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WASHINGTON — The baby had so many pustules ravaging his face he could barely open his right eye, a photograph that left the president, national security adviser and close aides nearly speechless with horror.

A global pandemic had begun in a hospital in Oklahoma City. Doctors soon diagnosed smallpox, a virulent, deadly and disfiguring infection that had disappeared from the planet two decades before. What would the president do?

This was the scenario that a cast of Washington power players sought to tackle over two days at Andrews Air Force Base in June 2001. The exercise, code-named Dark Winter, has passed into Washington lore as the first high-profile alarm of the dire consequences of a pandemic. For months after Dark Winter, advisers to President George W. Bush attempted to come to grips with what they predicted would happen in such a contagion: overwhelmed hospitals, broken medical supply chains and frenzied grocery buying. 

Three months later, the 9/11 attacks made the panic all too real.

In the nearly 20 years since, federal agencies have run similar simulations numerous times, including one code-named Crimson Contagion that the Trump administration undertook just last year. Partly as a result of these exercises, hundreds of billions of dollars have been spent to study medicines, build biocontainment laboratories and set up a strategic stockpile to house the “nation’s largest supply of lifesaving pharmaceuticals and medical supplies.” Billions more were directed to bioterror and pandemic readiness at the defense department and spy agencies.

The nation, it seemed, was prepared for the worst.

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In the Dark Winter Congressional Hearing, in 2001, Senator Mary Landrieu quoted Chinese strategist Sun Tzu: “The supreme act of war is to subdue the enemy without fighting.”

And yet somehow, this past March, the U.S. government found itself woefully unprepared for the global pandemic that has come to be called Covid-19, a virus that first appeared in a seafood and poultry market in Wuhan, China, and then spread rapidly to other parts of the world. It has now infected 1.8 million people in 175 countries, including more than half a million Americans. Despite all the planning and stockpiling, frontline health workers at hospitals from New York to San Francisco have been left unprotected and overwhelmed because of a shortage of masks, gloves, hospital gowns and ventilators. 

As harmful as these shortages are, there is widespread confidence that they can be solved, if not in weeks, then months. But there is one major challenge to U.S. readiness that no government simulation has reckoned with, where the gap cannot be closed this year, and probably not even next year: China’s near-total control of the world’s antibiotic supply. 

The country where the novel coronavirus originated makes 80 percent of all antibiotics, humanity’s primary weapon against bacterial infection.

They are “the fire extinguishers of medicine,” according to Dr. John Rex, former head of Infections and Global Medicine Development at AstraZeneca. “Infections can progress quickly and not having the right antibiotic can be the difference between life and death.” 

China now makes nearly all supplies of penicillin G, for instance, which is needed for parenteral antibiotics — the infusions and injectables that are vital for stopping infections in hospitalized patients. While Covid-19 is a virus and thus not treatable with antibiotics (although some reports suggest that azithromycin can be helpful), hospitalized patients often sustain bacterial infections later because their immune systems are overwhelmed. Most of the victims of the 1918 Spanish influenza are thought to have died from bacterial infections secondary to the flu, not from the flu itself.

Professor Alexander Fleming, who first discovered penicillin, in his laboratory in London (1943). | The Wire
Professor Alexander Fleming, who first discovered penicillin, in his laboratory in London (1943).
Credit: Imperial War Museums U.K.

Alexander Fleming discovered penicillin in 1928, but it wasn’t used broadly until the U.S. government poured resources into making its development an imperative for the wounded in World War II. Pfizer and other American drug companies helped mass-produce it and set the stage for the development of later discoveries like amoxicillin, one of the most widely prescribed antibiotics today. 

As recently as the late 1980s, there were more than 30 antibiotic manufacturing facilities in the United States. Today, the world’s richest nation — home to some of the most advanced pharmaceutical operations — does not have a single large-scale producer of penicillin or other antibiotics. When it comes to crucial medicines like parenteral antibiotics, which have a more limited shelf life than pills, even a fairly brief cutoff of Chinese supplies could cause havoc in American hospitals. 

In addition to antibiotics, China has a huge market share of the active ingredients in most generic medicines. Beyond pandemics and the associated risk in supply chain disruptions, health experts say this control over the world’s medicine cabinet presents a daily threat to global health because China’s manufacturing quality standards are notoriously bad.

A 1957 fermentor used to get penicillin in the London Science Museum. | The Wire
A 1957 fermentor used to get penicillin in the London Science Museum.
Credit: Matt Brown, CC BY 2.0

For years, experts and some government officials warned of the U.S. vulnerability to China’s near-lock on medication production, including the antibiotic supply.

Randall Larsen, a retired Air Force colonel who participated in the Dark Winter simulation and advised the White House on bioterrorism, said he raised the dangers of the U.S. losing its antibiotic-making capabilities over and over again, until he concluded it was futile.

“I’ve got a flat spot on my forehead from banging it against the same wall for so long,” Larsen said. “I just couldn’t do it anymore.”

Margaret Hamburg, who served as Commissioner of the Food and Drug Administration under President Obama and worked on the emergency planning for the federal government, was more emphatic.

“It’s enormously worrisome that the United States has come to depend so heavily on medical products manufactured, in whole or in part, from countries like China,” she said in an interview with The Wire. “This has led to terrible capacity gaps to make antibiotics and other drugs that are vital to U.S. health, and in fact crucial to our national security.”

She added: “The sad and scary truth is that China has become the sole source for many of them. It’s a point I have been making for more than a decade to some the most powerful people in government and industry, but to little avail.”

As tensions have risen between the U.S. and China, it looks like Washington might finally be ready to act. A top economic adviser to the Chinese government warned recently that China’s ultimate weapon in the trade war could be an antibiotic embargo imposed on the U.S., which would create chaos even without a raging pandemic to deal with. 

Senators Tom Cotton and Marco Rubio, Republicans respectively from Arkansas and Florida, recently proposed legislation mandating national sourcing for antibiotics. Peter Navarro, President Trump’s director of Trade and Manufacturing Policy, is pushing an executive order to similar effect.

Reversing the tide in the supply chain won’t be easy, however. And it could even be too late. Low labor costs, state subsidies and weaker enforcement of anti-pollution regulations helped make China attractive as a manufacturing hub. Environmental watchdog groups have accused Chinese and Indian plants of dumping millions of tons of antibiotics and their byproducts into the environment, creating perfect incubators for antibiotic-resistant organisms that are already sweeping the world. This, in turn, made the drugs far less effective. And when antibiotics no longer work, the coronavirus will seem like a walk in the park.

THE EXODUS

By the 1990s, Bristol-Myers Squibb’s penicillin factory in East Syracuse, New York, was under siege. The yellow-brick plant was a company icon — it was built in 1943 to mass-produce the new wonder drug in time for D-Day — and workers there tended the two-story tall fermentation vats and shipped the goods 24 hours a day. 

Pfizer helped mass produce antibiotics like terramycin, shown here in its original packaging. | The Wire
Pfizer helped mass produce antibiotics like terramycin, shown here in its original packaging.
Credit: Science Museum, London, CC BY 4.0

Antibiotics were part of the company’s DNA. Researchers at Squibb, a predecessor company, shared medical science’s prestigious Lasker Award in 1955 for showing that the antibiotic isoniazid could treat tuberculosis.

“There was quite a bit of pride there” in making life saving drugs, said Charles Borgognoni, a former community-relations manager at the plant.

But environmental investigations of emissions from the factory had tarnished its reputation. Some neighbors worried that solvents used to extract the drug from the yeasty fermentation mix were leaking and causing cancer. In 1992, the company pleaded guilty to violations of the federal Clean Water Act, paid a fine and was forced to spend at least $30 million on a new water treatment plant. 

As Bristol-Myers settled with the federal government, competitive issues were mounting in the global market. American plants like the one in East Syracuse were getting old and needed costly updates, but state-backed enterprises in China were building modern plants and producing antibiotics in volumes that were driving down prices. One of the chief builders was the North China Pharmaceutical Company.

The former Pfizer factory in Brooklyn, New York. | The Wire
The former Pfizer factory in Brooklyn, New York.
Credit: AP/Mark Lennihan

“I think we realized it in the mid-90s, the challenge from China,” said Cindy Greene, a retired Bristol-Myers manager responsible for bulk sales of antibiotics. “That’s when they were really putting the pressure on — NCPC, particularly. They were starting to build huge, brand new facilities.”

Bristol-Myers Squibb stuck with antibiotics longer than most companies. But in 2004 it called it quits and made plans to shutter the facility. It was the last major penicillin factory in the United States. 

Low-cost Chinese competition may have been the prevailing reason for the demise of the factories. But the eradication of America’s once-healthy capacity to make antibiotics was also aided by domestic factors.

In 1984, a new law established the generic drug industry and reshaped the U.S. market. Generic drugs could be sold at a discount to the brand-name medicines they copied, which was intended to make healthcare more affordable but took a toll on the profitability margins of many off-patent drugs, including antibiotics.

Then there were the costs of environmental oversight. Antibiotics production creates an enormous amount of dirty water that must be cleaned before it is discharged. Making a single kilogram of penicillin can produce 10 tons of effluent. 

Another adverse trend, meanwhile, was the declining number of new U.S. drug discoveries, which increased the pressure to cut costs. In the 1990s and early 2000s, industry consolidation began creating huge drug companies with large research and development operations — and therefore the need to pursue blockbuster drugs delivering fatter profits to sustain them.  

 Relatively inexpensive, widely used generic antibiotics didn’t fit the bill. “A tablet of amoxicillin is now cheaper than chewing gum,” said Fritz Fuchs, a former head of sales of active pharmaceutical ingredients at Sandoz.

For many American companies, the easiest solution was to move manufacturing offshore or to source from Chinese companies. Pfizer, Glaxo and others either formed joint ventures in China and India or dropped out of the antibiotics business entirely. 

Bristol-Myers closed East Syracuse mostly for financial reasons, according to Greene. Worry about environmental issues “was a concern,” she said. “But cost was a bigger concern.” 

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The Oak Ridge National Laboratory prepared a report in 1988 outlining the “most efficient” way to meet the nation’s antibiotic needs in the event of a nuclear disaster.

When American textile and apparel factories began to close after China’s entry into the World Trade Organization, groups in the U.S. complained bitterly about American jobs being sent overseas to China. The same could not be said for the jobs lost when the last of the nation’s highly polluting penicillin plants went off line.

Until recently, no one seemed to notice that America no longer produces these vital medicines.

“It just happened. It was naivete,” said Bill Fischer, a management professor at the International Institute for Management Development, a Swiss business school, who has worked and taught in China. “The decisions weren’t made at strategic levels. It was tactical. There was always the assumption that [China] might never catch up … But they caught up.” 

 What closed in places like East Syracuse, Groton, Connecticut, and West Lafayette, Indiana, was effectively reborn in Chinese cities called Hohhot, Xi’an and Shijiazhuang.

THE WORLD’S MEDICINE CABINET

The first time Sue Capie got off the train in Shijiazhuang, on a fall day in 1984, the smell was overpowering. Shijiazhuang, a small, hardscrabble city southwest of Beijing, was a hub for China’s burgeoning pharmaceutical industry with rows upon rows of enormous factories. Fermentation vats let off a sharp, acrid smell, like the entire city had been doused in ammonia. “You could smell the penicillin,” Capie said.

Shijiazhuang was not a place that foreigners usually visited, but Capie, a young American with a master’s degree in Chinese, had stumbled into a job selling technology and equipment to Chinese manufacturers. She considered herself lucky if there was a functioning hotel to stay, even though hot water was only available from 5:30 a.m. to 8:30 a.m.

But Shijiazhuang’s shortcomings as a tourist destination were its strengths as a manufacturing hub. The city’s dry, frigid winters, punctuated by a cold blustery wind, proved perfect for brewing pharmaceutical ingredients. Abundant coal deposits in the nearby mountains provided ample power for an insatiable industrial base. 

Sue Capie meets with representatives from Harbin Pharmaceutical in Harbin, China, in 1987. | The Wire
Sue Capie meets with representatives from Harbin Pharmaceutical in Harbin, China, in 1987.

One of Capie’s biggest clients was the state-owned pharmaceutical giant North China Pharmaceutical Company, which operated from a sprawling compound near the city center. The factory grounds housed a school, hospital, shops and a large recreation area.

 “You didn’t have to go out of the compound to do anything,” said Oliver Wang, a Shijiazhuang native who worked as a translator in the international business division. It was the old Iron Rice Bowl in action, a government-run system that at the time assured lifetime employment.

But with China’s economic reform and liberalization well underway, the government was beginning to push industrial policies aimed at upgrading and modernizing its plants and factories and making the country a hub for more advanced manufacturing. China’s state-owned enterprises would lead the way, and perhaps some day compete with multinational corporations on the world stage.

To get there, the company began hiring Westerners like Capie. The state financed major investments in new technology and production capacity. At the beginning, few believed these relics of the old planned economy would be able to manage.

Fuchs, the pharmaceutical executive, said that his first visit to a Chinese factory in the 1990’s was like a scene from “The Terminator” movies. “It was all dark and smoky and terrible,” he said. “And you gasped. They just let the red, stinky water run into the adjacent river.” 

Visiting American and European executives routinely dismissed the Chinese factories as competitors. During one tour, a visiting executive questioned whether the factory would ever make money, to which Capie shot back: “You don’t understand. It’s state-owned. They can afford this.”

Indeed, North China was the centerpiece of a much larger, state-directed plan for Chinese antibiotic self-reliance — an effort that dated back to Mao Zedong himself.

Construction of the company’s antibiotic factory in Shijiazhuang began in 1953, as a crucial component of China’s first Five Year Plan. During the Civil War, Mao had seen his troops felled in large numbers by diseases like dysentery, which was fatal when penicillin was unavailable. “Gold is valuable,” went an old folk saying, “but medicine is priceless.”

In 1958, the company produced its first batch of high-quality penicillin, ending the country’s reliance on penicillin imports. The company, designated a key enterprise by the government, would be rewarded with state financing. But growth would only come in the 1990s, through a series of partnerships and joint ventures with German, Japanese and American firms. So eager was the company to modernize that it purchased a penicillin plant in Neubrandenburg, Germany, and arranged to have it transported to Shijiazhuang.

Before long, North China was producing huge amounts of penicillin, so much so that when it struck a deal with Nichimen of Japan, it paid in tons of penicillin, rather than cash.

By 1992, it was the largest pharmaceutical manufacturer in China, and exporting to 25 countries. As American companies started looking for ways to cut costs or shutter their operations, North China was setting its sights on international domination.

The rapid expansion was in line with a broader strategy that the State Development Planning Commission referred to as “global pharmaceutical transfer” — the movement of production capacity and expertise from the West to China.

By the mid-1990s, NCPC and other domestic manufacturers were producing too much, creating a glut of domestic supply and undercutting each other on prices, especially for penicillin and vitamin C. Capie estimates that during this time, “China’s real capacity was twice what world demand was.”

In response, in November 1996, 12 of China’s leading penicillin manufacturers agreed to form a cartel to control supply and price. The strategy was so successful that in 2003 another penicillin cartel was formed to control exports to India.

In 2004, to squeeze out the few remaining American pharmaceutical manufacturers like Bristol-Myers Squibb, the Chinese cartel dumped a key penicillin precursor onto the global market at bottom-barrel prices. The strategy worked; that year, the plant in East Syracuse announced its closure, and Forbes named NCPC one of the most valuable industrial brands in China.

At its peak in the mid-2000s, Wang, the NCPC translator, estimated that the company employed 22,000 people; counting family members, about 50,000 people lived inside the company’s compound in Shijiazhuang.

The company’s spectacular growth also created an environmental disaster zone. The company has been accused of dumping toxic antibiotic runoff into nearby waterways, and the yeasty smell of the fermentation plants has helped make Shijiazhuang one of the world’s most polluted cities. 

The smog in Shijiazhuang, China, in 2014. Shijiazhuang is one of the world's most polluted cities. | The Wire
The smog in Shijiazhuang, China, in 2014. Shijiazhuang is one of the world’s most polluted cities.
Credit: AP/Alexander F. Yuan

Though the unique penicillin smell is mostly gone — most factories have moved their production to Inner Mongolia — Shijiazhuang is still a major pharmaceutical hub. Amid the smog, NCPC’s old factory has been converted into a museum, “to remind people of the good old days,” Wang says — when working at the factory was considered an honor and NCPC was idolized as “the harbinger of Chinese antibiotic self-reliance.”

NCPC’s story, however, symbolizes more than just Chinese self-reliance. It is emblematic of how China became the world’s medicine cabinet. “If you’re going to sell at rock-bottom prices,” Dr. Rex, the former AstraZeneca executive, said, “that is where the manufacturing is going to go. China said it could make [drugs] cheaper. The industry went the same way as socks and computers.”

The numbers tell of China’s dominance. In 2019, 12,462 companies in China were engaged in the export of active pharmaceutical ingredients, or APIs, the critical chemical content. And according to official data, China exported $7.4 billion in APIs and antibiotics to the United States last year. India, which supplies approximately 40% of generic pharmaceuticals used in the United States, imports nearly 70% of its active ingredients from China.

American drug makers are no longer in the business. “I don’t think anyone ever had a strategy aimed at putting our country’s drug supply in foreign hands,” Mike Evanisko, a pharmaceutical company analyst in the 1990s, said. “Rather, we are realizing the implications of many rational decision- makers doing what made sense at the time.”

Or, as Capie said of the change, “I just don’t think anyone was looking at the big picture.”

ALARM IN WASHINGTON

In March 2019, nearly a year before the novel coronavirus ripped through the city of Wuhan, China’s top political advisory committee gathered for its annual meeting in the nation’s capital. One of the speakers was Li Daokui, a 56-year-old economist with strong American ties. Professor Li had earned a Ph.D in economics from Harvard and had helped set up the Schwarzman Scholars program at Tsinghua University with money from the American billionaire Stephen Schwarzman.  

Li Daokui speaking in 2009. | The Wire
Li Daokui speaking in 2009.
Credit: World Economic Forum (Natalie Behring), CC BY-SA 2.0

But as he addressed the troubling economic slowdown China was facing in 2019, Li singled out America for sharp criticism, suggesting that the U.S. was jealously blocking China’s path to prosperity.

“As some analysts in the world have pointed out, we are indeed subject to constraints on semiconductors,” he said, referring to U.S. dominance of high-end microchips. “But China is the world’s largest exporter of vitamins and antibiotic raw materials. Once exports are reduced, some developed countries’ medical systems will not work.”

With the U.S. and China facing off over trade, the message was chilling: If China felt cornered, it could always wreck the American health care system by halting exports of vitamins and antibiotics. As a longtime adviser to China’s top leaders on economic policy, Li’s comments were republished by the state-run news agency Xinhua, making the remarks more worrisome. 

At the time, Washington and Beijing were at odds over a number of issues. The Trump administration had imposed tariffs on China as part of a long-running trade dispute. The federal bureaucracy was seeking to stifle the overseas expansion of the Chinese telecom giant Huawei. The State Department was firing off critiques of Beijing’s severe lockdown in Xinjiang. And the F.B.I. was busy gathering evidence to prove that Chinese spies were infiltrating America’s best universities and medical centers and carting valuable technology back to China. 

The speech by Li added more fuel to the fire and, two months later, there were hearings on Capitol Hill focused on China’s role in global health. One by one, a series of expert panelists recounted how China’s dominance of drug manufacturing posed risks to America’s national security because of counterfeit and substandard drugs, price manipulation and the country’s ability to use its leverage to disrupt global medicine supplies.

One of the panelists, Rosemary Gibson, an author, health care expert and senior advisor at the Hastings Center, pointed out that the U.S. can no longer make penicillin, and that China dominates the supply chain for every major generic drug, including drugs used to treat Alzheimer’s, HIV/AIDS, diabetes, Parkinson’s, epilepsy and just about every other major ailment. 

“If China shut the door on exports of medicines and their key ingredients and raw materials, U.S. hospitals and military hospitals and clinics would cease to function within months, if not days,” Gibson told the committee, adding: “A natural disaster, global public health crisis or adverse foreign government action could disrupt the supply of medicinal ingredients and finished drugs.”

And it’s not just ordinary Americans at risk, she said; the federal government and the military could be specifically targeted.

“Medicines in the hands of an adversary can be weaponized,” Gibson said. “Medicines can be made with lethal contaminants or sold without any real medicine in them, rendering them ineffective.” 

Chinese companies have gained a reputation for producing counterfeit, substandard and tainted drugs. More than any other importer into the U.S., China has racked up “import alerts” with the FDA. A recent warning letter from the FDA said a cancer-causing substance was found in valsartan, a drug used to treat high blood pressure.

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The FDA warned Zhuhai United Laboratories, one of the world’s largest antibiotics exporters, that some of its drugs were considered “adulterated.”

But there is virtually no way for Americans or even the federal government to know which drugs come from China or have active ingredients from China. 

“I can’t tell you where things are made,” Barbara Unger, an auditing and regulatory affairs specialist and Eli Lilly veteran, told The Wire. “There is no requirement in rules and regulations that says drugs need to be labeled by country of origin.”

Janet Woodcock, director of the Center for Drug Evaluation and Research at the FDA, even testified before Congress last year that the agency has no way of tracing the raw materials or active pharmaceutical ingredients that go into the country’s most widely used medicines. The FDA is required by law to certify and inspect domestic and overseas manufacturing facilities. But the agency’s data shows that overseas facilities are rarely inspected. Agency officials have admitted under oath that they are often confused by the locations and addresses in China and have, on occasion, inspected the wrong facility.

But if concerns over convoluted supply chains and Chinese pharmaceutical domination set off alarm bells before, coronavirus has only deepened geopolitical divisions.

Shortly after the outbreak was announced in January, U.S. Secretary of Commerce Wilbur Ross said on Fox News, “I don’t want to talk about a victory lap over a very unfortunate, very malignant disease. But the fact is, it does give businesses another thing to consider when they go through their review of their supply chain.”

“I think it will help to accelerate the return of jobs to North America,” Ross said.

Instead of a helping hand, China saw posturing from the U.S. Beijing later shot back in an official statement that claimed the coronavirus was developed by the U.S. Army.

Xinhua, the official news outlet, went further. In a March 4 release, just as China was beginning to slow the spread of the virus, Xinhua published an article saying that if China placed controls on its exports of masks and pharmaceuticals, the U.S. might be “plunged into the mighty sea of coronavirus.”

Soon after, the virus began sweeping across the United States.

WILL ANTIBIOTIC MANUFACTURING COME BACK?

Even before the novel coronavirus began infecting large numbers of Americans, there were signs of trouble in the United States.

On February 27, two days before the first coronavirus death was confirmed in the U.S., the FDA announced the first drug shortage tied to the global pandemic. Though the agency did not release the name of the drug, experts concluded that it was almost certainly an antibiotic or antimicrobial agent, categories of drugs that Chinese manufacturers dominate.

More shortages soon followed.

According to a database maintained by the American Society of Health System Pharmacists, there have already been 49 new drug shortages in 2020, with some tied to the coronavirus outbreak.

Medical shortages have already begun to strain American hospitals and clinics, particularly those in the state of New York, where 188,000 people have been infected. And on April 1, federal officials announced that the country’s Strategic National Stockpile — the federal government’s repository of millions of antibiotics, vaccines and other essential medical supplies — was nearly depleted. Despite all the pandemic practice exercises like Dark Winter, few health experts were surprised.

The strategic stockpile “is really a misnomer,” said Dr. Gerard Anderson, a professor of health policy and management at Johns Hopkins University. “You don’t have enough gloves, masks or drugs to handle a pandemic. It’s really not designed for that. It’s designed for hurricanes, natural disasters and regional problems.”

Now, American health care providers face the possibility of running out of essential and lifesaving medicines, including penicillin and chloramphenicol, an antibiotic used to treat meningitis, plague, cholera and typhoid.

Chemical reagents, which are used in polymerase chain reaction assays, or PCR tests, are in short supply at testing labs around the country. Despite slim scientific evidence, chloroquine and hydroxychloroquine, anti-malarial drugs that also treat lupus and rheumatoid arthritis, have been touted by President Trump as a potential “game changer” in the treatment of the novel coronavirus. Some hospitals have been forced to ration supplies.

“We don’t have a choice. We need the drugs as soon as they can be sold . . . We need them now. And right now, we don’t have the manufacturing capacity to produce them at scale.”

Dr. Gerard Anderson, Johns Hopkins University

Patients who suffer the most serious consequences of the viral infections often gasp for breath, leading doctors to place them on hospital ventilators that pump oxygen into the lungs. But to insert the tubes into a person’s throat, they need analgesics and sedatives.

“Without those drugs, you can’t use a ventilator,” said Erin Fox, a senior pharmacy director at the University of Utah Health. “It’s very painful and very anxiety producing. You wouldn’t want to be awake while that is happening.”

The shortages have touched off a global scramble for medicines and medical supplies, pitting state against state and hospital against hospital in the U.S., forcing a rethink of the world’s manufacturing grid. A global market is supposed to reduce costs and find the most efficient location to produce, assemble and package a good, regardless of how far the factories are from the end consumer. But what happens if nations big and small cut off exports to hoard critical medical supplies or threaten embargoes as leverage to negotiate other matters?

In the past month, more than 20 nations, including China, India and members of the European Union have imposed limits or bans on the export of some medical supplies, creating new bottlenecks in the global drug supply chain.

China is at the center of debate. In Washington, federal officials are trying to manage an unprecedented health crisis amid concerns that China might decide to delay or block certain medical goods from being shipped to the U.S. The White House recently set up a task force to track the global supply chain and to draw up long term plans to produce more drugs and medical supplies at home.

Congress is also acting. Last week, lawmakers on Capitol Hill passed the Mitigating Emergency Drug Shortages Act, an effort to better track the nation’s drug supply, and also assess national security risks related to the lack of domestic manufacturing capacity. (It does not, however, call for drugmakers to build new manufacturing capacity.) The law passed just days after a congressional study warned lawmakers that drug and medical shortages could intensify if China decides to selectively release those goods to countries “according to political calculations.”

The concern, in other words, was that China might hold back shipping medical goods to the U.S. if diplomatic relations soured.

There are reasons to be nervous. At the height of its own coronavirus battle, China nationalized controls over production of some major companies, even the China-based operations of the American company 3M. Beijing also pressed its own industrial companies to purchase large quantities of medical supplies from overseas.

Now, the White House is considering an executive order to tighten “Buy American” laws, in order to force federal agencies to purchase American-made pharmaceutical and medical equipment. The move amounts to a peacetime war effort.

For that reason and others, a growing number of American health experts now accept that the country’s inability to produce penicillin and other crucial medicines and antibiotics is a national security risk. And yet there are serious doubts that the U.S. can reestablish enough new drug manufacturing capacity to become self-reliant.

The costs to rebuild and maintain huge chemical, drug and fermentation plants would be enormous. Complying with regulations on emissions and wastewater standards would add to the bill. The cost of healthcare and generic drugs in the U.S. could rise dramatically. And perhaps most challenging of all: The global supply chain would have to be rewired and reconfigured, around the U.S.

Still, the most immediate concern in the weeks and months ahead is how to combat the coronavirus with the existing, China-centric supply chain. Health experts say American scientists, doctors and drugmakers will likely be pressed into alliances with manufacturers and drugmakers in China because there is no other way to meet the growing demand for test kits, vaccines, antibiotics and other medical equipment.

“We don’t have a choice,” said Dr. Anderson at Johns Hopkins. “We need the drugs as soon as they can be sold, after approval by the FDA. We need them now. And right now, we don’t have the manufacturing capacity to produce them at scale.”

The pandemic is also highlighting the need for new types of antibiotics. A recent study tracking coronavirus patients at two hospitals in Wuhan, China, found that one in seven had acquired a dangerous secondary bacterial infection resistant to conventional antibiotics. Half of the patients who died from complications of the virus in the two hospitals had developed such infections.

Health experts warn that the overproduction and overuse of low-price antibiotics around the world in the past decade has led to increased resistance by bacteria that can adapt defenses to the drugs, rapidly making a growing number of antibiotics less effective. According to some estimates, by 2050 antibiotic-resistant infections could kill 10 million people a year, outpacing even cancer as a cause of death.

To encourage innovation in the antibiotics market, the federal government has occasionally made grants or low interest loans to American biotech startups. One of those promising companies, San Francisco-based Achaogen, received about $124 million from the U.S. Department of Health and Human Services, as part of a biodefense program, according to Bloomberg Law.

Then it went bankrupt. Last year, while in bankruptcy, the firm decided to sell the rights to some of its promising drugs. The buyers? The U.S. subsidiary of an Indian drugmaker, and Qilu Antibiotics Pharmaceutical Company, an antibiotics company with 15,000 employees. The company is based near the center of the country’s antibiotics manufacturing base: in Northeast China.


David Barboza contributed reporting from Boston.

Gardiner Harris is an award-winning journalist who spent most of his career at The New York Times and The Wall Street Journal, including stints covering public health, South Asia and the White House. He is now writing a book. @GardinerHarris

Alex W. Palmer is a writer based in Washington, D.C. His work has appeared in The New York Times Magazine, GQ, WIRED, and other publications.