A few years back, the punditocracy was in a tizzy because it had come to their attention that the US had become dependent on China for rare earths, which are critical to the production of high-performance magnets, low carbon products, diesel additives, lasers and many other goods. We pointed out then that rare earths were far from an isolated case. China has become the biggest supplier of ascorbic acid, which is widely used in food production to improve quality and stability.

A recent book, China RX: Exposing the Risks of America’s Dependence on China for Medicine by Rosemary Gibson and Janardan Prasad Singh, appears not to have gotten the attention it warrants. I learned about it thanks to reader Patrick F, who recommended a C-SPAN panel on the book with author Gibson plus other experts, such as former Clinton Administration official Patrick Malloy. If you go to C-SPAN, you can read a transcript auto-generated from the closed captioning. You can also listen Gibson describe some of the key points from her book in the interview below.

The big message of Gibon’s and Singh’s book is that the US relies on China for the production of active ingredients in drugs and in many cases, of the medications themselves, to the degree that we would have a public health crisis if supplies were interrupted. As Gibson said on C-SPAN:

Many people that we spoke to, both former government officials and some in industry said that if China shut the door on exports, within months, pharmacy shelves in the United States to be empty, and hospitals would cease to function.

And don’t assume generics king India would step into the breach. India gets many of the active ingredients for its pharmaceuticals from China. Gibson forecasts that China will overtake India in generics manufacture within a decade.

As Gibson explains, the US no longer makes its own penicillin, in part because China dumped penicillin in 2004, driving the last US plant out of business.

The medications where the US relies on China include heparin, a blood thinner that among other things is used for IV drips. No heparin, no IV treatments. Due to the difficulty in tracing the source of drug company ingredients, the authors could make only case by case investigations, but they China production to be critical for treatments for Alzheimer’s HIV, depression, schizophrenia, cancer, epilepsy, and high blood pressure.

Dependency is not the only risk. US drug companies shifted production to China not just to save cost but to escape regulation. The FDA has only limited access to Chinese factories, with the Chinese having well over 700, yet the FDA able to inspect only 15 a year on average. As Gibson said on C-SPAN:

The FDA is trying to get inspection on site in China. The Chinese have severely restricted the number of inspections that they will allow and the whole program has become completely ineffective.

And the Chinese are often less than cooperative. Gibson describes even then how the agency has been directed to a Potemkin facility, as in the goods were made somewhere else…and the FDA was not able to figure out where. Similarly, reports presented by the health authorities to the FDA is understood to be as reliable as Chinese economic data.

This picture is particularly troubling given China’s poor record on production quality and sanitation. And worse, the US can’t even afford to bar imports of all substandard products. Gibson again:

In 2015, the FDA inspected a plant in China. It did that because it was getting a lot of customer complaints, presumably industry complaints, about the active ingredients that they were getting from this plant. There was bacterial contamination, some of the products. They did not have full therapeutic value. If that’s an antibiotic or chemotherapy, that could be devastating. So the FDA went in and they found what they called systemic data manipulation. This is a plant that had passed muster by the FDA, the Chinese FDA and other inspections over many years. So the FDA banned 29 different products from coming into the United States. But because the United States is so dependent, the FDA had to exempt 14 of those products from its own ban. Some of those included antibiotics or ingredients for antibiotics and ingredients for chemotherapies, because the FDA was concerned about drug shortages in the United States. That is how dependent we are as a country.

It’s telling with the trade battle of wills with China a daily news item for months, that this critical piece of the picture is absent from the debate. One has to assume that it’s because Big Pharma doesn’t mind.