Introduction

COVID-19 is the latest episode of shortages of critical medical supplies. Historically, and to the present day, medical supplies have been sourced from single regions in the world, thus rendering the supply chain vulnerable to a myriad of harmful circumstances. We argue that shortages in medications related and unrelated to COVID have illustrated the need for the United States to diversify its medical supply sources before future pandemics, political crises, or natural disasters occur.

March 1942: The Japanese Empire occupies the East Indies, eliminating 90% of the world’s supply of quinine, the most effective antimalarial drug of the era. ^{Reference Worthen1} Cases of malaria constantly haunted the United States (U.S.) military throughout the war, impacting all theaters.

September 2017: Hurricane Maria devastates the territory of Puerto Rico, resulting in a shortage of intravenous (IV) saline across the United States. About 50% of U.S. hospitals relying on IV fluid from Baxter International scramble to find alternative supplies. ^{Reference Mazer-Amirshahi and Fox2}

January-March 2020: SARS-CoV-2 emerges from China and rapidly evolves into a pandemic, resulting in disrupted production and exportation of medications and personal protective equipment (PPE) around the world. The ensuing shortages hamper the U.S. pandemic response.

Despite the separation in time and space, all 3 scenarios share 1 common mistake: a lack of diversity in sourcing essential medical supplies. As World War II erupted, Japan quickly captured Java, the epicenter for the world’s quinine production. The United States, caught off-guard, suddenly found itself facing malaria across the globe without sufficient treatment. This unpreparedness resulted in major hospitalizations from malarial infections throughout different battles and theaters. ^{Reference Worthen1} If the U.S. had invested into diversifying its quinine source well before World War II, the military would not have faced such a drastic shortage. Hurricane Maria devastated U.S. hospitals’ small-volume IV saline supply 80 years after World War II. 50% of America’s supply came from Puerto Rico, which enabled a single storm to catapult hospitals nationwide into a shortage. As was true for quinine and Java, this saline shortage highlighted that depending on 1 geographical region is rife with risk. Moreover, this risk is clearly higher for medications already in low supply, which is unfortunately a common scenario. ^{Reference Mazer-Amirshahi and Fox2} Action must be taken quickly, starting with healthcare leaders identifying which medications are mostly sourced from 1 area or country and then quickly diversifying them.

SARS-CoV-2 again highlighted how quickly an event around the world can rupture America’s healthcare supply. At the start of the pandemic, China supplied active ingredients for most medications in the US. ^{Reference Choo and Rajkumar3} Such dependence left the American healthcare system extremely vulnerable, and within a few weeks of viral spread in America, the demand on the medical system out-paced supply. ^{Reference Choo and Rajkumar3} Importantly, PPE shortages contributed to the chaos as well. Approximately 66% of the global glove supply was sourced from Malayasia. ^{Reference Oanh Ha and Raghu4} Yet, a disrupted workforce, and the desire to provide for its own country’s needs led to a global shortage that reverberated in America. The lack of source diversification created a perilous scenario for the U.S. and forced hospitals into impossible situations.