing for retatrutide on another Indian marketplace described it in its own specification table as a prescription medication, indicated for chronic weight management, above a photograph of a vial marked research use only.
One page. Both claims. The seller wrote both of them.
On a site that ships to India, under a line reading not for human consumption, a customer had left a review saying he had run BPC-157 for six weeks after ACL surgery and his physiotherapist could not believe how fast he was progressing. No pain at the injection site. Clean vials. Fast shipping.
And in April, officials in Haryana seized more than two hundred and sixty suspected counterfeit tirzepatide pens. The man selling them held no pharmaceutical licence. He had bought peptide raw material from a Chinese wholesale platform, printed the brand's labels locally, and sold the result on IndiaMART at a discount.
That is the supply chain, in this country, in a police case.
The loudest post in the argument this week says that while the West approves peptides, Indian doctors are busy checking whether it was in their MBBS syllabus. It is meant to sting and it does.
The same post says India needs a body that regulates this properly rather than doctors who dismiss it outright, and about that he is simply right.
What I was, before
In second year the syllabus changed under me and I could not score. I was reading the big Western textbooks and loving them, loving the way a hard idea gets built up over several pages until it stands, and then failing short tests, because I could not tell which of those pages the examiner cared about.
So I would walk into a senior's room with the book open and ask what to read. And they would take my book and mark it. A double tick for what mattered enormously, a single tick for what mattered, a cross for what could be left.
Somebody sat with my book and told me where to spend myself.
I also cross-referenced between textbooks, which produced questions, which I took to my teachers. Not afterwards. During. I interrupted lectures. Some of what I asked was intelligent and some of it was stupid, and sometimes I got the stare, the same brief tightening, a class broken by a boy who could not wait.
And sometimes they put the question down gently and explained what I had misunderstood, and those are the hours I still have.
Then I became the senior, and juniors came to me struggling with things I found obvious, and I thought: how can you not understand this.
I did not remember being that stupid myself.
It did not change what I said to them. I sat with them and opened books and told them where their thinking had gone wrong.
But that is what I was thinking while I did it.
The room with no queue
What I keep returning to is not that people have stopped being sceptical.
The man in 2018 was sceptical. He had files from every major centre in the country and a trainee was editing one of the lines, so he interrogated the edit, for an hour. He was protecting expert consensus from the youngest person in the building.
The man buying a vial on Telegram is also sceptical.
He doubts the institution, the guidelines, the training, me.
He does not doubt the vial.
And whatever else the seller is selling, he is selling time.
There is no queue in his room. No nurse at the door, no consultant arriving at four, no clock. He has the whole evening, and he is delighted you asked.
The acid suppressant was dhania-mirchi. It had travelled from prescription to prescription almost unnoticed, as these drugs often do.
But the patient did notice when I removed it.
Every senior cardiologist before me had left that line alone. I was the black-haired boy in blue scrubs who decided to change it.
Of course he wanted to know why.
The afternoon, again
The man in 2018 did take an hour.
He repeated himself. He wanted a senior doctor to check a line I had already checked. There were patients waiting outside who had travelled further than he had, and the nurse who kept coming to the door was doing exactly what she was supposed to do.
What I did not understand was what he was asking me.
He had been angioplastied several times, by different men, in different cities, and he was carrying the paperwork of all of it in a plastic bag. Pages and prescriptions and angiograms from people whose names he probably remembered better than they remembered his.
The acid suppressant was the smallest thing on those pages.
It was the one thing he could point to and ask: why this? Why are you changing it? Will it be safe?
I answered him.
Then he asked me whether it would be safe again.
I had already answered the question.
He was not asking me to repeat the answer.
When the nurse came back because the clinic was falling behind, I gave her the stare. She was doing her job. The pressure had arrived at me from somewhere above, and I passed it to somebody below.
I never saw him again.
My posting changed. I finished my training. I passed the exam. I went on to do interventional cardiology in the same building.
For years, when I remembered him at all, I remembered the hour.
We are usually taught the Gītā as Krishna teaching Arjuna. But the Gītā is also a conversation made possible by a man who keeps asking because the answer has not yet settled the question.
Arjuna asks. Krishna answers. Arjuna asks again.
And in the Gītā's own instruction on how knowledge is to be sought, there is paripraśna: inquiry, questioning.
The questions are not outside the teaching.
He was frustrating. He repeated himself. He took too much time.
And he was right to ask.
There is no Gītā without Arjuna asking.