America’s Drug Shortage Is a National Security Crisis

There is a phrase that no physician wants to hear when walking into an intensive care unit: “Doctor, we don’t have it.” I have heard variations of that phrase more times than I care to remember. Sometimes it is an antibiotic. Sometimes it is an intravenous medication that we use routinely. Sometimes pharmacy is conserving a drug because supplies are running dangerously low. In perhaps one of the most absurd examples of modern American medicine, sometimes the scarce commodity is not an exotic monoclonal antibody, an experimental cancer therapy, or a complicated biologic agent. It is a simple intravenous fluid.

Think about what that means. We practice medicine in a country capable of replacing heart valves through catheters, sequencing a human genome, performing robotic surgery, supporting failing lungs with extracorporeal membrane oxygenation, and developing entirely new classes of medications within a few years. Yet I can walk into an American intensive care unit caring for critically ill patients and discover that a basic medicine or fluid I have used for decades is unavailable.

The nurses know the drill, and the pharmacists know it even better. A message comes from pharmacy telling us to conserve a medication, use a different concentration, substitute another antibiotic, change the infusion, or save the remaining bags for patients who absolutely need them. Suddenly, clinical decisions that should be based entirely upon physiology, microbiology, pharmacology, and the needs of the patient acquire another participant at the bedside: the supply chain. What was once perceived as an occasional inconvenience has become something much more serious. It is a warning.

As of June 2026, the American Society of Health-System Pharmacists reported 227 active drug shortages in the United States, and nearly half of the new shortages reported during 2026 involved products available from only a single manufacturer.[1] Current shortage lists contain products whose names would be utterly unremarkable to anyone who has practiced hospital medicine: dextrose injections (water with sugar), sodium chloride products, amiodarone, midazolam, morphine, anti-infective agents, and numerous injectable medications that constitute the ordinary machinery of modern inpatient care.[1] These are not luxury items or niche therapeutics. They are the plumbing of medicine.

A High-Tech Medical System Built on a Surprisingly Fragile Foundation

Drug shortages are frequently discussed as isolated events. A factory experiences a quality problem, a production line shuts down, a raw material becomes scarce, demand unexpectedly increases, or a hurricane damages a manufacturing facility. Each shortage receives its own explanation, and eventually many of them resolve. Looking at these events individually, however, misses the much larger problem: the American pharmaceutical supply chain has been optimized for efficiency, low prices, and lean inventories, but it has not always been optimized for resilience.

Over several decades, pharmaceutical manufacturing steadily migrated outside the United States. According to the FDA, more than half of pharmaceuticals distributed in America are manufactured overseas. As of 2025, approximately 69 percent of generic drug products were manufactured outside the United States. Even more striking, only about 11 percent of active pharmaceutical ingredient manufacturers were located in the United States, compared with approximately 22 percent in China and 44 percent in India.[2]

This does not mean that Chinese or Indian manufacturers are inherently problematic. Many produce high-quality medicines that American patients depend upon every day, and a resilient pharmaceutical system should unquestionably include global suppliers. The problem is concentration. When the production of an essential drug, its active ingredient, or a critical chemical precursor becomes concentrated among only a handful of manufacturers or geographic regions, economic efficiency can quickly become a strategic vulnerability.

A quality-control failure at one factory, a geopolitical conflict, a transportation disruption, an epidemic, a natural disaster, an export restriction, or a shortage of a precursor chemical can reverberate thousands of miles away until eventually a pharmacist in an American hospital tells a physician that a medicine is unavailable. At that moment, globalization stops being an abstract economic discussion and becomes a clinical problem affecting an actual patient. We saw this during the pandemic and have seen it again during recent armed conflicts.

The Economics of Cheap Medicine

One of the great ironies of the drug-shortage crisis is that many of the medicines most vulnerable to shortage are not extraordinarily expensive medications. They are extraordinarily inexpensive ones. Generic sterile injectable drugs are among the most important products in hospital medicine and among the most difficult to manufacture reliably. Their production requires specialized equipment, meticulous sterile technique, rigorous quality controls, and significant capital investment.

Yet intense purchasing pressure has driven the prices of many older generic injectable drugs extraordinarily low. The result is a market in which manufacturers may have very little financial incentive to maintain redundant factories, modernize equipment, increase reserve capacity, or even remain in the market. A 2024 analysis from the Department of Health and Human Services examined the economics of generic injectable medicines and found that although the market was profitable in aggregate, that profitability was heavily influenced by a relatively small number of successful products. Most individual generic injectable products examined remained unprofitable even 36 months after launch.[3]

The Government Accountability Office has described the same fundamental problem. Sterile injectable drugs dominate many persistent shortages because they combine complicated manufacturing requirements with low prices, limited production capacity, and low profit margins.[4] For years, Americans have been told that lower drug prices are an unquestionable victory, and usually they are. Nobody wants patients paying unnecessarily high prices for medications that have existed for decades. There is, however, a point at which relentless price compression produces something other than efficiency. It produces fragility.

If the price paid for an essential injectable medicine becomes so low that only one or two manufacturers are willing to produce it, we have not created an efficient marketplace. We have created a single point of failure. The cheapest medication in the world offers very little comfort to the critically ill patient when it is no longer sitting on the pharmacy shelf. This can translate into disasters in patient care!

When a Shortage Reaches the Bedside

For people outside medicine, a drug shortage may sound primarily like an inventory or procurement problem. Inside an intensive care unit, it can become something entirely different. Imagine a patient arriving in septic shock. His blood pressure is collapsing, his lactate is increasing, and his organs are beginning to fail. Every intensivist understands that timely and appropriate antimicrobial therapy can make an enormous difference in that patient’s outcome.

Now suppose that the antibiotic we ordinarily would select is unavailable. The physician must choose an alternative that may have broader coverage than necessary, greater toxicity, a different dosing profile, or less familiarity among the clinical team. The substitution may affect antibiotic stewardship efforts throughout the hospital. Pharmacy must develop alternative protocols, nurses may need to administer different concentrations or schedules, electronic medical record order sets may need modification, physicians must be notified, and remaining inventory must be monitored carefully. Multiply that experience across hundreds or thousands of hospitals, and what appeared to be a simple shortage becomes a systemic disruption of care.

A systematic review published in Clinical Microbiology and Infection examined 74 studies involving antibiotic shortages. Manufacturing disruptions, active pharmaceutical ingredient problems, and economic viability repeatedly appeared among the causes. Reported clinical consequences included longer hospital stays, treatment failure when inferior alternatives were required, and disruption of antimicrobial stewardship programs.[5] Over the past several decades, I have seen patients die in hospital settings where medications or fluids were not available.

We also know independently that antibiotic delays in critically ill patients are not trivial. In a 2024 multicenter study of patients with septic shock, delays in administration of the second antibiotic dose were associated with higher mortality and longer ICU and hospital stays.[6] That study was not designed to prove that drug shortages caused those delays, but it underscores an essential point: in critical illness, reliable and timely drug availability is not simply a logistical convenience. Time matters, and access matters.

The same principle applies throughout critical care. Vasopressors keep patients alive when circulation collapses. Sedatives allow safe mechanical ventilation. Electrolytes correct potentially fatal abnormalities. Anticonvulsants control seizures. Antiarrhythmics treat unstable cardiac rhythms. Injectable bicarbonate may be required in selected patients with severe metabolic derangements. These medications are so familiar to clinicians that we rarely stop to consider the enormous industrial system required to place a vial in a medication dispensing cabinet. We notice that system only when the vial disappears.

Researchers studying a worldwide shortage of intravenous sodium bicarbonate demonstrated that conservation measures significantly altered how clinicians treated critically ill patients with acidemia.[7] That experience illustrates something physicians already understand intuitively. When supply disappears, medical practice changes, not because the physiology changed, the evidence changed, or the patient’s needs changed, but because the shelf was empty.

When America Almost Ran Out of IV Fluid

Perhaps nothing demonstrates the fragility of the system better than intravenous fluid. In September 2024, Hurricane Helene devastated portions of the Southeastern United States and flooded Baxter International’s North Cove manufacturing facility in North Carolina. Production stopped, and the consequences quickly spread far beyond the region affected by the storm. I saw firsthand the consequences.

North Cove was not simply another pharmaceutical factory. It was the largest American manufacturer of intravenous and peritoneal dialysis solutions, and estimates indicated that the facility produced approximately 60 percent of the IV solutions used in the United States. The disruption became significant enough that the Centers for Disease Control and Prevention issued a national Health Alert advising healthcare facilities to assess inventories, conserve intravenous solutions, develop mitigation plans, and use alternatives when clinically appropriate.[8]

Hospitals across the United States began rationing and conserving fluids. Allocation limits were imposed. Some facilities reconsidered procedures, federal agencies worked with manufacturers, and the FDA permitted temporary importation of products from facilities outside the United States. All of that disruption occurred because one major factory flooded.

There could hardly be a better illustration of the difference between efficiency and resilience. Intravenous saline is not cutting-edge technology. The concept of delivering salt water into a vein predates almost everything else in the modern hospital. Yet the United States had allowed production of one of medicine’s most fundamental commodities to become concentrated enough that damage to a single manufacturing complex could force hospitals across a continent to conserve fluid.

That episode should have been treated as a national security warning. Instead, like most shortages, it gradually faded from public attention when supplies improved. The immediate crisis may have receded, but the underlying lesson remains very much alive.

Preventing New Shortages Does Not Eliminate Existing Ones

There is an apparent statistical paradox worth explaining. The FDA has made significant progress in preventing new shortages. FDA officials reported only four new shortages during 2025, far below the extraordinary peak seen in 2011, and the agency routinely works with manufacturers to prevent potential disruptions before they become national shortages.[9] That is genuine progress and deserves recognition.

At the same time, the American Society of Health-System Pharmacists reported 227 active shortages in June 2026.[1] Both figures can be accurate because the organizations track shortages differently and, more importantly, because preventing new shortages does not eliminate longstanding ones. Some drug shortages persist for months or even years. Others improve temporarily and later recur. Certain medicines remain vulnerable because the economic, manufacturing, and sourcing conditions that created the shortage never fundamentally changed.

We have become increasingly “sophisticated” at firefighting without fully fireproofing the building. Regulatory agencies and manufacturers can work heroically to prevent an individual shortage or restore supply after disruption, but the larger structural weaknesses remain if the underlying production system continues to depend upon limited suppliers, aging manufacturing lines, thin margins, and geographically concentrated sources.

This Is a National Security Issue

Americans usually think about national security in terms of aircraft carriers, missiles, energy supplies, semiconductor factories, telecommunications infrastructure, and strategic minerals. Medicines belong on that list. A country that cannot reliably supply its population with antibiotics, anesthetics, vasopressors, chemotherapy agents, sterile injectables, IV solutions, and other essential medications has a strategic vulnerability whether policymakers acknowledge it or not.

During ordinary times, international pharmaceutical trade functions remarkably well. Ships move, factories operate, active pharmaceutical ingredients cross borders, distributors deliver products, and hospitals receive their supplies. National security planning, however, is not designed for ordinary times. It exists precisely because ordinary assumptions can fail.

What happens during the next major pandemic? What happens during a military confrontation involving a nation responsible for important pharmaceutical inputs? What happens if export restrictions are imposed, several manufacturing facilities fail simultaneously, or another major natural disaster affects a geographically concentrated production region? Covid-19 should have permanently eliminated the assumption that globally optimized supply chains will function normally during extraordinary events. Yet many of the same vulnerabilities remain embedded in the supply of essential medicines.

America does not need to manufacture every pill, vial, and chemical precursor within its own borders. Complete pharmaceutical autarky would be enormously expensive, inefficient, and probably counterproductive. There is, however, a vast difference between participating in global trade and accepting strategic dependence.

A rational national strategy would identify medications whose absence could rapidly threaten life or cripple hospital operations, determine where their active ingredients and critical starting materials originate, identify products dependent upon one manufacturer or one geographic area, and create incentives for redundant production. For truly essential medicines, redundancy should not be regarded as waste. It should be regarded as insurance.

We Need to Stop Buying Medicines as Though Price Is the Only Thing That Matters

The solution is not simply to throw money at pharmaceutical manufacturers, nor should the drug-shortage crisis become an excuse for companies to demand unlimited prices. What needs to change is the way we define value. Hospital purchasing organizations and government programs naturally seek lower prices, but procurement systems should also consider manufacturing quality, geographic diversification, production redundancy, reserve capacity, and a manufacturer’s history of reliable supply.

A manufacturer capable of supplying a medication for 90 cents per vial from one vulnerable factory is not necessarily providing society with greater value than another manufacturer charging $1.05 while maintaining redundant high-quality production lines. The additional fifteen cents looks wasteful only until the ninety-cent vial disappears.

I am convinced that essential medicines should also receive strategic reserve consideration similar to other critical national resources. Not every medication can be stockpiled indefinitely. Drugs expire, storage costs money, and clinical demand changes. Critical products can nevertheless be identified, rotating inventories can be maintained, and manufacturers can be incentivized to preserve surge capacity.

In this context, regulatory policy also matters. The United States has already begun recognizing the problem. Federal initiatives are attempting to streamline construction and regulatory review for domestic pharmaceutical manufacturing, and the FDA has launched programs intended to facilitate new American production capacity.[2,10] Those efforts are encouraging, but building factories alone will not solve the problem if the economics later drive those same factories out of business.

The objective should therefore not simply be “Made in America.” The more important objective is “Available in America when patients need it.” Achieving that goal requires domestic manufacturing where strategically appropriate, diversified foreign suppliers where beneficial, transparent sourcing, multiple qualified API producers, better visibility into upstream chemical dependencies, reasonable reserve inventories, and purchasing policies that reward reliability rather than price alone.

The Empty Shelf Is Trying to Tell Us Something

I have spent much of my life in intensive care units, and critical care teaches physicians to recognize warning signs before catastrophe occurs. A falling blood pressure is not merely a number; it may be the first signal of cardiovascular collapse. A rising lactate is not simply an abnormal laboratory value; it may indicate worsening shock. Increasing oxygen requirements tell us that a patient’s pulmonary reserve is deteriorating. Physicians learn not to ignore these warning signs merely because the patient has not yet crashed.

However, when physicians repeatedly walk into American hospitals and discover that ordinary, essential medications are unavailable (such as simple IV fluids), that too is a warning sign. We should stop treating it as background noise or another routine inconvenience of hospital administration. Nurses should not have to develop workarounds because a basic IV solution is scarce. Pharmacists should not spend countless hours searching for substitute suppliers because an old injectable medicine has become economically unattractive to manufacture. Physicians should not have to choose a second-line antibiotic for a critically ill patient because the first choice vanished somewhere between a chemical plant overseas and the hospital pharmacy.

Most importantly, patients should never have to know that any of this occurred. In a functioning medical system, these products are almost invisible. The saline bag hangs from the pole, the antibiotic arrives from pharmacy, the vasopressor is mixed, the chemotherapy drug is prepared, and nobody at the bedside spends much time wondering where the active ingredient originated or how many factories in the world are capable of manufacturing it. That invisibility is a luxury created by reliability, and we are gradually losing some of that reliability.

The United States of America can, and should, continue celebrating extraordinary advances in biotechnology, artificial intelligence, genomic medicine, transplantation, precision therapeutics, and other frontiers of modern healthcare. None of those accomplishments, however, excuses our failure to secure the medications physicians already know how to use. There is something profoundly wrong with a medical system capable of designing tomorrow’s miracle drug while occasionally being unable to supply yesterday’s antibiotic.

We do not need every medicine manufactured in my hometown. We do not need to close our borders to pharmaceutical trade, and we certainly should not abandon the enormous economic and medical benefits of generic competition. I would simply like to walk into an ICU and know that when a patient is septic, the antibiotic will be there; when the blood pressure collapses, the vasopressor will be there; when the patient requires sedation, the medication will be available; and when a critically ill person needs intravenous fluid, a bag of saline will actually be hanging on the pole.

That does not seem like an unreasonable expectation in the wealthiest and most technologically sophisticated medical system in human history. It should be the minimum standard. A nation that cannot reliably supply its hospitals with essential medicines is not merely experiencing an inconvenient drug shortage. It has discovered a strategic vulnerability, and the next time that vulnerability is exposed may be precisely when we can least afford it.

References

1. American Society of Health-System Pharmacists. Drug shortages statistics: national drug shortages, January 2001 to June 2026. Bethesda (MD): ASHP; 2026.
2. US Food and Drug Administration. FDA PreCheck Pilot Program: strengthening the domestic pharmaceutical supply chain. Silver Spring (MD): FDA; 2026.
3. US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. An Examination of the Return on Investment of Generic Injectable Prescription Drugs. Washington (DC): HHS; 2024.
4. US Government Accountability Office. Drug shortages: HHS should implement a mechanism to coordinate its activities. GAO-25-107110. Washington (DC): GAO; 2025.
5. Pandey AK, Cohn JE, Nampoothiri V, Gadde U, Ghataure A, Kakkar AK, et al. A systematic review of antibiotic drug shortages and the strategies employed for managing these shortages. Clin Microbiol Infect. 2025;31(3):345-353. doi:10.1016/j.cmi.2024.09.023.
6. Jabir ZH, Grey TS, Morelli AR, Nornhold BD, Carlson JN, Thompson DV, et al. Association of second antibiotic dose delays on mortality in patients with septic shock. J Crit Care. 2024;84:154866. doi:10.1016/j.jcrc.2024.154866.

7. Leong AY, Soo A, Bond A, Wunsch H, Zuege DJ, Bagshaw SM, et al. An IV sodium bicarbonate shortage in the critically ill: an interrupted time-series analysis. Crit Care Med. 2025;53(11):e2167-e2178. doi:10.1097/CCM.0000000000006813.
8. Centers for Disease Control and Prevention. Disruptions in availability of peritoneal dialysis and intravenous solutions from Baxter International facility in North Carolina. Health Alert Network Advisory CDCHAN-00518. Atlanta (GA): CDC; 2024 Oct 12.
9. US Food and Drug Administration. Ensuring quality and access: FDA’s approach to generic drug oversight. Silver Spring (MD): FDA; 2026.
10.  Executive Order 14293. Regulatory relief to promote domestic production of critical medicines. Fed Regist. 2025;90:19615.