China controls the upstream production chemistry for many of the most widely used generic drugs in the United States, leaving few backup suppliers if that access were disrupted, according to a recent report by former U.S. government officials. The vulnerability is drawing fresh attention as Chinese leader Xi Jinping is expected to travel to Washington, D.C. for a state visit on September 24, the first trip by a Chinese leader to the U.S. capital in more than a decade.
American and Chinese officials have spent recent weeks preparing for the visit, and artificial intelligence and trade friction are expected to dominate the agenda. Still, pharmaceutical dependence carries the same kind of coercive potential Beijing has shown in other sectors, and it touches medicines that tens of millions of Americans take every week.
Beijing has used that kind of leverage before. It restricted rare-earth exports to Japan during a 2010 territorial dispute, imposed trade barriers on Australian barley and wine after Canberra called for a COVID-19 origins inquiry, and curtailed trade with Lithuania after Vilnius opened a Taiwanese representative office. In none of those cases did Chinese officials announce the move or explain the reasoning beforehand.
According to the recent report published on September 2 by Scalare Advisors, a consultancy based in Washington, D.C., China supplied more than 70 percent of the antibiotic active ingredients by volume imported into the United States in 2024, and three of the most commonly used outpatient antibiotic drugs – amoxicillin, azithromycin, and ciprofloxacin – all depend on Chinese-made ingredients. A simultaneous disruption in all three would leave doctors with no reliable outpatient antibiotic option that could be obtained at the necessary scale and speed.
One Chinese conglomerate, CSPC Pharmaceutical Group, produces both amoxicillin and azithromycin for the U.S. market, meaning a single company controls the fermentation-to-tablet chain for two of the three dominant outpatient antibiotic drugs. No equivalent domestic or allied producer exists for either drug.
Bristol-Myers Squibb announced the closure of its last U.S. penicillin fermentation plant in 2004 and ended production there the following year, eliminating domestic manufacturing of 6-aminopenicillanic acid, the building block for the penicillin-class drugs used to treat strep throat, ear infections, pneumonia, and Lyme disease. Today, no U.S. plant produces penicillin from scratch. This decision conceded penicillin production to China, which now makes about 90 percent of that ingredient worldwide.
Heparin – one of the most commonly used blood thinners – illustrates the same pattern. Pfizer has one heparin injection product on an active shortage list maintained by the Food and Drug Administration. The two remaining U.S.-based producers of the raw ingredient used to make it – Scientific Protein Laboratories in Wisconsin and Smithfield BioScience in Ohio – are both now owned by Chinese parent companies. The broader supply of crude heparin traces back to China, leaving roughly 550,000 Americans who rely on the anticoagulant for dialysis with no clinical substitute if that supply were interrupted.
Hydrocortisone, a prescription drug essential for treating inflammation, is manufactured by Pfizer in Michigan but still depends on a Chinese supplier – a state-owned enterprise named Tianjin Tianyao Pharmaceuticals – for the drug’s active ingredients, according to the same review of federal drug-safety programs. The FDA detected hydrogen cyanide contamination in active ingredient shipments from Tianjin Tianyao Pharmaceuticals in December 2015, following a chemical warehouse explosion in August of that same year. If the FDA had not caught the tainted ingredients, it would have triggered a public health crisis in the United States.
This has happened before. Back in 2008, contaminated heparin traced to a supplier in China killed at least 149 Americans. At the time, Chinese officials denied that the contamination originated there and refused U.S. federal investigators access to conduct a criminal inquiry.
Industrial policy in Beijing adds a different type of risk. The 15th Five-Year Plan, issued in March, named biomanufacturing as one of the sectors targeted for “decisive breakthroughs.” An industry analysis published in May found that the number of product categories in which China held a dominant market position rose from 192 in 2021 to 315 in 2024.
Analysts increasingly view China’s dominance in supply chains as a national security threat, rather than a purely economic one. The concentration of drug manufacturing in China means that decisions made in Beijing shape whether American hospitals can fill a prescription.
Experts also point to the drug manufacturers’ lack of transparency about their supply chain exposures to potentially hostile markets like China. Currently, there is little U.S. federal regulation that requires these companies to publicly disclose the origins of active pharmaceutical ingredients or key starting materials of their products. Experts agree that both relevant agencies and the pharmaceutical industry should be held more accountable to make this information more transparent, especially as these market exposures increasingly become national security concerns.
Washington has confirmed the September 24 date for Xi’s state visit, and U.S. and Chinese trade officials held a video call in July to prepare for the visit. Neither government has signaled that pharmaceutical supply chains will be part of the formal agenda, yet the medicines Americans use every day are intrinsically linked to the broader China-U.S. relationship, whether or not they are named in a joint statement.