Opinion: U.S. dependence on China is a national security risk

First Opinion is STAT’s platform for interesting, illuminating, and provocative articles about the life sciences writ large, written by biotech insiders, health care workers, researchers, and others. To encourage robust, good-faith discussion about issues raised in First Opinion essays, STAT publishes selected Letters to the Editor received in response to them. You can submit a Letter to the Editor here, or find the submission form at the end of any First Opinion essay. In a recent STAT op-ed, Pooja Yerramilli argues that U.S. pharmaceutical supply chain vulnerabilities are not about geopolitics but result from weak U.S. regulation and an industry that prioritizes profit over public health. In so doing, her argument mistakenly treats these two explanations as mutually exclusive when they are in fact quite interrelated. While she agrees China “dominates nearly every step in the pharmaceuticals production process,” she also insists that U.S. national security risks from that dependence are overstated, including in our recent Council on Foreign Relations report, and does not adequately consider the origins of that dependence. We were among the authors of the CFR report she critiques, which drew on a yearlong study group of pharmaceutical, regulatory, China, and national-security specialists and former officials dedicated to identifying the true scope of U.S. biopharmaceutical dependence on China, assessing the associated risks for U.S. security and patients, and recommending practical ways to reduce those risks. Yerramilli rightly concludes that thin margins for older U.S. generic drugs, concentrated U.S. purchasing structures, and U.S. regulatory challenges and constraints undermine the viability and resilience of U.S. pharmaceutical production, contributing to persistent U.S. drug shortages. But her diagnosis mistakes cause for effect. She ignores the overt role that the Chinese state has played in concentrating biopharmaceutical production on its shores, the reasons U.S. pharma companies have not invested sufficiently in redundancy, and why U.S. drug shortages have proven slow to resolve. Market forces and efficiency-based competition alone did not drive pharma and biotech to China. For decades, China has heavily subsidized its pharmaceutical and chemical sectors. Then, Made in China 2025 designated biopharmaceuticals as a strategic sector Beijing intended to dominate, providing the financing and political mandate for everything in the decade that followed: tax holidays, low-interest loans, land discounts, dedicated biotech hubs, joint venture requirements, forced technology transfer, and “a scientific-ethics system with Chinese characteristics” that has reportedly permitted animal and gene-editing experiments off-limits in the West. In the pharmaceutical and biotech sector (as in many other sectors), the Chinese state operates simultaneously as owner, lender, regulator, purchaser, land allocator, and strategic investor. Beijing has a legal framework that enables integrating and enhancing support for almost every aspect of the biopharmaceutical industry. A 2025 International Monetary Fund paper estimates China’s industrial-policy support, across industries, at roughly 4.4% of GDP, close to $700 billion annually, with its chemical and pharmaceutical manufacturing sector among the largest beneficiaries. Private pharmaceutical manufacturers cannot compete with firms that have access to state-backed capital, subsidized infrastructure, preferential procurement, and state-owned enterprises with an explicit mandate to build national industrial dominance. The profit motive, which Yerramilli calls the root cause, helps explain why U.S. pharmaceutical manufacturers followed the low cost/price signal, but it is Chinese industrial policy which helped manufacture that signal in the first place. Yerramilli points out that pharmaceuticals are not exhaustible resources like critical minerals, so they cannot be a chokepoint. But the analogy we make in the CFR report is not about geology. Essential medicines are a dangerous chokepoint because China dominates their supply chain, therapeutic substitutes would not be readily available if those supplies were withheld, and Beijing has already proven it’s willing to weaponize the pharmaceutical supply chain against other nations. Essential drug supplies are constrained, especially in the short term, because drugmakers must obtain FDA approval for new manufacturing facilities or production lines to address supply shortfalls, and new production facilities are expensive and time-consuming to establish. FDA can authorize temporary importation of foreign unapproved versions of medicines in short supply, but does so as a last resort and after months of delay, as our analysis in the New England Journal of Medicine shows. Once U.S. drug shortages occur, they tend to persist, lasting three years on average. In the meantime, patients and providers must resort to substitute medicines, which can lead to adverse drug reactions, higher hospital costs, and preventable patient harm. Beijing’s previous weaponization of critical minerals, rare-earth, and agricultural supply chains does not worry Yerramilli that the same may occur in pharmaceuticals, but the U.S. military believes otherwise. In 2023, a U.S. Department of Defense official charged with studying the problem testified that the U.S. national security risks of Chinese dominance of the global market for active pharmaceutical ingredients “cannot be overstated” for both “domestic and military uses.” Beijing has already demonstrated a willingness to weaponize pharmaceutical supply chains for diplomatic, trade, and geopolitical leverage. China imposed export controls on dual-use products shipped to Japan, including those used in pharmaceutical manufacturing, after remarks by Japan’s prime minister on the Taiwan Strait. Chinese producers flooded the market with below-cost exports to cripple the pharmaceutical ingredient suppliers that India’s government had been seeking to establish for domestic resilience. In 2019, a prominent Chinese economist told the country’s top political advisory body that if China reduced exports of vitamins and antibiotic raw materials, the “medical systems of some developed countries will not work.” Weaponization of pharmaceutical supply chains need not resemble a public embargo on exports from China to the U.S. It could take the form of calculated degradation of the quality of critical medical exports, selective enforcement actions to slow supplies, or pressure on third-country manufacturers. In 2020, voices amplified by Beijing stressed “90% of the drugs imported by the United States are related to China” and China could “ban exports,” which would “plunge the U.S. into the hell of the COVID-19 pandemic.” China is overtly seeking to displace U.S. leadership across the innovative biopharmaceutical value chain — discovery, clinical development, and manufacturing. This competitive erosion is not simply the result of market conditions or a rapacious industry but rather the product of decades of coordinated Chinese state intervention. It will require an equal, coordinated and sustained U.S. response. Stronger FDA capacity, quality oversight, competition policy, affordability measures, and agile importation are part of that solution. But so are the other targeted inventions to improve the resilience of U.S. biopharmaceutical value chains, including: robust investment in U.S. clinical research capacity, long-term purchase commitments of U.S.-made essential medicine inputs, grants and low-cost financing for local production, accelerated, FDA oversight for advanced manufacturing, functional emergency stockpiles, and genuine allied sourcing partnerships focused on medicines and ingredients where we have true upstream chokepoints in China (or elsewhere). The answer to reducing pharmaceutical dependence on China is disciplined, coordinated industrial policy that maximizes U.S. advantages, not blunt tariff-based protectionism, loosely defined multilateral partnerships, or lambasting U.S. companies and regulators alone. Prashant Yadav is a senior fellow for global health at the Council on Foreign Relations. Thomas J. Bollyky is the Bloomberg chair in global health and director of the Global Health Program at the Council on Foreign Relations. Rush Doshi is the C.V. Starr senior fellow for Asia studies and director of CFR’s China Strategy Initiative. Paul Friedrichs, M.D., is a retired U.S. Air Force major general and senior adviser at CSIS. Victor A. Suarez is a retired U.S. Army colonel and founder of Blu Zone Bioscience & Supply Chain Solutions.