Globalization has delivered tremendous benefits — greater competition, lower costs, and broader access. But that same interdependence becomes a liability when it rests on a single, fragile pillar. China’s power over two sectors of commodities critical to the United States affords it powerful economic leverage and creates significant risks for American economic and health security.
One of those sectors was in the news earlier this month when Beijing announced it would expand export controls on rare earth minerals, which come primarily from China and which are critical to the American production of consumer electronics, cars, and military hardware. President Donald Trump quickly threatened 100% tariffs on all Chinese imports, sending equity markets tumbling.
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Another, less publicized but hugely important sector is pharmaceuticals, more specifically “active pharmaceutical ingredients,” or APIs. As the name suggests, APIs are the critical active ingredients in many of the pills and injectable drugs sold in the U.S. — from antibiotics and blood pressure medications to cancer treatments. And like rare earth minerals, a staggering share of them come from one place: China.
This dependency has far-reaching implications for the U.S. economy, national security, and public health — implications magnified by renewed trade turmoil, especially tit-for-tat threats of tariffs. Although finished pharmaceutical products are largely protected from tariffs by World Trade Organization rules, the bulk chemicals and APIs used to make them are explicitly exempted. That omission leaves the generic drug market — which accounts for about 90% of all U.S. prescriptions — highly exposed.
Even without overt trade retaliation, the sheer scale of U.S. dependence on China for pharmaceutical inputs is cause for concern. A report from the U.S.-China Economic and Security Review Commission described the risks. Some of its most significant conclusions:
• China is the world’s largest producer of APIs, and the U.S. relies heavily on drugs either made in China or derived from Chinese-sourced ingredients.
• Drug companies are not required to disclose the country of origin for their APIs, leaving U.S. consumers unaware of the risks.
• Should China weaponize this dependence by cutting API exports, the effect on the health of U.S. consumers could be severe.
China’s dominance, coupled with spotty regulatory oversight, has already led to quality control scandals, including the distribution of contaminated or substandard drug ingredients. Because labeling laws disclose only the final place of assembly, most Americans have no idea their daily medications may contain materials sourced from poorly regulated Chinese factories.
But safety is only one aspect of the risk; strategic vulnerability is the other. If China were to restrict API exports during a geopolitical crisis — over Taiwan, trade disputes, or another flashpoint — the health consequences could be catastrophic.
Chronic conditions such as hypertension, diabetes, infections, and heart disease rely on continuous access to a broad range of generic drugs. A sudden shortage could leave hospitals scrambling and patients without treatment options. Lives could be lost — not due to a lack of medical knowledge, but because of a lack of drugs.
This is no hypothetical scenario. As of Oct. 10, the U.S. FDA listed shortages of 76 drugs — including chemotherapy agents, antibiotics, and other lifesaving medicines. These disruptions stem not from surging demand, but from supply-chain bottlenecks — precisely the kind of vulnerability worsened by dependence on a single foreign supplier.
This complex, worrisome situation presents an obvious question: What do we know about China’s intentions toward the U.S. and its population?
As described in a shocking CBS 60 Minutes segment on Oct. 12, China has already hacked, and continues to penetrate, vital U.S. infrastructure: water treatment facilities, the electrical grid, telecommunications, transportation networks, and more.
In a sobering interview on that program, retired Air Force four-star General Timothy Haugh, who until April headed both the U.S. Cyber Command and National Security Agency, noted that there is no clear economic or intelligence-collection advantage to many of these hacks. Rather, they are preparing “pre-positioning” access so that, in a geopolitical crisis or war, the attackers can inflict damage or exert leverage on the U.S. He suggests that even attacking small, rural utilities may present a distraction and sow fear and confusion.
And like disrupting our national infrastructure, interfering with the supply chain of pharmaceuticals could inflict tremendous damage on Americans. How, then, can we mitigate the risks of our current predicament?
First, Congress must quantify the extent of U.S. dependence on Chinese APIs by commissioning an audit of the pharmaceutical supply chain and identifying alternative sources, both domestic and international.
Second, Congress should empower the FDA to expand its oversight capacity in China. While the FDA does maintain a limited presence there, the number of inspectors is woefully inadequate given the scale of production, and our regulators should ensure compliance with U.S. safety standards.
Third, transparency is critical: Drug manufacturers should be required to disclose not only where a medication was assembled, but where its ingredients were sourced.
Fourth, Congress can harness its budgetary power to stimulate domestic production by requiring government health systems — Medicare, Medicaid, and the Department of Veterans Affairs — to prioritize drug purchases from domestic sources.
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Finally, and most important in the short term, the Trump administration must consider carefully the implications of tariffs it intends to apply to imported active pharmaceutical ingredients and finished drug products.
We must act. The uncertainty and danger we are experiencing are reminiscent of an old Chinese proverb: “It is better to be a dog in a peaceful time than a man in a chaotic period.”
Henry I. Miller, a physician and molecular biologist, is the Glenn Swogger distinguished fellow at the Science Literacy Project. He was the founding director of the FDA’s Office of Biotechnology.
