In the vast machinery that keeps the U.S. healthy, one of the most essential yet overlooked systems is the pharmaceutical supply chain. From everyday painkillers like ibuprofen and acetaminophen to critical antibiotics and chemotherapy agents, the medications Americans depend on are increasingly sourced abroad — especially from China.
Although the efficiencies of globalized production have driven down costs, they have also introduced serious risks: dependency, diminished oversight and questionable product quality.
Much of the public concern has focused on finished drugs or active pharmaceutical ingredients. But the deeper vulnerability lies even further upstream. Many of the chemical building blocks that make modern medicine possible — reagents, solvents and key starting materials — are now overwhelmingly produced in China. These raw materials are essential for synthesizing active pharmaceutical ingredients, and in many cases, they have no viable substitute outside China.
China’s dominance is evident in hard numbers. According to U.S. trade data, 95 percent of U.S. ibuprofen imports, 91 percent of hydrocortisone, 70 percent of acetaminophen and up to 45 percent of penicillin come from China. Yet the more dangerous dependency may be indirect. India, for example, supplies the majority of generic drugs to the United States. But India itself imports nearly 70 percent of its active pharmaceutical ingredients from China. That means many of the drugs labeled “Made in India” are, in practice, deeply reliant on Chinese upstream supply.
This complex web of dependencies was sharply analyzed in a 2025 report by the Brookings Institution. The authors argued that while the aggregate exposure of U.S. drug volume to Chinese-made active pharmaceutical ingredients is likely below 25 percent, such averages obscure acute vulnerabilities in certain drug categories — especially antibiotics and chemotherapy agents. Their findings also revealed a troubling misconception: the idea that simply shifting active pharmaceutical ingredients production to the U.S. would eliminate risk. In reality, unless the production of upstream chemicals is also relocated or diversified, the core vulnerability remains.
In fact, Brookings highlighted that more than half of India’s solvent and reagent inputs — used for making the drugs later exported to the U.S. — come from China. Furthermore, India lacks domestic infrastructure for some high-risk processes like fermentation (essential for many antibiotics) and fluorination (used in synthesizing cardiovascular and psychiatric drugs). Over time, these environmentally hazardous or technically demanding operations have been outsourced almost entirely to China — not just for economic reasons, but because of regulatory and safety complexities.
Meanwhile, quality control issues associated with Chinese-made generics continue to raise alarm. Reports have documented instances of ineffective anesthetics, blood pressure medications that fail to reduce pressure and non-functional laxatives. These are not rare outliers. Rather, they reflect structural deficiencies: inadequate regulatory oversight within China and a procurement system that prioritizes cost over quality.
China’s centralized drug procurement program awards contracts to the lowest bidder. While this has brought down prices, it also pressures manufacturers to cut corners. Alarmingly, there have been documented cases of falsified bioequivalence data — meant to prove that a generic drug works the same as a branded one.
One recent scandal involved nearly 2,000 generics whose clinical data was “identical to the last decimal place,” a statistical improbability that drew public criticism from Chinese doctors and health experts.
Even within China, these issues have drawn criticism from medical professionals. But their warnings are often met with censorship rather than reform. For American patients, this presents a serious dilemma. While the U.S. Food and Drug Administration oversees drug safety, its inspection presence in China is minimal. Many production sites are rarely, if ever, inspected. And pharmaceutical companies are not currently required to publicly disclose where their ingredients come from — leaving patients, physicians and even regulators in the dark.
Given the scale and complexity of the threat, mitigating this exposure requires a comprehensive strategy:
- Incentivize Domestic Manufacturing: The U.S. must invest in restoring domestic production not only of finished drugs and active pharmaceutical ingredients, but of the essential chemicals and raw materials that feed the entire process. Without this, “onshoring” becomes a shallow solution.
- Enhance Transparency: Companies should be required to disclose the origin of active pharmaceutical ingredients and key inputs. This would allow government agencies and health systems to identify chokepoints and plan around them.
- Increase FDA Oversight Abroad: The number of FDA inspectors stationed in foreign countries — especially in China — must be significantly expanded. Regulatory oversight cannot be optional.
- Develop Strategic Stockpiles: The federal government should build and maintain reserves of essential medicines and their components, similar to the Strategic National Stockpile, to buffer against geopolitical shocks.
- Partner with Allies: Rather than trying to build an entirely self-sufficient pharmaceutical system, the U.S. should collaborate with trusted partners such as Japan, South Korea and Germany to create a diversified and resilient international supply chain.
- Support Advanced Manufacturing: Technologies such as continuous manufacturing, which allow for more efficient and higher-quality drug production, should receive federal research and development support and regulatory fast-tracking.
Brookings rightly notes that not all vulnerabilities are created equal. Some drug classes — like controlled substances — have little or no exposure to China. Others, like antibiotics and statins, are almost entirely dependent. A one-size-fits-all policy approach will fail. Instead, the U.S. needs targeted assessments that prioritize essential medicines and their specific points of failure, especially those with no readily available alternatives.
Yes, these actions will come at a cost. But so would a sudden disruption in Chinese pharmaceutical exports — whether caused by a geopolitical crisis, pandemic or trade war. The difference is that the cost of action is predictable and strategic, while the cost of inaction is chaotic and potentially fatal.
Cheap medicine should not come at the expense of safety or sovereignty. America must confront the uncomfortable truth: the health of its people is precariously tied to supply chains it does not control. Rebalancing this equation will require leadership, investment, and a willingness to prioritize resilience over short-term savings. The clock is ticking, and the next drug shortage may not wait for policymakers to catch up.
Jianli Yang is a research fellow at Kennedy School of Government at Harvard University. He is founder and president of Citizen Power Initiatives for China and author of “For Us, The Living: A Journey to Shine the Light on Truth” and “It’s Time for a Values-Based ‘Economic NATO.’”
