Inside America’s Medicine Supply Shortage

CHRISTIANE AMANPOUR, HOST: Next, almost three years after the COVID pandemic began, the U.S. health care system is still struggling with shortages of medicine and supplies. Dr. Mahshid Abir is an emergency physician and senior policy researcher at the Rand Corporation. And she tells Hari Sreenivasan what’s behind these crises and how to solve it.

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HARI SREENIVASAN, CORRESPONDENT: Christiane, thanks. Dr. Mahshid Abir, thanks for joining us. Over the past few weeks, we’ve seen lots of headlines of different types of medications and drugs that are in short supply. And I want to ask, as an E.R. doc, are you seeing the same thing on the ground or what are you seeing?

DR. MAHSHID ABIR, EMERGENCY PHYSICIAN AND SENIOR PHYSICIAN POLICY RESEARCHER AT THE RAND CORPORATION: Yes, Hari, you’re touching on a really critical issue that is not new for hospitals and health systems. Over the course of the years, even before the pandemic, we experienced various shortages, including in IV fluids and also, cancer medications. The reason why, currently, the issue is highlighted of the way it is and brought a lot of attention to is that it involves children, and some of the medications that are important for the care of children, including amoxicillin, which treats various infections and also, albuterol for the treatment of asthma. And this is happening all at the same time as having spikes in RSV infections and COVID and influenza. So, it’s a particularly sensitive time to be experiencing these shortages.

SREENIVASAN: Help me understand the direct impact on patience if albuterol or Adderall or amoxicillin is not available, what is the health concern here?

DR. ABIR: Yes, absolutely. So, you know, starting with albuterol. So, as you all know, there is a spike in RSV cases, influenza and COVID, and both in children and adults. Albuterol is a medicine for asthma. And any asthmaticus who is infected with any of these viruses may experience an exacerbation of their asthma, and they will really need their albuterol. And if not treated appropriately, asthma can be life-threatening. So, that’s one problem. Amoxicillin is an antibiotic that’s used for the treatment of bacterial infections in both children and adults. And particularly if, in addition to these viruses that are now going around, someone has a bacterial infection and needs amoxicillin, because it is so effective against so many types of bacterial infections, it can potentially cause issues as far as patient’s inability, because it’s relatively inexpensive. Patients may not be able to get a substitute antibiotic because they can’t afford it or their insurance is not paying for it, or that the treatment of their, you know, bacterial infection may get delayed.

SREENIVASAN: So, give me an example of something that might be happening at your hospital right now or other hospitals about what type of a patient is coming in and what is happening to them.

DR. ABIR: You know, I will speak to a couple of — actually, the issues that we faced, you know, recently, actually. So, a shortage of morphine, which is an important IV administered drug that it is important for pain control. And particularly in the pediatric population or pregnancy, it’s one of the to go medicines for acute illness and pain that we administer to patients. And if we’re not able to give that medicine or the times when we’ve had IV fluid shortages, you know, you don’t want to be in an acute care setting like an emergency department and have to think twice about ordering IV fluids for patients who need it. So, these have real-life consequences for people, whether it is pain management or ensuring that you can give IV fluids to a patient to his own septic shock, you know, these potentially can affect patient outcomes and how well they do from their illness.

SREENIVASAN: So, why are these shortages happening, especially if we’re talking about antibiotics that, you know, some of which are completely off patent now and there are generic versions, they should be available pretty far and wide in the United States?

DR. ABIR: It’s usually a function of two issues. So, either decreased supply or increased demand. So, I think that we’re at a juncture right now where we are experiencing both. So, given the increase in respiratory illnesses, both in children and in adults, amoxicillin is being used particularly if there is a bacterial infection in addition to a viral infection like RSV and influenza. And also, if there’s any kind of disruption in getting the medication to these hospitals and health systems. So, that last mile. And getting these medications to the pharmacy, that also will impact folks getting the medications they need.

SREENIVASAN: So, what’s the — where is the kind of kink in the supply chain here?

DR. ABIR: So, the supply chain is really could be either the production of the medicine. So, if there is an issue with the facility, if they have shortages in the components of what goes into the medication, for example, amoxicillin, or that if the actual company or the location where the medication is made, if there is issues of staffing or labor shortages or any other issues that slows down production at the site, then you can experience it as is a user or patient.

SREENIVASAN: You know, you are on a very special committee, The National Academy of Science, Engineering and Medicine, and you issued a report earlier this year on the security of Americas product and supply chain. I just want to quote a paragraph here. Over the past several decades, medical product supply chain disruptions and shortages have plagued the U.S. health care system, putting the lives of Americans that risk, costing medical facilities millions of dollars per year and threatening the clinical research enterprise. I mean, this is not something new, as you’ve said, we’ve had these sort of decades long problems. Why aren’t these problems being fixed? Who is sort of responsible for getting that fixed?

DR. ABIR: So, a lot of the issues that we are facing right now, and have historically faced, is due to lack of transparency. So, the companies that make these medications are not obligated to report who — where they get the ingredients from, who is the primary supplier and where they are even made. So, the setting of this lack of transparency and not really holding these companies accountable, then it’s hard to predict when there’s going to be a shortage in any of these medications. So, a lack of ability to know that there is a potential shortage is going to make it very difficult to come up with strategies to mitigate and come up with solutions. And that is why one of the most important policy changes that we can make in the U.S. is incentivizing. And this incentivizing manufacturers of medicines and medical equipment to share more information about their ingredients and where things are made and where their products are made and that that kind of transparency, ultimately, can lend itself to surveillance of supply chain issues so that you can mitigate in advance and implement strategies.

SREENIVASAN: I think when people read in the newspapers that there are shortages of critical medicines, they are doubly shocked that it’s happening in the United States where not only do we have such wide range of access to medications and medical facilities and doctors, but also the amount of money that we all spend on health care. So, is there a structural fix that is necessary?

DR. ABIR: I think multiple fixes that are necessary. You know, yes, I think that the average and user of any of these medications would be shocked to know that we have any shortages here. But part of the issue is that a lot of these medications are made abroad and imported. So, China is a big producer, India, there’s others. So, that’s one part of the problem. And so — and also, the fact that, again, we rely on foreign producers. If there’s any kind of bottleneck in the production of these medicines, overseas, and also medical equipment, so, it’s not just medicines, then that’s going to cause problems and issues and delays in getting the medications that we need and shortages. And ultimately, sometimes, doctors and health systems have had to resort to using alternates. And sometimes the alternates are not as effective or they can have, you know, unforeseen consequences for patients who use them.

SREENIVASAN: Is this something, given that some of the ingredients for these medications that are in short supply today are coming from overseas, how long would it take for the United States to bring the manufacturing back for some of, at least, the incredibly important ones that were short on?

DR. ABIR: Yes, I think you’re referring to onshoring. So, you know, production of medicines here in the United States, which certainly is part of the toolkit of strategies that we need to think about, thinking forward — moving forward. However, you know, it is not really kind of the ultimate solution because you have to think about, you know, the degree of demand and the time sensitivity of getting these medicines to the end user. So, you know, as part of, again, a toolkit of various strategies, including diversifying manufacturers abroad and ensuring that we have options of bringing in medicines that we need. Also, yes, I think onshoring is part of the solution but not the entire solution.

SREENIVASAN: Do you think that we start with medicines that are kind of the most — I guess, lack of that medicine would be the most life- threatening and then, kind of work our way down the chain? I mean, how do you prioritize where to start trying to make some of these changes?

DR. ABIR: Yes. I think it’s a challenging issue. Because, just as you point out, there are certain products like IV fluids that are critical to the care of many sick patients, similar with antibiotics or albuterol, which, you know, is important for asthma and many other very common lung diseases. So, I think it makes sense to start with medicines that are used more commonly and for — apply to a wider population, or the whole population when they get sick. But at the end of the day, we also can’t ignore those medicines that really are pertinent to a smaller, you know, proportion of the population or for rare conditions. But I can think starting off with the more common medicines and equipment that are critical in many conditions certainly make sense.

SREENIVASAN: You know, I wonder, the past couple years brought to sharp relief all the different types of things that we are dependent on we learned the hard way that it doesn’t hurt to save a little bit for a rainy day. And I wonder, have you seen any big changes like that?

DR. ABIR: So, these are all excellent questions. Typically, health systems in the U.S. don’t plan that far ahead. Because the return in investment for them is low. So, imagine that they have to prepare for an incident where the next public health emergency that may never arrive. So, I mean, the perfect example is on a day-to-day basis, many health systems, even for staffing, they don’t plan ahead of time. They really kind of determine on a day-to-day basis or maybe even 72-hour basis at best, how much nursing staff they need. So, it really goes against the paradigm of health systems to think that far ahead and plan. But you really raise an important point. I mean, so, we’ve had stockpiles for medicines and supplies in the U.S. and some of that came to good use during the pandemic. But otherwise, you know, outside of ensuring that our stockpiles are ready and available and they’re designed for the modern issues that we’re facing today, we also need to share resources. So, for example, during the pandemic, not all cities and hospitals were hit hard at the same time, and some had lax — they have more resources than others. And having, you know, strategies in place and agreements in place to share those resources in addition to thinking about how we can do a better job of stockpiling is going to be really important.

SREENIVASAN: You know, I understand, say, for example, if profit is a central motive here, that you want to be as efficient as you can and you want to sort of maximize shareholder return or however you want to call it. But at the same time, I also wonder whether — you know, isn’t there a financial incentive to kind of plan for a rainy day? Meaning, is it still profitable for you medical institutions not to plan ahead further?

DR. ABIR: So, you know, in the case of this once in 100-year pandemic, Hari, absolutely, that had they planned in advance, as far as having more equipment for a rainy day or PPE, or many other things that were needed at the end of the day, it would’ve come in handy. And this ended up being an extremely expensive public health emergency for health systems. However, again, I think that the thought process is more behind, you know, the unlikeliness of an event occurring. And, you know, every time that there’s a disaster of public health emergency, it energizes both health systems and policymakers to do something so that we can do better the next time around. And I think some of the important incentives are, what is the patients and communities that we serve that will ultimately suffer in the setting of not planning and also, the health system workforce? So, that as you know, and I’m sure the viewers have heard and seen, that the workforce, there’s major attrition and people are leaving the health system in throws. And part of the better planning that the system is to protect our health system. Because they are truly a national — not just a national treasure, but also part of the national health security that the country needs to invest in and do a better job of protecting.

SREENIVASAN: Did we learn anything from the pandemic? I mean, I remember those horrible stories, essentially the State of California competing with the State of New York for the same finite number of whatever it was, masks and so forth. But here we are in this scenario, how — is there a greater amount of collaboration on the ground when you see these drug shortages where if a clinic is running short in a rural area, a major metro hospital that might have more, is working hand in — hand and say, OK, look, you can borrow 50,000 of these today. We know you’ll be good for it in a couple months?

DR. ABIR: You know, we saw some of that. So, you know, various states, including in Michigan, where I am right now, some of the hospitals that were not as busy and overwhelmed by COVID patients did accept patients and transfers from other hospitals in the state that were really overwhelmed and overcapacity. So, that is one way of sharing resources. Also, for example, assuring some capacity around critical care through tell a critical care where doctors kind of advice physicians in community or remote hospitals around the care of COVID patients. So, we saw some of that. But we certainly need policies in place and more defined strategies to disseminate the importance of collaboration and cooperation during public health emergencies, you know, more routinely. So, although — for example, the United States are good examples of that. It’s not something that was done, you know, on a routine or regular basis or enough.

SREENIVASAN: Recently, a lot of people were made aware of how acute some of these supply chain shortages can be in the context of baby formula. If you had an infant, this was an enormous source of stress for several months. And the administration had to step in. And I wonder if, is there something similar to a Defense Production Act sort of impetus that an administration can do or members of Congress can do to try to say, here’s the 15 or 25 things we can never be short of in the U.S.?

DR. ABIR: Yes. Certainly. I mean, I think that, you know, the Defense Production Act, outside of a public health emergency like COVID will be more difficult to trigger. However, you’re absolutely right. I mean, having a list of critical medicines and supplies and equipment that are important to sustaining the work of hospitals and health systems would be really important. So that we start by addressing the supply chain issues in the context of those priority items. And then, overtime, once we find the effective strategies and implement them, kind of expand those strategies to other items.

SREENIVASAN: So, I’m giving you a magic wand here. If you could set a prescription for how to fix this, where would you start and what would you tell policymakers?

DR. ABIR: Demand transparency from manufacturers and put patients first. Because, at the end of the day, it maybe their family member or their loved ones who are in a stretcher or in a hospital or E.R. somewhere, needing that medicine that is not available. So, I think that, in order to create that transparency, we need to identify clear incentives and disincentives to ensure that the manufacturers follow- through. So, that we have more transparency in drug manufacturing and ultimately, have the ability to predict bottlenecks and shortages in order to be able to mitigate them ahead of time.

SREENIVASAN: Dr. Mahshid Abir, thanks so much for joining us.

DR. ABIR: Thanks for having me.