By Morton Wendelbo, Lecturer, Bush School of Government and Public Service; Research Fellow, Scowcroft Institute of International Affairs; and, Policy Sciences Lecturer, Texas A&M University Libraries, Texas A&M University and Christine Crudo Blackburn, Postdoctoral Research Fellow, Scowcroft Institute of International Affairs, Bush School of Government and Public Service, Texas A&M University.

Note – This article was first published on

Flu season in the U.S. typically peaks in February, but this year’s outbreak is already one of the worst on record. As of Jan. 6, 20 children have died from the flu, and overall mortality caused by the flu is already double that of last year’s.

One reason the flu is so severe this season is that the dominant strain is H3N2, which has an impressive ability to mutate and is particularly aggressive against Americans over 50.

Making the threat worse is the fact that most of the IV saline bags used in common medical treatments and procedures – including severe cases of the flu – are made in Puerto Rico, which is still reeling from Hurricane Maria. Hospitals in some areas around the country that are operating at or above capacity because of the flu are quickly running low on saline, resorting to time-consuming and potentially dangerous treatments of patients.

The IV saline shortage is unlikely to cause a life-threatening breakdown of medical treatments. But the shortage does expose a dangerous flaw in the medical supply chains that everyone relies on to counter disease outbreaks or bioterrorism. Many different types of important medical equipment and medicines either come from abroad or rely on a single producer.

Global supply chains

Globalization has changed the way we produce, transport and store almost anything, including medicines and medical supplies. Now that it’s inexpensive to transport goods, many can be easily produced abroad at substantially lower costs. In nearly all cases, that benefits producers and consumers alike.

For the medical industry, approximately 80 percent of all pharmaceuticals used by Americans are produced overseas. The majority of this production takes place in China and India.

Forty-three percent of saline in the U.S. comes from Puerto Rico. The U.S. was already running below optimal levels of saline when Hurricane Maria hit.

Rapid transportation of goods also allows most industries to rely on “just in time” deliveries. That means goods arrive only shortly before they are needed, rather than arriving in large shipments.

In most situations, and for most goods, that causes few issues. However, when there’s an insufficient stockpile, delivery delays can be life-threatening. Many of our hospitals receive shipments of critical pharmaceuticals three times a day.

Unhappy coincidences

As researchers studying how countries can prepare for disease and disasters, it’s clear to us that the IV saline shortage is just the tip of a gigantic iceberg.

Destroyed communication satellite in Humacao, Puerto Rico. Dan Vineberg, CC BY

There are two ways the “just in time” system can be disrupted: an unexpected surge in demand or a delay in delivery. In this case, both occurred simultaneously. The U.S. is dealing with an unusually potent strain of the flu, while Hurricane Maria brought production in Puerto Rico to a grinding halt. If only one of the two had occurred, it’s unlikely the U.S. would have experienced a shortage.

Now, hospitals overrun with flu patients have to turn to alternatives to IV saline. One is an IV push procedure, in which medications are manually “pushed” into the IV line. This can be deadly if not done correctly.

In the case of IV saline, the simultaneous occurrence of both demand and delay was accidental. Unfortunately, it’s not only possible that such confluence will occur in the future – it’s likely. In the case of pandemics or biological warfare, there will likely be both a surge in demand for important goods and a simultaneous disruption of production and delivery.

If a pandemic disease severely affected China or India, where large shares of medicines come from, production could be knocked out or slowed. That would leave the rest of the world vulnerable to the disease’s spread, because there would be no supply of crucial medicines to combat it. The 1918 influenza pandemic caused disruptions that prevented coal from being delivered to the northeastern U.S. That left some without heat in the height of winter, causing people to freeze to death and compounding the deadly pandemic.

Today, such a breakdown could leave hospitals and other crucial infrastructure without electricity. If the spread of the disease is intentional, as in cases of bioterrorism or bio-warfare, adversaries could target global supplies of crucial treatments.

Preparing for problems

The destruction in Puerto Rico and the impact it has had on the supply of small IV saline bags in American hospitals is a warning. This time, it’s IV saline. Next time, it might be electricity to run intensive care units or critical antibiotics to treat infections.

Global supply chains are a massive puzzle, but public health and emergency preparedness officials need to, at a minimum, understand every link in the chain of critical goods. Without a thorough understanding of the supply chain, it’s difficult to preempt problems that could arise in times of emergency. Hospitals and other crucial infrastructure, such as power plants and the transportation industry, may want to diversify their suppliers of critical goods and encourage those suppliers to not focus production in a single area, especially not to an area prone to natural disaster. A final, but far more costly, option is to ensure we can produce most of these goods domestically in times of emergency.

In our view, the solution depends on a partnership between government and industry. Federal, state and local governments have to alter procedures, but private companies involved in the production and delivery of critical goods have to plan ahead for emergencies.

If these weaknesses in our global supply chains are not addressed, especially as they relates to medical supplies, pharmaceuticals and other critical goods, we are headed for disaster.


  1. My little boy dog has been coughing and acting like he has something in his throat, that he couldn’t clear out of his airway. I had noticed this after I got the flu, and wondered if he might have caught the influenza virus too, or the dog flu. I also worried that maybe he had caught kennel cough, even though he has had his vaccinations and they are up to date. Last night about 11:00, as he was lying in bed with us, he starting coughing really bad. We tried to hold him with his head lower than his body, and patted his back gently. Started looking for an emergency vet clinic on the computer……..

  2. We debated back and forth as to whether to go out into the night and take him to one. He quit coughing and went back to sleep so we waited and this morning took him to the vet. I told the vet what I suspected that might be wrong with him. Well, I was wrong. He doesn’t have the dog flu, or kennel cough after all. They did an x-ray of his chest, and he has an enlarged heart and a heart murmur. His heart is also too rounded in shape, and has began to press against his main airway, the trachea, I think the vet said, and this is causing him to cough to try to breathe correctly. He gave him a medicine that makes it easier on his heart to pump and thus makes his heart “smaller” I guess you would say. Plus some other meds to take. The vet showed me his x-ray and his heart did look big and round, and he showed me how it should look……

  3. His lungs were fine, and very clear, no fluid buildup. However the vet said my dog will have to be on this heart medicine, Hydralazine, for the rest of his life, and will have to be monitored to watch out for heart congestion, that could start to build up fluid on his lungs. So it is both good news and bad news. I love my little boy. He has been eating great and is spunky, but at least now I know, and that it is not some contagious dog disease, or something foreign stuck in his airway, but instead what happens when pets get older like us people.

  4. Did anyone else see that wrecked and totaled car on Illinois St. and 436, right on the same side of the road on 436 as Ammco Transmission shop, the next road up, east from the transmission shop which is Illinois? It is a little silver Chevrolet car, Aveo, and looks like it was in a very bad head- on wreck, and looks totaled in the front end. It is sitting sideways just off the side road, and has yellow tape wrapped around it. I don’t know what happened, but wonder if it had been stolen, maybe someone went joyriding around and wrecked it. I am not saying that it was stolen, and wrecked, but just wonder what did happen there? I hope no one got hurt in that front end collision!


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