Immediately following Russia's unprovoked invasion, hospitals and pharmacies across Ukraine witnessed a severe interruption in the drug supply chain. Pharmacies were looted and shelves were quickly emptied with no replenishment in sight. In just a few days, the profound benefits of a century's worth of modern pharmaceutical development were nullified, with lifesaving drugs for heart disease, high blood pressure, infections, diabetes, cancer, and innumerable other conditions suddenly unavailable.
Americans who think that such shortages could never happen here should think again. In fact, we are already experiencing them. University of Chicago researchers in 2018 surveyed 719 pharmacists at large and small hospitals across the country and found that all of them reported experiencing at least one drug shortage over the previous year, and 69% had experienced at least 50 shortages in that time. The majority were generic injectable pharmaceuticals commonly used in hospitals, including analgesics, cancer drugs, anesthetics, antipsychotics for psychiatric emergencies, and electrolyte solutions needed for patients on IV supplementation. According to the Food and Drug Administration, there are currently shortages of 120 drugs, many of them commonly used and critically important.
One of the reasons is that we, like Ukraine, are at the mercy of foreign sources for our pharmaceutical supply. China has become the world's largest producer and exporter of the essential "active pharmaceutical ingredients" (APIs) used in the manufacture of drugs in many countries, including the United States. According to the World Health Organization, 36% of pharmaceutical manufacturing plants are government owned, and that figure roughly doubles when calculated on facility square footage rather than facility numbers. Even India, a dominant manufacturer of generic drugs, is dependent on China for its APIs.
Many of the Chinese APIs are produced without sufficient quality control to ensure drug safety and efficacy, according to the findings of an important analysis by the U.S.-China Economic Security Review Commission, which was established in 2000 by Congress when China was permitted to enter the World Trade Organization. The commission found that China's pharmaceutical industry "is not effectively regulated by the Chinese government" and has been responsible for a number of drug safety scandals. The United States' dependence on Chinese pharmaceutical products, the commission concluded, means that "the American public, including its armed forces, are at risk of exposure to contaminated and dangerous medicines."
Thus, China's takeover of pharmaceutical manufacturing represents an enormous public health and national security risk, which comes not only from the possibility of poorly overseen manufacturing, but also because of possible interruptions in production or a trade war. "Should Beijing opt to use U.S. dependence on China as an economic weapon and cut supplies of critical drugs," the U.S.-China Economic Security Review Commission's report noted, "it would have a serious effect on the health of U.S. consumers."
Geopolitics could also affect the availability of pharmaceuticals in the U.S. Given China's enormous influence over the pipeline and its increasing cooperation with Russia, it could decide to interrupt pharmaceutical shipments to any country that opposes its efforts to challenge Western democracy and power, or its expansionist aspirations. For example, it doesn't require too much imagination to envision China threatening to interrupt our drug supply in order to "persuade" the U.S. to remove our naval forces from the Taiwan Strait.
Americans might think that our government or pharmaceutical companies have sufficient stockpiles of drugs in case of emergencies, but they don't; nor do ordinary Americans. Because commercial insurance companies permit only a 30-day (or, in some cases, a 90-day) supply of most prescription medications, any widespread pharmaceutical supply chain disruption could quickly become a dire threat.
A sustained interruption in supply would be disproportionally felt by the elderly and other medically vulnerable groups. The heart-wrenching stories coming from Ukraine show what happens when pharmaceutical supplies seemingly vanish overnight. The COVID-19 pandemic and the invasion of Ukraine have shown that product supply chains, especially of pharmaceuticals and medical equipment, are exquisitely sensitive to interruptions.
Bottom line: When it comes to America's pharmaceutical supply, we should diversify our sources, so that we are no longer heavily dependent on our adversaries.
Dr. Gortler, a pharmacologist and pharmacist, is a fellow at the Ethics and Public Policy Center. He was a professor of pharmacology and biotechnology at the Yale University School of Medicine, and was later a senior advisor for drug safety to the FDA commissioner. Dr. Miller, a physician and molecular biologist, was a consulting professor at Stanford University's Institute for International Studies and the founding director of the FDA's Office of Biotechnology.